QUEENSLAND UNIVERSITY OF TECHNOLOGY

School of Nursing, Faculty of Health

THE QUALITY OF LIFE AND

CAREGIVING BURDEN AMONG
CAREGIVERS OF PEOPLE WITH
DEMENTIA IN HANOI, BAC NINH
AND HAI PHONG, VIETNAM

QUANG TRUNG TRUONG

RN, MSc: Health Care Management

This thesis is submitted to fulfil the requirements for Doctor of Philosophy at

Queensland University of Technology, Australia

2015

i
 Keywords

Quality of life, caregiving burden, dementia caregiver, Vietnam.

ii
 Abstract

The aim of this study was to develop an understanding of how Vietnamese

caregivers of family members with dementia are affected in terms of how the role

impacts their lives and the impact of traditional values and culture on these carers’

experience. The study involved three phases. Initially, two cross-sectional surveys

were used to describe carer’s quality of life (QoL) and perceived burden, and to

explore the associations between family carer characteristics, burden and perceived

QoL. Surveys were administered to carers in Hanoi during Phase 1 (N= 153) as well

as carers from Hanoi, Hai Phong and Bac Ninh in Phase 2 (N=347). The instruments

employed were: Kingston Standardised Behavioural Assessment (KSBA), Barthel

Index, Zarit Burden Interview, Sense of Coherence, Filial Piety Scale, Positive

Aspects of Caregiving instrument and WHOQOL-BREF. In Phase 3, qualitative

methods were used to explore specific issues associated with daughter carers (N=24).

Phase 1 and 2 survey results showed dementia carers reported low QoL, which

was predicted by high perceived burden and lower Sense of Coherence, with lack of

confidence in managing situations and performing health promotion. Carer

characteristics, including age, gender and family income, were significantly

associated with QoL. Other cultural factors included filial piety and positive aspects

of caregiving, which also contributed to explain QoL. These findings were

considered to be consistent with the research framework of the stress and coping

model of Lazarus and Folkman (1984). Phase 3 results suggest that filial piety and

positive aspects of the role may be the source of explanation and influence for the

caring experience among daughter carers. These perspectives appear to help daughter

carers to adjust to carer role stress.

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 Table of Contents

Keywords ................................................................................................................................. ii
Abstract ................................................................................................................................... iii
List of Publications and Conference Presentations ................................................................ vii
List of Tables ........................................................................................................................ viii
List of Figures ...........................................................................................................................x
List of Abbreviations .............................................................................................................. xi
Statement of Original Authorship .......................................................................................... xii
Acknowledgements ............................................................................................................... xiii
Glossary of term used in the thesis .........................................................................................xv
Chapter 1: INTRODUCTION .................................................................................. 1
1. Background ...........................................................................................................................1
2. Research aims and questions.................................................................................................7
3. Significance...........................................................................................................................8
4. Methodology .........................................................................................................................8
5. Structure of thesis .................................................................................................................9
Chapter 2: LITERATURE REVIEW .................................................................... 11
1. Quality of life among dementia caregivers .........................................................................11
2. Caregiving burden among dementia caregivers ..................................................................37
3. Theory/model of quality of life ...........................................................................................42
4. Research framework ...........................................................................................................50
Chapter 3: THE 1ST SURVEY – PHASE 1 ............................................................ 53
I. Methodology........................................................................................................................53
1. Study design ........................................................................................................................... 53
2. Population, setting and sampling ........................................................................................... 53
3. Measurement .......................................................................................................................... 56
4. Data collection procedure ...................................................................................................... 61
5. Data analysis .......................................................................................................................... 63
6. Ethical considerations ............................................................................................................ 64
II. Results of the 1st survey......................................................................................................67
1. Descriptive profile of study participants and their care-receivers .......................................... 67
1.1. The demographic characteristics of people with dementia and caregivers .................... 67
1.2. Employment of dementia caregiver ................................................................................. 67
1.3. Family financial income and caregiving hours ............................................................... 68
1.4. Kinship between caregivers and people with dementia .................................................. 69
2. Descriptive statistics of research variables and its comparison – correlation test .................. 70
2.1. Health profile of people with dementia health ................................................................ 70
2.2. Dementia caregiver ......................................................................................................... 71
2.3. Perceived caregiving burden .......................................................................................... 71
2.4. Sense of Coherence ......................................................................................................... 73
2.5. WHOQOL-BREF ............................................................................................................ 74
3. Multivariate analysis .............................................................................................................. 76
3.1. Multivariate analysis to predict perceived caregiving burden ....................................... 76
3.2. Multivariate analysis to predict quality of life among dementia caregiver .................... 77

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III. Discussion on findings of 1st survey .................................................................................82
1. Characteristics of participants ................................................................................................ 82
2. Perceived caregiving burden .................................................................................................. 83
3. Quality of life ......................................................................................................................... 86
Chapter 4: THE 2nd SURVEY – PHASE 2 ............................................................ 90
I. Introduction .........................................................................................................................90
Research framework .................................................................................................................. 95
II. Methodology ......................................................................................................................96
1. Study design ....................................................................................................................... 96
2. Population, setting and sampling....................................................................................... 97
3. Measurement .................................................................................................................... 100
4. Data collection procedure ............................................................................................... 101
5. Data analysis ................................................................................................................... 102
6. Ethical considerations ..................................................................................................... 104
III. Results of the 2nd survey .................................................................................................105
1. Descriptive profile of study participants and their care-receivers ........................................ 105
1.1. The demographic characteristics of people with dementia (PWD) ............................... 105
1.2. The demographic characteristics of caregivers ............................................................ 106
1.3. Kinship between caregiver and people with dementia .................................................. 108
2. Descriptive statistics of research variables and its comparison – correlation test ................ 109
2.1. Caregiving hours .......................................................................................................... 109
2.2. Health status profile of PWD ........................................................................................ 110
2.3. Perceived caregiving burden ........................................................................................ 114
2.4. Filial piety ..................................................................................................................... 116
2.5. Positive aspect of caregiving (PAC) ............................................................................. 117
2.6. Sense of Coherence ....................................................................................................... 118
2.7. WHOQOL-BREF .......................................................................................................... 119
3. Multivariate analysis to predict quality of life among dementia caregivers ......................... 123
3.1. Predicting quality of life by employing WHOQOL-BREF ............................................ 123
Chapter 5: QUALITATIVE STUDY ................................................................... 127
I. Introduction .......................................................................................................................127
II. Literature review ..............................................................................................................129
III. Methodology ...................................................................................................................136
1. Study design ......................................................................................................................... 136
2. Participant and data collection strategies ............................................................................. 138
3. Data analysis ........................................................................................................................ 139
5. Ethical considerations .......................................................................................................... 140
IV. Results & discussion .......................................................................................................140
1. General information of study participants ............................................................................ 140
2. Themes of interview ............................................................................................................ 143
2.1. Obligation, sacrifice and love ....................................................................................... 143
2.2. Providing an example to children ................................................................................. 152
2.3. Mixed emotion (Ambivalence) ...................................................................................... 156
2.4. Need for family support while provide care .................................................................. 158
2.5. Fear of losing social reputation .................................................................................... 159
Chapter 6: DISCUSSION ...................................................................................... 164
6.1. Characteristics of participants ........................................................................................164
6.2. Behavioural profile of people with dementia .................................................................167
6.3. Perceived burden ............................................................................................................168
6.4. Quality of life .................................................................................................................170
6.5. Quality of life in the context of the research framework ...............................................172

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6.6. Filial piety ......................................................................................................................177
Chapter 7: GENERAL DISCUSSION AND CONCLUSION ........................... 185
7.1. Implications....................................................................................................................185
7.2. Limitations .....................................................................................................................189
7.3. Conclusion .....................................................................................................................194
Bibliography ........................................................................................................... 196
Appendices ……………………………………………………………………….214
Ethical clearance approvals from Vietnam and Australia .....................................................214
Questionnaire of the 1st survey (English and Vietnamese) ...................................................215
Questionnaire of the 2nd survey (English and Vietnamese) ..................................................216
Other relevance material .......................................................................................................217

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 List of Publications and Conference Presentations

Truong, Q. T., & Beattie, E. (2012). Perceived burden and Quality of life of

dementia caregivers in Hanoi, Vietnam. Paper presented at the 12th International

Psychogeriatric Association Meeting 2012, Cairn, Australia.

Truong, Q. T., Beattie, E., & Sullivan, K. A. (2014). Perceived burden and

quality of life of dementia caregivers in Hanoi, Vietnam in 2011. The New

Vietnamese English journal of Medicine, 4(1.2014).

Truong, Q. T., & Beattie, E. (2012). The Burden Of Care Among Dementia

Caregivers In Hanoi, Vietnam. Paper presented at the 65th GSA – Gerontology

Society of America Annual Scientific Meeting, San Diego, California, US.

Truong, Q. T., Beattie, E., & Sullivan, K. A. (2014). Perceived experiences

and caregiving burden among dementia caregivers in three provinces of Vietnam in

2012. In progress.

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 List of Tables

Table 3. 1. Demographic characteristics of people with dementia and their

caregivers ............................................................................................ 67
Table 3. 2. Employment profile of dementia caregiver ........................................... 68
Table 3. 3. Family financial income and caregiving hours ...................................... 69
Table 3. 4. Kinship between caregivers and people with dementia ......................... 69
Table 3. 5. Correlation between Barthel Index and KSBA and characteristics
of people with dementia ...................................................................... 71
Table 3. 6. Correlation between Zarit Burden interview and characteristics
of caregivers and people with dementia .............................................. 73
Table 3. 7. Sense of Coherence sub-domains and Total score ................................. 73
Table 3. 8. Correlation between caregivers’ Sense of coherence and
characteristics of caregivers and people with dementia ...................... 74
Table 3. 9. WHOQOL-BREF domain scores........................................................... 75
Table 3. 10: Correlation between WHOQOL-BREF domains and
characteristics of caregivers and people with dementia ...................... 75
Table 3. 11: Differential tests on WHOQOL-BREF domains ................................. 76
Table 3. 12. Means, SD and correlations for ZBI total score and predictor
variables (N=133) ................................................................................ 77
Table 3. 13. Simultaneous multiple regression analysis summary for ZBI
total score in KBSA, Duration with dementia, education level,
caregiver’s age ..................................................................................... 77
Table 3. 14. Means, SD and correlations for WHOQOL- BREF (Physical
domain) and predictor variables (N=132) ........................................... 78
Table 3. 15: Simultaneous multiple regression analysis summary for
WHOQOL-BREF (Physical domain) in caregiver gender,
caregiver’s real age, Zarit Burden Interview ....................................... 78
Table 3. 16: Means, SD and correlations for WHOQOL- BREF
(Psychological domain) and predictor variables (N=133) .................. 79
Table 3.17. Simultaneous multiple regression analysis summary for
WHOQOL-BREF (Psychological domain) in caregiver’s real
age, caregiver’s employment status, Duration with dementia,
Zarit Burden Interview and Sense of coherence ................................. 80
Table 3.18. Means, SD and correlations for WHOQOL- BREF (Social
relationships) and predictor variables (N=127) ................................... 81

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Table 3. 19: Simultaneous Multiple regression analysis summary for
WHOQOL-BREF (Social relationships) in caregiver’s
employment status, Zarit Burden Interview and Sense of
Coherence ............................................................................................ 81
Table 3. 20. Means, SD and correlations for WHOQOL- BREF
(environment domain) and predictor variables (N=133)..................... 82
Table 3. 21. Simultaneous Multiple regression analysis summary for
WHOQOL-BREF (social activity domain) in caregiver’s
employment status, Duration with dementia, Zarit Burden
Interview .............................................................................................. 82
Table 4. 1. PWD characteristics ............................................................................. 105
Table 4. 2. Caregivers’ characteristics ................................................................... 107
Table 4. 3. Kinship between caregiver and people with dementia......................... 108
Table 4. 4. Female caregiver and kinship with people with dementia ................... 109
Table 4. 5. Caregiving hours per week .................................................................. 110
Table 4. 6. Barthel Index score .............................................................................. 110
Table 4. 7. Difference test between Barthel Index score and PWD
characteristics .................................................................................... 111
Table 4. 8. Correlation between Barthel Index total score and PWD
characteristics .................................................................................... 111
Table 4. 9. Kingston Standardized Behavioural Assessment total score ............... 112
Table 4. 10. Level of behaviours based on KSBA ................................................. 112
Table 4. 11. Different test on KSBA total score and PWD characteristics ............ 113
Table 4. 12. Correlation between KSBA total and characteristics of
Caregiver and PWD .......................................................................... 114
Table 4. 13. Zarit Burden Interview total score ..................................................... 114
Table 4. 14. Perceived burden level ....................................................................... 115
Table 4. 15. Correlation between Zarit Burden Interview and characteristics
of Caregiver and people with dementia............................................. 116
Table 4. 16. Sense of Coherence total score .......................................................... 118
Table 4. 17. WHOQOL-BREF domain scores....................................................... 121
Table 4. 18. Pearson correlation between WHOQOL-BREF domains by
province ............................................................................................. 121
Table 4. 19. Different test WHOQOL-BREF domains and caregiver’s
characteristics .................................................................................... 122

ix
Table 4. 20. Correlation between WHOQOL-BREF domains and
characteristics of caregiver and people with dementia...................... 122
Table 4. 21. Caregiver Quality of life domains regressed on PWD and
Caregiver’s characteristics with contribution of place of
residence ............................................................................................ 124
Table 4. 22. Caregiver Quality of life domains regressed on PWD and
Caregivers’ characteristics ................................................................ 126
Table 5. 1. Main Characteristics daughter or daughter-in-law dementia
caregivers .......................................................................................... 141

List of Figures

Figure 1: Ferrans’s Quality of life model ................................................................ 44

Figure 2. Conceptual quality of life model of Ferrans ............................................. 45
Figure 3. Research framework ................................................................................. 52
Figure 4. Data collection procedure ........................................................................ 62
Figure 5. Recruitment process of the 1st survey ....................................................... 63
Figure 6: Modified research framework for the 2nd survey showing additive
of Filial Piety and Positive Aspects of Caregiving ............................. 96
Figure 7: Map of three chosen provinces ................................................................. 99
Figure 8. Recruitment process for the 2nd survey ................................................. 102
Figure 9. Proposed future model of research framework ....................................... 189

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 List of Abbreviations

AD Alzheimer’s disease

ADL Activities of daily living

FB Filial Piety

HRQoL Health related quality of life

IADL Instrumental activities of daily living

KSBA Kingston Standardised Behavioural Assessment

PAC Positive aspects of caregiving

PWD People with dementia

QoL Quality of life

SOC Sense of Coherence

WHOQOL-BREF World Health Organisation Quality of Life – Short version

ZBI Zarit Burden Interview

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 Statement of Original Authorship

The work contained in this thesis has not been previously submitted to meet

requirements for an award at this or any other higher education institution. To the

best of my knowledge and belief, this thesis contains no material that has been

previously published or written by another person, except where due reference is

made.

QUT Verified Signature

Signature:

29/1/2015
Date: _________________________

xii
 Acknowledgements

I wish to thank the people who have encouraged and supported me throughout

my thesis-writing process. First, I would like to express my sincere thanks and

appreciation to Professor Elizabeth Beattie, my primary supervisor and Chair of the

committee. She has continuously supported and encouraged me throughout my

studies. I thank Professor Karen Sullivan, my associate supervisor, for her valuable

guidance; her tremendous support provided not only the material, but also spiritual

encouragement. I truly appreciate having such distinguished professors. Their

support is beyond words: they were my mentors during the time I was studying for

Master of Applied Science (HL84) and Doctor of Philosophy (IF49) in the School of

Nursing, Queensland University of Technology, Australia. They were there for me

when I faced sensitive and difficult situations, and for that I am very thankful. In

Vietnamese culture, teachers are respected and regarded like our own parents,

because they teach us how to begin to understand and discover the real world; just as

our parents have done. I thank them very much and I am deeply grateful for their

supports.

My heartfelt thanks go to all caregivers of people with dementia who shared

their experiences in three provinces within Vietnam (Hanoi, Bac Ninh and Hai

Phong). Despite the complexities encountered in the lives of the informal caregivers,

whose relatives suffer from dementia, they nonetheless took the time to complete the

interviews and questionnaires. Without these people’s participation, this thesis

would not be possible. Thanks to all of you.

I would like to thank my friends, who provided support in many ways. In

particular, I would like to thank Tran Khanh Long, Nguyen Thuy Ly, Le Tong Giang

xiii
Nguyen Thi Thanh Huong, Hoang Lan Van, Huyen Nguyen, among others, for their

efforts, enthusiasm, and encouragement and for sharing other tasks. I would like to

express my appreciation to Dao Thi Tiet Hanh, who studied in the same office

station, for taking the time to discuss with me, not only in academia, but also

recreational topics.

With my best regards,

Truong Quang Trung

Dedication

I dedicate this PhD thesis to my family: to my father, Truong Quang Tam, who

now rests in peace; my mother, Nguyen Thi Mong Hiep; to my two sisters, Thuy and

Cham, and their families; to my parents-in-law; to my two young sisters-in-law,

Chau and Thao, and their families, for their love and support. Last but not least, I

dedicate this thesis to my wife, Duong Thi Thu Huyen and to my two children, Giang

(Na) and Minh (Mit), who always stand beside me with their emotional, intellectual

and instrumental supports throughout my life. Thanks for your interest in this project

and your excellent questions; thank for your willingness to discuss and give precious

advice whenever needed. I appreciate the time we spent playing and enjoying

invaluable time with all of you. I would like to express my appreciation towards all

kind people who have surrounded me with your constant help, encouragement,

patience and love.

xiv
 Glossary of term used in the thesis

Term/concept Theoretical Definition Operational definition

(Defining a concept in terms of (Ways the concept is being

other concepts (Waltz, measured or utilised (Waltz et
Strickland, Lenz, Stat!Ref, & al., 2010, p. 32)
Teton Data, 2010, p. 31)

Caregiver The person who provides A person, aged 15 years or

assistance to another person more, who provides any

who increasingly requires informal assistance and informal

constant care. The informal care to family members or

caregiver is defined as the relatives who suffer from

person who provides care to dementia. This definition

assist with personal activities applies in Australia (Australian

of daily living and/or personal Bureau of Statistics, 2008) and

instrumental activities of daily America (Fredman et al., 2012).

living, without payment, and The term “caregivers” as used in

whose relationship to the care this report, refers to unpaid care

recipient is due to personal persons.

attachment (Loboprabhu,

Molinari, & Lomax, 2006, p.

25)

Quality of Life “ A person’s sense of well- An individuals' perceptions of

being that stems from their position in life in the

xv
 satisfaction or dissatisfaction context of the culture and value

with the areas of life that are systems in which they live and

important to him/her” (Ferrans, in relation to their goals,

1996) expectations, standards and

concerns (World Health

Organization, 1996).

WHOQOL-BREF 26 items was

employed to measure the quality

of life across four key domains,

namely Physical, Psychological,

Social Relationships and

Environment.

xvi
 Chapter 1: INTRODUCTION

1. Background

Chronic diseases associated with aging involve pathogenic changes in physiological

systems and physical structures that manifest during senescence. Dementia is becoming a

major worldwide public health issue. Dementia is significant, because it results in memory

decline and disruption to other cognitive functions, personality changes, behavioural

problems and the loss of independent capacity to care for oneself (National Institute of

Health, 2011). In 2005, approximately 24.3 million people were diagnosed with dementia,

with 4.6 million new cases of dementia being diagnosed every year (one new case every

seven seconds). This trend means that the number of sufferers is likely to double to 81.1

million by 2040. People with dementia who are living in developing countries would

constitute a major percentage (60% in 2001, rising to 71% by 2040). Rates of increase are not

uniform and numbers in developed countries are forecast to increase by 100% between 2001

and 2040, but by more than 300% in India, China, and their south Asian and Western Pacific

neighbours (Ferri et al., 2005). In a recent report, there were approximately 35.6 million

people with dementia worldwide. 2.48 million people with dementia in 2010 within South

East Asia (including Vietnam) would increase by 114% to 5.30 million in 2030 (Prince et al.,

2013). With the high prevalence and incidence of dementia, the disease obviously impacts

individuals, families and health-care systems.

The number of elderly people in Vietnam is increasing. In 2009, people aged over 60

comprised nearly 9% of the population (7.66 million in a population of 85.80 million) and

this proportion is predicted to increase to 11.64% of 96,18 million by 2020 (Vietnam General

Statistic Office, 2010, p. 64). By 2049, the percentage of people aged 64 and older would

increase from 6.4% (2009) to either 16.3% or 19.9%, depending on the model of fertility

1
variant in Vietnam (Vietnam General Statistic Office, 2011, p. 26). With this rapid growth in

the number of elderly people, prevention and treatment for chronic age-related diseases,

including dementia, would be important (Rattan & Kassem, 2006, p. 2).

In 2013, there were nearly 9 million elderly people in Vietnam. Nearly 70% of them

suffer from at least 2 types of diseases—on average, 2.7 diseases per person (Ha, 2013).

Dementia was identified as a major cause of burden among all mental disorders within

Vietnam in 2008 in males and females over the age of 60. Moreover, it was also ranked as the

second most burdensome of disability inducing diseases for females and the ninth most

burdensome of disability inducing diseases for males in people over the age of 70, and it has

been identified as among one of the ten leading causes of disease burden due to disability (T.

T. N. Nguyen et al., 2011, pp. 51 - 62). Other evidence showed that dementia was screened in

7.9% of elderly people in Thai Nguyen Province, Vietnam, which revealed that the rate of

dementia is increasing (Viet & et al., 2009). Common problems identified among those

diagnosed with dementia included loss of calculating ability (91.5%), memory loss (87.9%),

reduction of abstract thought (inability to comply with command for three consecutive

actions) (86.2%), language impairment (inability to read and comply with command

sentences) (67.2%), and spatial disorientation (50%). Another recent study that recruited

5,892 older persons in the Bavi District, a suburb of Hanoi in Vietnam, indicated a dementia

prevalence of currently 4.5% (4.3% in males and 4.7% in females). Similar to findings in

other Asia and Western countries, prevalence of dementia in this research increased with age

by: 0.8% (1.2% in males and 0.5% in females) in those aged between 60 – 64 years old; 3.7%

(3.5% in males and 3.8% in females) in those aged from 70 – 74 years old; and 17.6% (22.2%

in males and 16% in females) in those aged over than 85 years old (Thang, Thanh, & et al.,

2010). While these two studies show different proportions of people diagnosed with dementia

2
in communities within Vietnam, data is limited for other regions of the country because no

study has been conducted on dementia either nationally or regionally.

The number of carers in the general population of Vietnam has not been officially

reported. In 2004 and 2005, Nguyen and Nguyen (2010) analysed the secondary data of 979

elderly participants from five provinces in Vietnam (Quang Nam, Hochiminh City, Thanh

Hoa, Son La and Kon Tum). Among 938 responders who chose home-based care when

suffering from illness, 74.2% (696) of participants received care from their children, 22%

(206) provided self-care, and 2.1% (20) received care from friends or others. Only 0.5% (5)

of the participants hired a housemaid to take care for them. These numbers may increase or

differ from the current situation, because of economic development, industrialization and

urbanization within Vietnam.

Vietnam is an S shape, lying in the Indochina peninsular, and borders with China, Laos,

Cambodia, and the Gulf of Tonkin in the east. With a surface area of more than 330.000 Km2

and the distance from the northernmost point to the southernmost point of 1650 km, Vietnam

is a country with a diversified eco-system. There are 57 provinces and 5 centrally controlled

cities. The population was approximately 90 million in 2009, with 54 ethnic minority groups

(The Vietnam Education Foundation, 2009).

The model of caring for elderly people within the

community differed across different geographical regions

within Vietnam (Cuong, Oanh, Luong, & Tuan, 2006). In

the Southern and Central regions of Vietnam, the elderly

lived with their families and children in the same household,

while in the Northern regions, the elderly lived with their

spouses, separately from their children. In multi-generation

or extended families, the children paid more attention to

3
their elderly parents, and had more knowledge about caring for their elderly parents. However,

because of urbanization in the countryside, mature children spent less time looking after their

older parents. The elderly were only offered care from their children when they got sick

(Cuong et al., 2006). The bulk of the care required by Vietnamese elderly people and people

with dementia are expected to be borne by family members.

The effect of a dementia diagnosis not only impacts the person with the disease, but

also leads to several issues for their family caregivers, their family members, communities

and society (Arango-Lasprilla et al., 2010). The gravity of this impact is because the majority

of support (physically and mentally) for dementia patients in their home came from their

family members. Family members of people with dementia usually experience more stressors

directly and indirectly, and their health status and quality of life are lower than the general

population, with higher risks of depression. Caregivers of people with dementia carry the

entire caregiving burden, and as a consequence, they suffer with physical health

consequences and financial hardship (Collins & Swartz, 2011; Yamashita & Amagai, 2008) .

Dementia caregivers also experienced a significant lower quality of life (QoL), as evidenced

by significant decreases in the social functioning dimension (Andrieu et al., 2007). The other

main findings revealed that caregiver depression increased in line with the increased

disability of the care recipient, and the impact of disease severity on the caregiver depended

on the level of disability. The severity of cognitive impairment appeared to have less impact

on the caregiver’s experience than the severity of functional disability. Another concern in

providing services for both dementia caregivers and sufferers is how large the burden of care

for caregivers is when sufferers are living at home. It is clear that the lower functional

capability among people with Alzheimer’s disease (AD), a type of dementia, was

significantly associated with higher levels of caregiving burden (measured with 22 items on

the burden interview) as well as depression among informal caregivers (Mohamed,

4
Rosenheck, Lyketsos, & Schneider, 2010). In addition, as new care needs continue to emerge

with the progression of the illness, the caregiver’s burden level remains pressured. Therefore,

developing care requirements that result from care recipients' mental and functional status

should be considered thoroughly in order to ease caregiver burden. Caregiver burden has

been employed as a term to show the impact of numerous factors leaded to strain, stress and

distress on carers looking after people with dementia (Yap, Seow, Henderson, & Goh, 2005).

Caregiving burden was considered as the consequence of the increasing the prevalence of

dementia that impacted on those provide care for dementia suffered people. In an early

multination review of caregiver burden conducted in 2004 revealed that stage of dementia

and gender of caregiver contributed to predicted caregiving burden across culture, particular

in Asian societies (Torti, Gwyther, Reed, Friedman, & Schulman, 2004).

Families may have to assume full duty for caring or giving support to persons with

dementia, depending on the availability of services, resources and support for people with

dementia and their family caregivers. In Asian countries and societies, family is usually

considered as the primary source of support for dementia sufferers. Mature children are

expected to take responsibility for caring for their older parents (Chan, 2010). Asian countries

like China, Vietnam and Japan are strongly influenced by Confucianism and Buddhism.

According to the theory of Confucianism, caring for parents when they become older is the

major duty of the children, especially the son. Caregiving is regarded as a sign of duty and

loyalty. Confucian philosophy has strongly dominated the Vietnamese culture for thousands

of years (Yao, 2000). Confucianism defines a system of moral, philosophical and social

norms, virtue and value judgement. The three primary rules that a man must uphold in

relationships are: Ruled to Ruler, Son to Father, and Husband to Wife, and women must

comply with the following rules: Follow Father, Follow Husband, and Follow Son. A study

by Mok, Lai, Wong and Wan (2007) highlighted that Chinese people, with their traditional

5
culture, customs and religion, believed that the duty to care for family members with disease

is a social norm, and further, they believe that love and support from relatives and family

members are extremely important for people with dementia (Mok, Lai, Wong, & Wan, 2007).

Quality of life (QoL) is an important goal of treatment in chronic illness. It affects

family members, community and society. It also informs professionals, patients and the

public about the challenges associated with chronic diseases, including dementia (McGee,

2001). Understanding and reporting the current trends for informal caregivers (including

dementia caregivers) is critical in order to provide evidence for policy makers in Vietnam

(Prime Minister of Vietnam, 2007). In addition, the five-year health sector development plan

2011 – 2015, proposed by Vietnam Ministry of Health (2010), highlighted the need to

enhance the quality of care via meeting the growing and diverse needs for health care within

the population, thereby contributing to improvements in quality of life.

In summary, there is a clear need to provide accurate, relevant and scientific

information to report the current status of the health of both the general population and

informal caregivers within the community in order to improve the quality of care, and

thereby, improve quality of life within the population. Nevertheless, the existing data and

evidence that is available about these issues remains vague. With the contribution of

economic development and changes in the model of care for elderly people (including people

with dementia) within Vietnam’s community, there is a critical need to understand and grasp

evidence on the current status among caregivers. Moreover, QoL and caregiving burden

among dementia caregivers are important issues in the Vietnamese context, but have been

under-investigated. The vast majority of studies published in the literature consider the

domain of health using descriptive methodology. Caring for people with dementia whilst

living at home is the challenge, and it’s usually overwhelming because of the disparity

between the demand for and the supply of care. Carers of people with dementia warrant

6
attention, because dementia caregivers experience problems themselves, such as depression

and poorer health. These problems impact on their QoL as well as their capacity to continue

caring. Factors affecting QoL have been studied in Western countries, including caregivers’

gender (Valimaki, Vehvilainen-Julkunen, Pietila, & Pirttila, 2009), the health status of

caregivers (Gusi, Prieto, Madruga, Garcia, & Gonzalez-Guerrero, 2009; Vellone, Piras,

Talucci, & Cohen, 2008), health status of care-receivers (Andrieu et al., 2007; Vellone, Piras,

Talucci, & Cohen, 2008; ), depression (Kuroda et al., 2007; Mohamed, Rosenheck, Lyketsos,

& Schneider, 2010; Valimaki, Vehvilainen-Julkunen, Pietila, & Pirttila, 2009;), dependency

level of care-receivers (Serrano-Aguilar, Lopez-Bastida, & Yanes-Lopez, 2006), and

caregivers’ burden (Papastavrou, Kalokerinou, Papacostas, Tsangari, & Sourtzi, 2007; Takai

et al., 2009). Little is known about these situations either within the Vietnamese context, or in

regards to the family member carers’ responsibilities and experiences when caring for people

with dementia. Such knowledge may improve the quality of life for both the person with

dementia and their family, and also, inform the Vietnamese aged care policy.

2. Research aims and questions

The specific aims of this research in the context of Vietnamese primary caregivers of

persons with dementia are:

1. Describe the characteristics of the persons with dementia;

2. Describe characteristics of the caregiver;

3. Describe the level of perceived caregiving burden;

4. Describe the perceived QoL of caregivers;

5. Explore the associations between characteristics of people with dementia and their
caregivers, perceived burden of care and quality of life.

7
3. Significance

The significance of this study is that it is the first study to examine quality of life and

burden in Vietnamese carers of persons with dementia. The key issues of QoL and the caring

burden of caregivers are crucially important in both the short-term and long-term

management of families of people with dementia. Their QoL and burden of care remain

unaddressed within the Vietnam health care system. This study seeks to explore and highlight

the current status of QoL and the burden of care among caregivers of people with dementia

who are living in community settings, as well as explore some of the factors that affect their

issues.

Findings from this study will be instrumental in educating nurses and other health care

providers about the impact on families of caring for people with dementia, and further, have

the potential to increase their understanding of the needs of their clients with dementia and

the needs of their families. The findings of this research might be used as a baseline for

developing future interventions to support carers of people with dementia towards improving

resilience and satisfaction in caregiving, reduce the burden and promote wellness and positive

carer experiences. Moreover, results from this research will be a valuable reference in general

for health-workers, policy-makers and health-care planners in Vietnam in designing,

implementing and evaluating the effectiveness of supportive policies and programs for those

caregivers who look after demented and age-related disease sufferers.

4. Methodology

The methodology utilised in this study was designed to directly answer the research

questions. The present study was conducted via multi-method research, involving a cross-

sectional survey and semi-structured interview. Participants were 153 dementia caregivers in

the 1st survey and 347 dementia family caregivers in the 2nd survey. The respondents were

8
recruited from a list of people with dementia (with contact number and address) from the

Vietnam National Institute of Gerontology via a randomised sampling method.

Finding from the 2nd survey showed that several gaps in existed knowledge related to

the situation of Vietnamese dementia caregiver. In the qualitative phase, 24 caregivers who

were daughters or daughters-in-law of people with dementia participated in a semi-structured

interview. The qualitative research approach enabled the researcher to explore: the motivation

for caring; the mutual commitment to care for their parents who’re suffering from dementia;

the living experience from the perspective of the participants; and challenges experienced

among daughter caregivers of people with dementia when providing caregiving. The similar

structure of recruiting participants in the 1st and 2nd surveys was used, targeted to the daughter

or daughter-in-law of the person living with dementia.

5. Structure of thesis

The first chapter of this thesis introduces the rational for the current study, the research

objectives and the significance of the study. Chapter 2 presents a critical review of existing

literature on quality of life and burden of care among dementia caregivers, and evidence

concerning prevalence. This section also explains the methodology of the study and the

possible correlation between target factors and other perceived variables and demographic

and social characteristics. Chapter 2 concludes by presenting the conceptual framework of the

current study. Chapter 3 contains the details about the first study (phase 1). It presents the

methodology, results and a brief discussion of the 1st survey (phase 1) that was conducted in

Hanoi from October 2011 to January 2012. Chapter 4 presents the results of the 2nd study

(phase 2), with a similar approach to the 1st study, and was undertaken in three provinces

(Hanoi, Bac Ninh and Hai Phong). Chapter 5 presents the qualitative study, comprised of an

introduction, methodology as well as findings from the interviews. Chapter 6 presents the

discussion, based on the findings and current literature review with theoretical framework, an

9
overall discussion and conclusion for the thesis. The final chapter – chapter 7 shows the

limitations of the study as well as the implications of the study findings.

10
 Chapter 2: LITERATURE REVIEW

1. Quality of life among dementia caregivers

The literature search for this review was conducted on the databases of

PubMed 2006 – 2011, CINAHL 2006 – 2011 and Google scholar 2006 – 2011 and

the keywords “Quality of life”, “caregiver” and/or “dementia caregiver”, with the

limitation of publications in only English and Vietnamese. A total number of 355

articles were found. From these 355 articles, only 12 original studies met the criteria

of recruitment of informal caregivers for people with dementia and a focus on QoL

as the outcome, including the measurement of QoL. The same approach was also

performed in Vietnamese journals, which included The Journal of Practical Medicine

(Tạp chí Y học thực hành) 2006 – 2011, the Journal of Medical Research (Tạp chí

Nghiên cứu Y học) 2006 – 2011, and the Journal of Medicine Hochiminh City (Tạp

chí Y học Thành phố Hồ Chí Minh) 2006 – 2011. The same keywords were used in

Vietnamese, consisting of “Chất lượng cuộc sống”, “người chăm sóc”, and “người

chăm sóc người bệnh sa sút trí tuệ”. There was only one article on QoL among

elderly people that resulted from this search. It was considered that QoL among

dementia caregivers is a relatively recent area of study, particularly in Vietnam.

QoL has been defined differently, depending on the context and its application

by researchers. QoL is a critically important belief and issue for health care. Its

definition and classification are used narrowly and broadly, and different meanings

might lead to differences in results for research, clinical practice, and the allocation

of health care resources. Understanding the meaning of QoL is of great importance

and necessity for researchers to be able to determine universally acceptable

definitions and to reliably compare findings across studies. The term “Quality of

11
Life” can be given a number of meanings, depending on the scope of evaluating

factors concerning a personal life. In defining quality of life, many different factors

may be considered, such as the ability to think, make decisions and have control in

one's daily life, the physical and mental health of dementia sufferers, living

arrangements, social relationships between dementia patients and their families,

friends and others, and financial and economic situations (World Health

Organization, 1997).

In addition, the term QoL is used to evaluate the general well-being of

individuals and societies. It is used in a wide range of contexts, including the fields

of international development, healthcare, and political science. A study conducted in

Vietnam defined QoL as satisfying both physical and psychological human needs in

general activities in order to fulfil people’s demands, increasing with every passing

day (Nhat, 2008). QoL should not be confused with the concept of standard of living,

which is based primarily on income. Instead, standard indicators of the QoL include

not only wealth and employment, but also built environment, physical and mental

health, education, recreation and leisure time, and social belonging (Gregory, 2009).

QoL can be given a number of meanings, depending on the scope of evaluating

factors concerning personal life. In defining quality of life, many different factors

may be considered, such as: the ability to think, make decisions and have control in

one's daily life; the health of dementia sufferers both physically and mentally; living

arrangements; social relationships between dementia patients and their family,

friends and others; and financial and economic situations. Therefore, QoL among

dementia caregivers should include not only the physical domain and be judged as

the absence of disease like most of the research, but also other dimensions, such as

environment, spirituality/personal beliefs, level of independence, and social

12
relationships as well as how caregivers cope with and adjust their lifestyle to their

family members with dementia.

To understand the meaning of QoL among dementia caregivers, quantitative

and qualitative research methods have been used. As a response to the variety of

meanings of QoL found in the dementia literature, a study involving a group of 32

people who accompanied their relatives or friends with Alzheimer’s Disease (AD)

for routine visits in a medical centre in Rome, Italy employed an hermeneutic

phenomenological design to describe their meaning of QoL and identify factors

affecting their QoL (Vellone, Piras, Talucci, & Cohen, 2008). Through the use of a

Critical Reflection Technique, caregivers indicated that their QoL involved serenity,

tranquillity and psychological well-being, freedom, and general well-being, good

health and good financial status. They also named good health of the patient,

independence from the patient, and more help in caregiving as major factors for good

QoL. In contrast, the factors that negatively impacted on QoL included worries about

the future and progression of the patient’s illness and stress.

Health-related quality of life (HRQoL) was used to measure quality of life

among dementia caregivers. Gusi, Prieto, Madruga, Garcia, and Gonzalez-Guerrero

(2009) assessed the HRQoL by the mean of short form (36) health survey (SF 36)

within two groups of women (caregivers of people with dementia vs. non-caregivers)

in a community in the centre of Spain. Although the mental domain of HRQoL

within the caregivers group was significantly lower than that of the non-caregivers,

the physical domain of HRQoL was similar between two groups of women. Arango-

Lasprilla, et al., (2010) also employed the SF – 36 to assess the HRQoL of dementia

caregivers and healthy persons from the common Colombian population. Although

the healthy control group had a higher education level, socioeconomic status (SES),

13
and number of male participants, dementia caregivers showed significantly lower

scores on quality of life (SF-36) than the controls, after adjusting education, SES,

and gender. It was recommended that improving the HRQoL of caregivers of people

with dementia in Colombia could be achieved by applying a suitable professional

rehabilitation model.

A later study examined whether caregiver depression is associated with a

sense of coherence (SOC) and health related quality of life (15D questionnaire and a

visual analogue scale) in a cohort of AD caregivers living at home in the three

communities in Finland (Valimaki, Vehvilainen-Julkunen, Pietila, & Pirttila, 2009).

Male caregivers' SOC was appreciably higher than that of female caregivers.

Caregivers' HRQoL was high and HRQoL among men were higher compared with

women only in the dimensions of sleeping and feeling of distress. Quality of life

(HRQoL) and Sense of Coherence was notably correlated with depression and

distress. Moreover, low distress and less severe depressive symptoms of caregivers

were the main predictors for high HRQoL. The main predictor for low SOC was

depression, and women also reported more depressive symptoms and distress. These

results mean that the QoL of dementia caregivers can be explained through the stress

status and gender of the caregiver. Female caregivers suffered more stress compared

with male caregivers. In addition, the SOC was used to refer to the ability of

caregivers to deal with different conditions. Strong SOC indicates that those with

higher SOC will take more advantage of available resources.

Similar findings were found in a study conducted in Spain. The HRQoL of

Alzheimer’s Disease caregivers utilising European Quality of Life-5 Dimensions

(EQ-5D) was inversely correlated with patients’ dependency level (assessed by the

mean of Barthel Index) and caregivers’ age. HRQoL was higher in educated

14
caregivers as well as for son and daughter caregivers. It also showed that low levels

of HRQoL correlated significantly with high levels of caregiver burden (measured by

the mean of Zarit Burden interview). Furthermore, for the result of quality of life of

public health, the caregivers had a higher incidence of problems in each EQ-5D

domain (mobility, personal care, daily activities, pain/discomfort, and

anxiety/depression) compared with the general population. In contrast, the

caregivers’ quality of life was at a lower level than the general population for the

same age and gender.

HRQoL (measured by the mean of SF-12) was employed as the goal

measurement of an experimental study with intervention, focusing mainly on care

managers' support given to caregivers (Kuroda et al., 2007). The findings showed

that HRQoL (physical and mental domains) at baseline were significantly higher than

those at one year later. This result means that the HRQoL one year later was lower

than that at the starting point. In addition, the sense of coherence (SOC)

questionnaire was also measured. Logistic regression analysis on the change in

physical and mental domain of HRQoL displayed that the HRQOL- physical domain

score significantly correlated with the impaired elderly people geriatric depression

scale (GDS-15) and caregivers’ level of satisfaction with their care manager.

Meanwhile, the HRQoL- mental domain score was significantly associated with SOC

and caregiver’s level of satisfaction with their care manager. Therefore, caregivers’

HRQoL was significantly correlated with the level of satisfaction with the care

manager.

QoL (assessed by the mean of WHOQOL-BREF) was measured in a study

conducted with dementia caregivers living in a community in Japan to explore the

relationship of QoL with burnout (Pine Burnout Measure) and depressive symptoms

15
(Beck Depression Inventory II) (Takai et al., 2009). Total score of QoL and

subdomain scores (Physical, Psychological, Social relationship and Environmental of

WHOQOL-BREF) indicated a significantly inverted correlation with burnout and

depression. Lower QoL of dementia caregivers was linked to higher levels of

depressive symptoms and burnout. However, only the QoL score in each item was

showed without the overall score of WHOQOL-BREF, so it is quite difficult to

compare with other studies. Pattanayak, Jena, Vibha, Khandelwal, and Tripathi

(2011) also employed WHOOL-BREF to study the relationship between QoL and

coping strategies (measured by Coping Checklist) and severity of dementia (assessed

by clinical dementia rating) among dementia caregivers in India. Education was

positively correlated with total coping score. The Social support domain in coping

was found to be positively correlated with domains of QoL. The Problem-solving

domain was significantly positively correlated with psychological QoL, while

denial/blame domain had a significant inverted correlation with both Physical and

Psychological QoL. Both coping strategies and QoL had been shown to depend on

caregiver characteristics, rather than the severity of the patient’s dementia.

WHOQOL-BREF was also considered as the outcome measurement of

dementia caregivers in a single blind parallel group randomized controlled trial in

2003 in Moscow, Russia. In addition, the Zarit burden interview was also employed

to measure the caregiving burden of dementia caregivers. The intervention aim is to

provide basic education about dementia and specific training on managing behaviour

problems. After 6 months of intervention, it showed that caregivers in the

intervention group reported large and statistically significant net improvements in

burden at a 6-month follow-up, compared to controls. No group differences were

found on caregiver quality of life (assessed by the mean of WHOQOL-BREF)

16
(Gavrilova et al., 2009). Wang, Chien, and Ym Lee (2012) later conducted an

experimental study to test the effectiveness of a 12-weekly sessions mutual support

group program on Quality of life in Hong Kong (measured by WHOQOL-BREF) for

Chinese family caregivers of people with dementia. Comparison of measurement at

baseline and 24-week follow-up revealed that the mutual support group participants

had significantly greater improvements in distress levels (measured by the mean of

Neuropsychiatric Inventory-Caregiver Distress Scale) and quality of life (in the

domain of Psychology, Social relationship and total score) than the control group.

Those improvements in psychological distress and quality of life would provide

opportunities to carers for better caring services and more effective care for people

with dementia.

As a result of variability in the definition of QoL as life satisfaction, Kaufman,

Kosberg, Leeper and Tang (2010) used the Quality of Life Inventory (QoLI) to

evaluate subjective well-being of dementia caregivers in Alabama, America.

Statistically significant positive correlations were found between the participants’ life

satisfaction scores (quality of life inventory) and four dimensions of social support,

namely, tangible (the availability of concrete help and material assistance from social

network members), appraisal (the availability of persons to obtain advice from and

with whom to discuss problems), belonging (the availability of persons to talk to or

socialize), and self-esteem (receipt of positive regard and self-esteem from others).

There were no significant correlations between caregiver burden scores (measured by

the Consequences of Care Index) and any of the four dimensions of social support.

Stepwise multiple regression analysis revealed that only self-esteem and the

belonging dimension of social support contributed to explain quality of life. In this

17
study, the authors did not test the association between quality of life and caregiving

burden.

As mentioned previously, the QoL of family caregivers of elders with dementia

has not been given enough attention by researchers. Matsui (2006) defined quality of

life as “the degree to which person enjoys the important possibilities of his or her

life”. QoL was measured on the 15-item Bakas Caregiving Outcome scale (BCOS),

which was originally developed to measure changes in family caregiving outcomes

within stroke populations. However, this scale can be used in a variety of caregiver

populations, such caregivers of elders, Alzheimer’s disease and other dementias,

cancer and heart failure. This scale addresses the perceived changes in the social

functioning, subjective well-being, and physical health as a result of providing care.

Although many of the findings of this study on caregiver’s QoL (receivers’ living

status, working status, income status of participant) did not reach statistical

significance, some possible predictors of carers’ QoL were identified, namely, care-

receiver's cognitive function, caregiver’s age, and hours of caregiving per week. This

study suggested implications for nursing research, practice and education to

maintain, enhance, and improve the quality of life of family caregivers of elders with

dementia (Matsui, 2006).

Overall, in the above studies, researchers paid attention to QoL among

dementia caregivers; associations between QoL and other factors, such as the level of

dependency of persons with dementia, the depression level of those caregivers, the

ability to cope with stress, socio-economic status, and education, relationships among

caregivers and care-receivers, and available support were examined. As mentioned

previously, in assessing caregivers’ QoL, all of the authors focused solely on the

change in the QoL health domain. Comprehensive assessments of QoL should

18
include both objective and subjective dimensions, and direct and indirect approaches

(Brod, Stewart, Sands, & Walton, 1999). Most of the above studies investigated the

QoL among dementia caregivers by using actual health related quality of life

instruments, such as SF-36, SF-12, EuroQoL-5D, QoL-DA. These instruments were

used to evaluate the quality of life on physical and mental health (Gandek et al.,

1998; Ware, Gandek, & Project, 1998) and/or social domain only (Opara, 2012). The

WHOQOL-BREF 26 item scale was employed popularly in measuring Quality of

Life (Opara, 2012). In the analysis and report, WHOQOL-BREF was divided into

four subscales, namely, Physical, Psychological, Social relationship and

Environmental domains. This worldwide quality of life measurement is a multi-

dimensional scale, with developed cross-cultural concepts and is considered with the

meaning to participants of various aspects of life (Skevington, Lotfy, O'Connell, &

Group, 2004). Most studies on QoL have been conducted in Western countries, while

few or no studies relating to QoL of carers in general, or dementia caregivers in

detail, have been conducted in Vietnam. It is important to understand the impact of

dementia on caregivers in Vietnam, given the aging population figures and predicted

dementia figures. The traditional values and cultural issues that affect the health care

services and interventions for support carers need to be considered in any planned

study. Furthermore, there are complications in measuring the QoL and the terms of

caregiving and QoL are relatively new foci of concern in Vietnam. However, if the

understanding of the carer experience, carer QoL, the characteristics of people with

dementia receiving family care and the extent and nature of family carer’s work for

people with dementia are not discovered, the planning and implementation of health

care services and social support in Vietnam will not be informed and responsive.

Therefore, the study on QoL among dementia caregivers is needed in Vietnam.

19
20
 Author Objectives & Instrument Subjects Main results Note
Research method
Andrieu, et al., To study the impact of Generic QOL with the 145 caregivers of persons QOL measured with the SF-36 showed a significant
(2007) dependency on informal Dartmouth Primary Care with dementia decrease for the Social functioning dimension, reflecting
caregivers who assist Cooperative Information a poorer QOL (P = 0.0042). QOL measured with the
demented patients at Functional Health COOP/WONCA scale gave an increased score, also
home, with this new Assessment/World reflecting poorer QOL as the care recipient became more
useful tool (assesses the Organization Project of disabled in two dimensions: social activities (P = 0.0039)
impact of cognitive National Colleges and and physical fitness (P =0.0503).
impairment on functional Academics
status, taking into account (COOP/WONCA) charts. The impact of disease severity on the caregiver depended
disability in both the basic on the level of disability. The severity of cognitive
and the instrumental impairment appeared to have less impact on the
activities of daily living) caregiver’s experience than the severity of functional
Short Form Health disability.
A cross-sectional Survey-36 (SF-36)
analysis at 6-month in a Impact of dependency on the caregiver's experience was
prospective 1-year cohort significant for different constructs (satisfaction with
study. caregiving, subjective burden, quality of life, depression).
Medical and non-medical costs increased with the
severity of functional disability. Findings indicate that
this tool is also useful to assess the impact of progression
of functional disability in patients with dementia on the
caregivers’ issues.

Arango-Lasprilla, To examine the HRQoL SF-36, a measure of self- - Caregivers were defined The caregivers of individuals with dementia had lower
et al., (2010) of a group of Colombian reported HRQoL on 8 as family members who adjusted means on physical function, role physical, role
caregivers of individuals dimensions of health: are actively providing emotional, vitality, mental health, social function, bodily
with dementia. physical function, role- day-to-day care for a pain, and general health.
physical, bodily pain, person with dementia, and
general health, who were familiar with Results indicated that the healthy control group had a

21
 Author Objectives & Instrument Subjects Main results Note
Research method
energy/vitality, social the patient’s medical and higher level of education, socioeconomic status (SES),
function, role-emotional, social status. and number of male participants.
Comparison cross- and mental health range
sectional study from 0 to 100, with higher - Data from 194 After adjusting for education, SES, and gender, the
scores indicating better participants (99 caregivers caregivers of individuals with dementia scored
health. and 95 healthy controls) significantly lower on all of the SF-36 subscales than the
were included in the healthy controls.
analyses.

Bartfay & Bartfay To determine how QOL-Alzheimer’s Disease Primary caregivers: The mean QOL rating for support group caregivers was QoL was used to
(2013) community-based (QOL-AD) Scale developed 2.9 (SD = 0.46), whereas the mean QOL rating for evaluate – QoL
interventions, such as by Logsdon, consists of a (a) Group 1—caregivers caregivers of Alzheimer’s disease adult day program among caregivers in
adult day programs and 13-item questionnaire of Alzheimer’s disease clients was 2.76 (SD = 0.5). each group.
caregiver support groups, designed to provide both a clients who attended
affected the quality of life client report and a caregiver support groups (n = 28); A two-sample t test showed that the difference in QOL - The effectiveness
(QOL) of caregivers of report surrounding QOL. (2.9 vs. 2.76) did not reach statistical significance (t of intervention in
(b) Group 2—caregivers statistic = 0.95 and the corresponding p value = .35). community base 
Alzheimer's disease of Alzheimer’s disease
clients. These items include Pilot study.
“physical health,” “energy,” clients who were adult The mean QOL rating for caregivers of Alzheimer’s
A cross-sectional “mood”, “living situation,” day program clients (n = disease adult day program clients was 2.76 (SD = 0.5),
comparative design “memory,” “family life,” 15); and whereas the mean QOL rating for caregivers of
“marriage,” “friends,” “self Alzheimer’s disease-free adult day program clients was
(c) Group 3—caregivers 2.75 (SD = 0.37).
as a whole,” “ability to do
of Alzheimer’s disease-
chore,” “ability to have No difference in the reported QOL between caregivers
fun,” “money,” and “life as free adult day program
who looked after a loved one with Alzheimer’s disease
a whole.” evaluates each clients (n = 19).
and those who looked after a loved one without
item as poor (score = 1), fair Alzheimer’s disease (2.76 vs. 2.75). In this case, our
(score = 2), good (score = result yielded a t statistic = 0.05 and the corresponding p
3), or excellent (score = 4). value =0.96.

22
 Author Objectives & Instrument Subjects Main results Note
Research method
Gusi, et al.,(2009) To assess the health- Health-related quality of life Caregivers were The mental component scores of the caregivers were 22% Caregivers of
related quality of life and was measured by using the compared with non- lower (P <0.001) than those of the non-caregivers, but patients with
physical fitness of Short Form 36 in assessing caregiver women who did significant differences were not detected in the physical dementia have
women, who care for a eight functional parameters: not exercise regularly, component scores (test Mann-Whitney U-test). different health
relative with dementia, physical functioning (PF), significance level (0.05) related physical
compared with an age- physical role limitations and 90% of the power fitness profiles
matched group of non- (RP), bodily pain (BP), needed for a minimal Mean MCS was 41.87 (12.58) for carer vs. 53.89 (4.32) compared with the
caregiver women. general health (GH), vitality clinically relevant for non-carer. general population
(VT), social functioning difference of 0.5 SD (z- and their reported
(PS), emotional role score). Mean PCS was 47.23 (7.98) for carer vs. 44.94 (8.56) for psychosocial health
Cross-sectional study limitations (RE), and mental non-carer. related quality of life
health (MH). The required total sample is worse.
design was 87 participants. The caregivers had significantly better scores than non-
The scores of each carers about body composition (BMI and WHR) and the
parameter range from 0 Selected at least 105 muscular strength of the hands (as determined by the bi-
(worse health state) to 100 participants to exceed the handgrip test) and the legs (as determined by the chair-
(best health state). higher number by 20%. stand test), but lower strength endurance for the extensors
of the trunk. However, the two groups did not differ in
The first four parameters flexor trunk endurance, flexibility, or balance (motor
add up to the Physical fitness outcome).
Component Summary
(PCS), whereas the latter
four parameters add up to
the Mental Component
Summary (MCS).

Gavrilova, et al., This study tests the Behavioural and Sixty family caregivers of Most people with dementia were females with an average Report the
(2009) effectiveness of the 10/66 Psychological symptoms of people with dementia, of 4.5 years suffering from dementia. Three quarters of measurement at
caregiver intervention Dementia aged 65 and over, were the caregivers were also female, with an average age of based line and 6
among people with randomized to receive the around 60 years. Caregivers in the intervention group month follow-up on

23
 Author Objectives & Instrument Subjects Main results Note
Research method
dementia, and their carers. Caregiver: intervention and medical reported large and statistically significant net WHOQOL-BREF;
care as usual (n = 30) or improvements at 6-month follow-up in burden compared ZBI.
A single blind parallel Zarit Carer Burden medical care as usual only to controls. No group differences were found on caregiver
group randomized Interview (n = 30). Caregiver and quality of life.
controlled trial person with dementia
carer psychological distress outcomes were assessed at
Intervention: The (SRQ 20);
caregiver education and baseline and after 6
training intervention was Quality of Life months.
delivered over five, (WHOQOL-BREF
weekly, half-hour sessions
and was made up of three
modules: (i) assessment
(one session); (ii) basic
education about dementia
(two sessions); and (iii)
training regarding specific
problem behaviours (two
sessions).

24
 Author Objectives & Instrument Subjects Main results Note
Research method
Correlation analyses were run on participants’ QOLI
Kaufman, et al., To examine the Life satisfaction by the 16 141 rural-dwelling scores and their scores on each dimension of the ISEL to Be conversant in
(2010) experiences of African item Quality of Life dementia caregivers, determine if there were relationships between the English
American and White Inventor. Domain areas: family caregivers and participants’ reported life satisfaction and their reported
family caregivers who live health; self-regard; their dementia care levels of social support. As we note in Table 6, we found
in rural communities of philosophy of life; standard recipients. statistically significant positive correlations between the
older persons with of living; work; recreation; participants’ life satisfaction scores and their scores on
dementia. learning; creativity; helping; each of the four dimensions of social support. The
love; relationships; weakest relation was between the participants’ scores for
Cross-sectional design friendships; relationships
Structured telephone appraisal (the availability of persons to obtain advice
with children; and from and with whom to discuss problems), and their
interviews relationships with relatives, QOLI scores, which had a Pearson Correlation
home, neighbourhood, and Coefficient of .26 (p =.002). Their scores for tangible (the
community. availability of concrete help and material assistance from
social network members) and their QOLI scores had a
correlation coefficient of .36 (p < .001). Scores for
belonging (the availability of persons to talk to or
socialize with) and scores for self-esteem (receipt of
positive regard and self-esteem from others) both had
correlation coefficients of .49 (p < .001) with participants’
QOLI scores.
The results of a stepwise multiple regression analysis of
the QOLI with each of the four ISEL dimensions showed
that belonging (p < .001) and self-esteem (p < .001)
accounted for 32% of the variance of the caregivers’ life
satisfaction scores.

25
 Author Objectives & Instrument Subjects Main results Note
Research method
Kuroda, et al., To identify factors related HRQOL by SF-12 of 88 potential participants SF-12, the mean scores of PCS and MCS was 20.3±3.2
(2007) to the health-related Medical Outcome study and 22.5±3.2 in 1st phase; and 19.2±3.8 (paired t-test,
quality of life (HRQOL) short form health Survey: 55 caregivers providing p=0.013), and 2.17±4.0 (paired t-test, p=0.040) in 2nd
of caregivers providing continuing home care in phase indicate the HRQOL 1 year after was lower than at
continuing home care for - Physical component first phase from 10/2004 – the beginning.
the impaired elderly, summary (PCS) scores. 3/2005
focusing mainly on care Factors showed significant association with PCS score:
- Mental component 42 caregivers providing impaired elderly’s GDS-15 score (p=0.038) and
managers' support given summary (MCS). continuing home care in
to caregivers. caregiver’s level of satisfaction with their care manager
first phase from 10/2005 – (p=0.025).
Longitudinal study 3/2006
Factors showed significant association with MCS score:
Semi-structural interview caregiver’s SOC (p=0.046) and caregiver’s level of
1st phase: demographic satisfaction with their care manager (p=0.038).
variable, number of Logistic regression analysis with HRQOL shows that the
family members, caregivers' physical QOL was significantly related to the
HRQOL, satisfaction level depressive state of impaired elderly and the caregivers'
of care managers, coping satisfaction with their care manager, whereas the
ability and depressive caregivers' mental QOL was significantly related to the
state. caregivers' sense of coherence and satisfaction with their
2nd phase: Caregiver’s care manager.
HRQOL change

O'Connor & To determine the QOL using the short-form of One hundred and ninety- QoL of participant completed study was 65.69 (M, AD =
McCabe (2010) predictors of quality of the World Health two carers for people 14.05) in baseline. Those who did not complete the
life (QOL) among carers Organisation Quality of living at home with a follow-up had significantly lower QOL and mood. A
for people living with a Life questionnaire The 26- neurological illness series of paired-samples t-tests were conducted to
chronic degenerative item scale (WHOQOL- participated; 49 (25.5%) evaluate the differences over time for each of the illness
neurological illness, with BREF) measured four with motor neurone groups on income, economic pressure, QOL, mood,

26
Author Objectives & Instrument Subjects Main results Note
Research method
comparisons of the domains; physical health, disease (MND), 43 relationship satisfaction, and social support, None of the
differences in significant psychological health, social (22.4%) with other comparisons were significant.
predictors of QOL relationships, and Huntington’s disease
between illness groups environment. (HD), 40 (20.8%) with A multiple regression was conducted for each of the four
multiple sclerosis (MS), illness groups, to determine whether income, economic
Longitudinal study Responses were on a five- and 60 (31.3%) with pressure, mood, marital relationship satisfaction, and
point Likert scale from 1 = Parkinson’s. social support satisfaction at Time One predicted QOL at
very dissatisfied to 5 = very Time Two.
satisfied. To achieve the desired
- For MND carers, mood and relationship satisfaction
level of power of.80,
were significant predictors of QOL.
which translates to an
80% probability that a - For HD carers, mood and satisfaction with social
significant result will be support significantly predicted QOL.
detected if an effect does - For MS carers, economic pressure, mood, and social
exist, with a significance support satisfaction significantly predicted QOL.
level of .05, and a medium
effect size of .30,a sample - For Parkinson’s carers, income and mood were
significant predictors of QOL.
size of 64 was required.
Mood was a significant predictor of QOL for each of the
four illness groups, indicating that carer mood is an
important consideration for all research investigating
carer QOL. Social variables were significant predictors of
carer QOL. Economic variables did not play a strong role
in the prediction of QOL.

27
 Author Objectives & Instrument Subjects Main results Note
Research method
Matsui (2006) The purpose of this Bakas Caregiving Outcome a convenience sample - 35 Although many of the findings of this study on Defined QoL as
research is to identify and scale (BCOS 15-item scale the primary family caregiver’s QoL (receivers’ living status, working status, “The degree to
describe the state of addresses the perceived caregivers of homebound income status of participant) did not reach statistical which a person
quality of life of the changes in the social elders with dementia. significance, some possible predictors of carers’ QoL are enjoys the important
primary family caregivers functioning, subjective care-receiver's cognitive function, caregiver’s age, and possibilities of his or
of homebound elders with well-being, and physical hours of caregiving per week. This study suggested her life”.
dementia who reside in health as a result of implications for nursing research, practice and education
the community settings. providing care). Each item is to maintain, enhance, and improve the quality of life of
rated on a 7-point scale, family caregivers of elders with dementia.
Quality of life is defined ranging from -3 - “changed
by the Quality of Life for the worst”, to +3 –
Conceptual Framework “changed for the best.
developed by the Quality Three scales (Being Scale,
of Life Research Unit at Belonging Scale, and
Centre for Health Becoming Scale) were
Promotion, University of created by the principal
Toronto and the specific investigator after collecting
measurement tool, which data. These scales are based
is designed for caregivers. on Quality of
Life Conceptual Framework
which was employed in this
Descriptive and study. Each question of
correlational methods Bakas Caregiving Outcome
Scale was sorted to the
corresponding concept of
quality of life, “’Being’,
‘Belonging’, or ‘Becoming’

28
 Author Objectives & Instrument Subjects Main results Note
Research method
Pattanayak, et 32 key caregiver was Education was positively correlated to total coping score, The present study is
al.(2011) The aim of assessing - Hindi mental state defined as the family problem-solving, positive distraction, and acceptance, and the first to
coping strategies and examination member fulfilling at negatively correlated with religion and denial. specifically study the
Quality of life (QoL) as - Six domains of clinical least three out of the Use of social support as coping was found to be positively relationship of
well as studying the dementia rating (CDR) are following five criteria: (a) correlated with domains of QoL. Problem-solving was various cognitive
relationship between assessed, either spouse or children seen to have a significant positive correlation with and emotion focused
coping, QoL and severity namely: memory, of the patient; (b) has psychological QoL, while denial/blame had significant coping strategies
of dementia orientation, judgement and most frequent contact with negative correlation with both physical and psychological with quality of life in
Cross-sectional study problem solving, community the patient; (c) supports QoL. Both coping strategies and QoL has been shown to dementia caregivers.
affairs, the patient and his care depend on caregiver characteristics, rather than the Previously,
home and hobbies, and financially; severity of the patient’s dementia. only one study
personal care (d) most frequent assessed the fronto-
- 70 items Coping checklist: participant in treatment; temporal and
problem solving, denial, (e) is to be contacted by Alzheimer’s
positive distraction, negative the clinical staff in dementia caregivers
distraction, acceptance, emergency situation. The with respect to
religion/faith, and social key caregiver was burden, health-
support. included if he/she was related quality of life
- WHO – Quality of life aged 18 years or above, and coping and
provided care to the found that passive
patient for at least one coping strategies
year and was willing to were associated with
participate. decreased health-
related quality of life
(Riedijk et al., 2006)
Riedijk, et al., To assess the burden and HQoL was measured using 29 FTDH ANCOVAs demonstrated a two-way interaction effect The data were
(2006) quality of life as well as the Short Form 36 health patients and 90 AD (p<0.025) existed on the Mental Component Scale cross-sectional.
coping of Front temporal survey questionnaire (SF- patients living at home (MCS). Older caregivers of FTDH patients who had been Longitudinal follow-
Dementia and AD 36), consists of 36 items were included demented for a longer duration had the highest MCS up data will be
caregivers in order to representing eight functional in the study. scores (mean 83.3, SD=6.89). In contrast, younger

29
 Author Objectives & Instrument Subjects Main results Note
Research method
evaluate whether special dimensions: Physical caregivers of AD patients who had been demented for a needed to further
attention functioning, Physical role shorter duration had the lowest MCS scores (mean 63.7, investigate the role
needs to be paid to this limitations, Pain, SD=4.16). This implies that HQoL was more affected in of dementia
subset of caregivers. Energy/vitality, Emotional caregivers of AD patients who have been demented for a duration, burden and
role limitations, Social shorter duration. In regression analysis, MCS scores were institutionalization,
functioning, Mental health, predicted significantly by passive coping (β= –0.56, and these data will
and General health p<0.001), explaining 37% of variance. be published in due
perceptions. One additional time. Sample was
item measures Health No significant differences were found between FTDH quite small, which is
change over the past year. caregivers and AD caregivers on the Physical Component a limitation to
Scores on each dimension Scale (PCS). generalizability.
range from 0 (worst health However, the study
state) to 100 (best health ANCOVAs demonstrated two (near) significant one-way did include 72.4% of
state). interaction effects on the MCS. First, FTDN caregivers all FTD patients who
had lower (p = 0.027) MCS scores than FTDH caregivers were known
(mean 59.4, SD 6.00, and mean 75.0, SD 3.24, nationwide.
respectively).
Second, caregivers of FTD patients who had been
demented for a shorter duration had significantly lower
(p<0.025) MCS scores than caregivers of FTD patients
having been demented for a longer duration (mean 59.0,
SD 6.32, and mean 75.4, SD 2.55, respectively). In
regression analysis, MCS scores were predicted
significantly by passive coping (β= –0.55; p<0.001),
explaining 31% of variance.

No significant differences were found between caregivers

of FTDH and FTDN patients on the PCS.
Serrano-Aguilar, To assess the impact on HRQL: EuroQol-5D (EQ- 237 informal caregivers of The distribution of health problems or limitations for The sample under study
5D) questionnaire was used individuals with AD who caregivers according to each dimension of the EQ-5D was not selected

30
 Author Objectives & Instrument Subjects Main results Note
Research method
Lopez-Bastida, & health-related quality of to collect HRQL had Clinical Dementia questionnaire, were compared with the corresponding representatively of AD
Yanes-Lopez, life (HRQL) and the information. It contains five Rating bigger than 1 values for the general population on the Canary Islands severity levels, and
(2006) perceived burden of dimensions: mobility, self- (adjusted for age and gender). Caregivers had a higher consequently, there are
fewer patients in the
informal caregivers of care, usual activities, frequency of problems for each EQ-5D dimension
mild stages of the
individuals with pain/discomfort, and (p<0.01) than the general population. The general health disease. Although the
Alzheimer's disease (AD) anxiety/depression, with status of caregivers represented by the visual analogue data gathered have
three levels for each scale of EQ-5D shows lower levels (mean value 61.4, been collected by
Cross-sectional design dimension SD=16.6) than for the general population (mean value means of well-
65.9, SD=18.3). This difference (p<0.01) confirms a validated instruments,
lower HRQL for AD patients’ caregivers than for the most of the information
general population of the same age and gender. The relied on the subjective
experience of
impact of caregiving on caregivers’ HRQL was more
caregivers, without
significant in the limitations in ADL (8.80% in general including any element
population vs. 39.24% for caregivers); pain and of independent
discomfort (37.78 vs. 66.66%), and anxiety or depression observer-based
(19.23 vs. 78.48%). Caregivers’ HRQL was inversely assessment of the
associated with patients’ dependency level (p<0.01) and caregivers’ experience,
caregivers’ age (p<0.001). HRQL was better for more psychological state or
educated caregivers (p<0.001), as well as for son and functioning.
daughter (p<0.01) caregivers.

31
 Author Objectives & Instrument Subjects Main results Note
Research method
Takai, et al., - To examine the The World Health The participants were Mean WHO-QOL26 was 3.36 (SD=0.05). Study used the
(2009) relationships between Organization Quality of caregivers of patients with Japanese version for
burnout, depressive Life 26 (WHOQOL- dementia who first visited Results from ANOVA comparing the level of burnout all instruments that
symptoms, and quality of BREF) is a 26-item, self- the dementia with the scores on BDI-II and WHO-QOL26 revealed that were developed and
life in home caregivers of report measure designed to discrimination course in there were differences between the burnout groups and checked.
patients with dementia. assess quality of life. the Department of the scores on BDI-II and WHO-QOL26. The higher levels
Twenty-four items measure Psychiatry, Kitasato of burnout were found to correspond to higher levels of The description of
- To examine whether the four domains of QOL: University East Hospital depressive symptoms and lower QOL. QoL result was not
caregivers’ depressive Physical, Psychological, between November 2001 shown in detail in
symptoms and QOL Caregivers’ depression and QOL differed relative to the each domain. In
Social, and Environmental, and December 2006. levels of burnout, and found differences in the BDI-II
differed significantly in and the other two items addition, it was not
terms of their level of 106 potential participants scores (F (2, 81) = 22.56, p < 0.01) and WHO-QOL26 (F analysed deeply by
measure overall QOL and (2, 81) = 10.46, p < 0.01) for the burnout groups.
burnout. general health. The score for Twenty-two caregivers, the QoL researcher.
each question ranges from 1 who had more than three WHO-QOL26 scores in the no burnout group were They merely looked
to 5, and higher scores items missing on each significantly higher than the scores in the risk of burnout at the association
Descriptive study reflect higher QOL. questionnaire. and burnout present groups. between Burnout,
Depression and QoL.
84 valid response This association was
significant.
The author
mentioned that a
caregiver’s
perception of their
quality of life and
negative affective
responses to
caregiving might be
related to burnout.

32
 Author Objectives & Instrument Subjects Main results Note
Research method
Valimaki, et To examine the sense of HRQoL was measured using 170 patient-spouse The 15D scores were negatively correlated to depression Male caregivers'
al.,(2009) coherence (SOC) of the 15D questionnaire and a caregiver dyads in which (r=-_0.572, p<.001), distress SOC was
spouse caregivers. visual analogue scale the patient has recently (r=-0.568, p<0.001) and total amount of drugs used (r=- significantly higher
(VAS). diagnosed mild AD 0.450, p<0.001). A comparison of 15D profiles (mean than that of female
To investigate the scores of the dimensions) revealed that there were caregivers. The main
association of SOC, statistically significant differences between men and predictor for low
health-related quality of women in the dimensions of sleeping and feelings of SOC was depression,
life (HRQoL), depressive distress, with women feeling worse. Years of education or with 37% of spousal
symptoms, distress and income did not significantly associate with HRQoL. The caregivers reporting
how severity of stepwise (backwards) regression analysis was undertaken depressive
Alzheimer's disease (AD) with 15D as dependent variable and years of education, symptoms. Women
affects SOC. MMSE, NPI, CDR sum of boxes, total amount of drugs reported more
used, caregivers’ age, patient’s age, depressive symptoms, depressive
distress, income, ADCS-ADL as independent variables. symptoms and
This analysis indicated that total amount of drugs used, distress. Caregivers'
severe depressive symptoms and distress were statistically HRQoL was as high
significant predictors of low HRQoL (adjusted) as 0.8714, and a
R2=0.46 significant inverse
correlation was
found between SOC
and depression, r = -
0.632 and distress r
= -0.579.
Furthermore,
significant inverse
correlations were
found between
HRQoL and
depression (r = -
0.572) and distress (r
= -0.568). The main
predictors for high
HRQoL were female
gender and low
distress.

33
 Author Objectives & Instrument Subjects Main results Note
Research method
Vellone, et To describe the meaning Interview with open-ended Caregivers (n = 34). Participants used key words Because of the
al.,(2008) of quality of life for questions: Those willing to qualitative design,
caregivers of patients with participate (n = 32) were To describe the meaning of QOL and then elaborated on
• Considering the fact that these meanings, sometimes with personal examples. the aim of this study
Alzheimer's disease and to interviewed in Italian in a
you take care of a person was not to generalize
identify factors that affect separate room, without the Meanings of QOL divided into domain as (1) Serenity,
their quality of life. affected by AD, what do patients. the findings, but
you think QOL is like? tranquillity and psychological well-being, (2) Freedom, rather, to describe
A hermeneutic (3) General well-being, good health and good financial
the QOL experiences
phenomenological design • Which factors do you think status.
improve your QOL? of the participants,
- combines features of Interviewees talked about factors that they thought which may be
descriptive and • Which factors do you think improved their QOL and expressed what these factors
interpretive similar to those of
worsen your QOL? meant in terms of their caregiving situation. Factors other caregivers of
phenomenology. improving caregivers’ QOL were divided into domains as
Critical Reflection (1) Good health of the patient, (2) Independence from the patients with AD.
(Qualitative study) Technique was used to patient, (3) More help in caregiving.
analyse the interview
conversation, using several Caregivers were also invited during the interviews to
steps: express their thoughts about factors that could potentially
worsen their QOL. Factors worsening caregivers’ QOL
- Pre-understandings, were: (1) Worries about the future and progression of the
prejudices and assumptions patient’s illness, (2) Stress.
that researchers held were
identified before data
collection began.
- This process, traditionally
called bracketing, involved
the investigators writing
their beliefs and
assumptions about the
phenomenon under
investigation (the
experiences of caregivers’ of
persons with AD) and then
discussing these ideas
together.

34
 Author Objectives & Instrument Subjects Main results Note
Research method
Wong, Lam, Chan, Aimed to examine the Perceived Chronic Strains 276 caregivers with Sample of caregivers in this study had significantly lower Not suitable for
& Chan, (2012) differential roles of Scale/ caregiving burden: relatives attending QoL scores than other Chinese populations. Results also comparisons
caregiving burdens, the severity of perceived community psychiatric suggest that Chinese caregivers who had chronic illness,
strains experienced in the between dementia
caregiver characteristics, facilities in Hong Kong were younger in age, had a lower education level,
day-to-day lives of caregiving
and satisfaction with were invited to fill out a experienced more difficulties in handling negative
psychiatric services in caregivers when caring for questionnaire. symptoms, and were more dissatisfied with mental health populations, but will
caregivers' QoL. their mentally ill relatives. services, and had a poorer quality of life.. Indeed, be applicable to
Satisfaction with Mental A convenience sampling caregiver characteristics displayed a much stronger compare the results
Health Services in Hong method. association with caregivers' QoL than did caregiving of the WHOQOL-
Kong burdens and satisfaction with psychiatric services.
A cross-sectional survey BREF measurement.
World Health Organization
design. Quality of Life Scale –
BRIEF

35
 Author Objectives & Instrument Subjects Main results Note
Research method
Wang, et al., To test the effect of a The caregiver distress 78 family Chinese ANOVA tests revealed that the mutual support group Study reported not
(2012) mutual family support scale, Neuropsychiatric caregivers of people with participants had significantly greater improvements in only domains score
group program that Inventory-Caregiver dementia in Hong Kong; distress levels and quality of life (in the domains of of WHOQOL-
incorporated educational, Distress Scale (NPI-D) 39 were in each of the Psychology, Social relationship and total score) than the BREF, but also total
supportive and World Health experimental and control control group. Those improvements in psychological score. Results of
community mental health Organization Quality of groups. distress and quality of life would provide opportunities to baseline (pre-test)
care components within a Life Measure-Brief carers for better caring services and more effective care and post-test for
group of family members Intervention was for people with dementia. control and
who were caring for a The Family Support undertaken with a intervention group
relative with dementia at Services Index (FSSI) protocol, with an can be used to
home. advanced practice nurse compare.
guiding both the mutual
Experimental study support group process and The need of evaluate
the facilitator and peer the effectiveness
24-week mutual support leader training. index of intervention
group program
vs. control should be
presented.

36
2. Caregiving burden among dementia caregivers

Sherwood et al., (2005) defined caregiving burden as a “multidimensional bio-

psychosocial reaction”, arising from the imbalance of caring demands in areas such

as caregivers’ personal time, social roles, physical and emotional status, financial

resources, and formal care resources available for undertaking multiple roles. The

caregiving burden is considered a negative reaction to the impact of providing care

for the social, occupational and personal roles of caregivers (B. A. Given, Kozachik,

Collins, DeVoss, & Given, 2001). To investigate the perceived burden, which was

assessed by the mean of the 22-item Zarit Burden Interview on dementia caregivers,

Papastavrou, Kalokerinou, Papacostas, Tsangari, and Sourtzi (2007) utilised the

cross-sectional study of a sample of 172 caregiver/care dyads in a study conducted in

Cyprus. The results revealed that 68.02% of caregivers were highly burdened and

65% exhibited depressive symptoms. Most caregivers were daughters of people with

dementia (48.3%). Female caregivers demonstrated a higher burden than male

caregivers. The burden was significantly associated with the psychopathological

status of people with dementia, financial status and the educational level of dementia

caregivers. Post-graduate educated caregivers experienced a lower burden than

elementary school graduates. This means that carers, especially poor females with

less education looking after people with dementia with more evident symptom issues

are more at risk for experiencing higher perceived burden.

Although cognition, abilities in performing activities of daily living (ADL),

and behavioural disturbances of patients with Alzheimer's disease (AD) were found

to influence the level of caregiving hours and perceived caregiving burden among

dementia caregivers, the direct effect and the level of measurement on the severity of

each disease remains unclear. The length of caregiving time spent weekly can be a

37
predictive factor in burden of care. Bergvall and et al (2011) conducted cross-

sectional interviews on primary caregivers of people with dementia within Spain,

Sweden, the U.K. and the U.S.A in order to explore the associations between disease

indicators, informal care hours and caregiver burden (Zarit Burden Interview) in

different countries. The severity of behavioural disturbances and the length of daily

caregiving hours were the strongest predictors of caregiver burden. In addition, the

effect of ADL-abilities was, although attenuated, not negligible (0.28 SD increase in

ZBI score per SD increase in DAD score). The abilities of performing activities of

daily living of people with dementia were the main predictor of informal care hours,

and both behavioural disturbances and activities of daily living-abilities are

important predictive variables of perceived caregiver burden. These findings were

calculated consistently across the three countries (U.K., Sweden and America)

(Bergvall et al., 2011).

Caregiver burden (assessed by the mean of 22-item Zarit Burden Interview

Sweden version) perceived quality of life (measured by EQ-5D) and sense of

coherence (SOC) were explored among caregivers of persons with dementia who

were living at home in a municipality in Sweden (Andren & Elmstahl, 2008). The

findings revealed that the highest burden was reported among spouses, followed by

children, and other caregivers. Higher Burden (implied by Zarit Burden Interview

total score) had an inverted relationship with higher Sense of Coherence, after

adjusting for age and relationship. Lower burden was found among carers who had

higher SOC scores. The perceived caregiving burden and SOC scale seem to be

highly useful for identifying carers who are at risk of stress, their pattern of burden

and coping strategies. Caregivers with a higher risk of burden and low in SOC,

require more attention and should receive early interventions. In regards to the SOC,

38
the earlier study was interested in the relationship between Sense of Coherence,

coping, and caregiver role overload among 126 carers of dementing and non-

dementing chronically ill family members (Gallagher, Wagenfeld, Baro, & Haepers,

1994). The results showed that SOC was a protective factor, used to control the

meaning of the situation, to choose appropriate coping strategies, and to prevent

unhealthy behaviours. Through multivariate analyses, SOC alone was the most

explanative factor in accounting for the caregiving burden (accounting for 29% of

the variance).

Casado and Sacco (2012) utilised a modified stress-appraisal model to examine

the relationship between background and context characteristics of caregivers,

functional dependency of people with Alzheimer’s disease, caregiving hours, and

resources for the caregiving burden among Korean American caregivers. Higher

burden was identified among female caregivers and their spouses. Fewer family

support networks, less family agreement, and less care management self-efficacy

were correlated with higher perceived caregiving burden. The severity of dementia-

related symptoms and their correlation to caregiver burden and depression was

studied among 45 dementia caregiver-sufferer dyads over a period of two years

(Berger et al., 2005). Caregivers' depression and subjective burden were evaluated

using the Beck Depression Inventory and the Zarit Burden Interview (22 items). The

findings revealed that although global dementia severity, functional impairment, and

behavioural disturbances in persons with dementia significantly rose over the two-

year observation period, caregivers' burden stayed constant and caregiver depression

declined over time. Significant associations were found between caregiver burden

and dementia-related symptoms.

39
 Some evidence suggests that the burden of caregiving is different across

different types of dementia. Dementia has been categorised into five main types,

namely, Alzheimer’s disease (AD), vascular dementia, dementia with Lewy bodies,

Fronto-temporal dementia (FTD) and mixed dementia (National Colaborating Centre

for Mental Health, 2007, p. 146). Riedijk et al., (2006) compared caregiver burden,

HRQoL (measured by SF-36) and coping among caregivers of the FTD and AD.

Caregiver burden was assessed using the 10 point Visual Analogue scale on “How

much burden of caregiving”. The authors reported that FTD caregivers suffered more

burden than caregivers of people with AD, and caregivers of shorter dementia

duration patients had lower HRQoL. Furthermore, burden and HRQoL in caregivers

were affected more frequently by those FTD patients who were institutionalized after

a shorter duration of dementia (Riedijk et al., 2006). LBD is also a cause of

dementia. The research question of the study conducted was the burden in this

subtype of disease on 962 caregivers (Galvin et al., 2010). Caregivers of persons

with LBD, were believed to be concerned about fear of the future (77%), feeling

stressed (54%), loss of social life (52%), and uncertainty about what to do next

(50%). Most of them suffered middle to high burden and 80% of them reported

apathy and ignored their burden. It can be confirmed that the caregiving burden

among dementia caregivers is higher in some subgroups. Thus the type of dementia

diagnosis is an important predictor of burden.

Kim et al., (2009) focused on predicting the perceived burden among 609

dementia caregivers in Korea. Caregiver burden, evaluated with the Zarit Burden

Interview (Korean version), was higher in those who reported lower education.

Moreover, lower ability to perform Activities of Daily Living (ADLs) and

Instrumental Activities of Daily Living (IADLs) among people with dementia

40
significantly predicted higher caregiving burden. It was also suggested that health

care programs or interventions for assisting patients with dementia should be directed

at female caregivers, especially those suffering from an economic burden.

Interventions should also plan to improve the ADL and IADL of patients. Yoo, Jang

and Choi (2010) paid special attention to AD caregivers who seem to be suffering

from family burdens in caring as well as emotional distress. The findings revealed

that dementia caregivers in Korea experienced more family burden due to “impact on

finance” and “sense of entrapment”, compared with caregivers in America (7.4%, 29

of 390 messages vs. 3.2%, 13 of 407 messages, 2=7.18, p<0.01). Additionally, the

Korean caregivers stated more negative emotions relating to caregiving, including

anger and self-focused sadness (J. H. Yoo et al., 2010). This issue might have linked

with the traditional and culture values.

There are two methods of approaching research and investigation of the

caregiving burden. Many researchers have conducted studies to understand the

current status and factors affecting dementia caregivers. On the other hand, several

groups of researchers have developed other approaches to solve the dementia

caregivers’ problems. A group of researchers in Canada tested the effectiveness of an

intervention program on caregivers of AD clients using the QoL-AD score (Bartfay

& Bartfay, 2013). Two community-based interventions involved caregiver support

groups and adult day programs. QoL was measured by Quality of Life – Alzheimer’s

disease (QoL-AD) and compared among Group 1 (28 caregivers of AD clients who

attended support groups), Group 2 (15 caregivers of AD clients who were adult day

program clients), and Group 3 (19 caregivers of AD-free adult day program clients).

The QoL rating for Group 1 was not found to be statistically different from the score

for Group 2. Caregivers of AD clients who used community-based interventions

41
enjoyed similar levels of QoL as caregivers of non-AD clients. This result indicates

that community-based interventions may be beneficial when they are focused on the

various needs and desires of dementia caregivers. These interventions can include

improving caregivers’ knowledge of community resources and the disease as well as

strategies in coping with the disease.

Coyne, Reichman and Berbif (1993) disclosed their findings among 342

caregivers of persons with dementia. Caregiver burden and depression were

measured with the 22-item Zarit Burden Interview and Zung self-rating depression

scale, respectively. These caregivers, who had been providing care for more years,

cared for patients functioning at a lower level, displayed higher burden scores and

displayed higher depression scores.

In conclusion, caring for people with dementia who’re living at home is

challenging and usually the demand for care is far greater than the supply. Perceived

caregiving burden was shown to be associated with the number of caregiving hours

((Bergvall et al., 2011; Casado & Sacco, 2012), Sense of Coherence (Andren &

Elmstahl, 2008; Gallagher et al., 1994; Kuroda et al., 2007; Valimaki et al., 2009),

and abilities of people with dementia for performing activities of daily

living/instrumental of activities of daily living. Most researchers preferred the Zarit

Burden Interview for evaluating the level of burden among dementia caregivers.

3. Theory/model of quality of life

As mentioned in section 1 of chapter 2, the concept of QoL has been defined

differently, depending on the context and its application by researchers. Each of the

authors and researchers employs different terms for QoL to reflect factors concerning

personal life. Since 1997, The World Health Organization has suggested that several

factors should be reviewed when QoL is mentioned. Factors, such as the ability to

42
think, make decisions and have control in one's daily life, the physical and mental

health of dementia sufferers, living arrangements, social relationships between

dementia patients and their families, friends and other; and financial and economic

situations (World Health Organization, 1997) should be addressed when defining

QoL. In this study, the term and conceptual model of Quality of Life from Ferrans

(1996) has been adopted. Ferrans’ model provided the foundation for the

development of a measurement tool to assess Quality of Life. Figure 1 summarises a

QoL model that has four domains, namely, health and functioning,

psychological/spiritual, social and economic, and family. This conceptual model of

QoL was developed based on the three-steps of synthesis process. The first step was

a focus on clarifying and defining the concept and meaning of quality of life. Quality

of Life was defined as a person's sense of well-being that stems from satisfaction or

dissatisfaction with the areas of life that are important to him/her (Ferrans, 1996). The

Quality of Life index used in this study was designed to measure QoL,

acknowledging the life domains noted by experts, the subjective evaluation of

satisfaction with the domains, and the importance of domains to the individuals. The

second step was to identify elements in the concept of QoL, and accordingly 32 items

were identified. The next step was to cluster those 32 items into domains of quality

of life by applying factor analysis. According to Ferrans (1996) this model included

several elements under each of the four domains:

- Health and Functioning domain encompasses usefulness to others,

physical independence, ability to meet family responsibilities, pain,

energy (fatigue), leisure time activities, ability to travel, sex life, health

care, etc.;

43
 - Psychological/spiritual domain encompasses satisfaction with life,

happiness in general, achievement of personal goals, and peace in mind.

- Social and economic domain encompasses standard of living, financial

independence, home, job/unemployment, friend, and emotional support

from others.

- Family domain consists of family happiness, family health and

children.

Health & Functioning

Psychological/ Spiritual
QUALITY OF LIFE
Social and economic

Family

Figure 1: Ferrans’s Quality of life model

The meaning of QoL and the conceptual model of QoL, proposed by Ferrans

(1996), were also used to compare QoL across other studies of different participant

populations, such as haemodialysis patients, arthritis patients, cardiac patients and

the general population. Consequently, when the QoL among dementia patients and

caregiver dyads are evaluated, all of these four dimensions should be addressed. By

identifying the QoL of family caregivers of people with dementia, the model

developed by Ferrans (1996) would assist the healthcare system and providers to

identify the specific areas for intervention that are needed to improve QoL.

The conceptual quality of life model of Ferrans is presented in Figure 2

(Ferrans, Zerwic, Wilbur, & Larson, 2005).

44
 Figure 2. Conceptual quality of life model of Ferrans

The first variable, biological function reflects the function of organs or organ

systems that can be evaluated via several measures of physical assessment, medical

diagnosis and laboratory testing, functional explorations and imaging diagnosis tests.

The symptoms measured were cognitive, physical and psychological symptoms that

were experienced by a target person. The third variable was defined as functional

status, which covers the function of physical, psychological, social aspects as well as

the role of the person. The fourth block is the perception of general heath that reflects

the subjective aggregate grading of all health indicators. The final component is

overall quality of health that is described by subjective well-being, happiness, and

the perception of the degree of sacrifice by a carer within his or her life as a whole.

The arrows are used to imply the casual correlation (Ferrans et al., 2005). This model

was recommended to use because it is a better explanation of Quality of life (Bakas

et al., 2012)

The stress and coping theoretical framework, presented by Lazarus and

Folkman (1984), was adopted to conduct this research. This theory on stress and

emotions is endorsed, because this process of appraisal reflects the way diverse

45
persons construe the significance of their caregiving burden on their well-being, and

also, the theory refers to their coping practices (Lazarus, 2006, pp. 9, 34). This model

draws attention to the cognitive appraisal of stressors and resources and it also covers

direct coping responses and long-term adaptation to stress outcomes. Appraisal and

coping are considered to be the foundation theoretical constructs of stress and

emotion that influence the condition of the environment, and these constructs vary

with personality (Lazarus, 2006, p. 15). Lazarus (2006) defined psychological stress

as a correlation between environment and person, which have the potential to affect

one’s well-being.

Stress was defined as, “the relationship between the person and the

environment that is appraised by the person as taxing or exceeding his or her

resources and endangering his or her well-being”. This definition also covers the

characteristics of that person and the environmental event (Lazarus & Folkman,

1984, p. 21). Stress was determined through the process of appraisal, which was

defined as the cognitive determinant of emotion. Appraisal can be explained as the

process of “categorizing and encounter” with various situations and with “respect to

its significance for well-being” (Lazarus & Folkman, 1984, p. 31). Appraisal of the

event involves the mental activities that cover judgment, discrimination and decision

according, mainly in the context of their past experience. Emotional reaction replies

on appraisal, which is that each person recognises and evaluates events differently

through their cognitive appraisal of events. Based on caregivers’ cognitive appraisals

of an event or issue as positive or negative, each individual would have a different

result on their behavioural, physiological and psychological activities. In turn, those

reactions would also affect their coping strategies.

46
 Cognitive appraisals were categorised by Lazarus and Folkman (1984, p. 31)

into primary and secondary appraisal. Primary cognitive appraisal refers to the self-

evaluation process of being in trouble, or in benefit, in addition to the possible

contribution of this cognitive appraisal to their well-being in an event. Possible

stressful events were categorised as: (1) irrelevant, which carry no implications for

well-being of an individual; (2) benign- positive, which led to positive actions to

maintain and enhance well-being; or (3) stressful cognitive appraisals that contain the

feeling of harm/loss, threat and challenge. The feelings of appraisal of threats and

challenges are identified differently among people via their cognitive processes.

Secondary appraisal relates to the process of action for well-being, which is a by-

product of the analysed emotion, and information or coping process (Lazarus &

Folkman, 1984, p. 35). This is a complex evaluative process that necessitates that

possible coping options are concordant with a person’s personal ability to apply a set

of coping strategies. Evaluation of the consequences of applying coping strategies in

the context of internal and/or external demands and constraints is also critical. This

process involves comparisons between the power of environmental demands (harm,

threat or challenge) and personal psychological resources to manage those demands

based on the vulnerability or resistance of that person to their stressful situation

(Lazarus, 2006, p. 58). The process of appraisal also involves a process reappraisal,

which refers to changes in appraisal in response to new or updated information from

the person and/or environment. The reappraisal only appears in sequence after an

initial appraisal, and was also referred to as a mediating process (Lazarus &

Folkman, 1984, p. 38).

Commitments and beliefs are the most important personal characteristics of

cognitive appraisal. Commitments are defined as the importance and meaning of

47
something for a person (Lazarus & Folkman, 1984, p. 56). The beliefs of a person

determine the way humans evaluate the stress-inducing event. Since commitments

and beliefs affect the human appraisal process because of the identified role of

prominent character traits in determining well-being, developing an understanding of

individuals’ perceptions toward an event and using this as the foundation for

evaluating outcome, would not be considered as sufficient to explain appraisal.

Situation and person characteristics are considered to be interdependent. In

turn, the significant contribution of situation and personal characteristics to stress and

coping are revealed via cognitive processes (Lazarus & Folkman, 1984). Coping was

defined as, “constantly changing cognitive and behavioural efforts to manage

specific external and/or internal demands that are appraised as taxing or exceeding

the resources of the person” (Lazarus & Folkman, 1984, p. 141). Coping function

plays a role in managing or altering the environmental problem that has caused

distress and it involves regulating or manipulating the emotional reactions to the

problem. Cognitive appraisal is different and identified by individuals as well as

situational factors they encounter as harmful, dangerous, threatening or challenging.

Meanwhile burden refers to the management of specific tasks to be performed.

Burden is the term used to describe the perceived negative feelings arising (Pilisuk &

Parks, 1988).

Moreover, human adaptation outcomes are influence by cognitive appraisal and

coping processes (Lazarus & Folkman, 1984). The outcome measures have been

defined as work and social living, quality of life or life satisfaction and somatic

health. Stress can lead to physical changes, and feelings of positivity or negativity.

According to Lazarus and Forkman (1984) changes in the person’s physiology, affect

or emotion or impairment of health could be directly caused with ineffective coping.

48
In the long- term, the outcome of stress is the adaptation of the human. Significant

results could be anticipated in the person’s health/illness, morale, well-being and

social functioning defined as fulfilment of a different role, for example as a spouse or

parent.

The stress and coping theoretical framework presented by Lazarus and

Folkman (1984) has been retained for this study because it is the original stress-

focused framework and has broad applicability across cultures. The model of stress

proposed by Pearlin, Mullan, Semple, & Skaff (1990) presented a conceptual model

of caregiving stress, specific to Alzheimer’s caregivers, builds on Lazarus and

Folkman’s stress and coping process.. There are four domains of the stress process in

which each contain multiple components. The domains are the background and

context of the stress, the stressors, mediators of stress and the outcome of stress.

Stressors of stress had been divided into primary and secondary stressors. Primary

stressors arise directly from the needs of people with disease and include objective

burden and subjective burden. Secondary stressors arise from the demands of

caregiving. The outcomes cover negative mental health consequences described as

well-being, physical and mental health and the caregivers’ ability to maintain their

own roles.

Significance

The significance of this study is that it was the first study to examine quality of

life and burden in Vietnamese carers of persons with dementia. The key issues of

QoL and burden of care of those caregivers are so vital and important in both short-

term and long-term management of families who’re caring for family members with

dementia. Their QoL and burden of care have not received adequate attention in

Vietnam’s health care system. This study aims to introduce and highlight the current

49
QoL and burden of care among carers of people with dementia who are living in

community settings. This study also aims to identify some factors that affect their

ongoing challenges.

Findings from this study will be useful to inform nurses and other health care

providers of the key issues in regards to QoL and have the possibility of increasing

their understanding of the needs of both their clients with dementia and their

families. This study’s findings might be used as baseline for developing future

interventions to support carers of people with dementia in order to improve resilience

and satisfaction in caregiving, to reduce burden and to promote wellness and positive

carer experiences. Moreover, results from this research will be a valuable reference

for health-workers, policy-makers and health-care planners in Hanoi and Vietnam, in

general, in designing, implementing and evaluating the effectiveness of supportive

policies and programs for those caregivers looking after dementia and age-related

disease sufferers.

4. Research framework

The research literature revealed that QoL and caregiving burden of dementia

caregivers is directly impacted by the characteristics of the caregiver (age, gender,

education level, social economic status, employment status, health status, carer

status and cultural consideration) and characteristics of the person with dementia

(age, gender, health status, carer status and cultural consideration).

Caregiving burden was identified as having a negative association with quality

of life among caregivers of patients with breast cancer who were undergoing

autologous bone marrow transplantation (Gaston-Johansson, Lachica, Fall-Dickson,

& Kennedy, 2004), and caregivers of people with schizophrenia (Li, Lambert, &

Lambert, 2007). Moreover, burden of care has been considered to be a predictor for

50
quality of life in several clinical settings and for different subjects of clinical interest,

including family caregivers of children and adolescents who’re undergoing

chemotherapy treatment for cancer (Rubira, Marcon, Belasco, Gaíva, & Espinosa,

2012), family caregivers of patients with lung cancer, (Fujinami, Otis-Green, Klein,

Sidhu, & Ferrell, 2012), caregivers of the mentally ill in Taiwan (Chun Chieh &

Ying-Yeh, 2011), and caregivers of Fronto-temporal dementia (Galvin et al., 2010).

Based on the literature review, and a synthesis of the concept of Quality of Life

by Ferrans (1996) with the theoretical model by Lazarus and Folkman (1984), the

following research framework was developed to provide guidance for this study.

According to Lazarus and Folkman (1984) the theoretical schematization of stress,

coping and adaptation contain casual antecedents (including personal variables and

environmental) through the mediating processes of primary and secondary appraisal,

which in turn cause immediate effects. These effects emerge in a subject as

physiological changes and experiences of positive or negative feelings.

Subsequently, they contribute to long-term effects on well-being or the social

function of a person or group of people. Aranda and Knight (1997) highlighted that

stress and coping models cover: background variables, such as age, gender,

socioeconomic status, kinship of caregiver to patients, etc.; primary stressors and

secondary strains related to caregiving for the patient and the effect of these primary

and secondary stressors on other domains of a caregiver’s life; caregivers’

perceptions of demands as stressful or satisfactory; and the consequences of those

demands, for example, quality of health. In brief, with this model of stress and

coping, the way a person interprets a situation (i.e. the positive, negative or neutral

value) would have an impact on their own psychological well-being. In this study,

the antecedent variables were divided into caregiver variables (gender, age,

51
education, kinship to people with dementia, caregiving status); and people with

dementia variables (age, gender, duration suffering from dementia). The perceived

caregiving burden and Sense of Coherence were examined as potential mediators

between causal antecedents and caregiver’s Quality of life. The coping process was

not covered in this study because Lazarus (2006, p. 101) emphasized that coping is a

continuous process in managing psychological stress, and accordingly, requires a

longitudinal study design. Because of this, a cross–sectional study design was

utilised in this study. It is important to note that using a cross-sectional research

design hindered investigation of the caregiver’s coping processes. Figure 4 illustrates

the design of the study.

Caregiver characteristics PWD characteristics

- Demographic (age, gender, - Demographic (age, gender)
education, marital status) - Level of independence
- Health status - Behavioural profile
- Employment - income - Duration of disease
- Caregiving hours
- Household members

Caregiving burden
Sense of Coherence

Caregiver’s Quality of life

Figure 3. Research framework

52
 Chapter 3: THE 1ST SURVEY – PHASE 1

QUALITY OF LIFE AND CAREVING BURDEN AMONG CAREGIVERS

OF PEOPLE WITH DEMENTIA IN HANOI, VIETNAM

I. Methodology

1. Study design
A cross-sectional correlation survey was utilised to: (a) investigate the quality

of life and caregiving burden among family carers of those with dementia within 10

inner districts of Hanoi, Vietnam; and (b) explore the associations between care

recipient and carer characteristics and QoL.

2. Population, setting and sampling

The target population of this study was primary caregivers of people with

dementia in communities in the Hanoi area, Vietnam. The sample consisted of dyads

of persons with dementia and their primary family caregivers.

Family carers of people with dementia met the following criteria for inclusion,

which are similarly defined in Australia (Australian Bureau of Statistics, 2008) and

America (Fredman et al., 2012):

- Live in area of 10 inner districts of Hanoi during data collection;

- Identified as the current primary carer of a person with a medical

diagnosis of dementia;

- Care for at least the last three months;

- Able to speak and understand Vietnamese;

- Provide care for at least one hour/day and two days/week;

53
 Exclusion criteria included caregivers who had a cognitive impairment, or an

intellectual disability. Children and young people (< 15 years) and people with

intellectual or mental impairment were not included in this survey because it was not

likely that group of people would have sufficient understanding to complete the

study.

A randomised sampling method was utilised to recruit participants. The list of

names with the contact addresses of the people with dementia and their carers was

retrieved from the National Institute of Gerontology, based on patient records from

2005 – May 2011. The contact addresses of those people registered from January 1,

2010 onwards were withdrawn from patients’ documents from the Vietnamese

National Institute of Gerontology, the specialized hospital for elderly health care, and

the only institution in the North of Vietnam providing such services. This is a public

hospital which has a 170 bed capacity for inpatients, and it has an out-patient

department that provides health check-ups and medical consultations in both

gerontological and general areas. With approximately 80 medical physicians, 12

pharmacists, 80 nurses and a small number of administrative staff, the Institute

provides treatment for most common aging health problems and diseases, such as

hypertension, diabetes, stroke, dementia, COPD, cancer, and renal failure. The

National Institute of Gerontology is the only health care facility in the North of

Vietnam that provides services for the diagnosis, treatment and follow-up for

dementia. This institute is located in Hanoi, the Capital of Vietnam. Dementia

treatment and services are provided for people from both rural and urban areas.

People from the countryside and rural areas have to travel to hospital to receive the

treatment, consultation and care.

54
 The sample size was calculated according to the formula provided by Lwanga

and Lemeshow (1991):

n: sample size

1- α: Confidence level

P: Anticipate population proportion

d: Absolute precision required

With α = 0.05, Z1-/2 = 1.96 and P of quality of life at 0.87, these statistics were

taken from the study conducted by Huong, Ha, Nhung, and Chi (2009), where

d=0.055 and n= 144. The absolute precision is defined as, “the closeness with which

it can be expected to approximate the relevant population value” (Brown, 2007).

Relevant to this study, with absolute required precision at 0.055, the estimate of

quality of life among the dementia caregivers population (generated from the

mentioned sample) might vary from 0.815 to 0.925. The theoretical sample size was

144 participants, with a type I error of 5%. To account for a possible attrition rate of

20%, to increase the external validity and to reduce the possibility of Type II errors,

an additional 28 participants were recruited for a total sample size of 172 people.

Although the list of names of participants was drawn from the National

Institute of Gerontology, all of the research settings in this study were community

based. The National Institute of Gerontology agreed to provide the list of names with

the contact addresses of people with dementia and their caregivers for the study. The

supporting letter from the Director of the Institute was obtained before data

collection commenced, because people with dementia in the North of Vietnam

mainly get their prescriptions and treatments as out–patients.

In Vietnam, dementia diagnosis has typically been made following the criteria

and guidelines of the DSM-IV. The protocol for diagnosing dementia in the clinical

55
setting was nationally accepted and guided by Vu and Nguyen (2012) and covers 4

domains

- Assess the stage of memory loss by using MMSE, Neuropsychiatric

Inventory (NPI)

- Mental health assessment performed by the medical practician

- Blood tests include complete blood count, glucose fasting, electrolysis,

functional of thyroid (T3, T4, FT3, TSH) and syphilis screening with

TPHA

- Screening the brain with MRI

After receiving the diagnosis of dementia, people with dementia were

prescribed with medication to continue to live in their communities and homes. The

bulk of care for people for people with dementia was mainly the dementia sufferers’

family members and children. The study venue, Hanoi, was chosen because of the

primary researcher’s understanding of the health system in that province. Hanoi is

divided into 10 inner districts, 1 town and 18 outer districts. It is the Capital of

Vietnam and the country’s second largest city. Hanoi’s population in 2009 was

estimated at 2.6 million for urban districts and 6.5 million for the metropolitan

jurisdiction. The percentage of more than three generations of Hanoian households is

likely to be very small compared to the overall population of the city. The primary

data collection process for the survey was conducted within the participants’ homes

between October 2011 and January 2012.

3. Measurement
The survey was developed after reviewing the literature and gleaning advice

from experts. The survey covered basic demographics and items regarding the QoL,

56
burden of care and care recipient characteristics. The survey was organised in four

parts. Part A covered socio-demographic characteristics of both caregivers and care-

receivers. Part B investigated the level of dependency by using the Barthel Index and

Kingston Standardized Behavioural Assessment.

- The Barthel Index is an appropriate tool to collect information about

Activities of daily living (ADLs) (Serrano-Aguilar et al., 2006). This

instrument was first used to assess the independence/dependence level

for ten Activities of Daily Living (ADLs), primarily related to personal

care and mobility in a clinical setting (Mahoney & Barthel, 1965). With

scores ranging from 0 (high dependence) to 100 (high independence),

higher scores indicate higher levels of activities that they can perform.

The Cronbach’s alpha was 0.9354 and the test-retest reliability was

0.989 among 459 stroke patients in a Middle–Eastern country

(Oveisgharan et al., 2006).

- Kingston Standardized Behavioural Assessment (KSBA) was also

employed in this study to assess the number of behavioural symptoms

associated with dementia. This is an informant-based assessment to

organise 68 behaviours common to dementia into 12 categories.

Kingston Standardized Behavioural Assessment was also employed in

this study to assess the number of behavioural symptoms associated

with dementia. (Day, Bradford, Rows, Kilik, & Hopkins, 2006). Using

a yes/no format, the caregivers were asked to identify any activities that

have appeared within past months. According to the cut-offs proposed

by Hopkins, Kilik, Day, Bradford, and Rows (2006) the behavioural

profile of people with dementia was categorised based on the KSBA

57
 total score into level 1 (< 11), level 2 (11-24), level 3 (24-38) and level

4 (>38).

Part C measured perceived burden of care on caregivers by using the Zarit

Burden Interview (ZBI) – a 22-item self-report inventory. A 5-point scale, ranging

from “never” to “nearly always” was used. Responses of the individual items will be

scored, with scores ranging from 0 to 88, where higher scores indicate a higher

degree of burden. Five domains analysis was applied, including burden in the

relationship (items 1, 8, 11, 14, 18, & 22), emotional wellbeing (items 2, 4, 5, 9, 10,

21, & 22), social and family life (item 3, 6, 12, & 13), finances (item 15), and loss of

control over one’s life (item 7, 16, 17, & 19) (Rankin, Haut, Keefover, & Franzen,

1994). According to the cut-offs, proposed by Hebert, Bravo, and Preville (2000),

burden was “little or no burden” if ZBI total score was lower than 21, “mild to

moderate burden” if ZBI total score varied from 21 to 40, “moderate to severe

burden” if ZBI total score ranged from 41 to 60, and “severe burden” if ZBI was

higher than 61. Previous studies employed the Zarit Burden interview to measure the

burden of care among dementia caregivers, which can be listed (Serrano-Aguilar et

al., 2006), (Mohamed et al., 2010). This instrument is considered to be highly

consistent and valid when evaluating subjective burden (Etters, Goodall, & Harrison,

2008). The Cronbach’s alpha value was 0.93 and the test-retest reliability was 0.89

on the group of 149 Singaporean dementia caregivers (Seng et al., 2010).

The Sense of Coherence (SOC) questionnaire has not been studied within the

Vietnamese context. The SOC questionnaire included 13 items, scored on 7-point

Likert scales, where each item has two fixed and contradictory responses listed under

the endpoint of each item. The theoretical total score of SOC is from 13 (low SOC)

to 91 (highest possible SOC). The SOC consists of three dimensions:

58
comprehensibility (item 2, 6, 8, 9, & 11), manageability (item 3, 5, 10, & 13) and

meaningfulness (item 1, 4, 7, & 12) (Jakobsson, 2011). People with a higher score on

SOC are believed to be more confident in managing their situation and knowing how

to perform health promotion. Previous studies using SOC were conducted by

Valimaki, et al., (2009), and Andren and Elmstahl, (2008). The SOC – 13 items were

first developed by Aaron Antonovsky. It has been used in at least 33 languages in 32

countries, with at least 15 different versions of the questionnaire. Among 127 studies

using the original SOC-13, the Cronbach’s alpha value ranges from 0.70 to 0.92, and

that value in 60 modified SOC scale studies varied from 0.35 to 0.91. The means of

SOC-13 varied from 35.39 (SD 0.10) to 77.60 (SD 13.80) points. SOC tends to

increase with age. The authors mentioned that the SOC scale seems to be a reliable,

valid, and cross-culturally applicable instrument, measuring how people manage

stressful situations and stay well (Eriksson & Lindstrom, 2005).

Part D assessed the QoL among dementia caregivers by employing the

WHOQOL – BREF. The WHOQOL- BREF in this study was used based on the

WHOQOL-100 that was tested and validated by Huong (2009) in the Vietnamese

context. Three hundred and ninety senior people in the Haiduong province, Vietnam

participated in this study. The Cronbach’s alpha value was 0.93 and the test-retest

reliability was 0.87 (Huong et al., 2009). This research instrument was popularly

used in measuring Quality of life (Opara, 2012). This worldwide measurement is a

multi-dimensional scale, is inclusive of cross-cultural considerations and is evaluated

along with the meaning to participants of various aspects of life (Skevington et al.,

2004). Furthermore, WHOQOL-BREF has been used in the assessment of the quality

of life of normal people as well as dementia caregivers. This instrument includes 26

items that are rated on a five point-scale, where (1) is completely unsatisfied, (2)

59
unsatisfied, (3) neither satisfied nor dissatisfied, (4) satisfied, and (5) very satisfied.

The WHOQOL-BREF investigates four domains, namely, Physical, Psychological,

Social relationship and Environment. The Physical domain contains seven items in

WHOQOL-BREF (questions 3, 4, 10, 15, 16, 17, & 18). The theoretical scores of

this domain are 7 – 35 (0 – 100 transferred/standardised score). The Psychological

domain is measured on six items (questions 5, 6, 7, 11, 19, & 26) with possible

scores from 6 to 36 (0 – 100 transferred/standardised score). The Social relationship

domain includes three items (questions 20, 21, & 22), with achievable scores from 3

to 15 (0 – 100 transferred/standardised score). The Environment domain comprises

eight items (question 8, 9, 12, 13, 14, 23, 24, & 25), with a potential total from 8 to

40 (0 – 100 transferred/ standardised score).

The Caregiver Burden Interview and Sense of Coherence instrument were

subjected to forward and backward translation to ensure the accuracy of the tool

wording in the Vietnamese language. A bilingual Vietnamese colleague with

Master’s level English written and spoken competence translated the English version

of the tool into Vietnamese. The author and two primary Vietnamese language

speakers then reviewed the translation for accuracy and issues. The Vietnamese

version was then back translated into English by the bilingual colleague to ensure the

wording was accurate. A common strategy to ensure reliability of measurement,

especially for research purposes, is to replicate the measurements and evaluate the

degree of agreement (Beth & Robert, 1993). Reporting of Cronbach’s alpha

coefficient for internal consistency reliability of any scales or subscales used will be

employed. The analysis of the data then must use these to summate scales or

subscales, not individual items. Cronbach’s alpha does not provide reliability

estimates for single items (Gliem & Gliem, 2003). Ideally, the higher the value of

60
the index, the better it is. A value of Cronbach’s alpha above 0.5 can be acceptable

for internal consistency reliability (Black, 1999).

4. Data collection procedure

The list of people diagnosed with dementia, drawn from the Vietnamese

National Gerontology Hospital, was ordered by the date the record was registered.

The statistical Package for social sciences (SPSS) for Windows, version 19.0, with

the function of Random Number Generator, was employed to randomly select 172

potential participants from the Vietnamese National Gerontology Hospital. Those

initial participants were contacted by telephone to obtain verbal agreement for

participating in the study, as well as to make an appointment to meet with the

primary caregiver. This step was followed by two formal invitation letters that were

sent by the Faculty of Nursing and Midwifery at Hanoi Medical University. Three to

five days after delivering the first invitation letter with a copy of the consent form,

the second invitation letter was also activated. The reasons for sending 2nd formal

invitation letters within 5 days after the 1st invitations letters were sent were to

politely notify participants about the ongoing surveys as well as to allow sufficient

time for potential participants to receive their invitation letter via post. Two weeks

after delivering the first letter, phone calls were made to make appointments and to

allocate suitable times for participants. The participants chose a time that was

convenient for them to arrange individual appointments to complete the study

questionnaire in either their home settings, or in the community health station. The

data collection procedure is summarized in Figure 5, below:

61
 Data collection procedure
st nd
1 formal 2 formal Telephone call
invitation letter invitation letter

th rd th th
Day 0 Day 3 -5 Day 14

Figure 4. Data collection procedure

There were some people invited to participate who orally notified us via

telephone of their refusal to participate in the study 2 weeks after receipt of their

formal invitation letter. Consequently, the next participant in the potential list of

participants, provided by the SPSS program, was contacted. At the end of the data

collection process, 153 participants completed the research questionnaire. This

number of respondents was higher compared with the theoretical sample size

presented in section 2 of part I. There were 19 caregivers of people with dementia

who did not agree to participate in the study. The response rate in this study was

counted by the ratio of the number who completed the questionnaire (153) versus the

total number of potential participants (172). It was quite high, at 88.95%. The

recruitment process of participants is presented in Figure 6.

List of participant

Randomise sampling
Caregiver eligible and
invited
N= 172

Refused to participate
n=19

Caregivers completed and returned full set

of questionnaire
n= 153, response rate= 88.95%

62
 Figure 5. Recruitment process of the 1st survey

5. Data analysis
The Statistical Package for Social Sciences (SPSS) version 18 for Windows

was used to conduct data analysis for this research. The level of significance for all

analyses was set at less or equal to 0.05 (p≤0.05). The data was entered by the

primary researcher and a research assistant. Prior to analysing data, all variables

were examined for accuracy of data entry and missing values. First, frequencies and

percentages were calculated for each of the variables and the data was verified.

Kurtosis value was used to consider the distribution of target variables as normal. If

Kurtosis value is smaller or equal to 0.5, the applied tests will be parametric. If this

value is bigger than 0.5, the nonparametric test would be used.

Besides using descriptive tests, such as frequency and percentages, differential

tests were also applied. Students T tests for two groups or ANOVA (analysis of

variance) for more than two groups of independent variables was applied for normal

distribution continuous/scale dependent variables. The Mann Whitney U Test for two

groups or the Kruskal Wallist test for more than two groups of independent variables

was applied for binomial distribution continuous/scale dependent variables.

Moreover, bivariate statistics were conducted to examine the relationships between

two variables, especially among independent variables, the covariate or moderating

variables and dependent variables, depending on the research questions. Pearson’s or

the Spearman correlations were utilised to explore the strength of the relationship

between two scale variables. Pearson’s correlation is for normal distribution

continuous/scale dependent variables and Spearman’s Rho test is used for binomial

distribution continuous/scales dependent variables. This gives an indication of both

the dimension (positive or negative) and the strength of the relationship.

63
 To examine the effect of variables on QoL and caregiving burden among

dementia caregivers in this research, multiple-regression was utilised to predict the

perceived QoL and perceived burden of care. As the dependent variable in this study

is continuous, multiple regression analysis is the appropriate multivariate technique.

Variables were entered as predictors into the regression model. The equation for the

multiple linear models is as follows:

Y = B0 + B1X1 + B2X2 + ….+ BiXi

Where Y stands for quality of life among dementia caregivers at the time of

interview

B0 stands for intercept

Bi (i = 1, … i) stands for coefficient

Xi (i = 1, … i) stands for independent variable.

Statistical significance was set at p ≤.05.

Predictor variables used in models were several demographic characteristics of

people with dementia (age, gender) and their carer (age, gender, education level,

employment status), relationship with PWD, family income, care-recipient’s

functional activities (Barthel Index) and behavioural activities (Kingston

Standardized Behavioural assessment), duration with dementia, perceived caregiving

burden and Sense of Coherence total score.

6. Ethical considerations
All participant data was confidential and de-identified in the analysis and

reporting of study findings. Consenting participants were free to leave the study

whenever they wished and to request that their data not be used in the analysis.

Dementia caregivers who wanted to participate in the study signed the Consent

64
Form. This study was approved by the Queensland University of Technology Ethics

Committee (QUT Ethics Approval Number 1100001158) and the Hanoi School of

Public Health Ethical Committee (HSPH Ethics Approval Number 026/2011/YTCC-

HD3).

65
II. Results of the 1st survey

From November 2011 to January 7th 2012, 153 dementia caregivers completed

the questionnaire.

1. Descriptive profile of study participants and their care-receivers

1.1. The demographic characteristics of people with dementia and caregivers
Several demographic characteristics were collected, such as, age, gender,

education level of people with dementia and their caregiver (table 3.1).

Table 3. 1. Demographic characteristics of people with dementia and their

caregivers
People with dementia Caregiver

Age (mean, SD) 75.92 (11.63) 49.25 (13.95)

Gender (n,%)
Male 64 (41.8) 56 (36.6)
Female 89 (58.2) 97 (63.4)
Education profile (n,%)
Secondary school and lower 115 (75.2) 58 (37.9)
Senior high school 15 (9.8) 47 (30.7)
Junior college and above 23 (15) 48 (31.4)
Occupational profile (n,%)
Professional class 46 (30.1)
Businessman/woman 22 (14.4)
Worker 29 (19)
Farmer – Fisherman/woman 36 (23.5)
Armed force 3 (2)
Housewife 7 (4.6)
Other 9 (5.9)
The mean age of people with dementia in this study is 75.92 year (SD=11.61),

in which, oldest people with dementia was at 97 (0.7%) year and the youngest who

was diagnosed as vascular dementia, was at 34 (0.7%) year. Meanwhile, the mean of

dementia caregiver’s age is 49.25 year (SD=13.95). With regard to gender, women

with dementia made up larger proportion compared with males, 58.2% vs. 41.8%. In

the dementia caregiver group, male caregivers contributed a smaller part, 36.6% vs.

67
63.4%. Education levels of dyads of people with dementia and their caregiver were

categorised into secondary school or lower, high school, and junior college and

higher. The majority of people had only secondary school or lower, at 75.2%.

Meanwhile the education level of their caregiver was higher, 30.7% at senior high

school and 31.4% at Junior college and above.

1.2. Employment of dementia caregiver

Table 3.2 shows information related to dementia caregiver’s employment,

which includes the type of work they do and the distance from their home to the

office. Most of the caregivers had stable work (57.5%). Only 25 (16.3%) of people

were unemployed at the time of data collection. Only 59.2% of participants provided

information related to the time they spent commuting between their office and home.

Table 3. 2. Employment profile of dementia caregiver

Employment (n, %) n (%) Distance to office n (%)

Stable work 88 (57.5) < 10 minutes 38 (24.5)

Temporary work 24 (15.7) 10 – 30 minutes 40 (26.1)

Unemployment 25 (16.3) > 30 minutes 22 (7.2)

Missing 16 (10.5) Missing 64 (41.8)

1.3. Family financial income and caregiving hours

Information on family financial income and the number of family members

living in a household was collected to develop an understanding of the financial

status of caregivers and the possible cost required to care for people with dementia.

Nearly four fifths of respondents in this study reported their family monthly income

was 10 million VND or less ( $500 AUD). The mean number of household

members was 4.1 (SD: 2.17). 50% of participants reported that four family members

were living in the same house. Only one case had 20 people living in the same house.

Caregivers were asked to recall weekly caregiving hours, which were categorised

68
under eight options. 21.6% responders provided 10 hours of care or less to their

relative with dementia. Table 3.3 summaries these findings.

Table 3. 3. Family financial income and caregiving hours

Family income n (%) Caregiving hours weekly n (%)

< 5 million VND 73 (47.7) < 5 hours/week 13 (8.5)

From 5 – 10 million VND 48 (31.4) 5 – 10 hours/week 20 (13.1)
From 10 – 15 million VND 17 (11.1) 10 – 20 hours/week 32 (20.9)
From 15 – 20 million VND 9 (5.9) 20 – 30 hours/week 17 (11.1)
From 20 – 25 million VND 4 (2.6) 30 – 40 hours/week 11 (7.2)
> 25 million VND 2 (1.3) 40 – 50 hours/week 5 (3.3)
50 – 60 hours/week 14 (9.2)
> 60 hours/week 40 (20.6)

1.4. Kinship between caregivers and people with dementia

To investigate the kinship between those dyads, the researcher employed

multiple-choice questions, with answer options of spouse, parent, relative and others.

In this study, more than 2/3 (68%) of participants were caring for their parent who is

suffering from dementia. Nearly ¼ (25%) of responders were caring for their spouse

(husband or wife). There were four grandchildren who were caring for their grand-

parent with dementia. In addition, more daughters offered their care for parents than

sons (62.5% vs. 37.5%). A smaller number of husbands were taking care of their

wives, compared with wives taking care of their husbands (29.3% vs. 70.3%). Table

3.4 provides a summary of their responses.

Table 3. 4. Kinship between caregivers and people with dementia

Caregiver n (%)
Type of kinship Male Female Total
Spouse 11 (29.3) 26 (70.3) 37 (24.2)
Parent 39 (37.5) 65 (62.5) 104 (68.0)
Relative 5 1 6 (3.9)
Other 1 5 6 (3.9)

69
 2. Descriptive statistics of research variables and its comparison –
correlation test
2.1. Health profile of people with dementia health
The health profile of people with dementia was measured by the duration of the

dementia, the Barthel Index and Kingston Standardized behavioural assessment.

2.1.1. Duration with dementia

Duration of time with dementia was established by asking dementia caregivers

to recall when their family member first exhibited signs of dementia. Most of people

with dementia exhibited signs of the illness and were diagnosed with dementia

within the most recent five years. The mean (year) of the duration of dementia was

4.12 (SD=3.77) with a median of 3.0.

2.1.2. The Barthel Index and Kingston Standardized behavioural assessment

The reported mean of Barthel Index total score was 53.5 (SD: 30.24). 50% of

people with dementia had a Barthel Index total score of 55. There was a significant

difference in Barthel Index total scores depending on the number of hours spent

caregiving per week, at p <0.05 (FKruskal Wallist test = 15.815, p=0.001). This result

means that dementia caregivers spent less time caring for people with dementia when

the person with dementia was able to perform more or a higher level of activities of

daily living. The reported mean of the Kingston Standardized behavioural assessment

(KSBA) total score was 27.32 (SD: 10.94). 50% of people with dementia had a

KSBA total score of 27. According to the cut-offs proposed by Hopkins, Kilik, Day,

Bradford, and Rows (2006) the behavioural profile of people with dementia was

categorised based on the KSBA total score into level 1 for 5 PWD (3.3%), level 2 for

53 (34.6%), level 3 for 74 (48.4%) and level 4 for 21 (13.7%).

Relationship tests were also performed, with a significant correlation existing

between the measures of the Barthel Index and the Kingston Standardised

70
Behavioural Assessment (KSBA) and age and duration of dementia (table 3.5). The

negative correlative values for the care-recipient’s age and duration with dementia,

means that older people with dementia obtained lower scores on the Barthel index.

The shorter the duration of dementia the higher their score on the Barthel index is.

On the other hand, people with dementia in this study performed less functional

activities if they were older or had experienced symptoms of dementia for a longer

duration. There was a positive correlation between the duration of dementia with

KBSA scores. This result means that people with dementia in this study had more

behavioural indicators of dementia if they had suffered symptoms of dementia or

been diagnosed with dementia for a longer duration.

Table 3. 5. Correlation between Barthel Index and KSBA and characteristics of

people with dementia
People with dementia Barthel Index score KSBA
Age r = -0.187** r = 0.028
Duration with dementia r = -0.249** r = 0.178*

Note: Significant at *p<0.05, ** p< 0.01

2.2. Dementia caregiver
Self-report with sick/chronic disease among dementia caregivers was

investigated via yes/no questions. 44 (28.8) of participants reported with sick/chronic

diseases, while 108 (70.6) reported without sickness/chronic diseases.

2.3. Perceived caregiving burden

Zarit Burden Interview 22-item (ZBI) was utilised to measure the perceived

burden of caregiving. The Cronbach’s alpha value was employed to investigate the

reliability – internal consistency of the instrument. The Cronbach’s alpha for 22

items was 0.896, which indicated a high level of internal consistency for the ZBI

scale among Vietnamese dementia caregivers within this study. The mean of total

scores of ZBI among dementia caregivers was 30.56 (SD: 14.25), with the highest

71
score of 70 obtained. According to the cut-offs proposed by Hebert, Bravo, and

Preville (2000), burden was “little or no burden” for 51 caregivers (33.3%), “mild to

moderate burden” for 61 (41.2%), “moderate to severe burden” for 32 (20.9%, and

“severe burden” for 7 (4.6%).

Significant differences in Zarit Burden global scores were not found to be a

function of caregivers’ gender (28.23 for male vs. 31.90 for female, t = -1.54,

p=0.126), caregiver’s marital status (FANOVA= 1.117, p=0.344), caregivers’ self-

report with sick/chronic disease (31.80 for yes vs. 29.81 for no, t=0.78, p=0.436) and

relationship with people with dementia (FANOVA= 0.330, p=0.719). There was a

significant difference at p <0.05 in the Zarit Burden global score according to the

caregiver’s education level (38.90 for less or equal to primary school vs. 29.23 for

higher than primary school, t=2.963, p=0.004), employment status (FANOVA=4.523,

p=0.0013) and caregiving hours per week (FANOVA = 2.941, p=0.05).

Significant correlations existed between the Zarit Burden Global score and the

care-recipient’s Barthel Index, Care-recipient’s KSBA total score and duration with

dementia (table 3.6). Positive correlative values on the duration of dementia

symptoms/diagnosis means that the shorter the number of years since the dementia

appeared, the lower the score of burden they reported. Meanwhile, the negative

correlation on the care-recipient’s Barthel Index means that the higher level of

activities people with dementia were able to perform, the lower the degree of

caregiving burden for their caregiver.

72
Table 3. 6. Correlation between Zarit Burden interview and characteristics of
caregivers and people with dementia
Zarit Burden interview
Test value p value
Caregiver’s age r = -0.078 0.34
Duration with dementia r = 0.241 0.003**
Care-recipient’s Barthel Index r = -0.337 0.001**
Care-recipient’s KSBA total score r = 0.447 <0.001***

Note: Significant at ** p< 0.01

2.4. Sense of Coherence
Mean, standard deviation, median of three domains (Comprehensibility,

Manageability and Meaningfulness) and SOC total score are presented in Table 3.7.

Table 3. 7. Sense of Coherence sub-domains and Total score

Sense of Coherence
Mean Median Min Max

Comprehensibility (5 items) 24.32 (4.3) 10.0 10 32

Manageability (4 items) 16.88 (2.49) 17.0 10 25
Meaningfulness (4 items) 18.61 (2.88) 18 9 28
SOC total score (13 items) 59.82 (5.94) 60.0 29 76

There was a significant difference at p <0.05 in SOC total score according to

the caregivers’ gender (61.43 for male vs. 58.83 for female, t= 2.596, p=0.01). This

means that male caregivers had a higher score on SOC, or better problem solving

ability. Meanwhile, significant differences at p< 0.05 in SOC total scores were not

found to be associated with caregivers’ employment status (F(ANOVA) = 0.756,

p=0.472), caregiving hours per week (F(ANOVA) = 0.539, p=0.584), relationship with

people with dementia (F(ANOVA) = 1.055, p=0.37), and caregiver’s health status

(59.88 for yes vs. 59.83 for no, t= 0.05, p=0.96).

73
 Table 3.8 illustrates the test results of investigating the relationship between

SOC total score and caregiver’s age, care-recipient’s Barthel Index, duration with

dementia and caregiving burden (ZBI total score). Significant correlations existed

between SOC total score and care-recipient’s Barthel Index, Care-recipient’s KSBA

total score and ZBI total score. The inverted correlation on care-recipient’s KSBA

and ZBI total scores means that the more symptoms associated with the dementia or

the higher the level of caregiving burden, the lower the level of Sense of Coherence

their dementia caregiver appeared to have.

Table 3. 8. Correlation between caregivers’ Sense of coherence and

characteristics of caregivers and people with dementia
SOC total score
Test value p value

Caregiver’s age r = -0.08 0.326

Duration with dementia r = -0.115 0.126
Care-recipient’s Barthel Index r = 0.170 0.036*
Care-recipient’s KSBA total score r = -0.246 0.002**
ZBI global score r = -0.202 0.012*

Note: Significant at * p< 0.05, ** p< 0.01

2.5. WHOQOL-BREF
WHOQOL-BREF score was divided into 4 domains, including Physical (7

items), Psychological (6 items), Social relationship (3 items), and Environment (8

items). Among these domains, the two highest average standardised scores were

Social relationships (mean 65.22, SD=13.41, median=69), and Environment (mean

64.48, SD=13.02, median=63). The lowest average standardised scores were

Physical (mean 61.11, SD=13.84, median=63) and Psychological (mean 61.91,

SD=13.05, median=56). Cronbach’s alpha was 0.888 overall for this scale and it

ranged from 0.551 to 0.762 for the 4 domains. Table 3.9 summarises the scores and

the Cronbach’s alpha values for each domain among dementia caregivers. The

74
Cronbach’s alpha for 26 items of WHOQOL-BREF is 0.888, which indicates a high

level of internal consistency for the WHOQOL-BREF scale among Vietnamese

dementia caregivers in this study.

Table 3. 9. WHOQOL-BREF domain scores

Cronbach's WHOQOL – BREF (Mean, SD)
Alpha
Raw score Transferred score
Physical domain 0.762 24.12 (3.9) 61.11 (13.84)
Psychological domain 0.761 20.85 (3.14) 61.91 (13.05)
Social relationship domain 0.551 10.82 (1.59) 65.22 (13.41)
Environment domain 0.748 27.05 (4.13) 64.48 (13.02)

Table 3.10 presented the correlation tests among WHOQOL-BREF domains

and other variables. The relationship tests were performed with significant

correlations existing between those domains with Caregiver’s real age, duration with

dementia, ZBI total score and SOC total score. Caregiver’s real age, duration with

dementia and ZBI total score has negative correlational values with WHOQOL-

BREF domains. Only SOC total scores had positive relationship values.

Table 3. 10: Correlation between WHOQOL-BREF domains and characteristics

of caregivers and people with dementia
WHOQOL-BREF (M, SD)
Physical Psychological Social Environment
relationships
Caregiver’s age -0.451** -0.169* -0.102 -0.097
Duration with dementia -0.217** -0.252** -0.193* -0.246**
Care recipient’s Barthel Index 0.148 0.246** 0.246** 0.226**
Zarit Burden Interview -0.29** -0.447** -0.343** -0.351**
SOC total score 0.153 0.391** 0.443** 0.280**

Note: Significant at * p<0.05, ** p< 0.01

The differences between WHOQOL-BREF domains (Physical, Psychological,

Social activity and Environment) and caregiver’s gender, education level,

75
employment status, health status were also examined (table 3.11). There was a

difference in the mean scores of WHOQOL-BREF in some subgroups. Female

caregivers reported lower values in almost all QoL domains, compared with males.

Dementia caregivers with lower education presented lower values in all domains of

the WHOQOL-BREF when compared with those who reported higher education

levels. People with stable work reported higher values in all areas of the WHOQOL-

BREF than those without stable work.

Table 3. 11: Differential tests on WHOQOL-BREF domains

WHOQOL-BREF (M, SD)
Physical Psychological Social Environment
relationships
Caregiver’s Gender t=2.196** t=2.432** t=0.775 t=0.334
Male 64.33 (14.94) 65.23 (11.82) 66.33 (13.35) 61.96 (11.93)
Female 59.24 (12.88) 59.98 (13.4) 64.55 (13.37) 61.21 (13.65)
Caregiver’s education level F=7.798** F=4.165* F=3.859* F=8.354***
Primary school & lower 50.50 (11.74) 54.52 (10.89) 58.70 (9.84) 51.05 (14.41)
Secondary and high school 61.94 (12.25) 63.47 (13.57) 65.01 (13.75) 62.49 (12.83)
Junior College & higher 64.1 (15.24) 62.46 (12.12) 68.49 (13.29) 64.06 (10.73)
Sick/ chronic disease reported t=-7.577*** t=-3.361** t=-1.556 t=-2.391*
Yes 49.98 (8.74) 56.44 (8.86) 62.63 (11.38) 57.86 (12.22)
No 65.91 (12.6) 64.44 (13.36) 66.44 (13.94) 63.26 (12.64)
Employment status F=2.852 F=13.032*** F=6.613** F=8.138***
Stable work 62.72 (12.52) 65.97 (13.04) 67.56 (13.09) 64.72 (12.82)
Temporary work 61.92 (15.11) 52.04 (10.91) 56.82 (12.3) 53.96 (12.6)
Unemployment 55.44 (15.16) 58.08 (12.45) 61.33 (14.72) 56.96 (10.74)

Note: Significant at * p<0.05, ** p< 0.01

3. Multivariate analysis
3.1. Multivariate analysis to predict perceived caregiving burden
A multiple regression analysis, via the stepwise method, was conducted to

determine the best linear combination of the mentioned predictor variables for

predicting the perceived burden of caregiving. The mean, standard deviation, and

76
correlations between variables can be found in table 3.12. This combination of

variables significantly predicted ZBI total score, F4,128 = 14.335, p<0.001, with all

four variables significantly contributing to the prediction. The beta weight, presented

in table 3.13, suggests that people with dementia who had a higher score on KSBA

(dementia behavioural profile) contributed most to predicting perceived caregiving

burden, had been diagnosed with the disease earlier, and had a lower education level.

The caregiver’s age also contributed to this prediction. The adjusted R squared value

was 0.288. This indicates that 28.8% of the variance in ZBI total score was explained

by the model.

Table 3. 12. Means, SD and correlations for ZBI total score and predictor
variables (N=133)
Variable M SD 1 2 3 4

ZBI total score 30.09 13.82 0.465*** 0.313*** 0.258** -0.141

Predictor variable
1. KBSA 27.47 11.42 - 0.158* 0.21** -0.071
2. Duration with dementia 4.32 3.9 - 0.207** -0.003
3. Education level (1 ≤Primary school) 0.13 0.335 - 0.215**
4. Caregiver’s real age 47.85 12.81 -

Table 3. 13. Simultaneous multiple regression analysis summary for ZBI total
score in KBSA, Duration with dementia, education level, caregiver’s age
Variable B SEB β

KSBA 0.464 0.092 0.384***

Duration with dementia 0.683 0.271 0.193*
Education level 7.831 3.204 0.190*
Caregiver’s real age -0.166 0.082 -0.154*
Constant 21.33 4.92

Note. R2 = 0.288; F4,128 = 14.335, p<0.001

** p< 0.01, *** p<0.001
3.2. Multivariate analysis to predict quality of life among dementia caregiver
3.2.1. WHOQOL-BREF – Physical domain
Multiple regression analysis, via the stepwise method, was conducted to

determine the best linear combination of mentioned predictor variables for predicting

77
scores on the WHOQOL- BREF (Physical domain). The mean, standard deviation,

and correlations between variables can be found in table 3.14. This combination of

variables significantly predicted WHOQOL- BREF (Physical domain),

F3,127 = 23.138, p<0.001, with all three variables significantly contributing to the

prediction. The beta weight, presented in table 3.15, suggests that younger caregivers

contributed most to predicting scores on the WHOQOL-BREF (Physical domain),

and that being female, and having a lower perceived caregiving burden also

contributed to this prediction. The adjusted R squared value was 0.338. This

indicates that 33.8% of the variance in WHOQOL-BREF (Physical domain) was

explained by this model.

Table 3. 14. Means, SD and correlations for WHOQOL- BREF (Physical

domain) and predictor variables (N=132)
Variable M SD 1 2 3

WHOQOL-BREF: Physical domain 24.12 3.87 0.175* -0.443*** -0.281**

Predictor variables
1. Caregiver’s real age 47.85 12.84 - 0.77 -0.143
2. Caregiver’s gender (1=Male, 0=Female) 0.38 0.49 - -0.68
3. Zarit Burden Interview 30.40 13.69 -

Table 3. 15: Simultaneous multiple regression analysis summary for

WHOQOL-BREF (Physical domain) in caregiver gender, caregiver’s real age,
Zarit Burden Interview
Variable B SEB β
Caregiver’s real age -0.153 0.22 -0.506***
Caregiver’s gender (1=Male, 0=Female) 1.531 0.568 0.191***
Zarit Burden Interview -0.096 0.020 -0.34**
Constant 33.767 1.325

Note. R2 = 0.338; F3,127 = 23.138, p<0.001

** p< 0.01, *** p<0.001
3.2.2. WHOQOL-BREF – Psychological domain
Multiple regression analysis, by stepwise method, was conducted to determine

the best linear combination of mentioned predictor variables for predicting

78
WHOQOL- BREF (psychological domain). The mean, standard deviation, and

correlations between variables can be found in table 3.16. This combination of

variables significantly predicted WHOQOL- BREF (psychological domain), F5,126 =

17.775, p<0.001, with all five variables significantly contributing to the prediction.

The beta weight, presented in table 3.17, suggests that lower caregiving burden (Zarit

Burden interview total score) contributes most to predicting WHOQOL-BREF

(psychological domain), and that having a higher Sense of Coherence score,

caregivers with stable work, younger caregivers and suffering with dementia for a

shorter duration of time, also contributed to this prediction. The adjusted R squared

value was 0.39, indicating that 39% of the variance in WHOQOL- BREF

(Psychological domain) was explained by this model.

Table 3. 16: Means, SD and correlations for WHOQOL- BREF (Psychological

domain) and predictor variables (N=133)
Variable M SD 1 2 3 4 5

WHOQOL-BREF:
20.89 3.27 -.175* .377*** -.306*** -.439*** .390***
Psychological domain
Predictor variables
1. Caregiver’s real age 47.9 12.84 - -.262** -.036 -.143 -0.005
2. Caregiver’s employment
0.64 0.48 - -.044 -.175* .091
status (1=Stable, 0=other)
3. Duration with dementia 4.03 3.83 - .283*** -0.15
4. Zarit Burden Interview 30.14 13.86 - -.232**
5. Sense of coherence 59.87 5.87 -

* p<0.05, ** p< 0.01, *** p<0.001

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Table 3.17. Simultaneous multiple regression analysis summary for WHOQOL-
BREF (Psychological domain) in caregiver’s real age, caregiver’s employment
status, Duration with dementia, Zarit Burden Interview and Sense of coherence
Variable B SEB β
Caregiver’s real age -0.037 0.18 -0.147*
Caregiver’s employment status (1=Stable, 0=other) 1.707 0.492 0.252**
Duration with dementia -0.146 0.061 -0.171*
Zarit Burden interview -0.072 0.018 -0.304***
Sense of coherence 0.152 0.039 0.274***
Constant 15.22 2.773

Note. R2 = 0.39; F5,126 = 17.775, p<0.001

* p<0.05, ** p< 0.01, *** p<0.001
3.2.3. WHOQOL-BREF – Social relationships
Multiple regression analysis, using the Stepwise method, was conducted to

determine the best linear combination of mentioned predictor variables for predicting

WHOQOL- BREF (Social activities domain). The mean, standard deviation, and

correlations between variables can be found in table 3.18. This combination of

variables significantly predicted the Social Relationship domain of the WHOQOL-

BREF at F3,122 = 13.153, p<0.001 with all three variables. The beta weight,

presented in Table 3.19 suggests that lower caregiving burden contributed most to

predicting WHOQOL-BREF- Social relationships, and that having a higher Sense of

Coherence score and a caregiver with stable work also contributed to this prediction.

The adjusted R squared value was 0.226. This indicated that 22.6% of the variance in

WHOQOL- BREF (social relationships) was explained by the model.

80
Table 3.18. Means, SD and correlations for WHOQOL- BREF (Social
relationships) and predictor variables (N=127)
Variable M SD 1 2 3

WHOQOL-BREF: Social relationships 10.76 1.64 .299*** -.366*** .330***

Predictor variables
1. Caregiver’s employment status (1=Stable,
0.67 0.47 - -.178* .109
0=other)
2. Zarit Burden interview 29.79 13.81 - -.246**
3. Sense of coherence 59.84 5.93 -

* p<0.05, ** p< 0.01, *** p<0.001

Table 3. 19: Simultaneous Multiple regression analysis summary for
WHOQOL-BREF (Social relationships) in caregiver’s employment status, Zarit
Burden Interview and Sense of Coherence
Variable B SEB β

Caregiver’s employment status (1=Stable, 0=other) 0.780 .0277 0.226**

Zarit Burden Interview -0.032 0.01 -0.267**
Sense of coherence 0.066 0.022 0.240**
Constant 7.228 1.451

Note. R2 = 0.226; F3,122 = 13.153, p<0.001

* p<0.05, ** p< 0.01, *** p<0.001
3.2.4. WHOQOL-BREF – Environment domain
Multiple regression analysis, by stepwise method, was conducted to determine

the best linear combination of mentioned predictor variables for predicting

WHOQOL- BREF (Environment domain). The mean, standard deviation, and

correlations between variables can be found in table 3.20. This combination of

variables significantly predicted WHOQOL- BREF (Environment domain),

F3,128 = 15.164, p<0.001, with all three variables significantly contributing to the

prediction. The beta weight, presented in Table 3.21, suggests that lower caregiving

burden (Zarit burden interview) contributed most to predicting WHOQOL-BREF

(Environment domain), and that being a caregiver with stable work and suffering

dementia for a shorter duration also contributed to this prediction. The adjusted R

squared value was 0.245 which indicated that 24.5% of the variance in WHOQOL-

BREF (Environment domain) was explained by the model.

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Table 3. 20. Means, SD and correlations for WHOQOL- BREF (environment
domain) and predictor variables (N=133)
Variable M SD 1 2 3

WHOQOL-BREF: environment domain 27.04 4.1 .336*** -.388*** -.30***

Predictor variables
1. Caregiver’s employment status (1=Stable,
0.64 0.48 - -.189* -.045
0=other)
2. Zarit Burden Interview 30.19 13.82 - .287***
3. Duration with dementia 4.0 3.84 -

* p<0.05, ** p< 0.01, *** p<0.001

Table 3. 21. Simultaneous Multiple regression analysis summary for
WHOQOL-BREF (social activity domain) in caregiver’s employment status,
Duration with dementia, Zarit Burden Interview
Variable B SEB β

Caregiver’s employment status (1=Stable, 0=other) 2.341 0.66 0.274**

Zarit Burden Interview -0.082 0.024 -0.277**
Duration with dementia -0.223 0.085 -0.208*
Constant 28.9 0.94

Note. R2 = 0.245 F3,128 = 15.164, p<0.001; * p<0.05, ** p< 0.01, *** p<0.001

III. Discussion on findings of 1st survey

1. Characteristics of participants
There were fewer male caregivers of people with dementia in this study (36.6%

for male vs. 63.4% for female). This ratio was similar with other studies conducted in

Asia countries, for example, in India men accounted for 43.3% of caregivers (Raman

Deep Pattanayak et al., 2011), or in Taiwan, where men accounted for 45.6% of

caregivers (C. C. Fan & Chen, 2011). More than 2/3 (68%) participants were caring

for their parent who was suffering from dementia. Nearly ¼ (25%) of respondents

were caring for their spouse (husband or wife). In addition, there were four

grandchildren who were caring their grandparent with dementia. Despite similar

findings in previous research within Asia countries (Wong et al., 2012), the findings

of the current study contradicted the findings of previous studies in Western

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countries, where, for instance, spouses made-up a major part of caregivers, with a

percentage of 68% in America (Mausbach, Harmell, Moore, & Chattillion, 2011), or

72.6% in Ontario, Canada (Bartfay & Bartfay, 2013). The difference might be related

to the theory of Confucianism in Asian cultures, whereby caring for parents when

they become older is considered the major duty of the children, especially the son. It

is regarded as a sense of duty and love toward parents, and a recognition of parents’

needs was also evident in Vietnamese caregivers (Strumpf, Glicksman, Goldberg-

Glen, Fox, & Logue, 2001). Love and support from relatives and family members

was extremely important for those people with dementia (Mok et al., 2007). It is

clearly important to further develop an understanding of what motivates caring

behaviours for carers who have parents with dementia in Asia cultures, especially

among Vietnamese caregivers.

2. Perceived caregiving burden

According to the cut-offs, proposed by Hebert, Bravo, and Preville (2000),

burden was “little or no burden” for 51 caregivers (33.3%), “mild to moderate

burden” for 61 (41.2%), and “moderate to severe burden” for 32 (20.9%, and

“severe burden” for 7 (4.6%). Nearly one-third of respondents had little or no

burden. More than a quarter of participants were suffering from moderate or higher

distress. These rates are considered higher compared with those of other studies

(Andren & Elmstahl, 2008; Mohamed et al., 2010).

The correlation between caregivers’ gender and burden was inconsistent

among previous research studies. Andren and Elmstahl (2008), Chappell and Reid

(2002) and Mohamed and colleagues (2010) pointed-out that gender was not

statistically associated with burden of care, at p<0.05. Meanwhile, Campbell and

colleagues (2008), and Kim and colleagues (2009) confirmed high correlations

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existed between caregivers’ gender and perceived caregiving burden. Although

results of this study showed that the correlation between carers’ gender and

caregiving burden was not statistically significant, female caregivers reported higher

burden, compared with male carers. Female carers usually handle hygiene, such as

cleaning house, basic care and preparation of nutrition and food for PWD who need a

high level of care (Allen, 1994). In addition, the most common source of carers in

this study is from daughters or sons of PWD (68%), and in Vietnam it was 74.2% (L.

Nguyen & Nguyen, 2010). Therefore, female carers experienced higher burden.

Concordant with previous studies (N. L. Chappell & Reid, 2002; Kim et al.,

2009), caregiving burden was found to be statistically significantly correlated with

education level and caregiving hours. Caregivers with lower education suffered

higher burden. The longer hours of caregiving, the higher the perceived burden

dementia caregivers experienced.

Consistent with previous studies, a significant relationship was found between

the Zarit Burden interview Global scores and care-recipient’s Barthel Index (Berger

et al., 2005; Kim et al., 2009) as well as the Care-recipient’s KSBA total score

(Berger et al., 2005; N. L. Chappell & Reid, 2002) and time since the emergence of

dementia symptoms/diagnosis of dementia. The positive correlation on the time since

the emergence of dementia symptoms/diagnosis with dementia, means that the

shorter the amount of time since the emergence of any signs of dementia/diagnosed

with dementia, the lower the score of burden. Dementia caregivers in this study

experienced a lower level of caregiving burden if their care-recipients had a shorter

duration of dementia symptoms/diagnosis of dementia. In addition, high KSBA

scores among people with dementia were correlated with burden. The higher

behavioural profile, the higher the degree of distress experienced by carers.

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Meanwhile, the negative correlation on the care-recipient’s Barthel Index means that

the lower the deficits in activities of daily living among those PWD, the lower the

level of caregiving burden for caregivers.

Studies’ results on the relationship between care-recipients’ behavioural

activities, activities of daily living scores and perceived caregiving burden have been

consistent. Coyne and colleagues (Coyne et al., 1993) and Kim, et al. (2009)

indicated that caregivers displayed higher burden scores when people with dementia

perform worse on activities of daily living and function. The result of this study

indicated that the burden on caregiving increased as the behavioural profile score

increased (as indicated by the Kingston Standardised behavioural assessments), and

also, as functioning activities decreased (as marked by the Barthel Index). This

finding provides corroborating evidence for the findings of previous studies (Coyne

et al., 1993; Kim et al., 2009), which is that longer-term cognitive reduction and

behavioural changes due to dementia, as measured by more marked difficulties in

independently performing activities of daily living and more marked disturbances in

behaviour, are significant factors that weigh on the burden of care.

Caregiving burden (measured by the Zarit Burden Interview) was highly

inversely correlated with Sense of Coherence. This result means that the higher the

burden of care, the lower the level of Sense of Coherence their dementia caregivers

experienced, or the poorer the coping strategies performed by those carers. These

findings corroborate previous studies, especially with research conducted by Andren

and Elmstable (2008) and Antonovsky (1993), who confirmed that people with

higher SOC have better coping ability and more resources. Family income and

burden of care were not found to be significantly different statistically in this study,

but families with lower income seemed to experience a higher burden compared with

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higher income families. This finding is concordant with results of previous studies

(Kim et al., 2009).

From the regression analysis, 28.8% of the variance in ZBI total scores was

explained by the model. The strongest predictor of caregiving burden within the

model was the behavioural profile of PWD (presented by the Kingston Standardised

behavioural assessment), where fewer behavioural anomalies associated with

dementing-type illness predicted lower burden. The second largest contributor of

variance to the model is duration of dementia (the duration of time since the first

appearance of dementia symptoms). This result suggests that people caring for PWD

for a longer duration are predicted to experience a higher burden. The third largest

predictor variable was education level, where people with a higher education level

experienced a lower caregiving burden. Another indicator of burden from this model

was the caregiver’s real age. These findings in regards to burden were found using a

population of 153 participants living in Hanoi. The question is whether these results

would be replicated in different populations, with participants from different

economic and cultural backgrounds. It is considered prudent to expand the study by

recruiting more participants within a larger study area. Conducting similar research

across different populations would increase the generalizability of these findings,

which would be useful in order to better understand the burdens and needs of carers

of PWD in other populations.

3. Quality of life
As mentioned in Chapter 2, most previous studies have examined quality of

life among dementia caregivers in terms of health-related quality of life. The current

research investigated quality of life by using WHOQOL-BREF, which contains four

dimensions, namely Physical, Psychological, Social activities and Environment.

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Among these domains, the two highest average standardised scores were Social

Relationship, and Environment. The lowest average standardised scores were

Physical and Psychological.

Results on quality of life across the four domains (Physical, Psychological,

Social activities and Environment) among respondents in this study were much lower

than those among people with other types of diseases and healthy controls, as

evidenced by results across the four domains in a study conducted in the UK by

Skevington and McCrate (2012): Physical (76.49±16.19), Psychological

(67.82±15.56), Social Relationship (70.52±20.67), and Environment (68.20±13.8).

Nevertheless, findings in this study are quite similar to results of carers of elderly

people in the Skevington and McCrate (2012) study: Physical (61.53±20.87),

Psychological (65.78±14.56), Social relationship (61.68±20.34), and Environment

(68.95±14.67). Furthermore, results of this study are not different to findings from

research conducted by Cruz, Polanczyk, Camey, Hoffmann and Fleck (2011) on QoL

in a general population sample in Brazil: Physical (58.9±10.5), Psychological

(65.9±10.8), Social relationship (76.2±18.8), and Environment (59.9±14.9).

Moreover, mean scores in this study for the four domains were higher than those of

dementia caregivers in New Delhi, India (Raman Deep Pattanayak et al., 2011). The

mean scores on QoL were calculated for Physical (14.27±2.52), Psychological

(13.04±3.10), Social (13.00±2.93) and Environmental (13.61±2.84) domains, with a

maximum possible score of 20 in each domain. The mean values for Physical health,

Psychological, Social relationship and Environmental domains of the WHOQOL-

BREF among caregivers of the mentally ill within a sample in China, were

13.74±2.30, 12.06±2.63, 12.80±2.15, and 12.23±2.41, respectively (C. C. Fan &

Chen, 2011). Obviously, quality of life among dementia caregivers in this research is

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lower than normal people in the UK, but is comparable with a general sample in

Brazil. However, dementia caregivers in India and caregivers of mental illness

patients in Taiwan experienced poorer QoL than those in this study. Findings on

Quality of life in the current study were moderately high for both male and female

respondents, as domain standardised means ranged from 59 to 66 out of 100. These

results confirmed results of previous studies (Cruz et al., 2011; Skevington &

McCrate, 2012) in regards to the relationship between gender and education level.

Men reported better QoL than women and more highly educated participants

experienced greater QoL across all domains.

Multiple linear regressions were used to predict scores on each of the QoL

domains (Physical, Psychological, Social activities and Environment). For the

physical domain of WHOQOL-BREF, the perceived burden of caring (measured by

Zarit Burden Interview) was predicted by being a female caregiver and by the

caregivers’ age. Perceived caregiving burden, sense of coherence, duration of

dementia, stable employment status and caregivers’ age were significant predictors

for calculating scores on the Psychological domain of WHOQOL-BREF. For the

Social activities domain of WHOQOL-BREF, perceived caregiving burden, Sense of

Coherence and stable employment were significant predictors. Finally, perceived

burden, duration of dementia, and stable employment status were significant

predictors of the Environment domain of the WHOQOL-BREF. Each of the

measured variables significantly contributed to the calculation of QoL domains.

Caregiving burden significantly predicted QoL for each of the four domains, while

caregiver’s stable employment was also a significant predictor of QoL, except for the

Physical domain. Therefore, this study’s findings confirmed the results of a previous

study conducted by Gavrilova and colleagues (2009), which focused on improving

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QoL for dementia caregivers in Moscow and Russia, a study conducted by Wong,

Lam Chan and Chan (2012) on caregivers of psychiatric patients living within a

community in Hong Kong, as well as the results of Fan and Chen (2011) for

caregivers of the mentally ill in a Chinese population.

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 Chapter 4: THE 2nd SURVEY – PHASE 2

QUALITY OF LIFE AND CAREGIVING BURDEN AMONG

CAREGIVERS OF PEOPLE WITH DEMENTIA IN HANOI, BAC NINH AND

HAI PHONG, VIETNAM

I. Introduction

As mentioned in the discussion of the findings for the 1st survey (chapter 3),

this research was conducted with a relatively small number of participants (153

caregivers of PWD) in a single city, Hanoi, the capital of Vietnam. Participants

demonstrated higher burden and lower quality of life. This survey attracted

caregivers who were spouses or children of people with dementia. The non-

significant results might be partly due to the lower power of detecting differences

between/among groups due to the smaller sample size.

In evaluating the antecedent conditions of appraisal in the stress and coping

model, four subdomains of Environmental factors (demand, constraints,

opportunities and culture) that affect stress and emotion are considered. These four

substantive variables interacted with personal characteristics through the appraisal

process of the model (Lazarus, 2006, p. 61). Demand factors in the Environmental

domain cover the potential or obvious internal or external pressures or stress from the

environment to perform suitable behaviours. Those demands would be explained as

multi-faceted needs that include to love and be loved, to be respected and admired

and to be concerned with the well-being of an individual or their family (Lazarus,

2006, p. 62). Environmental demands and the conflicts created by personal goals and

beliefs would be the definitive source of stress, which is impacted by social

functioning and physical well-being. In contrast with environmental demands, the

90
constraints domain of Environment clarifies unsuitable behaviours, or what people

should not do. Those demands and constraints of the environment are compared with

the rules and regulations inherent in societal laws. The opportunities of the

Environmental domain, influenced the appraisal process, emerge from the timing of

good fortune and the personal wisdom of recognising chances and taking advantage

of them (Lazarus, 2006, p. 63). Culture, the last subdomain of Environment, has been

researched recently. Cultural differences have been identified, namely that

individualism is prevalent in Western societies, while collectivism is prevalent in

Asian societies. This cultural difference has been shown to have a major impact on

the emotional life of a person. Further, individualism versus collectivism has also

been shown to differ across societies and individuals (Lazarus, 2006, p. 64). The

variations among cultures and persons who are exposed to those cultures emerge as

the result of differences in cultural views about human relationships, which are

translated at the individual level. These cultural differences would lead to varying

emotional responses among different cultures. Furthermore, the stress and coping

theory, developed by Lazarus and Folkman (1984), utilised as a conceptual

framework for this study, discussed the contribution of cultural aspects of stress,

coping and wellbeing as well as the emotional life of a person.

Caregiving was shown to have negative effects on caregivers, including a

higher risk of incident and onset of cardiovascular disease (Capistrant, Moon,

Berkman, & Glymour, 2012), lower physical heath (Tremont, 2011) and higher

mortality rate than non-caregivers of the same age (Richard Schulz & Beach, 1999).

Previous studies were focused on identifying the negative consequences of

caregiving (Alliance, 2001) and the burden of caregiving, which are associated with

longer caregiving hours (Bergvall et al., 2011; Casado & Sacco, 2012), a lower sense

91
of coherence (Andren & Elmstahl, 2008; Gallagher et al., 1994; Kuroda et al., 2007;

Valimaki et al., 2009), and lack of abilities of people with dementia to perform

activities of daily living/instrumental of activities of daily living. There were very

few studies that explored the value of positive domains of caregiving. Cohen,

Colantonio and Vernich (2002) revealed that 73% of caregivers involved in their

study recognised at least one of following positive aspects of caregiving:

duty/obligation, companionship, fulfilling/rewarding, provide quality of life,

enjoyment, meaningful, love, and important. Caregivers with more positive feedback

from caregiving tended to not report burden, depression and poor health. Caregivers

of Alzheimer’s disease in America who possessed higher levels of anxiety had lower

scores on positive aspects of caregiving (Roff et al., 2004). The positive aspects were

reported to improve the caregiver’s well-being and decrease the burden of the

caregiving role for dementia caregivers (Carbonneau, Desrosiers, & Caron, 2010).

Research conducted with caregivers of people with Schizophrenia in the North of

India revealed a positive correlation between positive aspects of caregiving and

quality of life domains (Kate, Grover, Kulhara, & Nehra, 2013). No further studies

investigated the correlation between quality of life and positive aspects of caregiving

among dementia caregivers.

Filial piety has been defined as one important aspect of Vietnamese culture.

The concept of filial piety classically referred to the highly hierarchical relationships

that exist between parents and their children (Malarney, 2002, p. 112). Filial piety in

Vietnamese culture also dictates that children should try to do the best thing for their

parents in order to repay their parents’ sacrifices for them. The traditional structure

of Vietnamese families is underscored by the duty of children to respect and obey

adults, the expectation of women to defer to men, and further, elderly people must

92
always be respected. (Braun, Takamura, & Mougeot, 1996). Moreover, children are

expected to demonstrate filial piety towards their parents, living or dead (Bond,

1996). Filial piety encompasses love, respect, sacrifice and taking care of not only

their parents, but also their ancestors. Behaviors of children towards their parents are

guided and manipulated within the framework of filial duty. Among secondary

Chinese pupils in Hong Kong, life satisfaction, self-esteem, and social competence

were highly correlated with their perceived relationships with their parents as well as

with two facets of children's filial piety beliefs, namely Reciprocity and

Authoritarianism. Children with higher reciprocal filial beliefs appear to be more

motivated to support and care for their parents. They showed a higher appreciation

for their parents’ efforts in raising them (Nga-man Leung, Siu-fong Wong, Wai-yin

Wong, & McBride-Chang, 2010). Chinese male students from both Hong Kong and

Beijing had significantly higher scores on measures of positive filial attitudes than

female students did, while the distribution of filial piety between the two genders

was similar. Attitudes on filial piety were a powerful predictor of filial behavior, and

Social belief and self-construal were also significant predictors of filial behavior

(Chen, Bond, & Tang, 2007). Moreover, using the structural equation model, the

caregiving burden of elderly Chinese Canadian caregivers was directly explained by

caregiving appraisal and stressors (including caregivers’ health, ADLs and IADLs

caring task), and the caregiving burden was indirectly predicted with filial piety (D.

W. L. Lai, 2010). Although the meaning of filial piety has been discussed within

Vietnamese contexts (Duc, 2009; Tho, 2011; Thua, 2009), no research in Vietnam

has been found that addresses the relationship between quality of life and filial piety.

Therefore, it is important to investigate the impact of positive aspects of caregiving

and filial piety on quality of life among dementia caregivers within Vietnam.

93
 The specific aims of this research are in the context of primary carers of

persons with dementia in three provinces within Vietnam in order to:

- Describe characteristics of PWD and primary carers;

- Describe carer’s perceived burden of care;

- Describe the perceived QoL of carers;

- Explore the associations between family carer characteristics, perceived

QoL, perceived burden of care and care recipient characteristics with

the contribution of place of residence, positive aspects of caregiving

and filial piety.

To accomplish these objectives, results in this phase need to answer the

following research questions:

1. What characteristics of PWD in the three provinces are similar?

2. What characteristics of dementia caregivers in the three provinces are

similar?

3. What is the level of caregiving burden and quality of life among

dementia caregivers?

4. What is the contribution of place of residence of study participants in

predicting quality of life, using a similar approach used in the 1st

survey?

5. What is the contribution of filial piety and positive aspects of

caregiving in predicting quality of life?

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 Research framework
Similar to the 1st survey, the following research framework is based on the

literature review, and a synthesis of the Quality of Life by Ferrans (1996) and a

theoretical model by Lazarus and Folkman (1984). In this survey, the antecedent

variables were divided into caregiver variables (gender, age, education, relation to

people with dementia, caregiving status) and people with dementia variables (age,

gender, duration suffering from dementia). Perceived caregiving burden, Sense of

Coherence, Filial piety and Positive aspects of caregiving were examined as potential

mediating variables between causal antecedents and caregivers’ Quality of life. In

this study, the coping process was not covered, because Lazarus (2006, p. 101)

highlighted that coping is a continuous process in managing psychological stress,

which requires a longitudinal study design. Because of this, a cross-sectional study

design was utilised in this study. It is important to note that the cross-sectional design

of this study hindered investigation of the caregiver’s coping processes.

95
Figure 6: Modified research framework for the 2nd survey showing additive of Filial
Piety and Positive Aspects of Caregiving

II. Methodology

1. Study design
A cross-sectional correlation survey was utilised in the 2nd survey to:

investigate the quality of life and caregiving burden among primary caregivers of

those with dementia within three provinces in the North of Vietnam (Hanoi, Bac

Ninh and Hai Phong); explore the associations between care recipient, carer

characteristics and QoL; and compare these findings among the three provinces.

96
 2. Population, setting and sampling
The target population of this study were carers of people with dementia in

communities in Hanoi, Bac Ninh and Hai Phong. Hai Phong is a large city with an

important seaport in Vietnam. Hai Phong borders Quang Ninh Province to the north,

Hai Duong Province to the west, and Thai Binh Province to the south. With its wide

avenues and grand parks, lined with colonnaded buildings of a yellowed, aging

stucco, Haiphong is like a smaller, more manageable version of Hanoi. Hai Phong is

divided into six districts and eight rural districts, with a total surface area of 1,520.7

km2. The Population of Haiphong in April 2009 was 1.8 million. Bac Ninh is

a northern province of Vietnam, located in the Red River Delta. It is situated to the

east of Vietnamese capital, Hanoi, and borders Bac Giang province, Hung Yen

province, Hai Duong province, Vinh Phuc province, and Hanoi. Bac Ninh is divided

into six counties/ districts, one township and one city. Bac Ninh, with a total surface

area of 822.71km2, is the smallest of all provinces in Vietnam. The population of Bac

Ninh in 2010 was 1.034 million, and it has the highest population density compared

with any other provinces. 74.1% of Bac Ninh’s population live in the countryside and

25.9% live in urban areas (Department of Planning and Investment of Bac Ninh,

2012).

Hanoi and Hai Phong, located in the Red River Delta area in the North of

Vietnam, are categorised into two of five municipalities that are among the highest-

ranked cities in Vietnam. They share similar characteristics, such as being centrally

governed cities, their economic development is comparable, and they are both

important areas in terms of military, political, cultural, economic and social

motivation. Hanoi and Hai Phong are responsible for advancing the entire country,

rather than being confined in a province or inter-regions. Infrastructure, science and

97
technology are well developed and resourced in the two cities, with

many higher education institutions and universities, crowded populations with high

densities, and convenient transportation. The three provinces are chosen for

comparative purposes to compare results between respondents in major cities, versus

those living in rural areas, and to allow comparisons between areas with varying

levels of economic development and similar cultural backgrounds. The three

provinces are considered as among the largest economic development zones. There

are several reasons to explain why the three provinces were chosen. First, the three

provinces possess similar geographic and economic characteristics where they are

located in the Red River Delta Zone. The structure of agricultural land in the three

provinces is also similar: 56% in Hanoi; 54.58% in Hai Phong; and 58% in Bac

Ninh. The population density in Hanoi in 2012 was 2093 person/km2, meanwhile in

Hai Phong the density was 1253 person/km2 and in Bac Ninh the density was 1313

person/Km2. The Gross Domestic Product (GDP) growth rate in 2012 was similar:

8.1% for Hanoi and Hai Phong, and 12.3% for Bac Ninh. The GDP per capita index

in 2012 in Bac Ninh was 115.4%, Hai Phong 118%, and Hanoi, only 108.1%. (Bac

Ninh Statistical office, 2013; Hai Phong Statistical Office, 2013; Hanoi Statistical

Office, 2013). Second, the travel time between provinces is less than two hours. It

was not too difficult for the research team to access potential participants during the

data collection period. A similar reason was used to explain choosing the National

institute of gerontology as the place for their health check-up for those potential

participants. Moreover, the three chosen provinces have been considered as a

representative population of the Red River Delta area in Vietnam.

98
 Figure 7: Map of three chosen provinces

A randomised sampling method was utilised to recruit dementia caregivers,

who are defined similarly in Australia (Australian Bureau of Statistics, 2008) and

America (Fredman et al., 2012), and who met the following criteria for inclusion

(consistent with the 1st survey):

- Live in area of Hanoi, Bac Ninh and Hai Phong during data collection time

frame;

- Identified as the current primary carer of a person with a medical diagnosis of

dementia;

- Care for at least the last three months;

- Able to speak and understand Vietnamese;

- Provide care for at least one hour/day for a minimum of two days per week.

The sample size in this extended survey was calculated according to the

formula provided by Lwanga and Lemeshow (1991):

99
 n: sample size

1- α: Confidence level

P: Anticipate population proportion

d: Absolute precision required

With α = 0.05, Z1-/2 = 1.96, P as quality of life at 0.65, taken from the

previous study, and d=0.05, n= 350. The theoretical sample size was 350

participants, with a type I error rate of 5%. To account for a possible attrition rate of

10%, to increase the external validity and to reduce the possibility of Type II errors,

an additional 40 participants were recruited for a total sample size of 390 for the

entire study, or 130 participants for each province. The data collection process for the

survey was conducted at the participants’ home between June 2012 and January

2013.

3. Measurement
The survey research instruments, developed for the 1st study, were employed

for the 2nd extended study. Parts C was extended in the 2nd survey to cover positive

aspects of caregiving, and filial piety of the caregiving, as below:

- The Positive aspects of Caregiving scale presented statements about

carers’ mental or affective state in the field of experiencing caregiving.

The nine-items were arranged in 5 point-Likert scale (agree/disagree).

Higher scores indicate positive appraisals (Beach, 2000).

- The Filial Piety Scale (Hsueh-Fen, 2005) includes 22 items prescribing

how children should behave toward their parents, living or dead, as well

as toward their ancestors. Items were scored on a 6-point scale, varying

100
 from strongly disagree to strongly agree. Negative items were scored in

the opposite direction for data analysis.

4. Data collection procedure

Consistent with the 1st survey, the list of names of people diagnosed with

dementia were taken from the Vietnam National Gerontology Hospital, ordered by

the date of registry in each province. From experience gained in the 1st phase of the

current study, it was expected that 500 names, with the contact addresses of people

with dementia and their caregivers in each province, would be retrieved from the

National Institute of Gerontology (NIG). The Statistical Package for Social Sciences

(SPSS) for Windows, version 21.0, launched in 2012, with the function of Random

Number Generation, was employed to randomly select 390 potential participants

from the mentioned list of names (130 participants in each province). In addition, the

Faculty of Nursing and Midwifery, Hanoi Medical University, offered invitation

letters for this study. After receiving ethical approval from the Human Research

Ethics Committee of the Queensland University of Technology and the list of

potential participants from the National Institute of Gerontology, two formal

invitation letters were sent to request voluntary participation in the study. Three to

five days after delivering the first invitation letter with a copy of the consent form,

the same invitation letter was sent again. Within two weeks after delivering the first

letter, phone calls were made to canvass oral agreement for study participation, to

make appointments and allocate suitable times for participants. The participants

nominated a convenient time and place (e.g. at their home or in the community

health station) to complete the study questionnaire.

For those who orally refused to participate in the study via telephone call two

weeks after receiving the formal invitation letter, the next participant in the potential

list of participants, generated by the SPSS program, was approached. At the end of

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 the data collection process (January 2013), 347 participants had completed the

research questionnaire. This figure was quite close to the theoretical sample size

presented in the 2nd section of part II. There were 43 caregivers of people with

dementia who did not agree to participate in the study. The response rate in this study

was counted by the ratio of the number of completed questionnaires (347) to the total

number of potential participants (390); it was quite high, at 88.97%. The recruitment

process of participants is presented in Figure 8.

List of participants

Randomise
sampling
Caregiver eligible and
invited
N= 390

Refuse to participate
n=43

Caregivers completed and returned

full set of questionnaires
n= 347, response rate= 88.97%

Caregivers completed Caregivers completed Caregivers completed

questionnaires in Hanoi questionnaires in Bac Ninh questionnaires in Hai Phong
n= 127, response rate= 97.69% n= 110, response rate= 84.62% n= 110, response rate= 84.62%

Figure 8. Recruitment process for the 2nd survey

5. Data analysis
The SPSS version 21 for Windows was used to conduct data analyses for this

research. The level of significance for all analyses was set at less than 0.05 (p≤0.05).

The data was entered by the primary researcher and a research assistant. Prior to

analysing data, all variables were examined for accuracy of data entry and missing

values.

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 First, frequencies and percentages were calculated for each of the variables to

screen for data entry errors. Possible errors might include duplicated entry or

unrelated figures. With such situations, the rechecking process was employed by

cross-checking the questionnaire with target ID for comparison. Furthermore, a

random check of data entry was also used in this process. The main researcher

randomly selected 30 cases (10% of total cases) to review the data entry consistency.

Then, differential tests were applied. Depending on the nature of variables and their

possible relationships, T-tests, ANOVAs (analysis of variance), the Mann Whitney U

Test, the Kruskal Wallist test, and Pearson’s or the Spearman correlation were

utilised to explore the strength of the relationship. Results of those tests give an

indication of both the direction (positive or negative) and the strength of the

relationship. In addition, the different tests to examine gender differences among

variables of interest (QoL, caregiving burden, positive aspect of caregiving, unmet-

services) were conducted. Before examining the relationship among variables and to

examine the distribution of variables, either normal or binomial, one sample

Kolmogorov-Smirnov test was employed.

Moreover, to examine the effect of variables in accounting for gender

differences on QoL and caregiving burden among dementia caregivers in this

research, multiple-regression was utilised to predict the perceived QoL and perceived

burden of care. As the dependent variable in this study is continuous, multiple

regression analysis is an appropriate multivariate technique. Variables were entered

into the regression model as predictors. The equation for the multiple linear models

is as follows:

Y = B0 + B1X1 + B2X2 + ….+ BiXi

Where Y stands for quality of life among dementia caregivers at the time of

interview.

B0 stands for intercept

Bi (i = 1, … i) stands for coefficient

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 Xi (i = 1, … i) stands for independent variable.

Statistical significance was set at p ≤.05.

Predictor variables used in models were several demographic characteristics of

people with dementia (age, gender) and their carer (age, gender, education level,

employment status), relationship with PWD, family income, care-recipient’s

functional activities (Barthel Index) and behavioural activities (Kingston

Standardized Behavioural assessment), duration with dementia, perceived caregiving

burden, sense of coherence total score, filial piety scale and positive aspects of

caregiving scale.

6. Ethical considerations

Similar to the 1st survey, all participant data was confidential and de-identified

in the analysis and reporting of study findings. Consenting participants were free to

leave the study whenever they liked and to request that their data not be used in the

analysis. Participating caregivers signed the Consent Form prior to participation.

This study was approved by the Queensland University of Technology Human

Research Ethics Committee (QUT Ethics Approval Number 1100001158), the Hanoi

School of Public Health Ethical Committee (HSPH Ethics Approval Number

026/2011/YTCC-HD3).

104
III. Results of the 2nd survey

The findings are arranged in three sections. The first section presents the descriptive

profile of study participants. Section two presents descriptive statistics for key study

variables, as well as relevant tests of differences. Section three discusses multiple analyses of

key variables. Attempting to recruit as many participants as possible for this extended study

(from July 2012 to 2013) to increase the validity of the information, there were 347

participants who completed the questionnaire from three different provinces (Hanoi had 127

new participants, Bac Ninh had 110, and Hai Phong had 110).

1. Descriptive profile of study participants and their care-receivers

1.1. The demographic characteristics of people with dementia (PWD)
Several demographic characteristics were collected, such as age, gender, education,

pension and health insurance status. Table 4.1 summaries the characteristics of PWD.

Table 4. 1. PWD characteristics

Hanoi Bac Ninh Hai Phong Pooled data Statistical test

Age (mean, SD) 76.69 (8.91) 80.77 (7.90) 79.68 (8.03) 80.03 (8.31) F= 0.643

Gender (n,%) 2 =4.15

Female 101 (79.5) 55 (50) 86 (78) 242 (69.7)

Education profile 2 =19.377***

Secondary school and lower 99 (78) 105 (95.5) 99 (90) 303 (87.3)

Senior high school 8 (6.3) 3 (2.7) 5 (4.5) 16 (4.6)

Junior college and above 20 (15.7) 2 (1.8) 6 (5.5) 28 (8.1)

Have pension 55 (43.3) 9 (8.2) 36 (32.7) 100 (28.8) 2 =36.652***

Health insurance 97 (76.4) 93 (84.5) 104 (94.5) 294 (84.7) 2 =15.038***
Duration with dementia
Mean (SD) 4.43 (2.66) 3.38 (2.12) 5.21 (3.22) F=26.965***
95% of CI 3.95 – 4.91 2.89 – 3.78 4.6 – 5.82
Longest 13 11 13

Note: *** p<0.001; N=347

The distribution of PWD’s age is the same across three provinces (Hanoi, Bac Ninh and

Haiphong), where FANOVA = 0.643 and p=0.526. In regards to gender, female PWD made up a

105
larger proportion than male people, 60.5% (210) vs. 39.5% (137). A similar trend was found

in the three provinces. A chi-square test was performed and no relationship was found

between gender across the three provinces, 2= 4.15, p=0.125. A large proportion of the Chi-

square value in the comparison of differences in education profiles of PWD across the three

provinces (2 =19.377, p<0.001) can be explained by the fact that there are a large proportion

of PWD in Hanoi who undergo higher education, including Junior college and above. PWD

whose education went either as far secondary school or lower was more prevalent in three

provinces, at more than 78%. Regarding pension status, a very large amount of PWD who

were living in the province of Bac Ninh had no pension (91.8%). The duration PWD had

suffered symptoms of dementia was ascertained by asking dementia caregivers to recall when

any signs of dementia had first appeared. Most of people had dementia duration of 5 years

(78%). The mean (year) of duration with dementia was 4.34 (SD=2.79, SE=0.15). The

median of duration of the disease was 4.0, which means that 50% of PWD had exhibited

signs of dementia for four years or more. The distribution of duration with dementia is

significantly different among three provinces, where FKruskal-Wallis=26.965, n=341 and

p<0.001. A follow-up test showed that the mean duration of dementia for those with PWD in

Bac Ninh (M= 3.38, SD=2.12) was statistically lower than that in Hanoi (M=4.43, SD=2.66)

and in Hai Phong (M=5.21, SD=3.22). The mean duration of group PWD in Hai Phong was

significantly higher than that in Hanoi.

1.2. The demographic characteristics of caregivers

The mean age of caregivers overall (three provinces) is 48.44 years of age (SD=13.68,

SE=0.73), and the oldest caregiver was 88 (0.3%), while the youngest was 15 (0.3%). The

distribution of caregivers’ age was the same across the three provinces (Hanoi, Bac Ninh and

Haiphong), FANOVA = 0.614 and p=0.542. Summary of caregivers’ characteristics is

presented in table 4.2.

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 Table 4. 2. Caregivers’ characteristics
Hanoi Bac Ninh Hai Phong Pooled data Statistical test

Age (mean, SD) 49.16 (16.12) 47.26 (11.41) 48.78 (12.71) 48.44 (13.68) F= 0.614

Gender (n,%) 2 =29.791***

Female 68 (53.5) 72 (65.5) 70 (63.6) 210 (60.5)
Male 59 (46.5) 38 (34.5) 40 (36.4) 137 (39.5)

Education profile (n,%) 2 =24.267***

Secondary school and lower 47 (37) 73 (66.4) 59 (53.7) 179 (51.6)
Senior high school 32 (25.2) 20 (18.2) 16 (14.5) 68 (19.6)
Junior college and above 48 (37.8) 17 (15.4) 35 (31.8) 100 (28.8)
Occupation profile (n,%)
Professional class 55 (42.5) 15 (13.6) 27 (24.5) 96 (27.2)

Businessman/woman 16 (12.6) 5 (4.5) 8 (7.3) 29 (8.4)

Worker 16(12.6) 13 (11.8) 9 (8.2) 38 (11)

Farmer – Fisherman/woman 24 (18.9) 74 (67.3) 49 (44.5) 147 (42.4)

Armed force 3 (2.4) 1 (0.9) 0 (0) 4 (1.2)

Housewife 5 (3.9) 0 (0) 13 (11.8) 18 (5.2)

Other 9 (7.1) 2 (1.8) 4 (3.6) 15 (4.3)

Employment status 2 =25.003***

Stable work 58 (45.7) 32 (29.1) 44 (40) 134 (38.6)

Temporary work 16 (12.6) 2 (1.8) 4 (3.6) 22 (6.3)

Unemployment 53 (41.7) 76 (69.1) 62 (56.4) 191 (55.1)

Distance to office (time) 2 =13.701**

< 10 minutes 28 (38.4) 15 (42.9) 7 (14.6) 50 (32.1)

10 – 30 minutes 37 (50.7) 16 (45.7) 27 (56.3) 80 (51.3)

> 30 minutes 8 (11) 4 (11.4) 14 (29.2) 26 (16.7)
Family financial income (VND – Vietnam currency) 2 =78.231***
< 5 million 22 (17.3) 62 (56.4) 54 (49.1) 138 (39.8)
5 – 10 million 53 (41.7) 29 (26.4) 54 (49.1) 136 (39.2)
10 – 15 million 32 (25.2) 13 (11.8) 2 (1.8) 47 (13.5)
> 15 million 20 (15.7) 5 (5.5) 0 (0) 26 (7.5)

Household member (mean, SD) 5.06 (1.71) 4.75 (1.67) 3.94 (1.27) 4.61 (0.164 F= 15.906***
Reported with sick/chronic disease
Yes 55 (43.3) 37 (33.6) 32 (29.1) 124 (35.7)

Note: ** p<0.01, *** p<0.001; N=347

107
 In regards to the caregivers’ gender, female PWD made up a larger proportion

compared with male people, 69.7% (242) vs. 30.3% (105). A similar trend was found in

Hanoi and Hai Phong. For the whole study, most caregivers were unemployed (55%). 38.6%

(134) of the people had stable employment at the time of data collection. The rate of

unemployment among carers was the highest in Bac Ninh (at 69.1%) and the lowest was in

Hanoi (at 41.7%). 44.9% of the participants provided information related to the amount of

time spent commuting between home and work.

1.3. Kinship between caregiver and people with dementia

To investigate the kinship between these dyads, the researcher employed multiple-

choice questions, with optional answers of spouse, parent/parent-in-law, relative and other.

More than 2/3 (71.2%) of participants were caring for their parent/parent-in-law who was

suffering from dementia. Nearly 16.1% (56) of the responders were providing care for their

spouse (husband or wife). In addition, there were 20 grandchildren who were caring for their

grandparent/grandparent-in-law and four siblings caring for their sister/bother with dementia.

Moreover, there was one case of a person taking care of their adoptive parent/Godparent.

Table 4.3 summarises their responses.

Table 4. 3. Kinship between caregiver and people with dementia

Hanoi Bac Ninh Hai Phong Pooled data
n (%) n (%) n (%) n (%)
Spouse 30 (23.6) 8 (7.3) 18 (16.4) 56 (16.1)
Parent 27 (21.3) 65 (59.1) 51 (46.4) 143 (41.2)
Parent- in- law 46 (36.2) 28 (25.5) 30 (27.3) 104 (30)
Relative 13 (10.2) 2 (1.8) 4 (3.6) 19 (5.5)
Other 11 (8.7) 7 (6.4) 7 (6.4) 25 (7.2)

The researcher also explored the gender of dementia caregivers and their relationship

with people with dementia (table 4.4). The result shows that more daughters offered their care

for parents, compared with sons (66.8% vs. 33.2%). Also fewer husbands took care of their

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spouses, compared with wives (21.4% vs. 78.6%). Findings depicted in Table 4.4 show that

the daughter-in-law seems to be identified as the key-person taking care of their parents-in-

law.

Table 4. 4. Female caregiver and kinship with people with dementia

Hanoi Bac Ninh Hai Phong Pooled data
n (%) n (%) n (%) n (%)
Spouse 23 (76.7) 4 (50) 17 (94.4) 44 (78.6)
Parent 15 (55.6) 17 (26.2) 31 (60.8) 63 (44.1)
Parent-in -law 45 (97.8) 27 (96.4) 30 (100) 102 (98.1)
Relative 11 (84.6) 2 (100) 3 (75) 16 (84.2)
Other 7 (63.6) 5 (71.4) 5 (71.4) 17 (68)
Total 101 (79.5) 55 (50) 86 (78.2) 242 (69.7)

2. Descriptive statistics of research variables and its comparison – correlation test

2.1. Caregiving hours
The approximate duration of caregiving hours per week were also examined by asking

caregivers to estimate the total hours of weekly caring. This data was categorised into eight

levels (see Table 4.5). The mean caregiving hours per week overall was 24.05 (SD=17.7,

SE=0.95), in which the longest was 99 (0.3%) hours. The median of estimated caregiving

hours weekly was 20 hours, which shows that 50% of the participants spent 20 hours or more

taking care of their family member/relative suffering from dementia. The distribution of

caring hours was significantly different across the three provinces (Hanoi, Bac Ninh and

Haiphong), where FKruskal-Wallis = 70.9 and p<0.001. A post hoc test indicated that the mean

weekly caregiving hours for the group of participants in Bac Ninh (M= 16.93, SD=11.5) was

statistically lower than that of the group of participants in Hanoi (M=22.05, SD=19) and

those in Hai Phong (M=33.49, SD=17.29). The mean caregiving hours weekly for group

participants in Hai Phong was significantly higher than that in Hanoi.

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Table 4. 5. Caregiving hours per week
Hanoi Bac Ninh Hai Phong Kruskal Wallis
hours hours hours test
Mean 22.05 16.93 33.49 F=70.9
95% of CI 18.71 – 25.38 14.75 – 19.75 30.22 – 36.76 p<0.001
Longest 85 80 99

2.2. Health status profile of PWD

Health status of people with dementia was measured via the Barthel Index and the

Kingston Standardized behavioural assessment.

2.2.1. The Barthel Index

The reported Barthel Index total score is shown in table 4.7. The mean total Barthel

Index score was 61.63 (SD=28.91, SE=1.55). The distribution of Barthel Index total score

was significantly different among three provinces, FKruskal-Wallis=34.23 and p<0.001. A post-

hoc test suggested that the mean Barthel Index total score for the group of PWD in Bac Ninh

(M= 72.73, SD=28.46) was statistically higher than that of those in Hanoi (M=60.28,

SD=29.76) and Hai Phong (M=52.09, SD=24.52). The mean Barthel Index total score of

group PWD in Hai Phong did not significantly differ from that in Hanoi.

Table 4. 6. Barthel Index score

Hanoi Bac Ninh Hai Phong Kruskal Wallis test

Mean (SD) 60.28 (29.76) 72.73 (28.48) 52.09 (24.52) F=34.42***

95% of CI 55.05 – 65.5 67.35 – 78.11 47.46 – 56.72

Note: *** p<0.001, N=347

The Barthel Index score was identified as a binomial distribution, with DKolmogorov-

Smirnov = 1.718, p=0.005. For the overall study, the tests’ results indicated that the difference

between genders on the Barthel Index score among people with dementia was not found to be

significant at p < 0.05 (61.1 for male vs. 59.56 for female, Z(Mann-Whitney U test) = -0.618,

p=0.537). Similar findings were also identified in the province of Hanoi and Bac Ninh. These

results suggest that level of activities of daily living of PWD are statistically similar between

110
male and female PWD in Hanoi, Bac Ninh and overall. Level of activities of daily living

among male PWD was significantly lower than that of female PWD in the province of Hai

Phong. It can be understood that the level of activities of daily living of PWD seem to be

unrelated to gender overall. Table 4.7 summaries those results.

Table 4. 7. Difference test between Barthel Index score and PWD characteristics
Barthel Index total Mann-Whitney U test
PWD’s gender Hanoi Bac Ninh Hai Phong Pooled data

Mean Z Mean Z Mean Z Mean Z

Male 61.1 72.63 46.37 60

0.79 0.477 -2.183* -0.618
Female 59.56 72.78 55.35 62.69

Note: Significant at * p<0.05;

The relationship tests were also performed. A significant correlation existed between

the Barthel Index and PWD characteristics (age and duration with dementia), caregiving

hours per week in the whole study and across provinces (table 4.8). With the negative

correlative values on care-recipient’s age, duration with dementia and caregiving hours per

week, this result indicates that the older the person with dementia is, the lower their score on

the Barthel index. Conversely, the shorter the duration with dementia, the higher the score

they achieved on the Barthel index. Moreover, dementia caregivers spent less time with

people whose dementia allowed them to perform more or a higher level of activities of daily

living.

Table 4. 8. Correlation between Barthel Index total score and PWD characteristics
Barthel Index total
Variable
Hanoi Bac Ninh Hai Phong Pooled data

Age of people with dementia 0.04 -0.31** -0.221* -0.126*

Caregiving hours -0.201** -0.439** -0.516** -0.409**
Duration with dementia -0.290** -0.301** -0.208* -0.332**

Note: Significant at * p<0.05; ** p<0.01, N=347

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 2.2.3. Kingston Standardized behavioural assessment (KSBA)
Dementia caregivers were asked to recall whether their care-recipient had undertaken

68 mentioned categorised activities within the previous month. The mean of KSBA overall

(three provinces) was 21.18 (SD=8.33, SE=0.45) and the highest score was 53 (0.3%), while

the lowest score was 2 (0.3%). KSBA was identified as a normal distribution, with

DKolmogorov-Smirnov = 0.96, p=0.315. The distribution of KSBA was significantly different across

the three provinces (Hanoi, Bac Ninh and Haiphong), at FANOVA = 32.083 and p=<0.001.

Post-hoc comparisons using the Tukey HSD test indicated that the mean of the KSBA total

score for the group of PWD in Hanoi (M= 17.3, SD=8.66) was statistically lower than those

in Bac Ninh (M=21.04, SD=8.66) and in Hai Phong (M=25.44, SD=4.96). The mean KSBA

total score of PWD in Hai Phong was significantly higher than that in Bac Ninh. Table 4.9

summaries this information by provinces.

Table 4. 9. Kingston Standardized Behavioural Assessment total score

Hanoi Bac Ninh Hai Phong ANOVA test

Mean 17.3(8.66) 21.04 (8.66) 25.44 (4.96) F=32.093***

95% of CI 15.71 – 18.88 19.4 – 22.67 24.5 – 26.37

Note: *** p<0.001, N=347

According to the cut-offs, proposed by Hopkins, Kilik, Day, Bradford, and Rows

(2006), the behavioural profile of people with dementia was categorised into four levels,

based on the KSBA total score, in which level 1 of KSBA ≤ 11; level 2 of KSBA 11 – 24;

level 3 of KSBA 24 – 38; and level 4 of KSBA ≥ 38. Summaries of these findings are

reported in table 4.10.

Table 4. 10. Level of behaviours based on KSBA

Hanoi Bac Ninh Hai Phong Pooled data
n (%) n (%) n (%) n (%)
Level 1 (≤11) 26 (22.2) 14 (12.7) 1 (0.9) 41 (12.2)
Level 2 (11 – 24) 71 (60.7) 62 (56.4) 39 (35.5) 172 (51)
Level 3 (24 – 38) 16 (13.7) 26 (23.6) 70 (63.6) 112 (33.2)
Level 4 (≥ 38) 4 (3.4) 8 (7.2) 0 (0) 12 (3.6)

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 The tests’ results overall for the study indicated that the difference between genders on

the KSBA total score among PWD was not found to be significant at p < 0.05 (20.46 for male

vs. 21.64 for female, t Student T test = -1.28, df=307, p=0.203). Similar findings were also

identified in the provinces of Bac Ninh and Hai Phong (Table 4.11). From these results, it

would appear that the level of severity of dementia behaviour among PWD is, overall,

unrelated to gender.

Table 4. 11. Different test on KSBA total score and PWD characteristics
KSBA total Student T test
PWD’s gender Hanoi Bac Ninh Hai Phong Pooled data

Mean t Mean t Mean t Mean t

Male 15.55 22.11 25.65 20.46

-2.09* 0.94 0.34 -1.28
Female 18.85 20.47 25.31 21.64

Note: Significant at * p<0.05; N=347

A significant correlation existed between the KSBA total score and care-recipient’s

age, Barthel Index total, duration with dementia and weekly caregiving hours (table 4.12).

For the whole study, the positive correlation between duration with dementia and KSBA

score indicated that the longer the duration since the first emergence of dementia symptoms,

the higher their score on the KBSA. This result means that people with dementia in this study

experience more dementia-related behavioural changes if they’ve suffered the condition for a

longer duration. The negative correlative values on the Barthel Index score across provinces

and overall, indicates that the more functional activities people with dementia performed, the

lower the dementia-related behavioural changes those people reported.

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Table 4. 12. Correlation between KSBA total and characteristics of Caregiver and PWD
KSBA total
Variable
Hanoi Bac Ninh Hai Phong Pooled data

PWD’s age 0.5 0.411** 0.169 0.185**

Caregiving hours 0.07 0.388** 0.191* 0.251**
Duration with dementia 0.168 0.126 0.128 0.166**
Barthel Index -0.402** -0.536** -0.346** -0.438**

Note: Significant at * p<0.05; ** p<0.01, N=347

2.3. Perceived caregiving burden
Dementia caregivers were asked to answer a 22-item self-report inventory of the Zarit

Burden Interview (ZBI), with higher scores indicating a higher burden. The mean of ZBI total

score overall (three provinces) was 35.16 (SD=15.9, 95% CI: 33.52 – 36.87), where the

highest score was 67 (0.9%) and the lowest was 0 (1.4%). The median ZBI total score was

36, indicating 50% of participants had a perceived caregiving burden of 36 or over. ZBI was

identified as a normal distribution, with DKolmogorov-Smirnov = 1.279, p=0.076. The distribution

of ZBI was significantly different across the three provinces (Hanoi, Bac Ninh and Haiphong)

at FANOVA = 35.32 and p<0.001. Post-hoc test comparisons with Tukey HSD indicated that

the mean ZBI total score for the group of participants in Hanoi (M= 26.87, SD=16.03) was

significantly lower than those in Bac Ninh (M=42.15, SD=15.27) and Hai Phong (M=37.58,

SD=11.63). The mean ZBI total score of the group of dementia caregivers in Hai Phong did

not statistically significantly differ from those in Bac Ninh. Table 4.13 reports their responses

of caregiving burden.

Table 4. 13. Zarit Burden Interview total score

Hanoi Bac Ninh Hai Phong ANOVA test

Mean 26.87 42.15 37.58 F=35.32***

SD 16.03 15.27 11.63
95% of CI 24.05 – 29.69 39.27 – 45.04 35.65 – 40.04

Note: Significant at *** p<0.001, N=347

114
 According to the cut-offs proposed by Hebert, Bravo, and Preville (2000), perceived

caregiving burden was categorised into “little or no burden” ( ZBI < 21); “mild to moderate

burden” (ZBI 21 – 40); “moderate to severe burden” ( ZBI 41 – 60) and “severe burden”

(ZBI > 60). More than 40% of participants in Hanoi had little or no perceived caregiving

burden. Meanwhile, these figures in Bac Ninh and Hai Phong are much lower: 11.8% for Bac

Ninh; and 5.5% for Hai Phong. Moreover, 10.9% of participants in Bac Ninh reported

suffering from severe burden—ten times higher than those in Hanoi (0.8%), or nearly five

times higher than those in Hai Phong (1.8%). Table 4.14 presents a summary of these results

that analyse the perceived caregiving burden.

Table 4. 14. Perceived burden level

Hanoi Bac Ninh Hai Phong Pooled data
n (%) n (%) n (%) n (%)
Little or no burden (<21) 51 (40.2) 13 (11.8) 6 (5.5) 70 (20.2)
Mild to moderate burden (21 – 40) 50 (39.4) 36 (32.7) 59 (53.6) 145 (41.8)
Moderate to severe burden (41 – 60) 25 (19.7) 49 (44.5) 43 (39.1) 117 (33.7)
Severe burden (>60) 1 (0.8) 12 (10.9) 2 (1.8) 15 (4.3)

Since ZBI scores fell on a normal distribution, several parametric tests, such as Student

T-Test or one-way ANOVA were used. Significant differences in ZBI total score were not

found to be significant according to caregivers’ gender (35.94 for male vs. 34.87 for female, t

= 0.58, df=345, p=0.565); caregivers’ marital status (32.83 for Single vs. 35.41 for non-

single, t=0.838, p>0.05); employment status (35.2 for employment vs. 35.19 for

unemployment, t=0.003, p>0.005); type of relationship (34.13 for spouse vs. 35.94 for parent

vs. 32.39 for other, F=1.085, p>0.005); and educational level of caregivers (36.21 for

primary school and lower vs. 35.45 for secondary and high school vs. 34.17 for college and

higher, F=0.0338, p>0.05).

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 Pearson correlation tests were employed to investigate the relationship between ZBI

total score and PWD’s age, caregiver’s age, duration with dementia, weekly caregiving hours,

care-recipient’s Barthel Index, and KSBA. Table 4.15 summarises these tests’ results.

Significant correlations existed between ZBI total score and care-recipient’s Barthel Index,

Care-recipient’s KSBA total score and caregiving hours for the whole study. Positive

correlative values on KSBA, means that the higher the score on KSBA, the higher the level of

burden they reported. Meanwhile, the negative correlation on the care-recipient’s Barthel

Index means that the higher the level of activities people with dementia were able to perform,

the lower the level of caregiving burden that affected their caregiver.

Table 4. 15. Correlation between Zarit Burden Interview and characteristics of

Caregiver and people with dementia
Variable Zarit Burden Interview
PWD’s age r= 0.039
Caregivers’ age r= -0.022
Duration with dementia r= 0.034
Caregiving hours r= 0.209**
Barthel Index r= -0.184**
KSBA r= 0.409**

Note: Significant at * p<0.05; ** p<0.01, N=347

2.4. Filial piety

Participants were asked to complete 22 items measured on a 6-point scale, ranging from

1 (strongly disagree) to 6 (strongly agree). The mean filial piety score for the whole study

was 89.08 (SD=7.02). A one way ANOVA was conducted to explore the impact of region on

the level of filial piety. Participants were divided into three groups according to their place of

residence (group 1: Hanoi; group 2: Bac Ninh; group 3: Hai Phong). Statistically significant

differences in filial piety scores for the three provinces were not found, F2, 345=1.141, p>0.05.

The mean score for group 1 (M=86.88, SD=6.02) was statistically similar with that that of

group 2 (M= 88.18, SD=8.01) and group 3 (M=87.95, SD=7.28).

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 Gender and cultural group differences are tested by conducting a 2 (gender) x 3

(provinces) analysis of variance (factorial ANOVA). The ANOVA results for filial piety

indicated no significant interaction between gender and cultural group, F2,345=1.196, p>0.05,

partial 2=0.007. The main effect for gender was significant, F1,345= 4.155, p=0.042, partial

2=0.012, with males (mean = 89.08) scoring higher on filial piety than females (mean = 87),

but there were no significant differences among Hanoi (mean = 86.88), Bac Ninh

(mean=88.18) and Hai Phong (87.95) respondents, F2,345=0.306, p>0.05, partial 2=0.002.

One way ANOVA was conducted to explore the impact of relation with PWD on level

of filial piety. Participants were divided into three groups according to the nature of

relationship to PWD for the whole study (group 1: spouse; group 2: parent; group 3: other).

There was a statistically significant difference at p<0.05 in filial piety scores for the three

groups, F2,345=5.422, p=0.05. Despite reaching statistical significance, the actual difference in

mean scores between the groups was small. Post host comparisons using the Tukey HSD test

indicated that the mean score for group 1 (M=89.93, SD=6.82) was statistically different

from group 3 (M= 85.32, SD=6.58). Group 2 (M=87.52, SD=7.13) did not differ significantly

from either group 1 or 3. Similar findings were identified in the province of Hanoi and Hai

Phong.

2.5. Positive aspect of caregiving (PAC)

The 9-item 5-point Likert scale of positive aspects of caregiving questionnaire was

utilised to investigate the positive dimensions of providing care for relatives with dementia.

The mean of PAC score for the whole study was 31.88 (SD=5.69, 95% CI = 31.28 – 32. 48).

One way ANOVA was conducted to explore the impact of region on the level of PAC.

Participants were divided into three groups according to their place of residence (group 1:

Hanoi; group 2: Bac Ninh; group 3: Hai Phong). There was a statistically significant

difference in PAC score for the three groups, F2,346=25.063, p<0.001. Post hoc comparisons

using the Tukey HSD test indicated that the mean score for group 1 (M=32.42, SD=5.07) was

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statistically different from either group 2 (M= 34.06, SD=6.09) or Group 3 (M=29.08,

SD=4.77). Also, Group 2 differed significantly from Group 3.

Significant differences in PAC total scores were not found to be significantly different

according to caregivers’ gender (32.14 for male vs. 31.77 for female, t = 0.57, p>0.05) for the

whole study. It can be understood that the level of positivity in caregiving seems to not relate

to gender.

2.6. Sense of Coherence

The Sense of Coherence (SOC) questionnaire was utilised as a proxy measure of QoL.

Participants were asked to complete 13 items scored on a 7-point Likert scale. The mean of

SOC total score for the whole study (three provinces) was 57.71 (SD=7.95, SE=0.43), where

the highest score was 82 (0.3%) and the lowest was 35 (0.3%). SOC was identified as a

binomial distribution, with DKolmogorov-Smirnov = 1.545, p=0.017. The distribution of SOC was

significantly different across three provinces (Hanoi, Bac Ninh and Haiphong) at F Kruskal-Wallis

= 23.11 and p=<0.001. Follow-up tests showed that the mean SOC total score of group

participants in Hanoi (M=61.29, SD=7.02) was significantly higher than those in Bac Ninh

(M=55.29, SD=8.12) and in Hai Phong (M=56, SD=7.36). The mean SOC total score for the

group of dementia caregivers in Hai Phong did not statistically significantly differ from those

in Bac Ninh. Table 4.16 summarises these findings.

Table 4. 16. Sense of Coherence total score

Hanoi Bac Ninh Hai Phong Kruskal-Wallis test
Mean 61.29 55.29 56 F=23.11***
SD 7.02 8.12 7.36
95% of CI 60.06 – 62.52 53.76 – 56.82 54.62 – 57.4

Note: Significant at * p<0.05; ** p<0.01, N=347

Significant differences in SOC total scores were not found to be significantly related to

caregivers’ gender (58.25 for male vs. 57.48 for female, Z Mann Whitney U test = 1.179, p=0.238);

caregivers’ married status (57.1 for Single vs. 57.77 for non-single, Z Mann Whitney U test =0.57

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p>0.05); type of relationship (57.92 for spouse vs. 57.59 for parent vs. 58.98 for other,

FKuskal Wallist test =1.395 p>0.005); and educational level of caregivers (56.77 for primary

school and lower vs. 57.38 for secondary and high school vs. 58.84 for college and higher,

FKuskal Wallist test =4.54 p>0.05). Regarding the employment status of caregivers, the SOC total

score in the employment group was significantly higher than those in the unemployment

group for the entire study (58.73 for employment vs. 56.88 for unemployment, Z Mann Whitney U

test =2.007, p<0.05). This result may indicate that caregivers who are employed are more

confident in managing their situation and better understand how to perform health promotion,

compared with unemployed participants.

2.7. WHOQOL-BREF

The WHOQOL-BREF score was divided into 4 domains, including Physical (7 items),

Psychological (6 items), Social relationship (3 items), and Environment (8 items). Among

these domains in the whole study, the two highest average standardised scores were Social

relationship (mean score 64.87, SD=14.88), and Environment (mean score 62.39, SD=12.09).

The lowest average standardised scores were from the Psychological domain (mean score

57.79, SD=14.08) and Physical domain (mean score 61.97, SD=13.32) for the whole study. A

similar trend also existed in participants from Hanoi, Bac Ninh and Hai Phong. The mean of

Physical domain scores across three provinces was not significantly different, FANOVA= 2.32,

p=0.1. This result means that QoL on the Physical domain across participants in the three

different provinces are similar. Significant differences across three provinces on the

Psychological domain, the Social Relationship domain and Environmental domain were

found (Table 4.17). Post hoc comparison with Tukey HSD revealed that the mean

WHOQOL-BREF Psychological domain score of group participants in Hai Phong (M=18.55,

SD=4.21) was significantly lower than those in Bac Ninh (M=20.74, SD=2.45) and Hanoi

(M=20.23, SD=2.82). The mean Psychological domain score of the group of dementia

caregivers in Bac Ninh did not statistically significantly differ than those in Hanoi. Regarding

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the WHOQOL-BREF Social relationship domain, a follow-up test showed that the mean

social relationship domain score of group participants in Hai Phong (M=10.4, SD=1.91) is

significantly different from that in Hanoi (M=10.94, SD=1.4). However, the mean of the

Social relationship domain score of group caregivers in Bac Ninh (M=10.91, SD=1.95) did

not significantly differ from those in Hanoi and Hai Phong. Table 4.17 presents these

findings.

Significant correlations within the WHOQOL-BREF domains in the overall study were

identified, with p value varying from 0.05 to 0.001. Similar trends were also found in three

provinces. Correlation values, varying from 0.197 to 0.798, suggested that the four domains

of WHOQOL-BREF are highly associated with others. Table 4.18 presents this information.

The differences between WHOQOL-BREF domains (Physical, Psychological, Social

activity and Environment) and caregiver’s gender, education level, employment status and

health status were also examined (table 4.19). There was a difference in the mean score of

WHOQOL-BREF in some subgroups. The female gender reported lower values in almost all

domains when compared with the male gender. Dementia caregivers with lower education

presented lower values in all domains of WHOQOL-BREF when compared with those with

higher education levels. Employed people reported higher values in all areas of the

WHOQOL-BREF than unemployment participants.

The relationship tests were performed with significant correlations existing between

those domains with the duration of the dementia, hours of weekly caregiving, PWD’s Barthel

total score, PWD’s KSBA, perceived caregiving burden (ZBI total score) and SOC total score

(Table 4.20). Caregivers’ real age, duration of symptoms of dementia, PWD’s KSBA and

ZBI total score have negative correlation values with WHOQOL-BREF domains. Only SOC

total score and PWD’s Barthel index total score had positive relationship values.

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 Table 4. 17. WHOQOL-BREF domain scores

WHOQOL – BREF Raw score (Mean, SD) ANOVA WHOQOL – BREF Standardised score (Mean, SD)
Pooled data test Pooled data
Hanoi Bac Ninh Hai Phong Hanoi Bac Ninh Hai Phong
Physical 23.89 (3.73) 24.92 (2.53) 24.33 (4.47) 24.35 (3.68) F=2.32 60.45 (13.4) 63.85 (9.23) 61.84 (16.26) 61.97 (13.32)
Psychological 20.23 (2.82) 20.74 (2.45) 18.55 (4.21) 19.86 (3.35) F=13.999*** 59.3 (11.63) 61.4 (10.83) 52.43 (17.64) 57.79 (14.08)
Social relationship 10.94 (1.4) 10.91 (1.95) 10.4 (1.91) 10.76 (1.77) F=3.37* 66.52 (11.98) 65.85 (16.24) 62.09 (16.11) 64.89 (14.88)
Environment 27.25 (3.25) 29.15 (3.6) 25.88 (3.98) 27.42 (3.83) F=22.888*** 61.89 (10.17) 67.72 (11.41) 57.53 (12.6) 62.39 (12.06)

Note: Significant at * p<0.05, *** p< 0.001

Table 4. 18. Pearson correlation between WHOQOL-BREF domains by province

Hanoi Bac Ninh Hai Phong Pooled data

WHOQOL-BREF
1 2 3 1 2 3 1 2 3 1 2 3
1. Physical
2. Psychological 0.376*** 0.798*** 0.631***
0.575***
3. Social relationship 0.201* 0.546*** 0.495*** 0.530*** 0.312*** 0.492***
0.197* 0.367***
4. Environment
0.375*** 0.432*** 0.367*** 0.349*** 0.455*** 0.455*** 0.709*** 0.687*** 0.588*** 0.496*** 0.58*** 0.483***

Note: Significant at * p<0.05, *** p< 0.001

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Table 4. 19. Different test WHOQOL-BREF domains and caregiver’s characteristics
WHOQOL-BREF Student T test/ ANOVA
Physical Psychological Social Environmental
relationships
Carer’s gender t=4.234*** t=3.155** t=3.212** t=3.763***
Male 66.46 61.36 68.72 65.99
Female 60.02 56.24 63.2 60.82
Carer’s married status t=-1.5 t=0.644 t=3.728*** t=2.335*
None-Single 61.64 57.93 65.78 62.84
Single 65.52 56.17 55.21 57.41
Carer’s employment status t=4.335*** t=2.882** t=-0.967 t=0.749
Employment 65.31 60.17 64.04 62.92
Unemployment 59.24 55.84 65.58 61.95
Type of relationship F=31.915*** F=16.378*** F=1 F=3.357*
Spouse 50.68 49.13 62.53 58.59
Parent 63.32 58.69 65.11 63.13
Other 68.75 63.75 66.58 63.05
Carer’s education F=7.731** F=14.583*** F=2.091 F=2.878
Primary school and below 56.37 51.77 61.87 59.19
Secondary and high school 61.84 56.51 64.63 62.35
College and higher 65.14 63.41 66.99 64.11
Note: Significant at * p<0.05, ** p< 0.01, *** p<0.001, N=347
Table 4. 20. Correlation between WHOQOL-BREF domains and characteristics of
caregiver and people with dementia
WHOQOL-BREF
Physical Psychological Social Environmental
relationships
PWD’s age 0.007 0.068 0.116* 0.029
Caregivers’ age -0.519*** -0.28*** -0.009 -0.147*
Duration with dementia -0.150** -0.235*** -0.039 -0.124*
Caregiving hours -0.257*** -0.3*** -0.121* -0.179***
Barthel Index 0.265*** 0.274*** 0.173* 0.187***
KSBA total -0.063 -0.14** -0.104* -0.071
ZBI -0.1* -0.234*** -0.354*** -0.162**
SOC total 0.228*** 0.374*** 0.344*** 0.205***
Filial Piety -0.232*** -0.287*** -0.269*** -0.156**
Positive aspect of caregiving 0.203** 0.454*** 0.394*** 0.293***
Note: Significant at * p<0.05, ** p< 0.01, *** p< 0.001, Bolded values are Person correlation result
where p<0.0, N=347

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 3. Multivariate analysis to predict quality of life among dementia
caregivers
3.1. Predicting quality of life by employing WHOQOL-BREF
3.1.1. Predicting quality of life by employing WHOQOL-BREF with similar
approach of the 1st study with the contribution of place of residence– MODEL 1
Multiple regression analysis, via the enter method, was conducted to determine

the best linear combination of mentioned predictor variables for predicting Quality of

life of dementia caregivers (WHOQOL-BREF domains), with the contribution of

place of residence. Predictor variables used in models were several demographic

characteristics of people with dementia (age, gender) and their carer (age, gender,

education level, employment status), type of relationship with PWD, family income,

care-recipient’s functional activities (Barthel Index) and behavioural activities

(Kingston Standardized Behavioural assessment), duration with dementia, perceived

caregiving burden (Zarit Burden Interview - ZBI), Sense of Coherence total score

and place of residence (1: Hanoi, 0: Other). Summaries of the regression result of

WHOQOL-BREF domains on PWD and Caregivers’ perceptions and characteristics

are presented in table 4.22. The adjusted R squared values in these models vary from

0.177 to 0.417. This result indicated that 17.7% to 41.7% of the variance in

WHOQOL- BREF domains was explained by the model (table 4.21). For all

domains, Caregiver age, gender, Family income and Perceived burden contributed to

predict all domains of QoL. The Barthel index, Sense of Coherence and family

income contributed towards predicting three of the four domains of QoL. The place

of residence only contributed towards predicting the environmental domain of QoL.

It seems that the quality of life on the Environment aspect in Hanoi (metropolitan) is

poorer than that in Bac Ninh (countryside) and Haiphong (coastal province).

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Table 4. 21. Caregiver Quality of life domains regressed on PWD and
Caregiver’s characteristics with contribution of place of residence
Model 1
Adjusted R2 β t p
Physical domain 0.417
Caregiver age (1: Male, 0: Female) -0.316 -5.58 <0.001
Caregiver gender 0.120 2.68 0.008
Self-reported sickness/ chronic disease -0.342 -0.703 <0.001
Family income (: < 10 million, 0: Other) -0.107 -2.19 0.029
Barthel index total score 0.12 2.222 0.027
Perceived burden (ZBI total score) -0.177 -3.61 <0.001
Psychological domain 0.354
Caregiver’s education (1: high school and
higher, 0: less than high school) 0.15 2.97 0.003
Self-reported sickness/ chronic disease -0.111 -2.16 0.032
Duration appeared disease -0.126 -2.56 0.011
Family income (: < 10 million, 0: Other) -0.109 -2.11 0.036
Barthel index total score 0.138 2.43 0.016
Household members 0.13 2.40 0.017
Perceived burden (ZBI total score) -0.148 -2.65 0.009
Sense of coherence (SOC total score) 0.305 5.73 <0.001
Social Relationship domain 0.303
Age of People with dementia 0.131 2.61 0.01
Caregiver age -0.119 -1.93 0.05
Caregiver gender (1: Male, 0: Female) 0.12 2.42 0.016
Caregiver marital status (0: Married, 1: other) -0.289 -5.65 <0.001
Family income (: < 10 million, 0: Other) -0.105 -1.95 0.05
Barthel index total score 0.127 2.135 0.034
Perceived burden (ZBI total score) -0.287 -4.874 <0.001
Sense of coherence (SOC total score) 0.261 4.69 <0.001
Environmental domain 0.177
Place of residence (1: Hanoi, 0: Other) -0.14 -2.07 0.039
Caregiver age -0.132 -1.96 0.05
Caregiver gender (1: Male, 0: Female) 0.136 2.55 0.011
Caregiver marital status (0: Married, 1: other) -0.16 -2.89 0.004
Family income (: < 10 million, 0: Other) -0.207 -3.53 <0.001
Perceived burden (ZBI total score) -0.149 -2.36 0.019
Sense of coherence (SOC total score) 0.176 2.92 0.004

3.1.2. Predicting quality of life by employing WHOQOL-BREF –with the

constitution of Filial piety and Positive aspect of caregiving - MODEL 2
A multiple regression analysis, via the enter method, was conducted to

determine the best linear combination of predictor variables for predicting Quality of

life of dementia caregivers (WHOQOL-BREF domains) with the contribution of

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filial piety scale and Positive aspects of caregiving scale. Predictor variables used in

models were several demographic characteristics of people with dementia (age,

gender) and their carer (age, gender, education level, employment status), type of

relationship with PWD, place of residence (1: Hanoi, 0: Other), family income, care-

recipient’s functional activities (Barthel Index) and behavioural activities (Kingston

Standardized Behavioural assessment), duration with dementia, perceived caregiving

burden (Zarit Burden Interview - ZBI), sense of coherence total score, Filial Piety

Scale and Positive aspects of caregiving scale.

Summaries of the regression result of the WHOQOL-BREF domains on PWD

and Caregivers’ perceptions and characteristics are presented in Table 4.24. The

adjusted R squared values in these models vary from 0.213 to 0.439. This result

indicated that 21.3% to 43.9% of the variance in WHOQOL- BREF domains was

explained by the model (table 4.22).

Overall, regression models confirmed that the characteristics of PWD (age –

gender) do not contribute towards predicting the Quality of Life for dementia

caregivers. The gender of caregivers is exclusive and consistent correlations with the

four models of WHOQOL-BREFF domains were found, where being a male

caregiver predicted a better quality of life for dementia caregivers (Table 4.23).

Lower perceived caregiving burden (ZBI), higher family income, higher positive

aspect of caregiving and higher sense of coherence were distinctly significant and

related to three of the four WHOQOL-BREF domains. The age of the carer was

associated with two of the four domains, with p<0.05.

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Table 4. 22. Caregiver Quality of life domains regressed on PWD and
Caregivers’ characteristics
Model 2
Adjusted R2 β t p
Physical domain 0.439
Caregiver age -0.308 -5.5 <0.001
Caregiver gender (1: Male, 0: Female) 0.142 3.19 0.002
Self-reported sickness/ chronic disease -0.33 -6.88 <0.001
Family income (: < 10 million, 0: Other) -0.154 -3.09 0.002
Barthel index total score 0.119 2.24 0.026
Perceived burden (ZBI total score) -0.13 -2.61 0.01
Filial Piety scale -0.133 -2.71 0.07
Psychological domain 0.422
Caregiver age -0.115 -2.03 0.044
Caregiver gender (1: Male, 0: Female) 0.092 2.029 0.043
Caregiver’s education (1: high school and
higher, 0: less than high school) 0.116 2.38 0.018
Self-reported sickness/ chronic disease -0.095 -1.96 0.05
Duration appeared disease -0.114 -2.43 0.016
Family income (: < 10 million, 0: Other) -0.157 -3.12 0.02
Barthel index total score 0.148 2.75 0.006
Household members 0.059 1.13 0.05
Perceived burden (ZBI total score) -0.103 -1.929 0.05
Sense of coherence (SOC total score) 0.214 4.08 <0.001
Positive aspects of caregiving total score 0.282 5.53 <0.001
Social Relationship domain 0.366
Age of People with dementia 0.099 2.04 0.043
Caregiver age -0.121 -2.03 0.043
Caregiver gender (1: Male, 0: Female) 0.141 2.93 0.004
Caregiver married status (0: Married/
Cohabiting, 1: other) -0.287 -5.843 <0.001
Family income (: < 10 million, 0: Other) -0.151 -2.85 0.005
Barthel index total score 0.137 2.41 0.016
Perceived burden (ZBI total score) -0.248 -4.37 <0.001
Sense of coherence (SOC total score) 0.17 3.07 0.002
Positive aspects of caregiving total score 0.248 4.56 <0.001
Environmental domain 0.213
Caregiver age -0.138 -2.09 0.037
Caregiver gender (1: Male, 0: Female) 0.148 2.77 0.006
Caregiver married status (0: Married/
Cohabiting, 1: other) -0.16 -2.95 0.003
Family income (: < 10 million, 0: Other) -0.241 -4.08 <0.001
Positive aspects of caregiving total score 0.212 3.55 <0.001

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 Chapter 5: QUALITATIVE STUDY

UNDERSTANDING THE MEANING OF CAREGIVER ROLES AND FILIAL

PIETY AMONG FEMALE DEMENTIA CAREGIVERS

I. Introduction

Findings from the 2nd survey, conducted from June 2012 and January 2013,

showed that several gaps in knowledge existed, which required further investigation.

More than three quarters (76.7%) of participants were caring for a parent with

dementia. Nearly one fifth (17.3%) were caring for a spouse with dementia.

Although this finding is consistent with previous studies in Asia (Truong & Beattie,

2012; Wong et al., 2012), this result is not in line with findings from studies

conducted in Western countries, such as the US and Canada, where spouses are more

commonly cared for than parents (Bartfay & Bartfay, 2013; Haley et al., 2004;

Mausbach et al., 2011). In the 2nd survey, nearly 4% (n=12) of people with dementia

were considered in need of admission to a professional health care setting and 84.2%

were found to be in need of consultation and support services. Moreover, nearly 40%

of caregivers in the 2nd survey experienced moderate or intensive burden. This level

of caregiving burden is considered quite high compared to a study conducted in Paris

in 2005 on 152 dementia caregivers, 29.6% of whom experienced ‘moderate to

severe’ burden or higher (Ankri, Andrieu, Beaufils, Grand, & Henrard, 2005). That

there is a high prevalence of people with dementia, which would benefit from

professional input, in a context in which care is provided by overburdened family

members with low quality of life, constitutes good grounds for conducting further

study to explain why families of people with dementia keep PWD at home.

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 Lai (2010) suggested that filial piety might indirect affect the caregiving

burden experienced by family caregivers of PWD. It was described as a protective

factor that could enhance the positive impact of appraisal factors on caregiving. This

viewpoint has some support from the current study. The findings of the 2nd survey

showed that perceived burden had a positive association with filial piety and it

contributed to predicting the level of caregiving burden. The difference might be

accounted for by differing meanings of filial piety between Chinese–Canadian and

Vietnamese people. Moreover, results of regression analyses in the current study

filial piety explained the level of burden in caregiving (Gupta & Pillai, 2000). The

problems underlying this issue are, arguably, related to multi-faceted factors in

peoples’ evaluation of their parents and their parents’ expectations regarding their

children’s obligation to provide care for aging parents. Asian people in a study

conducted by Mok, Lai, Wong and Wan (Khalaila & Litwin) were found to hold the

belief that the duty of caring for their family members with disease is a standard

social norm. Further, love and support from relatives and family members were

found to be extremely important for people with dementia (Mok et al., 2007).

The notion of filial piety as experienced by the Vietnamese people has been

linked with Confucianism. Confucian philosophy has strongly dominated the

Vietnamese culture for thousands of years (Yao, 2000). Confucianism developed

interrelated traditions and institutions that have significantly impacted life in

Vietnam (Ratliff, 2008, p. 4); it defines a system of moral, philosophical and social

norms, virtue and value judgement. The three greatest relationships that a man must

uphold are, Ruled to Ruler, Son to Father, and Husband to Wife. The article 35 of the

Marriage and Family law, issued by the Vietnamese Government, highlighted the

responsibilities of children toward their parent as, “Children must cherish, respect,

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gratitude, filial practice their parents, to listen to the advice of their parents, to

preserve the honour and good traditional customs of the family. Children have an

obligation and right to care, foster parents. It is strictly forbidden to abuse, torture,

insult parents” (Vietnamese National Assembly, 2000). Generally, a woman is

expected to Follow Father, Follow Husband, and Follow Son, and children are

expected to demonstrate filial piety towards their parents, whether they’re living or

dead (Bond, 1996). The traditional structure of Vietnamese family and community

(inside the country and aboard) carry the expectation that within a family, children

respect and obey adults, women defer to men and the elderly people must be

respected at all times (Braun et al., 1996).

Specific to caregiving, values and beliefs may define perceptions and

responsibilities for caring, determine how responsibilities are allocated, and shape

differences in how outcomes of caring activities are reported. Although the meaning

of filial piety has been discussed within Vietnamese contexts (Duc, 2009; Tho, 2011;

Thua, 2009), no research has explored the motivations, the subjective meaning of

filial piety and the experience of daughter caregivers in Vietnam. Thus, the purpose

of this qualitative phase of the research was to understand how daughters who have

parents with dementia understand the meaning of the carer role and filial piety.

II. Literature review

A classical Vietnamese proverb in a six-syllable line and an eight-syllable line

format, defines filial piety as:

Công Cha như núi Thái Sơn The father's creative work is as great as
the Thai Son/ Everest mountain

Nghĩa mẹ như nước trong nguồn chảy ra The mother's love is as large as the river
flowing out to sea

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 Một lòng thờ mẹ kính cha Respect and love your parents from the
bottom of your hearts

Cho tròn chữ hiếu mới là đạo con Achieve your duty of filial piety as a
proper standard of well-behaved children

Adapted from (Phu, 1998)

The first two sentences can be linguistically interpreted as follows: The effort of a

father is like a tall mountain, and the caring of a mother is like a flowing spring.

Using “Thái Sơn” or Tai Shan in a Chinese mountain (Mount Taishan) to depict the

father’s efforts connotes a deep metaphorical meaning. Mount Taishan is the most

famous sacred mountain in China, which has been worshipped continuously

throughout the last three millennia. It is regarded as an important cradle of oriental

East Asian culture since the earliest time. The description of Mount Taishan draws a

strong connection with how a father is expected to be in an Asian family.

Traditionally, a father is seen as the key breadwinner, the sole pillar in both narrow

and broad meanings, and the guardian of his wife and children. It is popularly

believed that people will compare the father’s effort to another greater nature icon if

it does exist. Not less important, the caring of a mother is compared with a flowing

spring, which nurtures children throughout challenging periods of pregnancy, birth-

giving and breast-feeding and up-bringing. Putting the efforts of a father and a

mother equal to such great icons of the universe and worship, shows the highest level

of evaluation toward the birth-givers. After acknowledging such a greatness of the

birth-givers, the proverb reminds children of filial piety.

Another way of conveying the meaning of filial piety, is to consider the way

that it is written in Chinese. The character for filial piety, 孝, in Chinese (Hiếu in

Vietnamese) originated from the image of a child carrying his old father/ mother on

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his back, dutiful and submissive to one’s parents. This character, 孝, includes two

parts, “old 老” in the upper part signifies the person in the higher position, and

“child 子”in the lower part, indicating their child (Nhi, 1997, p. 267). All of the

previous studies in Vietnam only reported the meaning of filial duties. All authors

employed the ancestor or famous person’s quote, poems or stories to emphasize the

important role of filial piety in regards to children (Duc, 2009; Tho, 2011; Thua,

2009).

The concept of filial piety has also been compared between the East (Chinese)

and the West (American) societies. Piety is a socially approved virtue that has similar

and different aspects in the East and the West. The similar features are to respect, to

care for and to love your parents. The different characteristics relate to obeying

versus disobeying or opposing parents, narrow versus wider responsibility, and

legitimate support for parents (Yu-Tzu & Margaret, 1998).

Empirical studies of filial piety have also been undertaken. Filial piety was

found to be dimensional and measurable by two psychological factors (K. Sung,

1995). The first dimension, named “behaviourally oriented filial piety” included

sacrifice, responsibility and repayment, which accounted for 26.9% of variance in the

factor analysis model. The second dimension, labelled “emotionally oriented filial

piety”, covered family harmony, love/affection and respect, which accounted for

22.6% of variance (K. Sung, 1995).

A study of the relation between filial piety and other well established

psychological constructs has also been undertaken. Yeh and Bedfold (2003)

developed a dual model of filial piety, comprised of Reciprocity and

Authoritarianism, which was linked to the Five Factors of Personality, namely,

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Neuroticism, Extroversion, Openness to experience, Agreeableness and

Conscientiousness. Reciprocity filial piety had a positive correlation with Openness,

Agreeableness, and Extroversion; while Authoritarian filial piety had a negative

association with Openness and Extroversion. However both types of filial piety had a

positive association with Conscientiousness. Authoritarian filial piety was considered

as reflectively negative; it covers a sacrifice of someone’s wishes and a compliance

with his/her parents’ wishes because of their seniority in physical, financial or social

terms, as well as continuing the family lineage and maintaining the parents’

reputation (Yeh & Bedford, 2003).

The Confucian concept of filial piety was also investigated in relation to

understandings of contemporary psychological well-being of Hong Kong Chinese

fifth and sixth grade children (Nga-man Leung et al., 2010). Perceived relationships

with their parents and two facets of children's filial piety belief (Reciprocity and

Authoritarianism) were reported as uniquely associated with life satisfaction, self-

esteem, and social competence. Children with higher reciprocal filial beliefs

appeared more motivated to support and care for their parents. They showed a higher

appreciation for their parents’ efforts in raising them. The authors noted that

promoting interpersonal skills and relationships with their parents and other family

members should be considered as an important role of children. Conversely,

authoritarian reciprocal filial piety was significantly negatively associated with self-

esteem and social competence. It emphasizes children’s submission to hierarchical

authority and the oppression of self-autonomy. At higher levels of authoritarian filial

piety, children have been socialized to respect, but to never question authority. These

authors recommended that research could be extended to explore the different

aspects of filial piety.

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 Filial piety was divided into filial attitudes and filial behaviour in exploring the

relationship between attitude and behaviour in another Chinese study (Chen et al.,

2007). University students from Hong Kong and Beijing, China (N=405) completed

a cross-sectional survey, comprised of several instruments, including the Filial

Behaviour Scale, Filial Piety Scale, social beliefs, and self-construal to explain filial

behaviour. Male participants came up with significantly higher scores, or more

positive filial attitudes than female students did. Regarding filial behaviour, the

distribution between two genders was similar. Mainland Chinese students displayed a

higher level of filial behaviour than those in Hong Kong. Results of hierarchical

regression analysis showed that attitudes toward filial piety were a powerful

predictor of filial behaviour. Social belief and self-construal were also significant

predictors of filial behaviour.

Filial piety is defined somewhat differently in Vietnam than it is in China. It is

considered as one of the most important virtues to be cultivated in the family, which

encompasses love, respect, sacrifice and caring of not only their parents, but also

their ancestors. Behaviours of children towards their parents is guided and managed

within the frame of filial duties. Moreover, aging or getting married will not end their

duty of obedience (Phu, 1998). At a higher social level, filial piety is considered to

be part of national patriotism (Tho, 2011). In the traditional Chinese culture, filial

piety has been defined as an important cultural concept that impacts the caregiving of

a family member for their elderly parents/members. Expressing filial piety to parents

in traditional Chinese culture encompasses respect and care, obedience to parents,

protection and glorification as well as worshiping of deceased parents and ancestors

(Yu-Tzu & Margaret, 1998).

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 An earlier Chinese study in 2002 that sampled representatives of adult

residents in six Chinese cities in a national survey investigated the erosion of filial

piety by modernization in Chinese cities (Cheung & Kwan, 2009). The relationship

between the level of modernization in the cities and the expression of filial piety and

cash payments to parents was explored. Filial piety and cash payments were lower

when the participants lived in a city with higher or more advanced modernization.

The reduction in affirmations of filial piety correlated with higher modernization,

and this association was lower among participants with higher education. The study

also recommended that educational policy and practices can be a means to sustain

filial piety in the face of modernization.

Another study conducted in Israel that examined the effect of filial piety among

adult children caregivers of elderly Arab parents, showed that the caregiving burden

among traditional caregivers was a negative predictor of filial piety. Caregivers who

reported a higher degree of filial piety showed lower caregiving burden. Moreover,

filial piety was correlated with family caregiving network size (family household

member), care-recipient dependency and extent of caregiving per week (caregiving

hours weekly). The study also confirmed that being a female caregiver means

carrying a greater caregiving burden (Khalaila & Litwin, 2011).

Wang, Laidlaw, Power, and Shen (2010) focused on the concept of filial piety

to determine whether the Chinese elderly reduced their expectations of filial piety for

the younger generations. This study was the first of its kind to investigate

demographic characteristics in regards to expectations of filial piety in elderly

people. The regression model revealed that none of the social-demographic

characteristics (age, gender, living area, educational level, etc.,) predicted filial piety

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expectations. Filial piety expectations of older respondents were significantly and

positively associated with self-esteem and several sources of parent-child support.

Socio-demographic and family structural factors contributing to gender

dimensions of filial caregiving were investigated among employees (men and

women) of Canadian Organizations between 1991 and 1993 (L. D. Campbell &

Martin-Matthews, 2003). Several new concepts also employed in this study included

family obligations or motivations to provide care, commitment to care, legitimate

excuses, and caring by default. Traditional male care tasks were managing money

(48%), completing forms and documents (65%), regular housework assistance

(20%), home maintenance and yard work (56%). Multiple regression analysis

revealed that geographical distance was a significant, positive predictor of care

involvement. This means men who lived closer to their older relatives were likely to

provide more care. Men’s involvement in care was also significantly predicted by

education. The findings suggest that, for traditionally male tasks, legitimate excuses

or a commitment to care plays a minor role in influencing men's involvement than is

the case for traditionally female tasks. A later study investigated the possible

association of perceived filial piety of children among older adults in China in 2000.

Results from logistical regression showed that older adults who received financial

and instrumental support from children perceived their family as harmonious, and

those who were co-residents with a married son or married daughter were more

likely to consider their children as pious. Older adults who lived in urban areas were

more likely to perceive their children as pious, compared with their counterparts

living in rural areas (Mao & Chi, 2011).

Overall, the literature review shows that although many studies have

investigated filial piety, the object in the study is either the perception of children

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toward filial piety or the expectation of parents/elderly people toward filial piety

among their children. Fan (2006) recommended that filial piety in Confucian theory

can be applied to develop an appropriate model for long-term care of the elderly.

Piety expectations can provide caregivers with psychological strengths, tolerance and

patience to manage challenges and negative consequences of the caregiving

trajectory. This appears to be a strong motivating force behind family caregiving (D.

W. L. Lai, 2010), however its relevance to female Vietnamese caregivers of people

with dementia has not been yet been demonstrated. The aim of this study was to

determine how female caregivers of a person with dementia understand their role and

the extent to which filial piety affects their experience.

III. Methodology

1. Study design
A qualitative approach has been used in this phase to describe the meaning of

filial piety, the caregiving experience from the perspective of the participants, and

the challenge that dementia caregiving daughter participants faced when providing

care. The concept of filial piety, mentioned in the Yu-Tzu and Margaret report

(1998), was used to capture the meaning of the carer role and filial piety.

Semi-structured interviewing techniques were used in this phase of the study.

Language is central in qualitative research, because data is primarily in the form of

words. Punch (1998) emphasized the importance of language use, showing that the

meaning of words derives largely from their use, and that language is a central

feature of the socio-cultural situation. Semi-structured interviews allow for

modification or extension of questions throughout the interview process, and for

deep description using open-ended questions (Denzin & Lincoln, 2000; Silverman,

2010). There are a number of rationales guiding the researcher to design in-person

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semi-structured interviews. First, Brennen (2012, p. 28) and Leech (2002, p. 665)

highlighted the importance of ensuring that semi-structured interviews have great

flexibility, with open-ended questions, and which are appropriate for respondents to

share specific attitudes and experiences in depth (B. L. Berg, 2009, p. 166; Brennen,

2012, p. 27). The flexibility of semi-structured interviewing allows the researcher to

take notes during interviews. It also enables the use of follow-up questions

(Brennen, 2012, p. 32) to prompt interviewees to describe more of their perspectives

(Leech, 2002, p. 667). Second, the format allows the researcher to measure other

very ‘soft data’ (Neuman, 2011, p. 165) or ‘null data’ (Neuman, 2011, p. 455),

including symbols, sounds, tones, or omissions on the part of the interviewees, that

may be otherwise missed

An interview guide, developed in Vietnamese by the researcher and reviewed

in English by supervisors, consisted of two sections. The first section elicited

demographic and personal information from the participants. The second section

contained several open-ended questions designed to assist participants to describe the

meaning of filial piety and how it works in their life. The researcher used the

interview-guide to provide a semi-structured format for the participants. Interviews

occurred between July and September 2013. Each interview lasted approximately 1

to 1.5 hours.

Although tmixed methods have been employed to provide guidance to the

merging of qualitative and quantitative data in a single study, the current study did

not utilize mixed methods a priori. Rather the two studies were separate. Creswell,

Clark, Gutmann and Hanson (2003) mentioned the mixed method should incorporate

the integration of research designs as well as cover the dimensions or scope of the

empirical discussion. They also argued that the relationship of paradigms and design

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provide the foundations of the mixed method design. In a mixed method study, the

qualitative study justifies the findings and results of early quantitative research while

the quantitative study is utilised to offer a robust method of comparison. In this

current study the qualitative study was followed by the quantitative phase.

2. Participant and data collection strategies

There were 24 current carers who were the daughters of people with dementia,

recruited from the 2nd survey in three provinces (Hanoi, Bac Ninh and Hai Phong),

who participated in semi-structured, face-to-face, in-depth interviews with the

researcher.

First, a formal invitation letter calling volunteers to participate in the study was

sent. Then, three to five days later, a second invitation letter (identical to the first),

together with a copy of the consent form, was sent. Within ten days after delivering

the second letter, potential participants were contacted by phone to obtain their oral

agreement for participation in the study and to make appointments for interview in

their homes at a mutually agreeable time. Consent forms were completed before

commencing the interview. Interviews were conducted until no new themes and

insights were offered by participants. Trustworthiness, a critical requirement for

obtaining valid information from participants, is an important element of qualitative

research (Gratch, Wang, Gerten, Fast, & Duffy, 2007; Maggs‐Rapport, 2000). In this

study, rapport was established through initial and ongoing contact and

recommendations from respectable people in the Vietnamese context, for example,

village heads, community health workers and medical doctors treating people with

dementia, which assisted the researcher in developing trustworthiness within the

communities. To ensure accurate transcription of the data, every interview was tape-

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recorded and transcribed in Vietnamese. A proportion of interview transcriptions

were translated into English as part of the analysis process.

3. Data analysis
Data analysis was undertaken using content analysis and comparison to reveal

the expressed meaning of filial piety of daughters who care for a parent or parent-in-

law with dementia. Content analysis is an ‘observational’(Kolbe & Burnett, 1991, p.

243) and ‘non-reactive’ (Neuman, 1997, p. 272) research method, a popular

companion in a multi-method study (Brewer & Hunter, 1989; Macnamara, 2005).

The content analysis systematically evaluates all particular forms of recorded

communication in an effort to identify patterns, themes or bias (K. E. Berg & Latin,

2008; Leedy & Ormrod, 2005).

All audiotapes were transcribed verbatim in Vietnamese by the researcher as

each interview was completed. Transcripts were compared with the audiotapes to

note relevant information. Due to the high costs of translation and back translation,

not all interviews were able to be made available in English and it was preferable that

the first stage of the analysis be undertaken in Vietnamese by the researcher to

ensure meanings were not distorted by translation. The researcher first read the set of

transcribed interviews independently. The researcher carefully reviewed each

interview independently and paid attention to specific statements related to the

phenomenon of interest. Each time the participants indicated a new idea on the

meaning of the experience, the reader made a note. Coding and analysis then

occurred using an interactive processes of discussion with supervisors, the data

transcripts, and the memos, reflective journals and debriefing notes of the researcher.

Themes were compared, discussed and decided upon and this process was continued

until no new themes emerged from the data, in accordance with the practices

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recommended by Becker (1992); Bowden et al., (2009); Yu-Tzu and Margaret

(1998). Then, the most comprehensive set of ideas that depict participants’ views on

their experience were generated. Discussion of ambiguous statements was also an

important part of the coding and theme determining process and helped prevent a

single perspective from shaping the entire analysis of the data. Themes were based

on both the frequency of response across participants as well as the intensity of the

expression used by carers. The final data analysis step was to elucidate the essence

of the experience through each topic. In the final step, the researcher translated the

Vietnamese themes into English and discussed and reviewed these with his

supervisors.

5. Ethical considerations
Conducting a village and community-based study in Vietnam is difficult

because of numerous administrative and political obstacles. Support and

recommendations from local authorities and health stations were employed, as

needed. Along with the necessary sponsorship of a Vietnam research institution, the

help of numerous friends and acquaintances made this research possible. Moreover,

ethical clearance was sought from the Queensland University of Technology Ethics

Committee and the Hanoi School of Public Health Ethical Committee. Informed

consent was obtained from each prospective participant and all information privacy

of all participants is protected in all study reports.

IV. Results & discussion

1. General information of study participants

The 24 caregivers who were daughters or daughters-in-law of people with

dementia participated in the individual interview. The main characteristics of these

participants are presented in the table 5.1.

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Table 5. 1. Main Characteristics daughter or daughter-in-law dementia
caregivers
Par A Pla Hi People Relationshi
ticipant ge ce of ghest with dementia p to people with
number (years residence Education S A dementia
level ex ge
(years)
C 4 Ha H F 7 Mother
G1 5 noi S emale 2
C 3 Ha B F 6 Mother
G2 9 noi Sc emale 8
C 5 Ha B F 7 Mother-in-
G3 4 noi Sc emale 5 law
C 5 Ha P F 8 Mother
G4 5 noi G emale 0
C 3 Ha B F 7 Mother
G5 8 noi Sc emale 0
C 4 Ha B M 8 Father-in-
G6 4 noi Sc ale 6 law
C 3 Ha B F 7 Mother-in-
G7 8 noi Sc emale 7 law
C 5 Ha B F 7 Mother
G8 6 noi Sc emale 8
C 3 Ba H F 8 Mother-in-
G9 8 c Ninh S emale 0 law
C 5 Ba H F 8 Mother-in-
G 10 5 c Ninh S emale 4 law
C 5 Ba H F 7 Mother
G 11 4 c Ninh S emale 8
C 6 Ba H F 7 Mother-in-
G 12 3 c Ninh S emale 9 law

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 C 4 Ba H F 7 Mother-in-
G 13 2 c Ninh S emale 6 law
C 3 Ba B M 7 Father
G 14 6 c Ninh Sc ale 3
C 4 Ba B F 7 Mother-in-
G 15 9 c Ninh Sc emale 5 law
C 4 Ba H F 7 Mother
G 16 2 c Ninh S emale 0
C 5 Ha B F 7 Mother
G 17 1 i Phong Sc emale 2
C 5 Ha H M 7 Father-in-
G 18 1 i Phong S ale 0 law
C 6 Ha H F 8 Mother-in-
G 19 0 i Phong S emale 2 law
C 5 Ha B F 7 Mother-in-
G 20 0 i Phong Sc emale 8 law
C 6 Ha H F 8 Mother
G 21 5 i Phong S emale 2
C 4 Ha B F 7 Mother
G 22 8 i Phong Sc emale 6
C 4 Ha H F 7 Mother-in-
G 23 2 i Phong S emale 1 law
C 6 Ha B F 8 Mother
G 24 1 i Phong Sc emale 0

High school (HS); Bachelor (BSc); Post graduated (PG)

The mean age of interviewed caregivers was 46 (years) and the mean age of the

people with dementia for whom they provided care was 76 (years). Twelve

interviewees cared for their parent with dementia and 12 participants were the main

caregivers of their parent-in-law with dementia. There are 11 dementia caregivers

with high school education, 12 with bachelor level and 1 with post-graduate training.

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 2. Themes of interview
Analysis of the comments of daughter caregivers revealed six major themes:

(1) Obligation, sacrifice and love; (2) Providing an example to children; (3) Mixed

emotion (Ambivalence); (4) Need for family support while caregiving; (5) Fear of

losing social reputation. These themes are discussed below.

2.1. Obligation, sacrifice and love

All participants made symbolic comparisons of their parents to “ripened

bananas on the tree”…. This means that life expectancy of their parents, or their

elders, is unpredictably short and greatly uncertain as a result of the aging process;

people should treat them well when the parents are alive.

The nature of human beings contains both good and bad sides. Filial piety,

dignity and virtue, which are moral characteristics, are considered to be the good

aspects. People who present those good character traits would have undergone

training to develop these traits. Transferring those character traits to actions in real

situations is the expression of those virtues. All caregivers gave highly similar

accounts of the meaning of filial piety, which can be accurately summarised as

obligation. Caregivers used the word obligation or the required responsibility of

children towards their parents, because their parents are deserving of good treatment

from their children. Parents born, raised, nurtured, taught and guided children to be

people. The love and effort of parents for their children is incomparable. It was

expressed as great as a sea or as high as mountains. The caregivers recognised that

their parents had whole-heartedly cherished their children, using words such as:

unconditionally, always on their side, sharing and caring for their children in all

circumstances, despite difficulties or hardships. Therefore, their belief was that the

child should reciprocate these actions with tremendous gratitude. Children should

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have self-discipline: “Filial piety is normal; every child should know and practise it

(CG 19). Extending filial behaviours toward their parents is common in Vietnamese

society. These understandings and responses were considered as being innate for all

children. It is an expression of gratitude to those who have had the great grace,

namely, their parents.

Filial piety was described as, “the most essential characteristic of a person”

(CG 6). It has been considered as a fine moral characteristic of humans. It plays an

important role and contributes to the feeling, emotions and thoughts of each person

toward their parents and ancestors. It helps people to understand the meaning of life.

Filial feelings towards parents are a foundation of love in human society. In spite of

a success or failure, family is still the only home. The following quote from CG8

illustrates these sentiments.

…. báo hiếu cha mẹ vô cùng. … showing and practising filial piety to

Tức là cái chữ vô cùng nó rộng lắm parents are unlimited and it varies. The

thì cô nghĩ rằng mình tức là nếu meaning of filial piety is very vast,

mà... cái này nó hoàn toàn phụ thuộc enormous… It may be better to look at filial

vào gia phong nền nếp thì đúng hơn, piety as a line of family traditions. I also

cô nghĩ rằng mình có báo hiếu cha think that we can never do enough to show

mẹ bao nhiêu cũng không đủ. our gratitude to our parent (CG 8)

The caregivers recognized that filial piety can be shown in many different ways. It

might be the way children take the advice from their parents, take care of their

elderly parents when getting older or sick, or listen respectfully to their parents’

counsel. The way of expressing children’s gratitude toward their parents is variable

and enormous. There was no boundary for proving how much children love their

parents via the means of caring.

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 “Caring for parents adequately is one of children’s obligations” (CG 12).

Daughter caregivers use of “đầy đủ”/ “adequately” is very meaningful. Services

offered for their parents contain not only physical as well as mental and spiritual

domains. Presenting filial piety toward parents is not only about attitudes, but also

behaviours and actions. Children should know and act appropriately towards their

parent. Simple ways in which this value can be expressed includes via the care

shown towards one’s parents, sharing with or just a polite word, which may make

parents feel warm and happy.

“My only thought as to how and whenever I show gratitude to parents is my

right to do/ achieve – filial piety. I feel very happy to do so. It is likely to repay

parents’ love. Filial piety or showing gratitude to parents is preferable to benefits

and loss, or jealousy or comparing with other people, even with my brothers and

sisters. I never consider or think about that. Even with my younger sister-in-law, I’ve

never compared jealously my advantages and disadvantages with her” (CG1). In this

case, the participant highlighted her filial obligation towards her mother, not only to

make her happy, but also because of her legal right and authority to do so. From this

point of view, caregivers’ recognised practising filial piety is not only their

responsibility, but they also have the desire to do so. They understand that when they

feel happy, their parents will understand that they’re happy, and in turn, be happy

with them.

“We should offer care for our parents these days, as well as worship for our

ancestors as adequately and comfortably (CG 12)”. Filial piety has been illustrated

as involving not only the provision of unlimited support for parents (who are living),

but also the everyday worship for ancestors (who are dead). People should express

their gratitude for parents (who are alive) and their ancestors (who rest in peace). The

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custom of worshiping ancestors is also an aspect of performing filial piety, respecting

grandparents and ancestors, even if they are resting in peace. This custom also

represents the humanity of Vietnamese. The deceased have not been forgotten in the

minds of the living. With the worship ideology towards the ancestors, Vietnamese

people set an example and teach each other how to live to be worthy of meeting the

expectations of ancestors. Moreover, this practice also reinforces the existing linkage

between siblings, neighbours and relatives. Practicing-worship encourages people to

stick together, to temper the family and to cherish and love. This is also an

opportunity for children from different corners and places to join together, exchange

ideas and stories strengthen the intimacy of relationships, and visit and respect their

grandparents and elderly relatives if they are still alive.

Most of the daughter-caregivers who were interviewed had not felt burdened

by caring activities, such as, bathing and preparing food to serve their parent with

dementia due to filial piety. They do it because, “I just do not feel secure and right

when letting her stay there (with her son). I don’t think about showing gratitude/

filial piety or not. For me, I think that I’m in a good condition to take care for her

(CG 4). All caregivers decided to take responsibility as the main caregiver because

they felt more comfortable and safe taking care of the person with dementia, without

feeling an obligation of filial piety. In this case, the daughter thought that she was in

a better position to care for her parent than her brother. Her brother might be in

poverty. He might not have enough money to buy gifts or food and culinary treats for

parents, or be in a position to provide better support. Therefore, she felt unsafe and

wrong when letting her mother with dementia stay with her brother. She was worried

about the low quality of food as well as her mother’s health when she stayed with

him. She would take responsibility to take care of her, because she might offer better

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continuous service, including being able to talk and chat with her respectfully every

day. Moreover, she did it without hesitation.

“We have to try our best. We have no choice now. Mum is our mum. Even

mother-in-law is also the same. When I move here to live with mum, I must strive to

overcome [obstacles]” (CG 2). This quote illustrates that caregivers’ experience

filial piety as a duty to care for their parents and their parents-in-law. The meaning of

no-choice is that those duties cannot be passed to other people or organisations. In

this context, this can be interpreted as an expression of filial piety.

.. Thì bây giờ mình làm con thì …After I got married with her second

mình cứ phải làm cho nó tròn cái son, I became her daughter-in-law. I have to

nghĩa chứ bây giờ thì mẹ mình bỏ đi fulfil the affection and gratitude/ sentimental

đâu?... thì mình nghĩ mình là con thì attachment of children. How could we leave

bây giờ mình cứ phục vụ, trừ khi nào her? I think that I’m her child. It means that

không phục vụ được nữa thì thôi…. I give her support until I can’t do any longer

provide ” (CG 17).

The quote above illustrates how filial piety is experienced by daughter-in-law

caregivers of a parent dementia. The interviews revealed that daughter-in-law

caregivers were regarded asa “real” family member and a “real” daughter, to melt

and fit in with the customs of her husband’s family, even if these customs and are

unfamiliar and different from those of her family. Caring for elderly parents and

parents-in-law was also considered as a life-long commitment. Once committing to

care for them, children should do it, without any reluctance.

“Cô nghĩ rằng cái chữ hiếu thì với “Filial piety may mean a bunch of

mọi người nó to tát như thế nào nhưng very big things, but to me, it simply

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với cô thì cô nghĩ nó đơn giản là mình means the best things we could do for

làm như thế nào tốt nhất cho mẹ mình our parents that suits our situation and

theo cái tâm của mình, theo cái điều kiện for a regret-free soul.”

sống của gia đình mình. Mình làm thế

nào tốt nhất cho mẹ mình, cho cái tâm

can mình nó thoải mái.”

In this case, the caregiver used the word “đơn giản”/, meaning simple and very

normal; everyone can do it. They offer care for their parents, where the standards that

have been set as equivalent in importance to their health, economic and living

conditions. They also emphasized showing the best for their parents as the purpose of

their action.

…Ăn thì bà cũng không ăn được …Eating, mum doesn’t eat much

bao nhiêu đâu nhưng mà bà không thích but mum doesn’t like food prepared in

ăn cơm viện, không thích ăn cơm ngoài hospital or in restaurant. She only

(mua ở cơm bình dân ngoài). Mình nấu prefers food cooked at home. We

thì sạch sẽ. Như e biết đấy, những lúc cụ maintain food hygiene and safety. You

tỉnh táo thì cụ mong muốn như vậy. Do know, when she is conscious, she wants

đó khi cụ ốm đau mình phải chấp hành that. So, while she is ill, we have to

thôi. follow her desires…

In this case, they followed the desire and expectation of their mother when she

was conscious. The desires and expectations might be very simple; food prepared

and cooked at home by her children. For them, the behaviour of following her

mothers’ expectations is also an expression of filial piety. Children should know

what kind of food their parents like or dislike, know their parent’s taste, cook what

their parent wants to eat, and also know their parents ‘expectations of them in regards

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to their life, work and career. They should make sacrifices for achieving these filial

behaviours. The support and service usually depend on their financial capacity.

Caregivers always ensured that their elderly parents with weak teeth and stomachs

had food prepared for them that was soft, easily digested, nutritious and suitable to

parents’ taste. Further, children should also prepare soft, comfortable and suitable

clothing.

Naturally, I am supposed to stay and care only for my business here. Now I

have to be in two places / split body and mind into 2 places at the same time. In the

morning I have to get up a little earlier to visit her at my brother’s home. However,

sometimes I spent all morning or afternoon or whole day there. I couldn’t open my

shop and my business. I had to close my shop, my children went to school. In the

afternoon, I might open the shop for couple hours. If my children go to school, I have

to close my shop. But I’m in a very hard time and lose a lot. I lost many things, but

they belong to me (CG 1).

“Do everything to make a warm, loved family then she feels healthier” (CG 4).

In order to make their parent happier and healthier, they had sacrificed much to

create a warm, loving and friendly living environment. They had to get up earlier to

visit the parent and to go shopping, because in Vietnam, Vietnamese women usually

go shopping every day in order to prepare food for every member within their family.

If they get up earlier, they have the chance to buy better food and products, make

everything ready for cooking and provide better meals for their parents and other

family members. It also means that they would like to spend more time with their

parents, rather than sleeping. Moreover, to have more time with their parent, they

have to close their business and lose the income. In making these sacrifices, they

expect their mother would get better and healthier. In Vietnamese culture, food is

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also considered as a kind of medicine. The way food is cooked and preserved is

believed to help their mother’s health.

“It is hot this summer and the power is on and off at night, therefore I have to

use bamboo tape fan to cool her down the whole night” (CG 16). The behaviour of

fanning their parent all night and the feeling of needing to stay-up is also reflective of

filial piety and sacrifice. Instead of sleeping if the parent is uncomfortable in the hot

overnight conditions, the child stays awake to help their parent to be more

comfortable. With the symbol of “bamboo tape fan”, they also implied that if their

parents are not in the best life condition, they are trying their best to offer the best for

their parent who is suffering from the effects of aging and disease.

.. cô cũng gọi là gọi là cái tình “I named the motivation to care for

cảm và cái tình thương và động lực my father as affection of children to their

của người con mà đối với cha mẹ parents firstly. For them, the responsibility

mình như thế, đối với ông bà là nghĩa of children is to offer care for parents. The

vụ và một cái động lực nữa là chồng second motivation of attending to parents is

mình, mình làm hết sức mình để cho for my husband. I have to offer best services

chồng mình nó còn làm cho nó khỏi to my father-in-law to show to my husband

suy nghĩ lọ chai, các kiểu suy nghĩ về my love and gratitude to parent. When doing

những chuyện mà …ờ không làm cho that he has appraised as good and filial

cụ ảnh hưởng này khác thì nói chung daughter-in-law. But the most important is

không kiểu như là chồng mình nó sẽ affection for parents” (CG 16).

nghĩ rằng mình là một người tốt một

người hiếu thảo. Thế có động lực như

thế cũng không ấy được mình nữa,

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người ta cũng có một cái tình cảm rất

là quý.

“My brothers and sisters have to go to work, whenever they have free time;

they help care for our mother. I make the best of time and self-motivation to care for

my mother. I’ve never discriminated or compared jealously advantages and

disadvantages of doing so” (CG 1). ). Filial piety also implies the love among

siblings, and between children and parents. The siblings protect and help the other

siblings in times of distress and during the harder times. The daughter shares in the

responsibility with the son in caring for their mother who’s suffering from the effects

of aging and disease.

Thì cô làm, con cháu thấy chăm bà, thì hiểu thế là có hiếu thôi/ I offer care to

her, I take care for her. That is filial piety, just all (CG 17).

“I really regretted when my father and my uncles passed away. Because I

worked hard those days then I hadn’t showed my enough gratitude to them. It means

I always regret of not dutiful but showing less filial” (CG 8). Moreover, showing

gratitude to their parents was to do without regret. They would feel regret or guilty

not to do so. They would feel guilty if they did not have the chance to perform the

activities of caring for their parents.

“I do it for her… when she feels comfortable, best things for her I can do for

her. I also feel happy. When she is here, there is love here. Love and affection helps

her get better in recent years. It does not like when living over there (the son’s

house) she felt lonely” (CG 4).

Thôi thì cụ thọ như thế con cái cũng được hưởng phúc của cụ sống lâu/ when

she lives longer, her children will inherit good fortune/ Karma (CG17)

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 “My mum had to struggle to raise and care for us. When we grew up and got

married, it isn’t correct to say we are rich, but must say our lives are getting easier.

We wish mom could live longer. Now we have spacious house, we wish mum could

live for more several years (CG 2). Participants disclosed the motivation of caring

for people with dementia quite similarly as not an action taken to fulfil filial piety.

Rather, these actions come naturally from their feelings and emotion (8th participant

in Hanoi). She also mentioned that she felt comfortable when serving her mother

with dementia. The custom of supporting/caring for seniors or older people with

disease exists in her family across the generations as a routine and habit. She does it

naturally, without thinking.

In summary, filial piety is to sacrifice to have a happy harmonious family, to

work towards health for their parents, to repay the parents for their efforts in

promoting and educating them, and assigning themselves the role of caring for their

parent as their obligation towards their parents, was the main aspects of the theme.

2.2. Providing an example to children

Filial piety was expressed as “set an example to teach their children”.

Participants employed several Vietnamese Proverbs to highlight the importance and

meaning of filial piety:

Có rễ mới có cây, có gốc mới có When drinking the water, think of

ngọn its source (CG 1)

Con phải nhớ mình có nguồn, có You must remember your origins

gốc (CG 11)

Có phúc thì có phận. Share of happiness/ fortune one

was blesses with (CG17)

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 The symbolised connection between “water and its source” or “origins” are

utilised to teach their younger generation. "Water" is a precious thing. If there is no

water, humans and plants will be destroyed, no life. "Source" is the place of origin of

the water or the root. The merit of the birth parents is really incomparable. Children

should be grateful towards their parents and express deepest gratitude toward them.

Children should respect all daily food, clothing and medicine when we are sick,

comfort provided by their parent as well as the enforced role of nurturing them since

they were born. Although it is literally just a proverb, it has been utilised as a

profound implication of gratitude. "Water" was also implied as the heritage from the

father or previous generation. So, when inherited, people must remember and respect

who created it. Then, children should treasure and preserve as well as conserve. On

the other hand, the human has a duty to promote good moral character and pass it on

to the next generation. All those issues have been passed as heritage from this

generation to the next generation. Participants emphasized filial piety as “their

traditional custom/ habit or heritage (truyền thống)” (CG8) or “we are still

following”.

They used heritage or tradition to highlight the long process of “setting an

example”. Filial piety has been taught and propagated across family generations, for

example: “It should be hereditary from this generation to next generation” (CG 6).

Great grandparents set a good example for grandparents to imitate. Grandparents

then acted as good role models for the parent to follow. In this generation, parents

have kept and maintained the tradition in the family. This is a process of transferring

and contributing to develop the character of children.

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 Thực ra thì cái này cô nghĩ là In fact, I was educated by my

từ xưa trong cái truyền thống gia grandmother to follow our family’s

phong của nhà cô thì cô được bà nội traditional custom and reputation. She taught

dạy là con cháu báo hiếu cha mẹ vô us children should show and apply filial piety

cùng. Tức là cái chữ vô cùng nó to their parents plenty/ uncountable/largely.

rộng lắm thì cô nghĩ rằng mình tức The meaning of filial piety is very

là nếu mà... cái này nó hoàn toàn widely/enormous… It will also depend on the

phụ thuộc vào gia phong nền nếp thì traditional custom/habits of each family. I

đúng hơn, cô nghĩ rằng mình có báo also think that it is not enough for us to show

hiếu cha mẹ bao nhiêu cũng không gratitude and present filial piety to our

đủ. parent (CG 8).

In the family, children not only study from their parents, they are also educated

and guided by their grandparents and elderly relatives to maintain and improve the

reputation and traditional line of the family.

…Việc tôi làm tròn chữ hiếu là như “…The way I fulfil filial piety is like this:

thế này, là lúc mẹ khỏe thì mẹ làm mẹ when mom was healthy and young, she

ăn, giờ mẹ già mẹ dựa vào con cái. served herself. Elderly mother leans to her

Chúng tôi sống là để cho con cái sau children when gets older. We are living for

này, là cũng phải bắt chước mình là our children so that they imitate/duplicate

để làm sao để khi mẹ già, tự nguyện, what I have done for my mother- in -law. My

những thằng con rể, hoặc những đứa sons-in-law or daughter should

con gái đây nó cũng tự nguyện nó bảo spontaneously take responsibility for caring

ừ đấy trước mẹ sống như thế nên giờ for their parents or parents-in-law. They

coi là mình cũng bắt trước mẹ, sống will remind themselves of how to live and

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làm sao cho nó trọn làm chữ hiếu, cho treat them as their parents have performed

cha cho mẹ vui vẻ lúc tuổi già. Thèm in order to make parents happy and give

cái gì cho ăn đấy, mẹ sai mình cũng them pleasure with their aging. If they

phải bỏ qua, là mẹ mà, mẹ có sai lúc request for anything, we should satisfy them.

này mình không đốp chat… Sometimes, if parents make something not

correct, we should not mind. Never date

back or argue…

Filial piety involved not being jealous about others benefiting, and not from

setting a good example to children.

… tôi không bao giờ phân chia, 2 …I’ve never asked to share my

chị tôi là trên tôi thật,, chị có tâm đến duty of care with my sisters-in-law.

đâu thì biết đến đấy, trước tôi là con gái Although I understand that they are older

tôi chẳng, các chị cũng chẳng tị với tôi and in higher family position than I am,

thì tôi cũng thế, chẳng tị với các chị, the more support they offer, the better we

thương mẹ đến đâu thì giúp còn tôi làm (my family) gain. I’ve never been jealous

hết… with what property and fortune parents is

passed to them….(CG 11)

“In my family, there are four sisters-in-law and only a youngest sister. So, we

have already discussed and designated tasks. It seems not to be responsibilities….

For us, we are a solid and wonderful group, consisting sisters-in-law, brother-in-

law, brothers and sister” (CG 7). For this case, filial piety also can be described

clearly among children and other family members. They have solidarity as a family

unit.

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 “Parents are suffering from diseases when they are getting older. I’m their

child; therefore it is my responsibility to care for them by standing by, without any

signs of reluctance/signs.” (CG16).

“Although my husband is the youngest son in a family of 7 sons, we decided to

take responsibility as main caregivers for my father-in-law just because all of my

husband’s brothers got married and moved out before my husband and I married.

Since then, my parents-in-law still live with us. It is normal for me… We have not

asked for help from my husband’s brothers” (CG6). The reason to become a main

caregiver is quite simple in this case. The youngest son who got married last

naturally cares for his parents-in-law, because he lived with them before getting

married.

Respondents emphasized that they do not take into account whether they are

“daughter or son”. The reason they decided to care of their parent is just they, “have

better criteria to offer the service”. Those criteria include, “more spare time”, “better

health”, and “more supportive resources”. “Cho các cụ phấn khởi/ They are very

excited” (CG 12). The elderly relative is so proud and so motivated when their

children show gratitude and filial piety to their predecessors.

2.3. Mixed emotion (Ambivalence)

Interviewees reported that their emotional response to caregiving changed

overtime. The following was expressed by participants who used several Vietnamese

Proverbs:

Đầu tiên thì thương, sau thì thường Love at first, compassion later,

rồi cuối cùng đến ghét then hate at last.

Cô tự nhủ “ôi thế này thì chết”. I said to myself "oh, this is death/

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 how serious it is ".

Kể ra lắm lúc thì cũng bực, nghĩ cụ Sometimes, I felt angry and it’s

chửi cũng bất công, phục vụ cụ nhưng unfair because she scolds/gives verbal

mà cụ cứ chửi cũng thấy bất công chứ abuse towards me for all the things I did

nhưng mà bây giờ làm sao được bây for her. It is unfair, but what I can do

giờ?... Bình thường cụ cứ vui vẻ thì mình now? Normally, when she is happy, I

cũng chẳng có nghĩ ngợi gì cả. Nhưng don’t mind working. I feel happy. But

mà lúc cụ chửi rồi thì cũng thấy bự[Link]ứ when she abuses me verbally, I feel very

còn bình thường những lúc cụ vui vẻ fretful.

cũng cảm thấy vui

Bà thì rất khó tính. How fastidious is she

Mình phải chịu nhịn ấy chứ, bà già I should digest an insult regularly,

lẩn thẩn chấp làm sao được mà…. Bà because she is suffering from disease and

còn chửi… cô cứ mặc kệ vì cô hiểu mà … getting older… She has even abused me

verbally… I just ignore, because I

understand it…

“Never can we break the life cycle of our parents getting older and

fragile/vulnerable. When our parents were younger, they raised and fed us, and now

when they are getting older, we have to care for them. They don’t want to be in such

situation, but when they suffer from disease, their wish is to purely stay with their

children. They will be sad/ grievous if they are alone. Therefore, they will be dying/

dead if they do not receive any support and care from their children” (CG1). The

participant also considered the feelings of parents who are in need and lonely and

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might be desperate if they have not received care (physical and mentally) from their

children.

“We haven’t had any vacation that all my family go on together since my

father-in-law has been suffering from disease. One member should stay with him.

Then our vacation is always less than 3 days “ (CG 6)

“Muốn đi đây đi đó nhưng không đi được còn vướng cụ/. I’d like to go out,

travel somewhere, but it is impossible because of her (CG 17)”.

Caregivers had mixed emotions when caring for their parent who suffered with

dementia. They feel happy, comfortable and loving when their care-receiver is happy

calm and not aggressive. Nevertheless, they felt anger and a sense of unfairness when

things were difficult or prevented them from enjoying their own lives fully.

Moreover, they thought they might develop feelings of hate or despair when caring

for a parent for a long time.

2.4. Need for family support while provide care

All participants highlighted they needed and received support from other

family members and friends in order to fulfil their responsibility of filial piety. Filial

piety is a kind of emotional connection, created for all family members.

“Luckily my husband organises his time to share with me. He is a government

officer, so he can arrange weekend time to support caring for mom” (CG 2).

“My eldest son, six-years-old, is preparing to enter the first grade. During the

period since my mother has been in a severe condition, we have had to let my son

stay with his grandmother, 20 minutes away from here by motorbike. We had to ask

my mother-in-law to take care of him. In the interest of support, all individuals in the

family offer any kind of support, but in different ways, directly or indirectly. For

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instance, when my son is here with me, I have no time to teach and look after him.

But thanks for my parents-in-law, who take care my son, I have more spare time to

give care to my mum” (CG 2).

“My friends and colleagues understand my situation, especially when I have

felt tired after taking the night shift to care for him (father-in-law): Stop, stop, you

should take a rest, we can help you. Luckily I have such wonderful friends” (CG 16).

The support might include taking care of and monitoring their children when

they are providing care for their parent. Primary sources of support might be their

husband or parent-in-law. They also get physical support and empathy from their co-

workers.

2.5. Fear of losing social reputation

“Well, actually, what has to come will come, we cannot stop it. So our thoughts

are more comfortable now because all family did wholeheartedly care for mum.

Nothing to regret. We only wish mum would be alive for a few more years. That is

all; we haven’t avoided taking care of her, never mistreated her” (CG 2).

My eldest son is a good boy. He told me, “mum, you were too tired to take care

of my grandmother. Let me help you to take care of her tonight” when he was in the

12th grade. “Let me stay with her tonight. Don’t worry for me. I don’t have to wake

up a lot. I just lie down next to her bed. If she has any strange/abnormal signs, I will

call uncles – you” (CG 1). Filial piety is also described as being proud about having

such a good child to express gratitude towards their relative superiors (including

grandparents, uncles... etc.)

“When my son offers caring activities for her, I told her not to be embarrassed.

Children should do tasks such as these; boys and girls should do it as well.

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Sometimes I also teased her like this, “he will get married, and then he has to

serve/attend to his wife. Don’t be so worried” (CG 1). In this case, the motivation for

caring is just to receive support from the caregiver’s son. She feels happy and

proudly talks about those events. Her son (caregiver’s eldest son) understands and is

not reluctant to provide basic care for his grandmother. According to Vietnamese

culture and Confucianism, males and sons should not do any caring or the

performing of any household tasks.

Ms A is a 56 year-old who has been retired from her office administrative and

business career for two years. She is the eldest daughter of a 78-year-old mother with

dementia, who has two daughters and a son. Her mother is the wife of a patriotic

martyr. “It was very difficult for me to still keep working and take care of her at the

same time. We hired house maids to help us with the caring and observation of her

when we go to work. She was very hard to please/fastidious. She didn’t allow turning

on a fan when it was hot, or to turn on the power or light, etc. They couldn’t stand it

for more than three days. Then, I found another solution. My younger brother and I

visited a private nursing home. We discovered that there were many that were

inadequate and far from our expectations. I considered sending my mother to stay in

a nursing home, because I’m a trendy person. It is considered that those caring

services persecute/mistreat our parents, or are irresponsible with them. I would feel

regret if there is a social prejudice about it”.

From quotes above illustrate the fear of losing social reputation (including

family reputation and their own reputation) resulted in the family maintaining caring

at home with assistance. They rejected nursing home care, a new concept in

Vietnam, although it would have been convenient, because it went against traditional

values. Filial caring is expressed in the wish that their parents go on living longer,

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with healthy aging. If this good fortune occurs, their children will be blessed, and

their work/job goes smoothly. The harmony in the family is maintained.

Several reasons emerged to explain why participants keep their parent who is

suffering from dementia living at home. Main points can be illuminated via the

stories of dementia caregivers. CG 11 was taking care of her mother-in-law at home,

who suffered from dementia, while her husband works 1000km away from home. He

goes back his hometown twice annually. She disclosed a conversation with her

children:

…. bố gửi về thì gửi không thì mẹ “…If your father has not sent

cứ thu vườn gần đây mẹ cũng sống nuôi money, I still stay here to care for your

bà, còn không lo nghĩ gì, các con cứ vô grand mom with income from our farm

tư đi, mẹ đây mẹ sống để các con bắt and garden. You should not be worried

trước mẹ, thế rồi cứ phải theo bố xong for me. Take it easy. I have to live so that

bỏ bà ở đây, nhỡ bà làm sao thì của cái you will duplicate my style when you

có mua được cái danh cái tiếng không, treat your parents. If I followed your

cho nên thôi, mẹ không làm được father to settle in the south, your

grandmother would catch any problem.

I’m living with that. I should live with

good reputation ….(CG 11)

Thực ra thì … bon chị cũng phải cố … Actually, we have to try our

gắng thôi. Bây giờ mình cũng không có best. We have no choice now. Mum is our

sự lựa chọn. Mẹ thì là mẹ của mình. Cho mum. Even our mother-in-law is also the

dù kể là mẹ chồng cũng thế thôi. same.

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 Daughter caregivers had tried their best to care for the parent who was

suffering dementia and living at home. They do it for their parent, without any

consideration that the relationship is with the mother-in-law. Usually, in Vietnamese

culture, the relationship between daughter-in-law and mother-in-law is not

considered to be good, and there’s usually conflict. In all cases throughout the

interview, daughter caregivers firmly expressed their commitment to care for their

mother-in-laws, despite any reluctance due to conflict in the relationship with the

mother or mother-in-law.

Không nỡ bởi vì chắc chắn khi bà ….We do not have the heart to do

vào đó sẽ thiếu tình cảm, không có con this (let her mother to live in a nursing

cái ở bên cạnh. Đến đó toàn người lạ. home), because we know she will be

Nếu như bà hoàn toàn tỉnh táo thì có thể deficient of love and care, with no

không sao. Nhưng bây giờ bà bị bệnh children beside her. They are all

rồi, mà không nhìn thấy con cái, toàn strangers over there. If she is totally of

nhìn thấy bác sỹ - điều dưỡng, thì sợ. unsound mind, it is not a problem. But

Chắc là sẽ không được nên thôi. Bây giờ now she is so sick; if she doesn’t see her

dần cũng quen là một, với lại cũng dễ đi. children, she sees all doctors– nurses;

Bà cũng dễ đi rất nhiều. Nếu trước là 10 she feels scared. We guess it will not

phần thì bây giờ tình trạng của bà cũng work, so forget it. Now we are becoming

giảm còn 3 phần thôi ah. Hồi đầu mới về familiar and she is getting better. If her

đây cũng căng thẳng lắm. Bà phá phách condition was 10 before, now it

tung lên. Lúc thì gào thét, lúc thì kêu decreases to 3 ah. In the beginning it was

khóc. so stressful. She devastated everything.

Sometimes she shouted, sometimes she

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 cried.

Besides the fear of being a poor daughter, they also thought about the feelings

of their mother living in the nursing home; that she’d be deficient of love and care,

lonely, without seeing the faces of relatives, or their children. Living with family, the

health status of their mother became better and improved.

They also accept the situation of having a mother with a disease: “generally, it

is fate; we have to accept it. She is the one suffering distress”. The person who is

most suffering because of the disease and its consequences is their mother. They

could not compare their own difficulties with the distress that their parent was

suffering.

..sống để cho xã hội, dân là người …I live to with her to society/

ta nhìn vào thôi chứ không phải là con community grade/value reasons, rather

bảo bà ra đây ở là con xin tiền bà hay là than let her stay to receive her money or

con lợi lộc cái gì của bà hết any of her benefits”

In this case, the daughter-in-law took responsibility for caring for her mother-

in-law in her home. Her husband was the youngest son in the family of four sons.

Usually, in Vietnamese culture, caring for parents is the responsibility of the eldest

son in the family. The reason they chose to live with their mother was that they had

better resources to take care of her. Then, she pointed out that they would like to

demonstrate to others, including the community and society, how they treat their

mother in the best conditions.

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 Chapter 6: DISCUSSION

This study was the first to apply a well-established theoretical and conceptual

framework to explore factors that impact the quality of life among caregivers of

people with dementia in Vietnam. This chapter discusses the main findings of the

research program. The main purpose of this research was to describe the current level

of perceived burden and quality of life among dementia caregivers in Vietnam as

well as to explore the association between several factors, including characteristics of

people with dementia and caregivers, perceived burden and quality of life. This

chapter is divided in to several sections. Sections 6.1 and 6.2 highlight the

characteristics of dementia caregivers as well as the behavioural profile of people

with dementia of people within selected regions of Vietnam. Section 6.3 refers to the

perceived burden experienced among research participants. Section 6.4 reviews the

level of quality of life experienced by dementia caregivers, followed in Section 6.5,

by a discussion, with references to the literature, to explain predictors of quality of

life. The last, Section, 6.6, discusses the findings in relation to filial piety, which

appears to be an important cultural factor affecting the experience of Vietnamese

female caregivers of people with dementia.

6.1. Characteristics of participants

Before examining the study’s findings, it is critical to examine the

characteristics of this sample against other survey samples so that the generalizability

of the results can be reliably determined. Although male caregivers of PWD

comprised a smaller percentage of the study sample than females (39.5% vs. 60.5%),

this ratio is quite similar to that reported in other studies conducted in Asia. For

example, 37.4% of 401 dementia caregivers in a study in China were male (Yu,

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2011), in an Indian study of 1206 caregivers, 43.3% were male (Raman Deep

Pattanayak et al., 2011), and in a study conducted in Hong Kong which examined

144 caregivers, 33% were male (C. Lai & Chung, 2007). Thus it seems that male

caregivers of people with dementia in Asia typically varied from one third to less

than a half. The proportion of male caregivers in this sample was on the lower side of

the estimate.

When compared with studies conducted in non-Asian countries, the proportion

of male caregivers of people with dementia in Asia studies seems to be much higher

than studies conducted in Spain or America. For example 16.6% of the 1272

participants in Spain were male dementia caregivers (del‐Pino‐Casado, Frías‐Osuna,

Palomino‐Moral, & Ramón Martínez‐Riera, 2012), while 24% of the 160 primary

caregivers of people with dementia in the United States, were male caregivers

(Ornstein et al., 2013). While these comparisons must be interpreted cautiously,

because they are not derived from a single study, they could suggest that there are

important differences in the demography of the dementia caregiver populations based

on ethnicity or cultural factors.

Demographic differences in caring for people with dementia are also evident

from a descriptive analysis of the care-recipient characteristics. More than three

quarters (76.7%) of participants in this study were caring for a parent or parent-in-

law with dementia and nearly one fifth (17.3%) were caring for a spouse with

dementia. This finding is consistent with previous studies from Asia, where the

proportion of dementia caregivers who were children or children-in-law, varied from

two thirds to more than four fifths. For example, in a study conducted in Singapore,

86% of 246 dementia caregivers were caring for a parent or parent-in-law who

suffered from dementia (Tan, Yap, Ng, & Luo, 2013), while another study,

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completed in Hong Kong in 2012, reported that 66% of dementia caregivers were

caring for their parents or parents-in-law. This finding is dissimilar to the results of

studies within Western countries, where the relationship between dementia

caregivers and people with dementia was mainly spouses, while children or children-

in-law counted for a smaller proportion of dementia caregivers, with a range from

10% to 30%. For example, a cross-national study conducted in Sweden, UK and

USA revealed that the percentage of caregivers who were children or children-in-law

of people with dementia varied from 18.9% in Sweden to 19% in the UK and 27.4%

in the USA (Bergvall et al., 2011). In Canada 72.6% of dementia caregivers were

spouses of people with dementia (Bartfay & Bartfay, 2013). From these results, it

seems caregivers in Asia, including Vietnam are more likely to be children or

children-in-law of PWD, whereas studies conducted in non-Asian countries have

revealed that spousal caregiving is more dominant within those countries.

Furthermore, with the possible reason of kinship differences between studies

conducted in Asia versus non-Asia, the mean age of caregivers in Asian countries

seems be younger. The mean age of participants in this study was 48.44 years

(SD=13.68). This is quite similar to findings of studies within Asian countries, such a

Korean study completed in 2012, where the mean age of dementia caregivers was

55.3 (SD=12.4) years (Shin, Youn, Kim, Lee, & Cho, 2012) or the findings of an

Indian study where the mean age of dementia caregivers was 53.94 (16.16) years (R.

D. Pattanayak, Jena, Tripathi, & Khandelwal, 2010). The mean age of carers in

studies conducted in non-Asian countries appears to be slightly higher. For example,

the mean of age of caregivers of people with dementia in the USA was 66.9 years

(SD=13.6), in Sweden, which was 70.2 years (SD=12.2) or in the UK, where the

mean age was 71.3 years (SD=117) (Bergvall et al., 2011). These findings show that

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the profile of dementia caregivers in this study is similar to and typical of caregivers

in other Asian countries. The difference with the non-Asian studies is, arguably,

related to multiple factors, one of which may be filial piety, which is underpinned by

the valuing of parents and the expectation that children have a duty of care for

parents as they age.

6.2. Behavioural profile of people with dementia

As emphasized in Part 1 of chapter 3, the Kingston Standardised Behavioural

Assessment (KSBA) was used to determine the behavioural profile of people with

dementia who were being cared for. The higher the score on this scale, the more

behavioural issues people with dementia display. The KSBA is regarded as a reliable

and sensitive method of identifying behavioural changes among people with

dementia (Kilik et al., 2008). According to the total score cut-offs proposed by

Hopkins, Kilik, Day, Bradford, and Rows (2006), the behavioural profile of people

with dementia in the second survey (Phase 2) fell into the four categories as follows:

level 1, 41 PWD (12.3%); level 2, 172 PWD (51%);level 3, 112 PWD (33.2%); and,

level 4, 12 PWD (3.6%). In other words, only 3.6% of PWD were regarded as likely

to require admission to a professional health care setting, but the behavioural profile

of the care recipients indicated a significant need for consultation and support

services in the vast majority of cases (84.2% of the sample). Since Vietnamese

families in general prefer home care (L. Nguyen & Nguyen, 2010), there is a high

prevalence of people with severe dementia living in the community, with continuous

requirements for support (professional, information, resources, etc.), but there are

limited available services. Whilst the application of this tool in this context is new,

and results should be interpreted cautiously, it is necessary to conduct further studies

to determine why families of people with dementia provide home care, and whether

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as suggested by the results of the qualitative study, filial piety is a key factor in this

decision.

6.3. Perceived burden

The Zarit Burden Interview of 22-items was utilised in this study to measure

caregiving burden among caregivers of people with dementia. In the first survey, the

mean ZBI score was 35.16 (SD=15.9), and in the second study nearly 40% of

caregivers experienced moderate or intense burden. It seems that dementia

caregivers in this study experienced a higher degree of burden, compared with those

who reported an average ZBI burden of 18.9 (SD=16.5) in Singapore (Cheah, Han,

Chong, Anthony, & Lim, 2012), and those in a Chinese study, with mean ZBI score

of 26.6 (Tang et al., 2013). The rate of burden in this study was also higher than that

experienced in a French study of 152 dementia caregivers, 30% of whom had

‘moderate to severe burden’ or higher(Ankri et al., 2005), and it appears high when

compared to a Chinese study of 1425 caregivers of people with dementia, 19.1% of

whom reported an average burden (Tang et al., 2013). Possible reasons that might

account for this difference from the findings of studies conducted in Asian countries

might be the longer duration of disease awareness. In this survey, people with

dementia had a median duration of four years since the appearance of signs of

disease, while 31.4% of Chinese study respondents reported less than 6 months of

disease awareness, and only 23% of the sample had more known of the disease for

more than 3 years. (Tang et al., 2013). Meanwhile, the mean duration of dementia in

the current study was 4.34 years. The median duration with the disease was 4.0

years, which means that 50% of PWD had experienced signs of dementia for four

years or longer. It seems that caregivers in the current study suffered the stress and

consequence of a dementia diagnosis for longer than reported in other studies

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conducted in Asia, and this could account for the higher degree of burden that they

reported.

From another perspective, findings on the relationship between the care

recipient’s behaviours, independence with activities of daily living and perceived

caregiver burden from this study are consistent with previous reports conducted in

Asian and non-Asian countries (Berger et al., 2005; Casado & Sacco, 2012; Coyne et

al., 1993; Kim et al., 2009). Coyne and colleagues (1993), Kim, et al. (2009) and Lim

and colleagues (2011) indicated that caregivers displayed a higher burden score

among PWD who had poor scores on activities of daily living or function. Results of

this study showed that the burden of caregiving increased as the behavioural profile

score increased (as indicated by the Kingston Standardized behavioural assessments)

and functioning activities decreased (marked by Barthel Index). This finding

corroborates findings from previous studies (Coyne et al., 1993; Kim et al., 2009),

demonstrating that cognitive decline, behavioural symptoms and reduced activities of

daily living weigh on the burden of care.

The correlation between caregiver gender and burden was also explored in this

study because of previous reports that burden is typically higher for female compared

to male caregivers of people with dementia, despite some possible cultural

differences. Studies conducted in Western countries, such as Canada (N. L. Chappell

& Reid, 2002), America (Mohamed et al., 2010), or Sweden (Andren & Elmstahl,

2008) have shown that gender is not statistically associated with burden of care

among dementia caregivers at p<0.05. Meanwhile, studies conducted in Asian

countries, including China (J. Wang, Xiao, He, Ullah, & De Bellis, 2014), Korea

(Kim et al., 2009), and Malaysia (Rosdinom, Zarina, Zanariah, Marhani, & Suzaily,

2013), have found a high correlation between caregiver’s gender and perceived

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burden. Female dementia caregivers in these Asian countries experienced higher

burden, compared with males. Unlike the findings in studies conducted in Asian

countries, caregiver’s gender in this survey was not statistically significantly

correlated with caregiving burden. Possible reasons for this finding might relate to

the current situation of urbanisation in Vietnam and the contribution of the national

program on gender equity in Vietnam (United Nations Vietnam, 2010). Furthermore,

findings in this study were consistent with those from other studies conducted in

Asian and non-Asian studies among dementia caregivers, such that higher burden

was associated with longer caregiving hours (Bergvall et al., 2011; Casado & Sacco,

2012), and lower degree of Sense of Coherence (Andren & Elmstahl, 2008;

Gallagher et al., 1994; Kuroda et al., 2007; Valimaki et al., 2009).

6.4. Quality of life

Participants in this survey experienced a lower level of Quality of Life

(Physical, Psychological, Social relationship and Environment) than a group of

healthy people that were examined in the UK in the study of Skevington and

McCrate (2012), using the same research instrument (WHOQOL-BREF). The

percentage of mean standardised score difference varied from 15% to 20% across the

four domains. Moreover, dementia caregivers who participated in the survey reported

lower quality of life (standardised score) than elderly people without dementia who

were over 60 years and residing in Hai Duong in 2008 –2009 (Huong, 2009). With

one exception (see Cruz, Polanczyk, Camey, Hoffmann and Fleck (2011)) these

findings are broadly consistent with the hypothesis that caring for a person with

dementia results in diverse negative impacts on the family caregivers’ quality of life,

since quality of life is higher when caregiving is not involved.

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 When the quality of life of the dementia caregivers in this study is compared to

that of caregivers in other studies, a divergent pattern of results emerged, but it

appears that the caregivers in this study had higher quality of life than caregivers

elsewhere. For example, the Quality of Life domain scores in this study were higher

than those for dementia caregivers in New Delhi, India (Raman Deep Pattanayak et

al., 2011), caregivers of mentally ill patients in Hong Kong (Wong et al., 2012) and

Taiwan (C. C. Fan & Chen, 2011), or elderly Taiwanese caregivers (Lo, 2009).

There is one exception to this trend of higher quality of life in this sample of

caregivers compared to other caregivers; the quality of life of dementia caregivers in

this research was similar to (neither higher nor lower) that found in carers of elderly

people in the community (Skevington & McCrate, (2012). One possible reason for

the differences in the level of quality of life in these surveys could be the relative

duration of caregiving responsibility generally involved in caring for a person with

dementia versus caregiving for a person with mental illness. In this study all

participants had been identified as primary caregivers for people with dementia for at

least three months and were providing care for at least two days a week. The duration

of caregiving in current study is shorter compared with caregiving duration in Indian

study (12 months duration of caregiving for people with dementia) (Raman Deep

Pattanayak et al., 2011) or Taiwanese study (at least five days a week for at least 6

months duration of caregiving for people with mentally illness) (C. C. Fan & Chen,

2011). This study therefore represents a study of the effects and consequences of

dementia diagnosis and caregiving for more than three months.

Another explanation for the differences in the quality of life findings of this

and previous studies could be the different economic situations during the time

frames of these studies. The two reference studies were conducted in 2009 (in Hai

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Duong, North province in Vietnam) or in 2011 (in UK) respectively, as opposed to

this study, were the data was collected in 2012. The rate of GDP development in

Vietnam fluctuated from 2009 – 2011, ascending from 5.32% (2009) to 6.78%

(2010), then fell to 5.89% (2011). Then, the consumer price index in Vietnam

increased rapidly from 6.52% in 2009 to 18.3% in 2011 (Le, 2012). These

differences in the economic situation of the country may have impacted the income

and standard of living of carers recruited at different times, and this could have

affected the caregivers’ quality of life.

6.5. Quality of life in the context of the research framework

As mentioned in part 3 of Chapter 2, the research framework of this study was

developed based on the literature review, and a synthesis of Quality of life by Ferrans

(1996) and the theoretical model of stress and coping by Lazarus and Folkman

(1984). The theoretical schematization of stress and coping models contain casual

antecedents through the mediating processes of primary and secondary appraisal,

which, in turn, cause immediate effects. These effects can be experienced by

individuals as a physiological change, or emotionally as positive or negative feelings.

In longer term there may be impacts on the well-being or social function of a person

or group of people (Lazarus & Folkman, 1984).

In this study, the conceptual model was viewed as influenced by multiple

factors including: background variables, such as age, gender, socioeconomic status,

kinship of caregiver to patients, etc.; primary stressors and secondary strains related

to caregiving for the patient and the impact of those factors on other domains of the

caregiver’s life; the caregiver’s perceptions of demands as stressful or satisfactory;

and the consequences of those demands, for example, on quality of health (Aranda &

Knight, 1997). In brief, with the model of stress and coping, the way of person

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evaluates a situation (in terms of being positive, negative or neutral in value) would

have an effect on their own psychological well-being.

The findings from the empirical studies were generally with the relations

expected based on this model. Although, the 1st survey (Phase 1) revealed that the

status of employment among dementia caregivers contributed towards the prediction

of the quality of life domain (Truong & Beattie, 2012; Truong, Beattie, & Sullivan,

2014), employment status in the 2nd survey did not significantly predict quality of

life. A possible explanation of this discrepancy could be related to the differences in

the unemployment rate or employment type in these surveys. In the 1st survey (Phase

1), participants came from Hanoi, the Capital of Vietnam, and 23.5% and 16.3% of

the caregivers in this survey defined themselves as farmer/fisherman/woman, or

unemployed, respectively. In the 2nd survey (Phase 2), the dementia caregivers came

from three provinces, including Hanoi, but the census data for these areas suggests

that they are economically and socially diverse. In the second survey, the percentage

of caregivers who defined themselves as famer/fisherman/woman, or unemployed

was 42.4 and 55.1%, respectively. The status of employment would lead to

differences in family income. Families with higher income are economically better

able to provide services for family members who suffer from disease. The regression

model revealed that with beta value (β) that varied from -0.151 to -0.241, caregivers

with higher family income (more than 10 million Vietnam Dong (Vietnamese

currency) have a higher quality of life. This finding was supported by the work of

Sirgy (1986). Although Sirgy (1986) confirmed that people with higher income, on

average, are happier as individuals than those with lower income, the concept of

household or financial status at a national or regional level, should be operationalized

to cover a boarder range of financial indicators, such as housing, business assets,

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equity, cash investment, bank account, housing debt, personal debt, etc., to gauge

whether more precisely operationalizing financial status reveals that it is a stronger

predictor of quality of life or life satisfaction than household income only.

Furthermore, higher income seems be significantly correlated with lower negative

effects. Therefore, the concept of income should be thought about as a resource

within the model, so that a person can utilise the resource to enhance or improve his

or her wellbeing and quality of life.

The Sense of Coherence (SOC) questionnaire was utilised in this study as a

way of operationalizing coping. SOC was defined as the way a human interprets

events, which determines whether a person successfully copes with a situation or

becomes stressed by it, and the definition also encompasses a wide range of

behaviours inherent in managing stressful situations (Antonovsky, 1993). People

with a higher score on SOC are believed to be more confident in managing their

situation and tend to have better knowledge about how to perform health promotion

(Andren & Elmstahl, 2008; Eriksson & Lindstrom, 2005; Valimaki et al., 2009).

Consistent with previous studies, SOC among dementia caregivers in this study was

positively correlated with quality of life. Moreover, SOC also significantly predicted

QoL in the regression model.

In this study, consistent with findings from previous studies, caregiving burden

contributed to explaining scores in the domains of quality of life (Amendola,

Oliveira, & Alvarenga, 2011; N. L. Chappell & Reid, 2002; Mohamed et al., 2010;

Wong et al., 2012). Caregiver burden was the concept to describe the physical,

psychological, financial and emotional problems experienced by family members

providing care (C. W. Given, Given, Sherwood, & DeVoss, 2012). The increased

level of caregiving burden was correlated with a decreased mean score of QoL. The

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higher level of caregiving burden among dementia caregivers was associated with

lower quality of life. Burden impacts on many aspects of a caregiver’s quality of life.

As rates of dementia, and thus, caregiving in dementia are growing globally, it

is essential to understand the role of culture in the caregiving situation and how it

influences caregiving outcomes. Although researchers have recognised and agreed

that caregiving is a multi-dimensional concept, many studies have been conducted to

investigate caregiving burden as the negative outcome of caregiving, while

neglecting or paying less attention to the positive aspects of caregiving, which reduce

the stresses of caregiving and improve outcomes for caregivers (Jathanna & Latha,

2011). Carbonneau, Desrosiers and Caron (2010) also suggested that the

enhancement of positive aspects of caregiving might decrease the impact of burden

and stress on the well-being and quality of life of caregiving and then protect

caregiver’s mental and physical health. Positive Aspects of Caregiving (PAC) have

been defined as the rewards, enjoyment and satisfaction derived from caregiving.

The Positive Aspects of Caregiving scale is also a valid and reliable instrument in

evaluating the positive dimension of caregiving that people can experience (Barbara,

Stephen, Steven, Mark, & et al., 2004). The positive aspects were reported to

improve the caregiver’s well-being and decrease burden related to their caregiving

role as dementia caregivers (Carbonneau et al., 2010; Hilgeman, Allen, DeCoster, &

Burgio, 2007). Individuals with higher PAC reported less depression, burden, and

better subjective health than those who did not endorse PAC. Findings from this

study revealed a similar trend as the previous study. PAC had a positive relationship

with QoL (on all four domains). Using the regression models, PAC was

demonstrated to largely contribute towards predicting QoL (partial correlations

varied from 0.212 to 0.282). Dementia caregivers with higher degrees of positive

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aspects of caregiving reported better quality of life. Findings from this study

highlighted the positive effect of caregiving in a previous study (Richard Schulz &

Sherwood, 2008). Even when caregiving becomes harder and results in a higher level

of burden and lower quality of life, dementia caregivers reported positive aspects of

caregiving.

The 4th research question of the 2nd survey (Phase 2) was to test whether the

place of residence predicted quality of life. The three provinces had several different

characteristics related to population, economic status and health expenditure (Bac

Ninh Statistical office, 2013; Hai Phong Statistical Office, 2013; Hanoi Statistical

Office, 2013). Although bivariate analysis revealed a significant difference in quality

of life among the three provinces at p<0.05, by using the multivariate analysis

technique, the place of residence of respondents (Hanoi=1; other=0) was found to

significantly contribute to the prediction of the Environmental domain of quality of

life. For the rest of the quality of life domains (Physical, Psychological and Social

relationship), place of residence did not significantly contribute towards explaining

quality of life. This means that the quality of life on the Environment aspect in Bac

Ninh (countryside) is better than that in Hanoi (metropolitan) and Haiphong (coastal

province). A possible reason for this finding might be the unclear definition (or

operationalization) of place of residence in this study. Instead of acknowledging that

there may be variation within provinces (i.e., urban, rural, suburb or countryside),

this study sought data on the province more generally (i.e., Hanoi, Bac Ninh or Hai

Phong). Therefore, the contribution of place of residence did not reach a significant

level. This is a limitation of the 2nd survey.

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6.6. Filial piety

Among Spanish speaking countries in Western culture, the concept of familism

has been identified as a cultural value that describes a strong identification and

attachment of individuals with their family members and strong feelings of loyalty,

dedication, reciprocity, respect and obligation to parents and siblings into adulthood

(Sabogal, Marín, Otero-Sabogal, Marín, & Perez-Stable, 1987). Meanwhile, filial

piety, an important aspect in Asian societies, including Vietnam, emphasises the

duties of children to fulfil the needs of their parents. Those duties encompass

physical, material and emotional requirements (Yeh & Bedford, 2003). The principle

of filial piety includes respecting the elderly, loving and obeying parents, and

providing support for parents when they are getting older. The concept of filial piety

was classically defined as highly hierarchical relationships that govern relationships

between children and their parents (Malarney, 2002, p. 112). The concepts of

familism and filial piety were identified as being similar and they shared the same

roots in cultural values (Schwartz et al., 2010). Moreover, the filial piety in American

culture, which originated from Western culture, mainly consists of emotional

support, substantial aid and sense of gratitude and responsibilities towards parents

(Yu-Tzu & Margaret, 1998). From the preceding discussion from section 6.1 to 6.5,

it seems reasonable to conclude that, in most, but not all aspects, Vietnamese

caregivers of people with dementia appear to be more like those from other Asian

cultures, and less like those from non-Asian (or Western) cultures. This finding may

indicate that cultural variables strongly mediate the caregiving experience, as

proposed recently by Knight and Sayegh (2010). They also highlighted that attention

to local cultural values may be a more useful strategy in measuring cultural values.

In the second study of this thesis, the role of one such cultural factor, namely filial

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piety, as understood in the Vietnamese context, was examined to assess its influence

on the caregiving experience.

In the 2nd survey, participants were asked to completed The Filial Piety Scale

(Hsueh-Fen, 2005), which includes 22 items prescribing how children should behave

toward their parents, living or dead, as well as toward their ancestors. Items were

measured on a 6-point scale, ranging from 1 (strongly disagree) to 6 (strongly agree).

The mean of the filial piety score for whole study was quite high, at 89.08

(SD=7.02). Through the analysis of variance (factorial ANOVA), male dementia

caregivers were higher on filial piety than female caregivers, but there were no

significant differences between provinces (Hanoi, Bac Ninh and Hai Phong). The

first explanation of this finding might relate to close geographic proximity of the

three provinces. As shown in part 2 of Chapter IV, the three provinces (Hanoi, Hai

Phong and Bac Ninh) are located in the Red River Delta in the North of Vietnam

with similar cultural background, ethnic minority groups and culture (T. L. D. Pham,

2010). The other explanation might be related to the difference in gender

expectations. Like other studies in China, Hong Kong and Korea, Vietnamese males

showed higher filial piety scores than females, indicating that they held these beliefs

more strongly or were more likely to agree with statements that described actions

that would be regarded as appropriately pious (L. D. Campbell & Martin-Matthews,

2003; Chen et al., 2007; Chow & Chu, 2007; D. W. L. Lai, 2010; Lum et al., 2010).

Vietnamese males are quite conservative and are tied to filial piety and family. With

the son preference in Vietnam, the idea of maintaining family continuity is also

raised. The Vietnamese proverb is suitable to describe this phenomenon: “Nhất Nam

viết hữu/ Thập Nữ viết vô”, or “One boy child, write “yes”, ten girl children, write

“no”. Gender discrimination is a feature of Vietnamese culture, especially in

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communities. This proverb affirms the dominant role of the male in the family clan,

and yet if the baby turns out to be a daughter, her existence would mean nothing: her

name will not be registered in the family tree. This perspective of the older

Vietnamese generations lingers on, unfortunately. Filial piety is also the adherence of

Vietnamese people to the notion that children should try to do the best thing for their

parents in order to repay their sacrifice to them. They are also expected to keep their

family heritage and reputation. Lack of filial piety has been considered as arguing or

talking back or acting contrary to the wishes of their parents.

In Vietnam and other Asian societies and cultures, the physical, emotional and

social work of caregiving have significantly impacted on the women in those

societies, who are most likely to take on the role as the family caregiver (formal and

informal) (G. J. Yoo & Kim, 2009). This notion is supported by the findings of the

qualitative study, which showed that the daughter or daughter-in-law caregivers of a

parent with dementia defined their experience in ways that were consistent with

notions of filial piety. The meaning of their motivation for caregiving and filial piety

were categorised into six themes, namely: (1) Obligation, sacrifice and love; (2)

Providing an example to children; (3) Mixed emotion (Ambivalence); (4) Need for

family support while caregiving; and (5) Fear of losing social reputation. These

themes are reminiscent of those that have been expressed as defining filial piety, (i.e.,

as the provider of care, as a sacrifice or for compassion, happiness and comfort). In a

study of Vietnamese refugees/ immigrants in America (Hinton, Tran, Tran, &

Hinton, 2008) or in Victoria, Australia (Cole, Gucciardo-Masci, & Victoria, 2003),

similar themes have been expressed. Hinton, Tran, Tran and Hinton (2008) found

that the primary dementia caregiver expressed the term “compassion”, “happiness”

when expressing the meaning of and motivation towards caring for older family

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members with dementia. Another concept was repeated quite often in every

conversation between participants and the author as “good fortune’, or Karma. They

believed that what they do and perform in their demonstration of filial piety would

benefit (educate/model) the same appropriate behaviours for their children.

Furthermore, in Vietnam, the family orientation is reinforced by the practice of

extended families living together in compounds or households. In this traditional

cultural context, aging is seen as a blessing and elderly people are expected to relax

and enjoy their accomplishments and life with their children as well as share the

wisdom.

In the first theme, the concept of obligation, love and sacrifice in filial piety

have been extensively discussed in previous studies (Chang et al., 2010; Chen et al.,

2007; Duc, 2009; Luo & Zhan, 2012; Schinkel, 2012; Yeh & Bedford, 2003). This

discussion section covers some aspects of filial piety that are special to Vietnam. The

issue of worship for ancestors has been inherent inside the expressions of obligation

to complete tasks. This action is for the purpose of remembering the deceased family

member, expressing commitment to follow the good reputation of one’s family, and

expand the love and family network to other people with the same origin, which is

the core of relationships among Vietnamese people within communities. Vietnamese

people highlighted that the purpose of their relationships is to support each other. In

Vietnamese communities and villages, the foundation of the relationship within their

communities and among generations is based on the special relation among members

of a family and in a group of members having the same roots (Hinton et al., 2008; Q.

T. Nguyen et al., 2010; Tho, 2011). Although practicing worship is also identified as

an action of filial piety among Asian society (K.-T. Sung, 1998), this custom of

ancestor worship is practiced at home among the Vietnamese more prominently

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(Duc, 2009). The custom of worship is an expression of the link between the dead

and the living. With the worship ideology of the ancestors, Vietnamese people set an

example and teach each other how to live to be worthy of their ancestors. Moreover,

this practice also strengthens the existing linkage between siblings, neighbours and

relatives, cementing the relationship between members sharing the same ancestry and

family origin. Worship helps people to stick together, and teaches the family to

cherish and love. This is also an opportunity for children from different places to join

together, exchange ideas and stories, build intimacy and reinforce familial

relationships. Further, grandchildren visit and respect their grandparents and elderly

relatives if they are still alive.

The second theme was to set an example for children. In Vietnam, one of the

most important roles and responsibilities of parents is to train and teach their children

by virtue of principles. The parents will bear the disgrace brought about by the

activities of children who dishonour themselves, just as they share the honour and

fame of their virtuous and talented children. This theme is depicted in all research

and has been reported in Asia countries, including in Korea (Chow & Chu, 2007).

Participants in this study employed many Vietnamese Proverbs to describe the action

of setting an example for children in order to train and teach their children from the

time they are very young, and this practice has been transferred through generations.

This process is also considered family heritage. Moreover, this action is identified as

an aspect of filial piety actions (K.-T. Sung, 1998).

In Vietnam, providing care is seen as a normal and essential part of care for the

family and community, and family caregivers are part of large families who are

living in close proximity. Interviewees expressed their feelings about caring for their

relatives long-term by using Vietnamese Proverbs to express the feeling trajectory of

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caring, namely as love at first, compassion later, then hate at last, or sometimes anger

due to verbal abuse from PWD. They were engaged in a struggle between good and

bad emotional expression. In the good or positive feelings, they were happy and felt

comfortable when caring for their elderly parent. They tried to maintain and reserve

the harmony of the family towards trying to help their parent live longer. Conversely,

they felt a sense of unfairness or hate when stuck in this situation. All previous

studies investigated the attitudes of children or adults toward filial piety or practicing

filial piety (Neena L. Chappell & Funk, 2012; Chen et al., 2007; Dai, 1995; D. W. L.

Lai, 2010; Lum et al., 2010; K. Sung, 1995). Attitude has been defined in

psychological studies as “differing preferences for objects, ideas, behaviours or

people” (Johnson & Boynton, 2011). Nevertheless, this study seems be the first study

in Vietnam and Asian countries to explore the feelings and expression of daughters

or daughter-in-laws towards people with dementia when providing direct care for

them. Participants also raised the concern of the special relationship in the dyad of

mother-in-law and daughter-in-law, which is the most frequent source of family

conflict in traditional Vietnamese families and Asian families. Although participants

understand this special relationship, they expressed their commitment to equitably

treat and care for PWD, regardless of whether the PWD is their parents or parents-in-

law. When they agreed to become daughter-in-law, they committed to care for them

(Phu, 1998). Although ambivalence has been expressed when taking responsibility

for PWD as main caregiver, those daughters or daughters-in-law committed to care

for the PWD for the rest of their life. Furthermore, the participants also considered

the feelings of parents who are in need and lonely and might be desperate if they did

not receive care (physically and mentally) from their children. Their parents would

182
be grievously upset if they were to be alone. They would be likely to die if they did

not receive any support and care from their children.

The last theme is the objective and subjective expression of judgement, which

is fear of losing social reputation and fear of being considered a poor daughter or

daughter-in-law. The values that are emphasized and set as a high priority for

children in Vietnam are the values of preserving “good name”, “family reputation” or

“filial child”. To Vietnamese people, the recognition of good name is better than any

material possessions in the world. They are also expected to keep their family

heritage and reputation. It is believed that good reputation and to preserve family

reputation and heritage is the best thing that a man can pass to the next generation

once he has departed from this work. The person with a bad name would be

abandoned by his community’s members and might be a disgrace to family. Losing

face is a terrible thing in the Vietnamese communities and societies. Vietnam is a

country of various ethnic unity and solidarity in a long process of national

development and national patriotism. Vietnamese people live with others in villages

or communes. Vietnamese villages or communes are comprised of complex and

many social organizations that are primarily family. It is a social institution within

rural Vietnam, where there’s a rich structure that’s held tightly together. It is the

place to store and protect a village against cultural invasion and the assimilation of

foreign cultures. The links in village might come from similar occupational

categories or chains or partners, religious beliefs, neighbourhoods and same origin or

blood relatives. (D. D. Pham, 2006; T. L. D. Pham, 2010). Among those linkages, the

relationship of same origin or blood relatives is the most sustainable network. It is

seen as the village or community for the gathering of families. Whenever each

individual or family in the village or commune experiences difficulty or hardship,

183
other families and members nearby and within the neighbourhood are expected to

present to offer their help and support.

Lai (2010) suggested that reported filial piety indirectly affected the burden of

caregiving and that it played a protective function to enhance the positive effect of

appraisal factors on caregiving. Meanwhile, in the current study, perceived burden

had a positive association with filial piety and it contributed to predicting the level of

caregiving burden. The difference can potentially be explained by the different

meaning of filial piety between Chinese-Canadian and Vietnamese people. Piety

imbued caregivers with psychological strengths, tolerance and patience to manage

challenges and negative results of the caregiving trajectory. This might be a strong

motivational force behind family caregivers (D. W. L. Lai, 2010).

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 Chapter 7: GENERAL DISCUSSION AND CONCLUSION

Findings from the 1st and 2nd surveys showed that dementia carers reported low

QoL, as predicted by high perceived burden and lower Sense of Coherence, with lack

of confidence in managing situations and performing health promotion. Carer

characteristics, including age, gender and family income, were significantly

associated with QoL. Other cultural factors included filial piety and positive aspects

of caregiving, which also contributed to explain QoL. These findings were

considered to be consistent with the research framework of the stress and coping

model of Lazarus and Folkman (1984). Phase 3 results suggest that filial piety and

positive aspects of the role may be the source of explanation and influence for the

caring experience among daughter carers. These perspectives appear to help daughter

carers to adjust to carer role stress.

7.1. Implications

The importance of culture of caregivers’ quality of life was demonstrated in

this study. Leininger (Purnell, 2011) also highlighted the value of culture in nursing

care, an idea that may extend to family caregivers. By understanding the culture in

which they are living, the nurse is expected to obtain an understanding of different

people’s social and cultural contexts (Plummer & Molzahn, 2009). Since culture

accounted for the beliefs, values and practices of caring, the foundation of nursing

knowledge and its application to clinical nursing practice might need to be informed

by the cultural complexities of their nursing clients. In recognising the role of

cultural considerations in determining the quality of nursing services, particularly

considering the rapid growth in worldwide migration, it would seem important to

consider multicultural and multiethnic considerations in the Western Nursing training

185
curriculum. This process appears to have already started (Beamon, 2006; Betancourt,

Green, Carrillo, & Ananeh-Firempong 2nd, 2003; Jeffreys, 2010). In Vietnam,

although the role of culture and its values has been recognised in legal documents as

well as in common competencies in nursing practice and code of professional

nursing practice (Vietnam Ministry of Health, 2012; Vietnam Nurse Association,

2012), cultural values as well as the belief of patients have not been emphasised and

introduced as an essential part in any nursing curriculum in Vietnam. The subject of

civic education is one of the critical subjects in three levels of school (primary,

secondary and high school) (H. D. Pham, 2007). The primary goal of this subject is

to train and educate pupils in the three school levels (primary, secondary and high

school) on moral lessons to become good person. Various knowledge introduced in

this subject allows pupils to: distinguish right from wrong; respect themselves and

others; to live honestly; be humble; and brave. For the secondary and high school

pupil, this subject also helps students in the formation of basic life skills, such as

teaching a sense of organization and discipline and providing instructions on how to

behave in accordance with a recognition of and observance of the law (Hieu, 2014).

An empirical issue is that this subject is only taught for a period of 45 minutes in

each class, with either a lack of, or out of date teaching material. It also focuses on

theory, rather than practical issues. The role of Vietnamese culture, especially filial

piety, makes up a smaller part of these lessons and is introduced at just the primary

and secondary school levels. Therefore, the findings of this thesis would help nurses

in Vietnam to recognise the important role of culture in providing care for people

suffering from dementia and chronic diseases in general, and their family members.

To date culture has not been emphasised in the Nursing curriculum in Vietnam,

despite that fact that it is a very important aspect of understanding care. The results

186
of this study will be essential in highlighting the need for more cultural awareness in

the development of nursing curricula. These results will be applicable to clinicians

and policy makers.

The findings from this thesis showed that more than three quarters (76.7%) of

participants were caring for a parent with dementia. Nearly one fifth (17.3%) were

caring for a spouse with dementia. In the 2nd survey, nearly 4% (n=12) of people

with dementia were considered in need of admission to professional health care

setting and 84.2% were found to be in need of consultation and support services.

Moreover, nearly 40% of caregivers in the 2nd survey experienced moderate or

intensive burden. These data draw a picture of a community where there is a high

level of care required by community-dwelling people with dementia. Also, the most

of the care for people with dementia is provided by the children of people with

dementia. The primary characteristic of Vietnamese villages or communes is that the

relationships among residents are primarily between people of the same origin or

blood relatives, and in Vietnamese culture, this is the most sustainable network.

Whenever each individual or family in the village or commune experiences difficulty

or hardship, other families and members nearby and in the neighbourhood are

expected to provide help and support. Several gaps exist in our knowledge of the

Vietnamese dementia carer experience. For example, females were almost twice as

likely as males to be the primary caregivers of a person with dementia. In addition to

providing basic care for the person with dementia, including hygiene (such as

bathing, grooming, dressing or toileting), food preparation and feeding, and coping

with behavioural and psychiatric symptoms of dementia, this responsibility was

carried by women who are already in family caregiving roles related to their own

spouses and children. Thus, although there appears to be a slightly higher number of

187
male caregivers of people with dementia in Asian cultures than elsewhere, including

this study, the finding that women were still twice as likely as men to be the primary

provider of such care should assist policy makers and community leaders who are

tasked with the challenge of how such care will be provided to a growing number of

the people within the community.

The findings of this thesis should also assist in the identification of programs to

improve QoL and decrease caregiving burden for Vietnamese dementia caregivers.

For example, educational strategies for managing behaviour, stress reduction

programs or multi-component support programs that evolved from similarly focused

studies already completed in the West (Gavrilova et al., 2009; R. Schulz et al., 2002)

could be trialled in Vietnam. This survey’s findings show that more than 30% of

caregivers experienced moderate or higher burden. The high prevalence of people

with dementia who are living with advanced dementia and who would benefit from

support from professionals, together with the finding of a high prevalence of burden

associated with low quality of life for caregivers, constitutes good grounds to

continue further study in this area. A type of supportive network or task exchange for

caring for people with dementia inside the community might also be appropriate,

which would provide a chance for caregivers to have respite and have time alone. It

is important for caregivers to spend time away from their caregiving duties and to

become involved in outside interests or hobbies. In doing so, caregivers are able to

focus on their needs. By becoming self-aware, caregivers are able to take better care

of their physical, mental and emotional health. When they feel good about

themselves (mentally and physically), they feel better about their caregiving tasks,

which increases their positive feelings and decreases or eliminates the negative

feelings of caregiving.

188
 In terms of theoretical application, although the findings of this thesis matched

with the conceptual model of stress, coping and appraisal, proposed by Lazarus and

Folkman (1984) with respect to cultural values, further investigations of the specific

support needs of general dementia carers and the interaction among those factors in

different environments are warranted. A possible framework for future study might

be the following:

Figure 9. Proposed future model of research framework

7.2. Limitations

In addition to limitations acknowledged elsewhere in this thesis, there are

several overarching study limitations that must be kept in mind when interpreting

189
these results. First, the studies described in this thesis used a cross-sectional method.

This type of research design is useful to identify associations, and it can be used to

obtain relatively large samples, but it cannot demonstrate causality. With only one

time point, it is very difficult to recognize whether the chicken or the egg came first

(e.g., whether the higher level of caregiver burden was caused by, or as a result of, a

reduced economic situation). This study employed a simple descriptive correlational

design using a questionnaire to obtain data from dementia caregivers regarding QoL,

perceived caregiving burden and the possible correlation between caregivers’

characteristics, and perceived burden of care and QoL. No assumptions on cause and

effect can be made, and the relationships between QoL, caregiving burden and

carers’ characteristics could be consequences of the caring conditions and effect of

subjective judgment on those concepts.

The second limitation was the single QoL instrument used. This WHOQOL-

BREF (26 items) was developed to study normal populations and was not

specifically developed for people living with dementia and dementia caregivers,

although there are precedents for its use in this population (Raman Deep Pattanayak

et al., 2011; L.-Q. Wang et al., 2012). There is an increasing appreciation of the need

to develop programs designed to improve QoL and relieve the burden of care for

those people looking after dementia sufferers as well as many new measures

designed specifically for multiple aspects of dementia-specific QoL, which may

provide additional insights in future studies. The identification of the indications

contributing to QoL and caregiving burden might be helpful to provide a valuable

reference and framework for clinical management of PWD in community settings.

The third limitation was the use of a self-report questionnaire to recall carer

feelings and decisions from several weeks previously. While the use of such tools

190
cannot be avoided because of the nature of the construct, it is possible that study

participants may have over or under reported the real situation they have

experienced.

The fourth limitation was that the researcher was a stranger in some of the

communities in which data was collected, and in an attempt to overcome this barrier,

the researcher had to rely heavily on community leadership to assist him. A longer

engagement and deeper rapport building period might have improved participation.

This includes gaining recommendations from multiple local authorities to help gain

quicker access to the caregivers to allow more time to build relationships of trust.

With this kind of support, when the researcher approached the caregivers they may

have felt more comfortable and willing to provide information and perspectives.

Also, mutual respect between the carers, their family and the researcher would have

been improved.

The fifth limitation is the possibility of selection bias, which could affect

generalization. As mentioned in the criteria of inclusion, caregivers of people who

had a medical diagnosis of dementia from the National Institute of Gerontology in

Vietnam were invited to participate in this study. The rate of under diagnosis of

dementia is quite high; in the UK, under a half of the expected numbers of patients

with dementia are recognised by general practitioners who specialised in dementia

(Connolly, Gaehl, Martin, Morris, & Purandare, 2011). Furthermore, dementia is not

recognised by the Vietnamese elderly as an abnormal part of ageing, but rather, it is

seen as an illness that is an unavoidable part of growing old (Alzheimer’s Australia

Vic, 2008). Therefore, there are a hidden number of people who suffer from

dementia, without medical diagnosis, living in the community. The results of this

study may not generalize beyond the sample described by the selection criteria.

191
Strengths of the study

With the high prevalence and incidence of dementia, the disease obviously

impacts on individuals, families and health-care systems (Prince et al., 2013). This

study reported the current status of quality of life and caregiving burden and possibly

emphasised several predictors of Quality of life among dementia caregivers in

Vietnam. QoL and burden of care receive insufficient attention in regards to family

caregivers of people with dementia in the Vietnam health care system. This study

attempted to introduce and bring attention to the current status of QoL and burden of

care among caregivers of people with dementia who are living in community settings

as well as explore some factors that affect these issues. Findings from this study

should inform Vietnamese nurses and other health care providers who seek to

understand the needs of their clients with dementia and their families. The findings

might be used as the baseline for developing future interventions to support carers of

people with dementia to improve resilience and satisfaction in caregiving, reduce

burden and promote wellness and positive carer experiences.

The findings of this study enrich the knowledge of family caregivers of people

with dementia in the context of Vietnam and Vietnamese culture. The findings also

add some important points to existing theories and models of stress and coping on

family caregiving cross culturally. First, the findings support the common core of

stress and coping in caregiving of people with dementia; that is, that the caregivers’

appraisal from primary and secondary stressors leads to the consequences of

caregiving being experienced as burdensome, and in turn affecting quality of life for

caregivers. Moreover, the findings suggest the importance and effect of caregivers’

appraisal on positive aspects of caregiving, sense of coherence and filial piety

192
resulting from providing care to people with dementia, which influences caregivers’

quality of life.

This study is the first study to investigate the quality of life and caregiving

burden among dementia caregivers in Vietnam. It is also one of very few

comprehensive studies of the predictors of dementia caregiver’s Quality of life that

has included a broad range of empirical and theoretically-derived variables, such as:

the characteristics of both people with dementia and their caregivers; sense of

coherence; filial piety; caregiving burden; and positive aspects of caregiving.

Although dementia is considered as a leading cause of disease burden in the elderly

population of Vietnam, few studies have been conducted to investigate the effect of

diseases on other family members and primary caregivers of people with dementia in

Vietnam. This study approached and interviewed a large number of caregivers to

report the current situation on quality of life and caregiving burden of people

diagnosed with dementia who are living in communities in the three provinces

(Hanoi, Bac Ninh and Hai Phong) in Vietnam. Findings of this study also highlighted

that quality of life among dementia caregivers is multidimensional and has multiple

predictors.

The study employed internationally standardised, validated instruments in

measuring variables, including the Barthel Index, Kingston Standardised Behaviour

Assessment, Sense of Coherence, Zarit Burden Interview, WHOQOL-BREF, Filial

piety scale and Positive aspects of caregiving scale. Among those research tools,

only WHOQOL-BREF was validated and tested in the Vietnamese context. The rest

of the instruments were applied in Vietnamese by forward and backward translation

processes. A common strategy to ensure reliability of measurement, especially for

research purposes, is to replicate the measurements and evaluate the degree of

193
agreement, and to replicable measurement (Beth & Robert, 1993). Reporting

Cronbach’s alpha coefficient for internal consistency reliability of any scales or

subscales was used. The Cronbach’s alpha for those instruments varied from 0.551 to

0.896, which indicated a high level of internal consistency for those scales among

Vietnamese dementia caregivers in this study.

As mentioned in section 1 of chapter 2, the concept of QoL has been defined

differently, depending on the context and its application by researchers. Each author

or researcher uses different definitions of QoL to reflect factors concerning a

personal life. QoL is not a single domain. It is considered as a multi-dimensional

concept. The current study employed the concepts of QoL from Ferrans (1996)

which covered four aspects of QoL (Health and Function, Psychological, Social

relationship and Environment). Those domains were also evaluated by the valid and

reliable instrument, WHOQOL-BREF, which was tested across cultures.

Further, the study adopted a famous conceptual framework related to stress and

coping to support the research findings. With the contribution of this conceptual

framework and literature review, several explanatory variables of quality of life were

confirmed and consistent with findings in previous studies in Asian countries and

non-Asian countries. It is expected that the findings of this study would be

generalizable to the population of caregivers of people with a dementia diagnosis in

the community of the targeted provinces. Furthermore, with the valid research

framework, the findings are expected to be duplicated in other regions in Vietnam,

and also replicable for caregivers who are from a Vietnamese background.

7.3. Conclusion

This study was undertaken to explore current Vietnamese family dementia

carer responsibilities and experiences. The thesis reported on the current status of

194
quality of life and caregiving burden among Vietnamese dementia caregivers.

Results provide a first insight into dementia caregiver’s status and experience in

Vietnam which is valuable information for policy makers in Vietnam and may help

improve the support provided to caregivers and the quality of dementia care, to meet

the growing and diverse needs for the health care of its ageing population.

195
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213
 Appendices

Ethical clearance approvals from Vietnam and Australia

214
Questionnaire of the 1st survey (English and Vietnamese)

215
Questionnaire of the 2nd survey (English and Vietnamese)

216
Other relevance material

217
 Appendices

Ethical clearance approvals from Vietnam and Australia

212
 University Human Research Ethics Committee
HUMAN ETHICS APPROVAL CERTIFICATE
NHMRC Registered Committee Number EC00171
Date of Issue: 1/7/14 (supersedes all previously issued certificates)

Dear Mr Quang Trung Truong

This Approval Certificate serves as your written notice that the proposal has met the requirements of the National
Statement on Ethical Conduct in Human Research and has been approved on that basis. You are therefore
authorised to commence activities as outlined in your proposal application, subject to any specific and standard
conditions detailed in this document.

Project Details

Category of Approval: Human Negligible-Low Risk

Approved From: 10/11/2011 Approved Until: 10/11/2014 (subject to annual reports)

Approval Number: 1100001158

Project Title: Quality of life and caregiving burden among caregivers of people with dementia living
in Hanoi, Bac Ninh and Hai Phong, Vietnam

Investigator Details

Chief Investigator: Mr Quang Trung Truong

Other Staff/Students:
Investigator Name Type Role
Prof Elizabeth Beattie Internal Supervisor
A/Prof Karen Sullivan Internal Supervisor
Dr Carol Windsor Internal Supervisor

Conditions of Approval

Specific Conditions of Approval:

No special conditions placed on approval by the UHREC. Standard conditions apply.

Standard Conditions of Approval:

The University's standard conditions of approval require the research team to:

1. Conduct the project in accordance with University policy, NHMRC / AVCC guidelines and regulations, and the
provisions of any relevant State / Territory or Commonwealth regulations or legislation;

2. Respond to the requests and instructions of the University Human Research Ethics Committee (UHREC);

3. Advise the Research Ethics Coordinator immediately if any complaints are made, or expressions of concern
are raised, in relation to the project;

4. Suspend or modify the project if the risks to participants are found to be disproportionate to the benefits, and
immediately advise the Research Ethics Coordinator of this action;
5. Stop any involvement of any participant if continuation of the research may be harmful to that person, and
immediately advise the Research Ethics Coordinator of this action;

6. Advise the Research Ethics Coordinator of any unforeseen development or events that might affect the
continued ethical acceptability of the project;

7. Report on the progress of the approved project at least annually, or at intervals determined by the Committee;

8. (Where the research is publicly or privately funded) publish the results of the project is such a way to permit
RM Report No. E801 Version 4.4 Page 1 of 2
 University Human Research Ethics Committee
HUMAN ETHICS APPROVAL CERTIFICATE
NHMRC Registered Committee Number EC00171
Date of Issue: 1/7/14 (supersedes all previously issued certificates)
scrutiny and contribute to public knowledge; and

9. Ensure that the results of the research are made available to the participants.

Modifying your Ethical Clearance:

Requests for variations must be made via submission of a Request for Variation to Existing Clearance Form
([Link] ) to the Research Ethics Coordinator. Minor
changes will be assessed on a case by case basis.

It generally takes 7-14 days to process and notify the Chief Investigator of the outcome of a request for a
variation.

Major changes, depending upon the nature of your request, may require submission of a new application.

Audits:
All active ethical clearances are subject to random audit by the UHREC, which will include the review of the
signed consent forms for participants, whether any modifications / variations to the project have been approved,
and the data storage arrangements.

Further information regarding your ongoing obligations regarding human based research can be found via the
Research Ethics website [Link] or by contacting the Research Ethics
Coordinator on 07 3138 2091 or ethicscontact@[Link]

If any details within this Approval Certificate are incorrect please advise the Research Ethics Unit within 10 days
of receipt of this certificate.
End of Document

RM Report No. E801 Version 4.4 Page 2 of 2

 School of Nursing

The Quality of Life and Caregiving Burden of Caregivers of People with Dementia in
Hanoi, Bac Ninh and Hai Phong, Vietnam

WHO: Truong Quang Trung

RN; MSc; PhD candidate, School of Nursing, Faculty of Health, QUT

Email: [Link]@[Link]

WHEN: Friday 4 April 2014 at 1:00pm – 2:00pm

WHERE: KG-A105, A Block, Ground Level, Kelvin Grove Campus

PANEL MEMBERS:

Professor Elizabeth Beattie (Principal Supervisor, Chair), Director of Dementia Collaborative

Research Centre: Carers and Consumers; School of Nursing, Faculty of Health, QUT

Professor Karen A. Sullivan (Associate Supervisor), School of Psychology and Counselling,

Faculty of Health, QUT

Associate Professor Carol Windsor (Panel Member), Postgraduate Research Coordinator,

School of Nursing, Faculty of Health, QUT

Associate Professor Christine Neville (External Panel Member), School of Nursing and
Midwifery, University of Queensland

This study aimed to understand what Vietnamese dementia family carers do, how the role affects their lives, and the impact of
traditional values and culture on the carer experience. The study involved three phases. Initially two cross-sectional surveys were
used to describe carer’s quality of life (QoL) and perceived burden, and explore the associations between family carer
characteristics, burden and perceived QoL. Surveys were completed by carers in Hanoi in Phase 1 (N= 153) and carers from
Hanoi, Hai Phong and Bac Ninh in Phase 2 (N=347). Applied instruments included: Kingston Standardised Behavioural
Assessment (KSBA), Barthel Index, Zarit Burden Interview, Sense of Coherence, Filial Piety Scale, Positive Aspects of Caregiving
instrument and WHOQOL-BREF. In Phase 3 qualitative methods were used to explore the specific issues faced by daughter
carers (N=24).

Phase 1 and 2 survey results showed dementia carers reported low QoL, predicted by high perceived burden. Other carer
characteristics including age, gender, family income, and perceived experience were significantly associated with QoL. Filial piety
contributed to only a single domain of QoL. However, Phase 3 results suggest that filial gratitude and positive aspects of the role
may influence the caring experience among daughter carers. These perspectives appear to help daughter carers to adjust to carer
role stress. Further investigation of the specific support needs of general dementia carers, and daughter carers in particular, in
Vietnam are warranted.
 PARTICIPANT INFORMATION FOR QUT RESEARCH PROJECT
THE QUALITY OF LIFE AND BURDEN OF CARE AMONG CAREGIVERS OF PEOPLE WITH
DEMENTIA IN HANOI, VIETNAM
QUT Ethics Approval Number 110001158

RESEARCHER CONTACT
TRUONG QUANG TRUNG, MSc Prof. ELIZABETH BEATTIE (supervisor)
Lecturer – Faculty of Nursing and Midwifery, Hanoi Medical University Director, Dementia Collaborative Research Centre (DCRC)
Director – Nursing Department, Hanoi Medical University Hospital Graduate Carers and Consumers, Queensland University of Technology
student – School of Nursing and Midwifery, Queensland University of Email: [Link]@[Link]
Technology Telephone: 61-7-3138-3389
Phone: +84 4 38523798 ext 474 (Vietnam) OR +61 415138805 (Australia)
Email: [Link]@[Link]
DESCRIPTION
This project is being undertaken as part of a Master’s project for Truong Quang Trung. Only the student and his
supervisor will have access to the data obtained during the project
The purpose of this project is to describe quality of life and perceived caregiving burden among family carers for
persons with dementia in Northern Vietnam and to explore the associations between carer characteristics, quality of life
and perceived burden of care
You are invited to participate in this project because you provide care to a person with dementia and your experience is
important to this research
PARTICIPATION
Your participation in this project is entirely voluntary. If you do agree to participate, you can withdraw from the project at any
time without comment or penalty. Any identifiable information already obtained from you will be destroyed. Your decision to
participate, or not participate, will in no way impact upon your current or future relationship with The Vietnamese National
Institute of Gerontology or with your local health station.
Participation will involve completing a 5-part questionnaire that will take approximately 40 to 45 minutes of your time.
You will be asked to answer approximately 60 questions about your quality of life and your role of caregiver
If you agree to participate you do not have to complete any question(s) that you are uncomfortable answering
EXPECTED BENEFITS
It is expected that this project will not directly benefit you, as carers or the person with dementia who you are caring for. It will
help us to understand your experience of caring and help us to design future intervention programs.
To recognise your contribution, should you choose to participate, the research team is offering participants a gift of 10
AUD or 210,000 VND
RISKS
There are no risks beyond normal day-to-day living associated with your participation in this project. In addition, where the
research may cause discomfort or distress, appropriate independent counselling services will be offered, and participants
provided with information on how to access these.

PRIVACY AND CONFIDENTIALITY

All comments and responses are anonymous and will be treated confidentially. The names of individual persons are not
required in any of the responses

CONSENT TO PARTICIPATE
We would like to ask you to sign a written consent form (enclosed) to confirm your agreement to participate.

QUESTIONS / FURTHER INFORMATION ABOUT THE PROJECT

If have any questions or require any further information about the project please contact the researcher named above.

CONCERNS / COMPLAINTS REGARDING THE CONDUCT OF THE PROJECT

QUT is committed to research integrity and the ethical conduct of research projects. However, if you do have any concerns or
complaints about the ethical conduct of the project you may contact the QUT Research Ethics Unit on [+61 7] 3138 5123 or
email ethicscontact@[Link]. The QUT Research Ethics Unit is not connected with the research project and can
facilitate a resolution to your concern in an impartial manner.
Thank you for helping with this research project. Please keep this sheet for your
information.
 THÔNG TIN DÀNH CHO NGƯỜI THAM GIA NGHIÊN CỨU
Bộ câu hỏi

CHẤT LƯỢNG CUỘC SỐNG VÀ GÁNH NẶNG CHĂM SÓC CỦA GIA ĐÌNH NGƯỜI BỊ SA SÚT
TRÍ TUỆ Ở HÀ NỘI, BẮC NINH VÀ HẢI PHÒNG, VIỆT NAM
Biên bản thông qua Hội đồng đạo đức của QUT số 1100001158

NHÓM NGHIÊN CỨU

Sinh viên: Thạc sỹ Trương Quang Trung, nghiên cứu sinh, QUT
Giáo viên hướng dẫn GS. Elizabeth Beattie, Trường Đại học Kỹ thuật Queensland
PGS. Karen Sullivan, Trường Đại học Kỹ thuật Queensland
GS. Nancy Pachana, Trường Đại học Queensland
TS. Maria O'Reilly, Trường Đại học Kỹ thuật Queensland
MÔ TẢ NGHIÊN CỨU
Đây là đề tài trong chương trình đào tạo Tiến sỹ của Trương Quang Trung, vì vậy chỉ có học viên và giáo viên
hướng dẫn sẽ có quyền sử dụng các thông tin thu thập trong nghiên cứu
Mục đích của nghiên cứu này là mô tả chất lượng cuộc sống và gánh nặng chăm sóc của gia đình người bị suy
giảm trí nhớ ở Miền Bắc Việt Nam và tìm hiểu mối quan hệ giữa đặc điểm của gia đình, chất lượng cuộc sống và
gánh nặng chăm sóc.
Nghiên cứu này cần sự hỗ trợ của ông/bà bởi vì ông/bà là người chăm sóc người bị suy giảm trí nhớ và những
kinh nghiệm của ông bà là quan trọng cho nghiên cứu này.
THAM GIA
Sự tham gia của ông/bà là hoàn toàn tự nguyện. Trường hợp ông/bà không muốn tiếp tục tham gia, ông/bà vẫn có thể
rút khỏi nghiên cứu này bất cứ lúc nào mà không gặp bất cứ rắc rối gì. Các thông tin về ông/bà sẽ được hủy. Quyết
định của ông/bà tham gia vào nghiên cứu này sẽ không ảnh hưởng đến mối quan hệ hiện tại và tương lai với Viện Lão
khoa Việt Nam hoặc với trạm y tế phường.
Tham gia vào nghiên cứu này, ông/bà sẽ trả lời bộ câu hỏi có 7 phần với khoảng 85 câu. Thời gian hoàn thành bộ câu
hỏi khoảng 50 - 60 phút liên quan đến chất lượng cuộc sống và vai trò chăm sóc của ông bà
Nếu ông/bà đồng ý tham gia vào nghiên cứu, ông/à được không cần hoàn thiện các câu hỏi mà mình cảm thấy không
thoải mái để trả lời.
KẾT QUẢ MONG ĐỢI
Nghiên cứu này được mong đợi sẽ không mang lại những lợi ích trực tiếp cho ông/bà, người chăm sóc hoặc với người bị
suy giảm trí nhớ đang được ông/bà chăm sóc. Kết quả của nghiên cứu sẽ giúp chúng tôi hiểu những trải nghiệm mà ông
bà đã trải qua khi chăm sóc người thân trong gia đình và giúp chúng tôi xây dựng những chương trình can thiệp trong
thời gian tới
Nhằm ghi nhận sự đóng góp của ông/bà tham gia vào trả lời bộ câu hỏi ông bà sẽ nhận được mức bồi dưỡng
tương đương với 10 AUD hoặc khoảng 210.000 VND.
RỦI RO
Sẽ không có rủi ro nào xảy ra khi ông/bà tham gia vào nghiên cứu này. Trường hợp ông bà cảm thấy không thoải mái
hoặc khó chịu khi tham gia nghiên cứu này, một số dịch vụ tư vấn hỗ trợ sẽ được giới thiệu để ông bà có thể sử dụng.
Các dịch vụ tư vấn có thể:
- TS. Nguyễn Trọng Hưng, trưởng khoa Thần kinh, Viện Lão Khoa Vietnam. VP: Số 1 Phương Mai, Đống Đa,
Hà Nội, Việt Nam. Tel: (+84) 4.35764558 (máy lẻ 201)
- Khoa Khám bệnh, Viện Lão khoa Vietnam. Số 1 Phương Mai, Đống Đa, Hà Nội, Việt Nam.
- Khoa Khám bệnh và Cấp cứu, Bệnh viện Đại học Y Hà Nội. Số 1 Tôn Thất Tùng, Đống Đa, Hà Nội, Việt Nam.
ĐT: (+84) 4.38523798 (máy lẻ 483)
BẢO MẬT
Tất cả thông tin thu thập được từ nghiên cứu này sẽ giấu tên và được bảo mật. Người tham gia nghiên cứu sẽ
không phải nói tên của mình
ĐỒNG Ý THAM GIA NGHIÊN CỨU
Nếu ông/bà đồng ý tham gia vào nghiên cứu này, xin vui lòng ký tên vào Phiếu Đồng Ý Tham Gia Nghiên Cứu (được
đính kèm).
THÔNG TIN CHI TIẾT LIÊN QUAN ĐẾN NGHIÊN CỨU
Mọi thắc mắc liên quan đến nghiên cứu này xin liên hệ với Nghiên cứu viên theo địa chỉ ở dưới đây
 Thạc sỹ Trương Quang Trung GS. ELIZABETH BEATTIE (Hướng dẫn)
Giảng viên – Khoa Điều dưỡng và Hộ sinh, Trường Đại học Y Hà Nội Giám đốc, Trung tâm hợp tác nghiên cứu Sa sút trí tuệ (DCRC)
Trưởng phòng Điều dưỡng – Bệnh viện Đại học Y Hà Nội Học viên Sau Người chăm sóc và người sử dung, Trường Đại học Kỹ thuật
đại học – Trường Điều dưỡng và Hộ sinh, Trường Đại học Kỹ thuật Queensland
Queensland
Email: [Link]@[Link]
Điện thoại: +84 4 38523798 máy lẻ 474 (Việt Nam) Hoặc
+61 415138805 (Australia)
Email: [Link]@[Link]
THẮC MẮC/ KHIẾU NẠI LIÊN QUAN ĐẾN NGHIÊN CỨU
QUT ủy quyền cho Nghiên cứu sinh thực hiện toàn bộ đề tài và chịu trách nhiệm về mặt đạo đức. Tuy nhiên, nếu anh/
chị có bất cứ thắc mắc hay khiếu nại gì liên quan đến vấn đề đạo đức nghiên cứu của nghiên cứu này, anh chị có thể
liên hệ với Hội Đồng Đạo Đức Nghiên Cứu của QUT theo số máy +61 7 3138 5123 hoặc viết thư điện tử theo địa chỉ
ethicscontact@[Link]. Hội Đồng Đạo Đức làm việc độc lập với nghiên cứu vào sẽ giải đáp các thắc mắc của anh/
chị một cách công bằng nhất.
Xin trân trọng cảm ơn. Xin ông/bà hãy giữ lấy phiếu này làm thông tin.
Please complete all following questions. Thank you very much for help in answering this Number
questionnaire. All your answers will be kept strictly confidential.
Code

About your relative that you are caring for

1. Gender: Male (1) Female (0) 2. Year of birth_____

3. Educational level:
(1) Illiterate (4) Senior high school
(2) Primary school (5) Junior college
(3) Secondary school (6) University and Above

4. Occupation of your relative (previous):

(1) Professional class (Teacher, scientist, (5) Armed force
architect, engineer, attorney, medical worker,
account, government staff  performs
personnel & so on)
(2)Businessman/woman (6) Housewife
(3) Worker (7) Other
(4)Farmer – Fisherman/woman What do you do
5. Retired person: Yes (1) No (2)
6. Does your relative have health-insurance? Yes (1) No (2)
7. Relationship to with you is:
Spouse (1) Parent (2) Relative (3) Other (4)_________
8. When did your relative appear sign of disease? _______________
9. When were your relative diagnosis with dementia?____________
Ask about you:
10. Date of birth (Date/ month/ Year) ___/___/19___ Actual age:______
≤ 18 years old (1) 40 – 49 years old (4)
19 – 29 years old (2) 50 – 59 years old (5)
30 – 39 year old (3) ≥60 years old (6)
11. Marital status
(1) Single (3) Divorce/ Widow/ Separated
(2) Married (4) Cohabiting
12. Gender: Male (1) Female (0)
13. Ethnicity:
14. Religion:
(1) Buddhism (4) No religion
(2) Christian (5) Other
(3) Catholic What is your religon: ___________
15. Highest educational level
(1) Illiterate (4) Senior high school
(2) Primary school (5) Junior college
(3) Secondary school (6) University and Above
16. Occupation
(1) Professional class (Teacher, scientist, (5) Armed force
architect, engineer, attorney, medical worker,
account, government staff  performs
personnel & so on)
(2)Businessman/woman (6) Housewife
(3) Worker (7) Other
(4)Farmer – Fisherman/woman What do you do
17. Employment
(1) Stable work
(2) Temporary work
(3) Unemployment

1
 Number
Code

18. How long does it take you from your home to your office/ factory? (If you have no
job, you do not need to complete this item)
(1) Below 10 minutes (3) Over 30 minutes
(2) 10 – 30 minutes
19. Are you currently ill? Yes (1) No (2)
If something is wrong with your health what do you think it is?
______________________________________________________illness/ problem
20. Are you suffering from any chronic disease? Yes (1) No (2)
If yes______________________________________________________

21. How many hours per week do you provide caregiving for your relative? _______
< 5 hours/week ( 1 hours/day and 5 days/week)
5 – 10 hours/week ( 2 hours/day and 5 days/week)
10 – 20 hours/week ( 4 hours/day and 5 days/week)
20 – 30 hours/week ( 6 hours/day and 5 days/week)
30 – 40 hours/week ( 8 hours/day and 5 days/week)
40 – 50 hours/week ( 10 hours/day and 5 days/week)
50 – 60 hours/week ( 12 hours/day and 5 days/week)
> 60 hours/week
22. How many people living with you in the same household___________________
23. Your family income is
< 5 million VND/ month
5 – 10 million VND/ month
10 – 20 million VND/ month
20 – 25 million VND/ month
25 – 30 million VND/ month
> 30 million VND/ month

2
 Number
Code

Part. B1. The Barthel Index

The index should be used as a record of what a patient does, not as a record of what a patient could do.
Usually the patient's performance over the preceding 24-48 hours is important
Score of each domain is based on the current activities that patient can perform.
No Activity Score
1. FEEDING
0 = unable
5 = needs help cutting, spreading butter, etc., or requires modified diet
10 = independent
2. BATHING
0 = dependent
5 = independent (or in shower)
3. GROOMING
0 = needs to help with personal care
5 = independent face/hair/teeth/shaving (implements provided)
4. DRESSING
0 = dependent
5 = needs help but can do about half unaided
10 = independent (including buttons, zips, laces, etc.)
5. BOWELS
0 = incontinent (or needs to be given enemas)
5 = occasional accident
10 = continent
6. BLADDER
0 = dependent
5 = needs some help, but can do something alone
10 = independent (on and off, dressing, wiping)
7. TOILET USE
0 = dependent
5 = needs some help, but can do something alone
10 = independent (on and off, dressing, wiping)
8. TRANSFERS (BED TO CHAIR AND BACK)
0 = unable, no sitting balance
5 = major help (one or two people, physical), can sit
10 = minor help (verbal or physical)
15 = independent
9. MOBILITY (ON LEVEL SURFACES)
0 = immobile or < 50 yards
5 = wheelchair independent, including corners, > 50 yards
10 = walks with help of one person (verbal or physical) > 50 yards
15 = independent (but may use any aid; for example, stick) > 50 yards
10. STAIRS
0 = unable
5 = needs help (verbal, physical, carrying aid)
10 = independent
Total (0 – 100)

Mahoney, F. I., & Barthel, D. W. (1965). Functional evaluation: The Barthel Index. Maryland
State Medical Journal, 14, 56

3
 Number
Code

Part B1: Kingston Standardized Behavioural Assessment

Please check all of the following behaviours that have occurred in the last month or are
presently occurring, and that are a change from your spouse/relative/client’s earlier behaviour
(prior to illness). Indicate whether they apply by marking the box beside the appropriate statement.
The Total Score equals number of boxes checked

1 Daily activities Forgets activities, conversations of only a

21
short time before
No longer takes part in favourite
1 22 Forgets important everyday information
pastimes (or greatly reduced).
Reduced personal hygiene. (E.g. < Total Attention/Concentration/Memory
Would not take a bath unless told to do so,
2
or wears the same clothes for days unless
made to change).
If left on his/her own, doesn't eat 3 Emotional Behaviour
3
properly
Unsafe in daily activities, if left
4 23 Shows little or no emotion
unsupervised
No longer uses some common objects
5 24 Mood changes with no apparent reason
properly. (e.g. telephone)
Expresses inappropriate emotions, either
6 Unable to handle personal finances 25
type or intensity
Is unable to perform usual household Makes uncharacteristically pessimistic
7 26
tasks. statements.
Gets confused in places other than
8 < Total Emotional Behaviour
home
Overly dependent, wants more
9
guidance than usual
Trouble appreciating subtleties in
10
conversations (e.g. recognizing humour).
11 Difficulty judging the passing of time 4 Aggressive Behaviour
12 Wanders aimlessly 27 Verbally abusive at times
28 Uncharacteristically excitable, easy to
13 Hides things
upset; reacts catastrophically
14 Hoards objects 29 Attempts to hit/strike out at others
15 Fails to recognize family or friends. < Total Aggressive Behaviour
Incontinence of urine/faeces in clothes
16
in daytime
17 Voids in non-toilet areas
< Total Daily Activities 5 Misperceptions/Misidentifications
Claims an object/possession looks
30
similar to, but is not the real one.
2 Attention/Concentration/Memory Claims a family member looks similar but
31
is not the true one.
Can't concentrate, pay attention for Thinks present dwelling is not their place
18 32
long of living.
19 Misplaces things more than usual. 33 Thinks people are present who aren't.
Has difficulty organizing his/her time
20 < Total Misperception Behaviour
or daily activities

4
 Number
Code

6 Paranoid Behaviour 10 Sleep/Activity/Sundowning

34 Suspicious of family and friends 52 Falls asleep at uncharacteristic times
Gets up and wanders or awakens
35 Suspicious about money issues 53
frequently at night, more than usual
Accuses others of stealing his or her
36 54 Sleeps more
things
37 Accuses spouse of infidelity
Behaviour more agitated or impaired in
Expresses suspicion around taking 55
38 late afternoon
medication.
< Total Paranoid Behaviour < Total Sleep/Activity/Sundowning

7 Judgement/Insight 11 Motor/Spatial Problems

Shows poor judgement in social Poor coordination seen in limb/finger
39 56
situations movements
Shows poor judgement about
40 57 Slowness of movement
driving
41 Shows uncharacteristic change in 58 Unsteadiness when walking
his or her concern about money
Poor choices in dressing. (e.g. wears
42 clothes that are inappropriate for season
59 Has trouble dressing, especially with
or temperature, wears the same clothes buttons or shoelaces
for days).
43 Makes inappropriate sexual 60 Difficulty judging object sizes or how near
advances an object is from themselves.
44 Shows less self control than usual < Total Motor Spatial Problems
Unable to identify personal safety
45
risks.
< Total Judgement/Insight 12 Language Difficulties
61 Reads far less frequently than previously
8 Perseveration 62 Substitutes some words for others
46 Repeats same actions over and 63 Does not watch or follow television
over
47 64 Does not speak unless spoken to. (e.g.
Repeats same words or phrases
Does not participate in conversations.)
48 Repeatedly shouts or calls out 65 Often cannot find the right word
< Total Perseveration 66 Trouble pronouncing words.
Does not understand simple commands,
67
explanations
9 Motor Restlessness 68 Does not produce meaningful speech
Desire to pace or walk almost <
49 Total Language Difficulties
constantly
50 Can't sit still, restless, fidgety.
51 Tries doors, windows.
< Total Motor Restlessness

Total score

Hopkins, R. W., Kilik, L. A., Day, D. J., Bradford, L., & Rows, C. P. (2006). The
Kingston Standardized Behavioural Assessment. Am J Alzheimers Dis Other
Demen, 21(5), 339-346

5
 Number
Code

Part C: BURDEN INTERVIEW

INSTRUCTIONS: The following is a list of statements, which reflect how people sometimes
feel when taking care of another person. After each statement, indicate how often you feel
that way; never, rarely, sometimes, quite frequently, or nearly always. There is no right or
wrong answers.

1. Do you feel that your relative asks for more help than he/she needs?

0. Never 1. Rarely 2. Sometimes 3. Quite Frequently 4. Nearly Always

2. Do you feel that because of the time you spend with your relative that you don’t
have enough time for yourself?

0. Never 1. Rarely 2. Sometimes 3. Quite Frequently 4. Nearly Always

3. Do you feel stressed between caring for your relative and trying to meet other
responsibilities for your family or work?

0. Never 1. Rarely 2. Sometimes 3. Quite Frequently 4. Nearly Always

4. Do you feel embarrassed over your relative’s behavior?

0. Never 1. Rarely 2. Sometimes 3. Quite Frequently 4. Nearly Always

5. Do you feel angry when you are around your relative?

0. Never 1. Rarely 2. Sometimes 3. Quite Frequently 4. Nearly Always

6. Do you feel that your relative currently affects your relationship with other family
members or friends in a negative way?

0. Never 1. Rarely 2. Sometimes 3. Quite Frequently 4. Nearly Always

7. Are you afraid what the future holds for your relative?

0. Never 1. Rarely 2. Sometimes 3. Quite Frequently 4. Nearly Always

8. Do you feel your relative is dependent upon you?

0. Never 1. Rarely 2. Sometimes 3. Quite Frequently 4. Nearly Always

9. Do you feel strained when you are around your relative?

0. Never 1. Rarely 2. Sometimes 3. Quite Frequently 4. Nearly Always

10. Do you feel your health has suffered because of your involvement with your
relative?

0. Never 1. Rarely 2. Sometimes 3. Quite Frequently 4. Nearly Always

6
 Number
Code

11. Do you feel that you don’t have as much privacy as you would like, because of your
relative?

0. Never 1. Rarely 2. Sometimes 3. Quite Frequently 4. Nearly Always

12. Do you feel that your social life has suffered because you are caring for your
relative?

0. Never 1. Rarely 2. Sometimes 3. Quite Frequently 4. Nearly Always

13. Do you feel uncomfortable about having friends over, because of your relative?

0. Never 1. Rarely 2. Sometimes 3. Quite Frequently 4. Nearly Always

14. Do you feel that your relative seems to expect you to take care of him/her, as if you
were the only one he/she could depend on?

0. Never 1. Rarely 2. Sometimes 3. Quite Frequently 4. Nearly Always

15. Do you feel that you don’t have enough money to care for your relative, in addition
to the rest of your expenses?

0. Never 1. Rarely 2. Sometimes 3. Quite Frequently 4. Nearly Always

16. Do you feel that you will be unable to take care of your relative much longer?

0. Never 1. Rarely 2. Sometimes 3. Quite Frequently 4. Nearly Always

17. Do you feel you have lost control of your life since your relative’s illness?

0. Never 1. Rarely 2. Sometimes 3. Quite Frequently 4. Nearly Always

18. Do you wish you could just leave the care of your relative to someone else?

0. Never 1. Rarely 2. Sometimes 3. Quite Frequently 4. Nearly Always

19. Do you feel uncertain about what to do about your relative?

0. Never 1. Rarely 2. Sometimes 3. Quite Frequently 4. Nearly Always

20. Do you feel you should be doing more for your relative?

0. Never 1. Rarely 2. Sometimes 3. Quite Frequently 4. Nearly Always

21. Do you feel you could do a better job in caring for your relative?

0. Never 1. Rarely 2. Sometimes 3. Quite Frequently 4. Nearly Always

22. Overall, how burdened do you feel in caring for your relative?

0. Not at all 1. A little 2. Moderately 3. Quite a bit 4. Extremely

Seng, B. K., Luo, N., Ng, W. Y., Lim, J., Chionh, H. L., Goh, J., et al. (2010). Validity and
reliability of the Zarit Burden Interview in assessing caregiving burden. Ann Acad Med 7
Singapore, 39(10), 758-763.
 Number
Code

Part D. WHOQOL-BREF
Please read each question, assess your feelings, and circle the number on the
scale that gives the best answer for you for each question.
(Please circle the number)
Very poor Poor Neither poor Good Very Good
nor good
1. How would you rate 1 2 3 4 5
your quality of life?

(Please circle the number)

Very Dissatisfied Neither Satisfied Very
dissatisfied satisfied nor satisfied
dissatisfied
2. How satisfied are you 1 2 3 4 5
with your health?

The following questions ask about how much you have experienced certain
things in the last two weeks.
(Please circle the number)
Not at all A little A moderate Very much An extreme
amount amount
3. To what extent do 1 2 3 4 5
you feel that physical
pain prevents you
from doing what you
need to do?

4. How much do you 1 2 3 4 5

need any medical
treatment to function
in your daily life?

5. How much do you 1 2 3 4 5

enjoy life?

6. To what extent do 1 2 3 4 5
you feel your life to
be meaningful?

8
 Number
Code

(Please circle the number)

Not at all Slightly A Moderate Very much Extremely
amount
7. How well are you 1 2 3 4 5
able to concentrate?

8. How safe do you feel 1 2 3 4 5

in your daily life?

9. How healthy is your 1 2 3 4 5

physical
environment?

The following questions ask about how completely you experience or were able
to do certain things in the last two weeks.
(Please circle the number)
Not at all A little Moderately Mostly Completely

10. Do you have enough 1 2 3 4 5

energy for everyday
life?

11. Are you able to 1 2 3 4 5

accept your bodily
appearance?

12. Have you enough 1 2 3 4 5

money to meet your
needs?

13. How available to you 1 2 3 4 5

is the information
that you need in your
day-to-day life?

14. To what extent do 1 2 3 4 5

you have the
opportunity for
leisure activities?

(Please circle the number)

Very poor Poor Neither poor Well Very well

9
 Number
Code

(Please circle the number)

nor well

15. How well are you 1 2 3 4 5

able to get around?

The following questions ask you to say how good or satisfied you have felt
about various aspects of your life over the last two weeks.
(Please circle the number)
Very Dissatisfied Neither Satisfied Very
dissatisfied satisfied nor satisfied
dissatisfied
16. How satisfied are 1 2 3 4 5
you with your sleep?

17. How satisfied are 1 2 3 4 5

you with your ability
to perform your daily
living activities?

18. How satisfied are 1 2 3 4 5

you with your
capacity for work?

19. How satisfied are 1 2 3 4 5

you with your
abilities?

20. How satisfied are 1 2 3 4 5

you with your
personal
relationships?

21. How satisfied are 1 2 3 4 5

you with your sex
life?

22. How satisfied are 1 2 3 4 5

you with the support
you get from your
friends?

23. How satisfied are 1 2 3 4 5

you with the

10
 Number
Code

(Please circle the number)

Very Dissatisfied Neither Satisfied Very
dissatisfied satisfied nor satisfied
dissatisfied
conditions of your
living place?

24. How satisfied are 1 2 3 4 5

you with your access
to health services?

25. How satisfied are 1 2 3 4 5

you with your mode
of transportation?

The following question refers to how often you have felt or experienced certain
things in the last two weeks.
(Please circle the number)
Quite Very
Never Seldom often often Always
26. How often do you 1 2 3 4 5
have negative
feelings, such as blue
mood, despair,
anxiety, depression?

Huong, N. T. (2009). Apply the validated quality of life tool for senior people to assess quality
of life among several senior groups in Vietnam. Hanoi School of public health, Hanoi

11
 Number
Code

Part D2 – The 13-item Sense of Coherence Questionnaire

Here is a series of questions relating to various aspects of your lives. Each question has seven
possible answers. Please mark the number, which expresses your answer, with number 1 and
7 being the extreme answers. If the words under 1 are right for you, circle 1: if the words
under 7 are right for you, circle 7. If you feel differently, circle the number which best
expresses your feeling. Please give only one answer to each question.

1. Do you have feeling that you don’t really care about what goes on around you?

1 2 3 4 5 6 7

very seldom Very often

or never

2. Has it happened in the past that you were surprised by the behavior of people whom you
thought you knew well?

1 2 3 4 5 6 7

never happened always happened

3. Has it happened that people whom you counted on disappointed you?

1 2 3 4 5 6 7

never happened always happened

4. Until now your life has had:

1 2 3 4 5 6 7

no clear goals or purpose very clear goals and

at all purpose

5. Do you have the feeling that you’re being treated unfairly?

1 2 3 4 5 6 7

very often very seldom or never

6. Do you have the feeling that you are in an unfamiliar situation and don’t know what to do?

1 2 3 4 5 6 7

very often very seldom or never

7. Doing the thing you do every day is:

1 2 3 4 5 6 7

a source of deep pleasure a source of pain and

and satisfaction boredom

12
 Number
Code

8. Do you have very mixed-up feelings and ideas?

1 2 3 4 5 6 7

very often very seldom or never

9. Does it happen that you have feelings inside you would rather not feel?

1 2 3 4 5 6 7

very often very seldom or never

10. Many people – even those with a strong character – sometimes feel like sad sacks (losers)
in certain situations. How often have you felt this way in the past?

1 2 3 4 5 6 7

never very often

11. When something happened, have you generally found that:

1 2 3 4 5 6 7

you overestimated or you saw things in the right

underestimated its proportion
importance

12. How often do you have the feeling that there’s little meaning in the things you do in your
daily life?

1 2 3 4 5 6 7

very often very seldom or never

13. How often do you have feelings that you’re not sure you can keep under control?

1 2 3 4 5 6 7

very often very seldom

Eriksson, M., & Lindstrom, B. (2005). Validity of Antonovsky's sense of coherence scale: a
systematic review. J Epidemiol Community Health, 59(6), 460-466

13
 Number
Code

Chân thành cảm ơn ông/bà tham gia trả lời câu hỏi. Toàn bộ các câu trả lời của
ông/bà sẽ được giữ kín.

Về người thân mà ông/ bà đang chăm sóc

1. Giới tính: Nam (1) Nữ (0) 2. Sinh năm:________________
3. Trình độ học vấn
(1) Mù chữ (4) Phổ thông trung học
(2) Tiểu học (5) Trung cấp - Cao đẳng
(3) Phổ thông cơ sở (6) Đại học và trên đại học
4. Nghề nghiệp (trước đây)
(1) Có tay nghề (Giáo viên, người làm khoa hoc, (5) Quân đội, Công an
kiến trúc sư, kĩ sư, luật sư, nhân viên y tế, kế toán,
nhân viên chính phủ, chính quyền)
(2) Buôn bán, doanh nhân (6) Nội trợ
(3) Công nhân (7) Khác
(4) Nông dân - Thuyền chài Chị làm nghề gì:___________________
5. Là cán bộ hưu trí : Đúng (1) Không đúng (2)
6. Bảo hiểm y tế? Có (1) Không có (2)
7. Người thân ông/bà đang chăm sóc là
Vợ/chồng (1) Bố/mẹ (2) Họ hàng (3) Khác (4)_________
8. Người thân của ông bà có biểu hiện của bệnh từ năm 20___
9. Người thân của ông bà được chẩn đoán bệnh từ năm 20____
Hỏi các thông tin về ông/bà:
10. Ngày sinh (ngày/ tháng/ năm) ___/___/19___ Tuổi thực:______
 18 tuổi (1) 40 – 49 tuổi (4)
19 – 29 tuổi (2) 50 – 59 tuổi (5)
30 – 39 tuổi (3)  60 tuổi (6)
11. Tình trạng hôn nhân
(1) Độc thân (3) Ly dị/ Ly thân/ Chồng chết
(2) Kết hôn (4) Sống chung
12. Giới tính: Nam (1) Nữ (0)
13. Dân tộc:
14. Tôn giáo:
(1) Đạo Phật (4) Không
(2) Đạo Cơ đốc (5) Khác
(3) Đạo Thiên chúa ___________
15. Trình độ học vấn
(1) Mù chữ (4) Phổ thông trung học
(2) Tiểu học (5) Trung cấp - Cao đẳng
(3) Phổ thông cơ sở (6) Đại học và trên đại học
16. Nghề nghiệp
(1) Có tay nghề (Giáo viên, người làm khoa hoc, (5) Quân đội, Công an
kiến trúc sư, kĩ sư, luật sư, nhân viên y tế, kế toán,
nhân viên chính phủ, chính quyền)
(2) Buôn bán, doanh nhân (6) Nội trợ
(3) Công nhân (7) Khác
(4) Nông dân - Thuyền chài Ông/bà làm nghề gì:________________
17. Công việc
(1) Công việc ổn định
(2 Công việc tạm thời
(3) Thất nghiệp

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18. Ông/bà đi từ nhà đến cơ quan mất bao lâu? (Nếu câu 8 trả lời là 3 bỏ qua câu này)
(1) Dưới 10 phút (3) Trên 30 phút
(2) 10 – 30 phút
19. Hiện tại ông/bà có mắc bệnh gì không? Có (1) Không (2)
Nếu ông bà có nghĩ rằng mình có vấn đề gì về sức khỏe không?
______________________________________________________Bệnh tật/ Vấn đề
20. Ông/bà có mắc bệnh mạn tính không? Có (1) Không (2)
Nếu có______________________________________________________Bệnh tật/ Vấn đề
21. Một tuần, Ông bà chăm sóc người thân bao nhiêu giờ? ____________
< 5 tiếng/tuần (tương đương khoảng 1 giờ/ngày và 5 ngày/tuần)
5 – 10 tiếng/tuần (tương đương khoảng 2 giờ/ngày và 5 ngày/tuần)
10 – 20 tiếng/tuần (tương đương khoảng 4 giờ/ngày và 5 ngày/tuần)
20 – 30 tiếng/tuần (tương đương khoảng 6 giờ/ngày và 5 ngày/tuần)
30 – 40 tiếng/tuần (tương đương khoảng 8 giờ/ngày và 5 ngày/tuần)
40 – 50 tiếng/tuần (tương đương khoảng 10 giờ/ngày và 5 ngày/tuần)
50 – 60 tiếng/tuần (tương đương khoảng 12 giờ/ngày và 5 ngày/tuần)
> 60 tiếng/tuần

22. Hiện tại đang có bao nhiêu người sống cùng với ông/bà: ______
23. Thu nhập trung bình hàng tháng của cả gia đình ông bà là (bao gồm của cả vợ
chồng ông bà cùng các thành viên trong gia đình)
[] Dưới 5 triệu đồng/tháng (1)
[] Từ 5 triệu đồng – 10 triệu đồng (2)
[] Từ 10 triệu đồng – 15 triệu đồng (3)
[] Từ 15 triệu đồng – 20 triệu đồng (4)
[] Từ 20 triệu đồng – 25 triệu đồng (5)
[] Từ 25 triệu đồng – 30 triệu đồng (6)
[] Trên 30 triệu đồng (7)

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PHẦN B1 : THANG ĐO CHỈ SỐ BARTHEL (Barthel index)

Đề nghị ông/bà cho điểm theo các hoạt động tương ứng nhằm xác định mức độ phụ thuộc
của người thân của ông/bà trong hoạt động chăm só[Link]ững hoạt động này được xác định
trong khoảng thời gian 2- 3 ngày trước đây.
STT Hoạt động Điểm đạt
1. Ăn uống
0 = Không thể tự ăn được
5 = Cần sự hỗ trợ trong việc ăn uống (cắt nhỏ hoặc cho thức ăn vào thìa..)
10 = Tự ăn mà không cần hỗ trợ
2. Tắm
0= Không thể tự tắm, phải có người hỗ trợ
5 = Tự tắm được, không cần người hỗ trợ
3. Chải đầu – Đánh răng
0 = Không tự thực hiện được, cần sự hỗ trợ trong chăm sóc bản than
5 = Tự thực hiện được việc chải đầu, cạo râu, đánh răng..
4. Mặc và thay quần áo
0 = Không tự thực hiện được
5 = Cần sự hỗ trợ vì chỉ mặc được một nửa nếu không có sự trợ giúp
10 = Tự thực hiện được việc mặc và thay quần áo (cài khuy, kéo khóa, buộc/ thắt dây..)
5. Đại tiện
0 = Không tự chủ (hoặc phải hỗ trợ để thụt tháo phân)
5 = Có khi tự chủ, có khi không tự chủ
10 = Hoàn toàn chủ động – tự chủ
6. Tiểu tiện
0 = Không tự chủ (hoặc phải đặt thông tiểu và không thể tự kiểm soát)
5 = Có khi tự chủ, có khi không tự chủ
10 = Hoàn toàn chủ động – tự chủ
7. Sử dụng nhà vệ sinh
0 = Hoàn toàn phụ thuộc- đại tiểu tiện tại giường
5 = Cần sự hỗ trợ, nhưng đôi khi có thể thực hiện được một mình
10 = Hoàn toàn độc lập (ra vào nhà vệ sinh, cởi quần, kéo khóa..)
8. Di chuyển (Giữa giường, ghế, xe đẩy và ngược lại)
0 = Không thể thực hiện được, không thể tự ngồi được
5 = Cần nhiều sự trợ giúp (1 – 2 người nâng đỡ), có thể ngồi được
10 = Cần ít sự hỗ trợ
15 = Hoàn toàn độc lập, chủ động
9. Đi lại
0 = Không thể đi được hoặc chỉ đi được trong phạm vị < 50 mét
5 = Sử dụng xe lăn độc lập, di chuyển trong phạm vi > 50 mét
10 = Đi bộ với sự hỗ trợ của 1 người (lời nói hoặc hành động) với phạm vi > 50 mét
15 = Hoàn toàn độc lập, chủ động (nhưng có thể sử dụng phương tiện hỗ trợ như gậy..) với
phạm vi > 50 mét
10. Lên xuống cầu thang
0 = Không thể thực hiện được
5 = Cần sự hỗ trợ (lời nói, hành động, với các phương tiện trợ giúp)
10 = Hoàn toàn chủ động
Tổng cộng (0 – 100)

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PHẦN B1 – XÁC ĐỊNH TÌNH TRẠNG HOẠT ĐỘNG

Đề nghị đánh dấu vào các bảng hỏi về các hoạt động/ hành vi mà người thân của ông/bà
thực hiện trong vòng 1 tháng gần đây.

1 Hoạt động hàng ngày Nhanh quên đi việc/ nội dung cuộc nói
21
chuyện mới xảy ra
Không hứng thú với các hoạt động
1 yêu thích trước đây (hoặc giảm hứng 22 Quên những thông tin quan trong hàng ngày
thú)
Vệ sinh cá nhân kém. (VD như không < Tổng cộng các hoạt động
tắm cho đến khi yêu cầu hoặc mặc
2
nguyên bộ quần báo bẩn và không chịu
thay).
Nếu để người đó một mình, họ sẽ 3 Hoạt động biểu cảm
3
không ăn uống đúng – đủ
Thực hiện các hoạt động hàng ngày
4 23 Ít hoặc không biểu hiện tình cảm/tâm tính
không an toàn nếu không có giám sát
Không thể sử dụng các vật dụng/
5 phương tiện quen thuộc đúng cách 24 Thay đổi tâm trạng đột ngột không lý do
(VD. Điện thoại)
6 Không thể tự quản lý tài chính 25 Thể hiện tình cảm không phù hợp
7 Không thể làm được các việc nhà. 26 Có những nhận xét bi quan khác thường.
Đi lạc ngay trong khu vực quen
8 < Tổng cộng các hoạt động
thuộc của họ
Phụ thuộc hoàn toàn và yêu cầu
9
nhiều sự trợ giúp hơn bình thường
Mất đi sự khôn khéo/ tinh tế trong trò
10
chuyện, trao đổi (VD. Sự hài hước).
11 Khó khăn trong việc xác định thời gian 4 Hành vi
12 Đi lại không chủ đích 27 Sử dụng lời lẽ thiếu văn hóa
28 Dễ bị kích động, dễ cáu giận, buồn hoặc
13 Dấu các đồ vật
phản ứng thái quá
14 Nhặt nhạnh các vật linh tinh 29 Đánh hoặc tấn công người khác
15 Không nhận ra người thân hoặc bạn < Tổng cộng các hoạt động
16 Ỉa/ đái không tự chủ
17 Đi vệ sinh không đúng chỗ
< Tổng cộng các hoạt động 5 Nhận thức
Quả quyết vật/ tài sản trông giống nhau
30
nhưng thực chất là khác nhau
2 Tập trung/ Chú ý/ Ghi nhớ Quả quyết giống một người trong nhà,
31
nhưng thực chất là giống.
18 Không thể tập trung trong thời gian dài 32 Nghĩ rằng đang sống ở một thế giới khác
19 Hay để quên đồ/ vật 33 Nghĩ về một người nào đó đã mất
Khó khăn trong xác định thời gian
20 < Tổng cộng các hoạt động
hoặc thực hiện các hoạt động

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6 Hoang tưởng 10 Ngủ/ nghỉ

34 Nghi ngờ bạn bè hoặc gia đình 52 Ngủ không theo quy luật
Tỉnh dậy và đi lại lung tung hoặc thường
35 Nghi ngờ mất tiền 53
xuyên thức dậy vào ban đêm
36 Buộc tội ai đó lấy đồ vật của mình 54 Ngủ nhiều hơn trước
37 Buộc tội vợ/ chồng không chung thủy Dễ bị kích động hoặc tổn thương vào
55
38 Nghi ngờ về việc uống thuốc buổi chiều
< Tổng cộng các hoạt động < Tổng cộng các hoạt động

7 Thẩm định/nhận xét 11 Thời gian/không gian

Đưa ra những nhận xét không phù Hoạt động phối hợp giữa các chi
39 56
hợp về tình huống trong xã hội (chân/tay) và ngón tay giảm hoặc yếu
Có những quyết định không phù
40 57 Giảm hẳn các hoạt động
hợp khi lái xe (ôtô, xe máy)
Thể hiện sự thay đổi không phù hợp
41 58 Đi lại không vững
khi lo lắng về tài chính
Lựa chọn trang phục không phù
hợp (VD. Mặc quần áo mùa đông khi Gặp khó khăn khi mặc quần áo, đặc biệt
42 đang là mùa hè, trời không mưa lại mặc 59
áo mưa, không chịu thay quần áo
là cài khuy, kéo phéc-mơ-tuya (khóa kéo)
nhiều).
43 Có những hoạt động tình dục không 60 Khó khăn trong xác định kích thước đồ
phù hợp vật hoặc khoảng cách giữa các đô vật
44 Khó khăn trong tự kiểm soát bản thân < Tổng cộng các hoạt động
Không thể nhận ra những nguy
45
hiểm với bản thân.
< Tổng cộng các hoạt động 12 Khó khăn trong ngôn ngữ
61 Đọc chậm hơn bình thường
8 Lặp lại 62 Vay mượn từ ngữ của người khác
46 Lặp đi lặp lại một/ nhiều hoạt động 63 Không xem hoặc theo dõi TV
Không nói chuyên trừ khi yêu cầu nói
47 Nhắc đi nhắc lại một từ/ ngữ 64
(VD. Không tham gia vào đối thoại)
48 Liên tục hò hét/ kêu la 65 Thường không thể sử dụng đúng từ/ ngữ
< Tổng cộng các hoạt động 66 Khó khăn trong phát âm.
Không thể hiểu được một yêu cầu, giải
67
thích đơn giản
9 Vận động 68 Không thể nói những câu có ý nghĩa
49 Di chuyển với bước đi đều nhau < Tổng cộng các hoạt động
50 Không thể ngồi yên, bồn chồn,
51 Rung/ lắc cửa sổ, cửa ra vào
< Tổng cộng các hoạt động

Điểm tổng

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Phần C: PHỎNG VẤN VỀ GÁNH NẶNG CHĂM SÓC

Dưới đây là 22 câu hỏi về những cảm giác của người chăm sóc khi chăm sóc người khác.
Phần trả lời của mỗi câu hỏi sẽ được trình bày dưới mức độ: không bao giờ, hiếm khi, đôi
khi, khá thường xuyên hoặc thường xuyên. Đề nghị ông/bà khoanh vào 1 (một) trong các
số từ 0 đến 4 tương ứng với câu trả lời của ông/bà. Không có câu trả lời đúng và sai.
Một số từ/cụm từ dùng thường xuyên:
Thuật ngữ Ý nghĩa

- Người thân dùng để chỉ người được nhận chăm sóc

- Người chăm sóc dùng để chỉ người thực hiện các nội dung chăm sóc

Chăm sóc ở đây bao gồm hỗ trợ ăn, uống, tắm, vệ sinh cá nhân,...

C1. Ông/bà có cảm thấy người thân đòi hỏi việc chăm sóc nhiều hơn mức họ cần không?
0 1 2 3 4

Không bao giờ Hiếm khi Đôi khi Khá thường xuyên Thường xuyên
C2. Ông/bà có cảm thấy không có đủ thời gian dành cho chăm sóc bản thân mình bởi vì
ông/bà dành hết thời gian cho chăm sóc người thân của mình?
0 1 2 3 4

Không bao giờ Hiếm khi Đôi khi Khá thường xuyên Thường xuyên
C3. Ông/bà có cảm thấy bị stress (áp lực) giữa việc chăm sóc người thân của mình và cố
gắng thực hiện đầy đủ các trách nhiệm đối với gia đình hoặc công việc?
0 1 2 3 4

Không bao giờ Hiếm khi Đôi khi Khá thường xuyên Thường xuyên
C4. Ông/bà có cảm thấy ngượng/ lúng túng về hành vi của người thân mình không?
0 1 2 3 4

Không bao giờ Hiếm khi Đôi khi Khá thường xuyên Thường xuyên
C5. Ông/bà có cảm thấy tức giận khi ông bà ở gần người thân của mình?
0 1 2 3 4

Không bao giờ Hiếm khi Đôi khi Khá thường xuyên Thường xuyên
C6. Ông/bà có cảm thấy người thân của mình đang gây nên những tác động tiêu cực đến
mối quan hệ với các thành viên khác trong gia đình hoặc bạn bè không?
0 1 2 3 4

Không bao giờ Hiếm khi Đôi khi Khá thường xuyên Thường xuyên

6
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C7. Ông/bà có cảm thấy lo lắng về tương lai của người thân mình đang chăm sóc không?
0 1 2 3 4

Không bao giờ Hiếm khi Đôi khi Khá thường xuyên Thường xuyên
C8. Ông/bà có cảm thấy người thân đang phụ thuộc hoàn toàn vào mình không?
0 1 2 3 4

Không bao giờ Hiếm khi Đôi khi Khá thường xuyên Thường xuyên
C9. Ông/bà có cảm thấy căng thẳng khi ông/bà ở gần người thân đang nhận được chăm
sóc không?
0 1 2 3 4

Không bao giờ Hiếm khi Đôi khi Khá thường xuyên Thường xuyên
C10. Ông/bà có cảm thấy sức khỏe của mình bị ảnh hưởng bởi vì ông/bà tham gia vào quá
trình chăm sóc người thân không?
0 1 2 3 4

Không bao giờ Hiếm khi Đôi khi Khá thường xuyên Thường xuyên
C11. Vì ông/bà tham gia vào chăm sóc người thân, ông/bà có cảm thấy mình không có
không gian riêng tư như mong muốn không?
0 1 2 3 4

Không bao giờ Hiếm khi Đôi khi Khá thường xuyên Thường xuyên
C12. Vì ông/bà tham gia chăm sóc người thân, ông/bà có cảm thấy hoạt động xã hội của
mình bị ảnh hưởng không?
0 1 2 3 4

Không bao giờ Hiếm khi Đôi khi Khá thường xuyên Thường xuyên
C13. Vì ông/bà tham gia chăm sóc người thân, ông/bà có cảm thấy không thoải mái về mối
quan hệ với bạn bè không?
0 1 2 3 4

Không bao giờ Hiếm khi Đôi khi Khá thường xuyên Thường xuyên
C14. Ông/bà có cảm thấy người thân của mình trông chờ việc chăm sóc của mình bởi vì
ông/bà là người duy nhất giúp đỡ họ?
0 1 2 3 4

Không bao giờ Hiếm khi Đôi khi Khá thường xuyên Thường xuyên

7
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C15. Bên cạnh các chi phí cho cá nhân của mình, ông/bà có cảm thấy mình không có đủ
tài chính để chăm chăm sóc người thân không?
0 1 2 3 4

Không bao giờ Hiếm khi Đôi khi Khá thường xuyên Thường xuyên
C16. Ông/bà có cảm thấy mình sẽ không đủ khả năng để chăm sóc người thân của mình
lâu hơn nữa không?
0 1 2 3 4

Không bao giờ Hiếm khi Đôi khi Khá thường xuyên Thường xuyên
C17. Kể từ khi người thân của mình bị bệnh, ông/bà có cảm thấy mình đang không thể
kiểm soát được cuộc sống của mình không?
0 1 2 3 4

Không bao giờ Hiếm khi Đôi khi Khá thường xuyên Thường xuyên
C18. Ông/bà có khi nào ông bà mong muốn giao việc chăm sóc người thân của mình cho
người khác thực hiện không?
0 1 2 3 4

Không bao giờ Hiếm khi Đôi khi Khá thường xuyên Thường xuyên
C19. Ông/bà có cảm thấy không chắc chắn về việc mình đang làm cho người thân không?
0 1 2 3 4

Không bao giờ Hiếm khi Đôi khi Khá thường xuyên Thường xuyên
C20. Ông/bà có cảm thấy mình phải làm nhiều hơn nữa cho người thân của mình không?
0 1 2 3 4

Không bao giờ Hiếm khi Đôi khi Khá thường xuyên Thường xuyên
C21. Ông/bà có cảm thấy mình thực hiện công việc chăm sóc người thân tốt hơn không?
0 1 2 3 4

Không bao giờ Hiếm khi Đôi khi Khá thường xuyên Thường xuyên
C22. Nhìn chung, ông bà cảm thấy về gánh nặng trong chăm sóc người thân của mình như
thế nào?
0 1 2 3 4

Không có gánh Một chút Trung bình Gánh nặng nhiều Mức độ rất lớn
nặng

8
 Number
Code

Phần D1. CHẤT LƯỢNG CUỘC SỐNG

Đề nghị Ông/Bà hãy đọc và khoanh vào những câu trả lời phù hợp nhất với
bản thân mình
(Đề nghị khoanh tròn vào câu trả lời)
1. Nhìn chung, ông/bà 1 2 3 4 5
tự đánh giá chất Rất Kém Kém Không tốt Tốt Rất tố
lượng cuộc sống của cũng không
mình là? xấu (trung
bình)

2. Nhìn chung, mức độ 1 2 3 4 5

hài lòng của ông/bà Rất không Không hài Phân vân/ Hài lòng Rất hài
với tình trạng sức hài lòng lòng lưỡng lự lòng
khỏe của mình như
thế nào?

Các câu hỏi dưới đây hỏi về mức độ các hoạt động mà ông/bà đã trải qua
trong thời gian 2 tuần trước đây.
(Đề nghị khoanh tròn vào câu trả lời)
3. Về mặt nào đó, 1 2 3 4 5
ông/bà có thường bị Không bao Hiếm khi Thỉnh Khá Thường
đau nhức/tê/mỏi cơ giờ thoảng thường xuyên
thể không? xuyên

4. Ông/bà có thường 1 2 3 4 5
xuyên phải dùng Không bao Hiếm khi Thỉnh Khá Thường
thuốc (thuốc uống giờ thoảng thường xuyên
đông/tây y; thuốc xuyên
tiêm/bôi) để chữa
bệnh không?

5. Mức độ ông/bà 1 2 3 4 5
hứng thú với cuộc Hoàn toàn Có một chút Vừa phải Thích thú Rất thích
sống như thế nào? không thú

6. Ông/bà cảm thấy cuộc 1 2 3 4 5

sống của mình có ý Hoàn toàn Một chút Vừa phải Nhiều Rất nhiều
nghĩa như thế nào? không

7. Khả năng tâp trung 1 2 3 4 5

khi suy nghĩ/làm Không thể Một chút Bình Tốt Rất tốt
việc của ông bà như tập trung thường
thế nào?

9
 Number
Code

(Đề nghị khoanh tròn vào câu trả lời)

8. Ông/bà có cảm thấy 1 2 3 4 5
cuộc sống của mình Hoàn toàn Có một chút Bình An toàn Rất an toàn
an toàn không (về an không thường
ninh/trật tự)?

9. Ông/bà nhận thấy 1 2 3 4 5

mức độ trong lành Rất không Không trong Bình Trong Rất trong
của môi trường tự trong lành lành thường lành lành
nhiên (nước, không
khí, tiếng ồn, rác
thải…) nơi mình
sống như thế nào?

Các câu hỏi dưới đây hỏi về mức độ hoàn thiện các hoạt động mà ông/bà đã
trải nghiệm hoặc ông/bà đã thực hiện trong thời gian 2 tuần trước đây.
(Đề nghị khoanh tròn vào câu trả lời)
10. Ông/bà có đủ năng 1 2 3 4 5
lượng trong các hoạt Hoàn toàn Có một chút Vừa phải Nhiều Rất nhiều
động hàng ngày không
không?

11. Ông/bà có cảm thấy 1 2 3 4 5

hài lòng về hình Hoàn toàn Có một chút Bình Hài lòng Rất hài
dáng bên ngoài của không thường long
mình không?

12. Ông/bà có đủ tiền 1 2 3 4 5

để chi trả cho các Không có Có đủ tiền Phân vân/ Đủ tiền để Đủ tiền để
nhu cầu sinh hoạt đủ tiền để để chi trả lưỡng lự chi trả chi trả tất
hàng ngày (ăn uống, chi trả chút ít hầu hết cả
điện nước,…) ở mức
độ nào?

13. Những thông tin mà 1 2 3 4 5

ông/bà cần cho cuộc Hoàn toàn Có chút ít Vừa phải Nhiều Rất nhiều
sống hàng ngày sẵn không có
có đến mức độ nào?

14. Ông/bà có cơ hội 1 2 3 4 5

tham gia các hoạt Hoàn toàn Một chút Vừa phải Nhiều Rất nhiều
động vui chơi- giải không
trí ở mức độ nào?

10
 Number
Code

(Đề nghị khoanh vào số)

15. Khả năng đi lại của 1 2 3 4 5
ông/bà như thế nào? Rất kém Kém Bình Tốt Rất tốt
thường

Các câu hỏi dưới đây hỏi về mức độ thoải mái/hài lòng của ông bà về các lĩnh
vực khác nhau của cuộc sống của ông/bà trong thời gian 2 tuần trước đây.
(Đề nghị khoanh vào số)
16. Mức độ hài lòng của 1 2 3 4 5
ông/bà với giấc ngủ Rất không Không hài Phân vân/ Hài lòng Rất hài
của mình như thế hài lòng lòng lưỡng lự lòng
nào?

17. Mức độ hài lòng của 1 2 3 4 5

ông/bà với các hoạt Rất không Không hài Phân vân/ Hài lòng Rất hài
động tự chăm sóc hài lòng lòng lưỡng lự lòng
(tắm rửa, vệ sinh..)
như thế nào?

18. Mức độ hài lòng của 1 2 3 4 5

ông/bà về năng lực Rất không Không hài Phân vân/ Hài lòng Rất hài
làm việc (Kinh hài lòng lòng lưỡng lự lòng
nghiệm, kỹ năng…) của
mình như thế nào?

19. Mức độ hài lòng của 1 2 3 4 5

ông/bà về khả năng Rất không Không hài Phân vân/ Hài lòng Rất hài
làm việc của mình hài lòng lòng lưỡng lự lòng
như thế nào

20. Mức độ hài lòng của 1 2 3 4 5

ông/bà với quan hệ Rất không Không hài Phân vân/ Hài lòng Rất hài
gia đình và xã hội hài lòng lòng lưỡng lự lòng
như thế nào?

21. Ông/bà có hài lòng 1 2 3 4 5

về đời sống tình dục Rất không Không hài Phân vân/ Hài lòng Rất hài
(quan hệ vợ hài lòng lòng lưỡng lự lòng
chồng/thái độ âu
yếm, vuốt ve..) hiện
nay của mình?

11
 Number
Code

(Đề nghị khoanh vào số)

22. Ông/bà hài lòng về 1 2 3 4 5
sự hỗ trợ (kinh tế/ sức Rất không Không hài Phân vân/ Hài lòng Rất hài
lực..) của con cái/ hài lòng lòng lưỡng lự lòng
bạn bè như thế nào?

23. Mức độ hài lòng của 1 2 3 4 5

ông/bà với điều kiện Rất không Không hài Phân vân/ Hài lòng Rất hài
nhà ở của mình như hài lòng lòng lưỡng lự lòng
thế nào?

24. Mức độ hài lòng của 1 2 3 4 5

ông/bà với khả năng Rất không Không hài Phân vân/ Hài lòng Rất hài
tiếp cận các dịch vụ hài lòng lòng lưỡng lự lòng
chăm sóc y tế ở mức
độ nào?

25. Ông/bà hài lòng với 1 2 3 4 5

khả năng di chuyển/ Rất không Không hài Phân vân/ Hài lòng Rất hài
đi lại của mình như hài lòng lòng lưỡng lự lòng
thế nào?

Câu hỏi dưới đây hỏi về mức độ thường xuyên ông/bà cảm thấy hoặc đã phải
trải qua những vấn đề nhất định trong khoảng thời gian 2 tuần gần đây.
(Đề nghị khoanh vào số)
26. Ông/bà có hay cảm 1 2 3 4 5
thấy buồn chán, lo Không bao Hiếm khi Thỉnh Khá Thường
lắng không? giờ thoảng thường xuyên
xuyên

12
 Number
Code

PHẦN D2: ĐÁNH GIÁ VỀ KHẢ NĂNG GẮN KẾT

Dưới đây là những câu hỏi về các sự việc/ sự kiện liên quan đến cuộc sống của ông/bà.
Mỗi câu hỏi có 7 sự lựa chọn, đề nghị ông/bà khoanh vào một (1) trong các số từ 1 đến 7,
phù hợp nhất.

D1. Ông/bà có cảm thấy mình thực sự không quan tâm đến các sự việc/ sự kiện đang diễn
ra quanh mình?

1 2 3 4 5 6 7

Rất hiếm Rất thường xuyên

Không bao giờ

D2. Với ông/bà, điều này đã bao giờ xảy ra trước đây khi “Hành động của một người nào
đó mà ông/bà cho rằng đã rất hiểu họ làm cho ông/bà ngạc nhiên”?

1 2 3 4 5 6 7

Chưa bao giờ xảy ra Thường xuyên diễn ra

D3. Với ông/bà, điều này đã bao giờ xảy ra trước đây khi người mà ông/bà rất kỳ vọng,
làm ông/bà thất vọng

1 2 3 4 5 6 7

Chưa bao giờ xảy ra Thường xuyên diễn ra

D4. Cho đến bây giờ, cuộc sống của ông/bà:

1 2 3 4 5 6 7

Hoàn toàn không có Có mục đích hoặc

mục đích hoặc mong muốn rất rõ ràng
mong muốn rõ ràng

D5. Ông/bà có cảm thấy mình bị phân biệt đối xử không?

1 2 3 4 5 6 7

Rất thường xuyên Rất hiếm hoặc

Không bao giờ

D6. Ông/bà có cảm thấy rằng ông/bà đang gặp phải tình huống hoàn toàn khác biệt và
không biết phải làm gì?

1 2 3 4 5 6 7

Rất thường xuyên Rất hiếm hoặc

Không bao giờ

13
 Number
Code

D7. Đối với ông/bà, việc thực hiện các công việc lặp đi lặp lại hàng ngày là:

1 2 3 4 5 6 7

Thực sự đam mê Thực sự chán

và hài lòng nản và buồn tẻ

D8. Đã bao giờ ông/bà có những cảm giác và suy nghĩ rất lộn xộn?

1 2 3 4 5 6 7

Rất thường xuyên Rất hiếm hoặc

Không bao giờ
D9. Đã bao giờ điều này xảy ra khi “ông/bà mong muốn mình không suy nghĩ và cảm
nhận thấy cái gì cả”

1 2 3 4 5 6 7

Rất thường xuyên Rất hiếm hoặc

Không bao giờ

10. Rất nhiều người, thậm chí cả những người có cá tính mạnh, đôi khi cảm thấy buồn,
chán nản trong một số tình huống nhất định. Từ trước đến giờ đã bao giờ ông/bà cảm
thấy mình gặp hoàn cảnh như vậy chưa?

1 2 3 4 5 6 7

Không bao giờ Rất thường xuyên

11. Khi một việc gì đó xảy ra, đã bao giờ ông/bà cảm thấy rằng:

1 2 3 4 5 6 7

Mình đã đánh giá quá thấp Mình đã nhận định sự việc

hoặc quá cao tầm quan đúng bản chất của nó
trọng của việc đó

12. Đã bao giờ ông/bà cảm thấy công việc mình làm hàng ngày thực sự không có ý nghĩa?

1 2 3 4 5 6 7

Rất thương xuyên Rất hiếm hoặc

Không bao giờ
13. Đã bao giờ ông/bà cảm thấy rằng mình không đảm bảo mọi việc được diễn ra suôn sẻ?

1 2 3 4 5 6 7

Rất thường xuyên Không bao giờ

14
 PARTICIPANT INFORMATION FOR QUT RESEARCH PROJECT
 
Questionnaire  

QUALITY OF LIFE AND CAREGIVING BURDEN AMONG CAREGIVERS OF PEOPLE WITH DEMENTIA LIVING
IN HANOI, BAC NINH AND HAI PHONG, VIETNAM
QUT Ethics Approval Number 1100001158 

RESEARCH TEAM    
Principal Researcher: Truong Quang Trung, MSc, PhD Student, QUT
Associate Researcher:  Prof. Elizabeth Beattie, School of Nursing and Midwifery, QUT (Primary Supervisor)
Ass. Prof. Karen Sullivan, School of Psychology, QUT (Associate Supervisor)
Prof. Nancy Pachana, School of Psychology, UQ (Associate Supervisor)
Dr. Maria O'Reilly, School of Nursing and Midwifery, QUT (Associate Supervisor)

DESCRIPTION 
This project is being undertaken as part of a PhD study for Truong Quang Trung. Only the student and his supervisors
will have access to the data obtained during the project
The purpose of this project is to describe quality of life and perceived caregiving burden among family carers of people
with dementia in Northern Vietnam and to explore the associations between carer characteristics, quality of life and
perceived burden of care
You are invited to participate in this project because you provide care to a person with a memory problem and your
experience is important to this research
PARTICIPATION 
Your participation in this project is entirely voluntary. If you do agree to participate, you can withdraw from the project at any
time without comment or penalty. Any identifiable information already obtained from you will be destroyed. Your decision to
participate, or not participate, will in no way impact upon your current or future relationship with The Vietnamese National
Institute of Gerontology or with your local health station.
Participation will involve completing a 7-part questionnaire that will take approximately 50 to 60 minutes of your time.
Questions will include measuring your current quality of life, caregiving burden and positive aspect of caregiving
If you agree to participate you do have to complete any question(s) that you are uncomfortable answering.
EXPECTED BENEFITS 
It is expected that this project will not directly benefit you, as carers or the person with memory loss who you are caring for. It
will help us to understand your experience of caring and help us to design future interventions program.
To recognise your contribution, should you choose to participate, the research team is offering participants an incentive
of 10 AUD or 210,000 VND
RISKS 
There are no risks beyond normal day-to-day living associated with your participation in this project.
QUT provides for limited free counselling for research participants of QUT projects who may experience discomfort or
distress as a result of their participation in the research. Should you wish to access this service please contact the
Clinic Receptionist of the QUT Psychology Clinic on 3138 0999. Please indicate to the receptionist that you are a
research participant.
PRIVACY AND CONFIDENTIALITY 
All comments and responses are anonymous and will be treated confidentially. The names of individual persons are not
required in any of the responses
CONSENT TO PARTICIPATE 
The return of the completed questionnaire is accepted as an indication of your consent to participate in this project. 
QUESTIONS / FURTHER INFORMATION ABOUT THE PROJECT 
If have any questions or require any further information please contact one of the research team members below. 
TRUONG QUANG TRUNG, MSc Prof. ELIZABETH BEATTIE (supervisor)  
Lecturer – Faculty of Nursing and Midwifery, Hanoi Medical University   Director, Dementia Collaborative Research Centre (DCRC) Carers and 
Director – Nursing Department, Hanoi Medical University Hospital   Consumers, Queensland University of Technology  
Graduate student – School of Nursing and Midwifery, Queensland University  Email: [Link]@[Link]  
of Technology   Telephone: 61‐7‐3138‐3389  
Phone: +84 4 38523798 ext 474 (Vietnam) OR +61 415138805 (Australia) 
Email: [Link]@[Link]  
CONCERNS / COMPLAINTS REGARDING THE CONDUCT OF THE PROJECT 
QUT is committed to research integrity and the ethical conduct of research projects.  However, if you do have any concerns or 
complaints about the ethical conduct of the project you may contact the QUT Research Ethics Unit on [+61 7] 3138 5123 or email 
ethicscontact@[Link]. The QUT Research Ethics Unit is not connected with the research project and can facilitate a resolution 
to your concern in an impartial manner. 
Thank you for helping with this research project.  Please keep this sheet for your information. 
 THÔNG TIN DÀNH CHO NGƯỜI THAM GIA NGHIÊN CỨU
Bộ câu hỏi

CHẤT LƯỢNG CUỘC SỐNG VÀ GÁNH NẶNG CHĂM SÓC CỦA GIA ĐÌNH NGƯỜI BỊ SA SÚT
TRÍ TUỆ Ở HÀ NỘI, BẮC NINH VÀ HẢI PHÒNG, VIỆT NAM
Biên bản thông qua Hội đồng đạo đức của QUT số 1100001158

NHÓM NGHIÊN CỨU

Sinh viên: Thạc sỹ Trương Quang Trung, nghiên cứu sinh, QUT
Giáo viên hướng dẫn GS. Elizabeth Beattie, Trường Đại học Kỹ thuật Queensland
PGS. Karen Sullivan, Trường Đại học Kỹ thuật Queensland
GS. Nancy Pachana, Trường Đại học Queensland
TS. Maria O'Reilly, Trường Đại học Kỹ thuật Queensland
MÔ TẢ NGHIÊN CỨU
Đây là đề tài trong chương trình đào tạo Tiến sỹ của Trương Quang Trung, vì vậy chỉ có học viên và giáo viên
hướng dẫn sẽ có quyền sử dụng các thông tin thu thập trong nghiên cứu
Mục đích của nghiên cứu này là mô tả chất lượng cuộc sống và gánh nặng chăm sóc của gia đình người bị suy
giảm trí nhớ ở Miền Bắc Việt Nam và tìm hiểu mối quan hệ giữa đặc điểm của gia đình, chất lượng cuộc sống và
gánh nặng chăm sóc.
Nghiên cứu này cần sự hỗ trợ của ông/bà bởi vì ông/bà là người chăm sóc người bị suy giảm trí nhớ và những
kinh nghiệm của ông bà là quan trọng cho nghiên cứu này.
THAM GIA
Sự tham gia của ông/bà là hoàn toàn tự nguyện. Trường hợp ông/bà không muốn tiếp tục tham gia, ông/bà vẫn có thể
rút khỏi nghiên cứu này bất cứ lúc nào mà không gặp bất cứ rắc rối gì. Các thông tin về ông/bà sẽ được hủy. Quyết
định của ông/bà tham gia vào nghiên cứu này sẽ không ảnh hưởng đến mối quan hệ hiện tại và tương lai với Viện Lão
khoa Việt Nam hoặc với trạm y tế phường.
Tham gia vào nghiên cứu này, ông/bà sẽ trả lời bộ câu hỏi có 7 phần với khoảng 85 câu. Thời gian hoàn thành bộ câu
hỏi khoảng 50 - 60 phút liên quan đến chất lượng cuộc sống và vai trò chăm sóc của ông bà
Nếu ông/bà đồng ý tham gia vào nghiên cứu, ông/à được không cần hoàn thiện các câu hỏi mà mình cảm thấy không
thoải mái để trả lời.
KẾT QUẢ MONG ĐỢI
Nghiên cứu này được mong đợi sẽ không mang lại những lợi ích trực tiếp cho ông/bà, người chăm sóc hoặc với người bị
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thời gian tới
Nhằm ghi nhận sự đóng góp của ông/bà tham gia vào trả lời bộ câu hỏi ông bà sẽ nhận được mức bồi dưỡng
tương đương với 10 AUD hoặc khoảng 210.000 VND.
RỦI RO
Sẽ không có rủi ro nào xảy ra khi ông/bà tham gia vào nghiên cứu này. Trường hợp ông bà cảm thấy không thoải mái
hoặc khó chịu khi tham gia nghiên cứu này, một số dịch vụ tư vấn hỗ trợ sẽ được giới thiệu để ông bà có thể sử dụng.
Các dịch vụ tư vấn có thể:
- TS. Nguyễn Trọng Hưng, trưởng khoa Thần kinh, Viện Lão Khoa Vietnam. VP: Số 1 Phương Mai, Đống Đa,
Hà Nội, Việt Nam. Tel: (+84) 4.35764558 (máy lẻ 201)
- Khoa Khám bệnh, Viện Lão khoa Vietnam. Số 1 Phương Mai, Đống Đa, Hà Nội, Việt Nam.
- Khoa Khám bệnh và Cấp cứu, Bệnh viện Đại học Y Hà Nội. Số 1 Tôn Thất Tùng, Đống Đa, Hà Nội, Việt Nam.
ĐT: (+84) 4.38523798 (máy lẻ 483)
BẢO MẬT
Tất cả thông tin thu thập được từ nghiên cứu này sẽ giấu tên và được bảo mật. Người tham gia nghiên cứu sẽ
không phải nói tên của mình
ĐỒNG Ý THAM GIA NGHIÊN CỨU
Nếu ông/bà đồng ý tham gia vào nghiên cứu này, xin vui lòng ký tên vào Phiếu Đồng Ý Tham Gia Nghiên Cứu (được
đính kèm).
THÔNG TIN CHI TIẾT LIÊN QUAN ĐẾN NGHIÊN CỨU
Mọi thắc mắc liên quan đến nghiên cứu này xin liên hệ với Nghiên cứu viên theo địa chỉ ở dưới đây
 Thạc sỹ Trương Quang Trung GS. ELIZABETH BEATTIE (Hướng dẫn)
Giảng viên – Khoa Điều dưỡng và Hộ sinh, Trường Đại học Y Hà Nội Giám đốc, Trung tâm hợp tác nghiên cứu Sa sút trí tuệ (DCRC)
Trưởng phòng Điều dưỡng – Bệnh viện Đại học Y Hà Nội Học viên Sau Người chăm sóc và người sử dung, Trường Đại học Kỹ thuật
đại học – Trường Điều dưỡng và Hộ sinh, Trường Đại học Kỹ thuật Queensland
Queensland
Email: [Link]@[Link]
Điện thoại: +84 4 38523798 máy lẻ 474 (Việt Nam) Hoặc
+61 415138805 (Australia)
Email: [Link]@[Link]
THẮC MẮC/ KHIẾU NẠI LIÊN QUAN ĐẾN NGHIÊN CỨU
QUT ủy quyền cho Nghiên cứu sinh thực hiện toàn bộ đề tài và chịu trách nhiệm về mặt đạo đức. Tuy nhiên, nếu anh/
chị có bất cứ thắc mắc hay khiếu nại gì liên quan đến vấn đề đạo đức nghiên cứu của nghiên cứu này, anh chị có thể
liên hệ với Hội Đồng Đạo Đức Nghiên Cứu của QUT theo số máy +61 7 3138 5123 hoặc viết thư điện tử theo địa chỉ
ethicscontact@[Link]. Hội Đồng Đạo Đức làm việc độc lập với nghiên cứu vào sẽ giải đáp các thắc mắc của anh/
chị một cách công bằng nhất.
Xin trân trọng cảm ơn. Xin ông/bà hãy giữ lấy phiếu này làm thông tin.
 HANOI MEDICAL UNIVERSITY

FACULTY OF NURSING AND MIDWIFERY

- - - o0o - - -

QUESTIONNAIRE
THE QUALITY OF LIFE AND BURDEN OF CARE AMONG CAREGIVERS OF PEOPLE
WITH DEMENTIA IN HANOI, BAC NINH AND HAI PHONG, VIETNAM

TRUONG QUANG TRUNG, MSc

Lecturer – Faculty of Nursing and Midwifery, Hanoi Medical University
Director – Nursing Department, Hanoi Medical University Hospital
Graduate student – School of Nursing and Midwifery, Queensland University of Technology
Phone: +84 4 38523798 ext 474 (Vietnam) OR +61 415138805 (Australia)
Email: [Link]@[Link]

August 2012
 2
Please complete all following questions. Thank you very much for help in answering this questionnaire. All your answers will be kept
strictly confidential.
About your relative that you are caring for

1. Gender : Male(1) Female(0) 2. Year of birth:________________

3. Education
(1) Illiterate (4) High school 4. Retired person: Yes (1) No (2)

(2) Primary school (5) College

(3) Secondary (6) Bachelor and above 5. Health insurance : Yes(1) No (2)

6. Occupation (previous)
(1) Professional teacher, scientist, architect, engineer, (5) Armed force
attorney, medical worker, account, government staff  per-
forms personnel & so on
(2) Business-man/woman (6) House-work
(3) Worker (7) Other
(4) Farmer/ fishman/woman What did he/she do:__________
7. Relationship to with you is
Spouse (1) Parents (2) Parents in law(3) Relative (4) Other (5)________

8. Appear sign of disease from 20___

9. Diagnosis of disease from 20____

About you

10. DOB (dd/mm/yyyy) ___/___/19___ Real age:______ 11. Married status

≤18 yrs (1) 40 – 49 yrs(4) (1) Single (3) Divorce/ Widow/ Separated
19 – 29 yrs (2) 50 – 59 yrs (5) (2) Married (4) Cohabiting
30 – 39 yrs (3) ≥ 60 yrs (6)
12. Gender: M(1) F(0)
13. Education
14. Religious
(1) Illiterate (4) High school
(1) Đạo Phật (4) Không
(2) Primary school (5) College
(2) Đạo Cơ đốc (5) Khác
(3) Secondary (6) Bachelor and above
(3) Đạo Thiên chúa ___________
15. Nghề nghiệp (trước đây)
16. Employment (1) Permance
(1) Professional teacher, scientist, architect, engineer, (5) Armed force
attorney, medical worker, account, government staff  per- (2 temporary
forms personnel & so on
(2) Business-man/woman (6) House-work (3) Unemploy
(3) Worker (7) Other
(4) Farmer/ fishman/woman What did he/she do:__________

17. How long does it take you from your home to your office/ factory ? (If question 16 is 3 skip this answer)
(1) < 10 minutes (2) 10 – 30 minutes (3) > 30 minutes

18. Are you currently ill ? Yes (1) No (2)

If something is wrong with your health what do you think it is? ? _____________________
19. Are you suffering from any chronic disease ? Yes (1) No (2)
If yes _______________________________________________________________________________
 3

20. How many hours per week do you provide caregiving for your relative ? ____________
< 5 hours ( 1 hours/day and 5 days/week ) 5 – 10 hours ( 2 hours/day and 5 days/week )
10 – 20 hours ( 4 hours/day and 5 days/week ) 20 – 30 hours( 6 hours/day and 5 days/week )
30 – 40 hours( 8 hours/day and 5 days/week ) 40 – 50 hours( 10 hours/day and 5 days/week )
50 – 60 hours ( 12 hours/day and 5 days/week ) > 60 hours

21. How many people live with you in your family: ____________
22. Average income of your family (including the income from your spouse and other member living with you)

< 5 millions/month (1) 5—10 millions/month (2)

10—15 millions/month (3) 15—20 millions/month (4)
20—25 millions/month (5) 25—30 millions/month (6)
> 30 millions/month (7)

The Barthel Index

The index should be used as a record of what a patient does, not as a record of what a patient could do. Usually the patient's perfor-
mance over the preceding 24-48 hours is importantScore of each domain is based on the current activities that patient can perform
No Activity Score No Activity Score
FEEDING TOILET USE
0 = unable 0 = dependent
1 5 = needs help cutting, spreading butter,
etc., or requires modified diet 7 5 = needs some help, but can do some-
10 = independent thing alone
BATHING 10 = independent (on and off, dressing,
2 0 = dependent wiping)
5 = independent (or in shower) TRANSFERS (BED TO CHAIR AND BACK)
GROOMING
0 = needs to help with personal care 0 = unable, no sitting balance
3
5 = independent face/hair/teeth/shaving
8 5 = major help (one or two people, physi-
(implements provided)
DRESSING cal), can sit
10 = minor help (verbal or physical)
0 = dependent
15 = independent
4 5 = needs help but can do about half unaid-
MOBILITY (ON LEVEL SURFACES)
ed
10 = independent (including buttons, zips, 0 = immobile or < 50 yards
laces, etc.)
5 = wheelchair independent, including
BOWELS
corners, > 50 yards
9
0 = incontinent (or needs to be given ene- 10 = walks with help of one person
mas) (verbal or physical) > 50 yards
5
5 = occasional accident 15 = independent (but may use any aid;
for example, stick) > 50 yards
10 = continent
BLADDER STAIRS
0 = dependent 0 = unable
5 = needs some help, but can do something 10 5 = needs help (verbal, physical, carrying
6 alone aid)
10 = independent (on and off, dressing, wip- 10 = independent
ing) Total (0 – 100)
 4

KINGSTON STANDARDIZED BEHAVIOURAL ASSESSMENT

Please check all of the following behaviours that have occurred in the last month or are presently occurring, and that are
a change from your spouse/relative/client’s earlier behaviour .

A Daily activities C Emotional Behaviour

No longer takes part in favourite pastimes (or
1 23 Shows little or no emotion
greatly reduced).

Reduced personal hygiene. (E.g. Would not take a 24 Mood changes with no apparent reason
2 bath unless told to do so, or wears the same clothes for days 25 Expresses inappropriate emotions, either
unless made to change).
type or intensity
26 Makes uncharacteristically pessimistic
3 If left on his/her own, doesn't eat properly
statements.
4 Unsafe in daily activities, if left unsupervised < Total Emotional Behaviour
No longer uses some common objects
5
properly. (e.g. telephone)
6 Unable to handle personal finances D Aggressive Behaviour
7 Is unable to perform usual household tasks 27 Verbally abusive at times
Uncharacteristically excitable, easy to up-
8 Gets confused in places other than home 28
set; reacts catastrophically
Overly dependent, wants more guidance 29 Attempts to hit/strike out at others
9
than usual
Trouble appreciating subtleties in conversa- < Total Aggressive Behaviour
10
tions (e.g. recognizing humour).
11 Difficulty judging the passing of time
12 Wanders aimlessly E Misperceptions/Misidentifications
30 Claims an object/possession looks similar
13 Hides things
to, but is not the real one.
31 Claims a family member looks similar but is
14 Hoards objects
not the true one.
32 Thinks present dwelling is not their place of
15 Fails to recognize family or friends.
living.
Incontinence of urine/faeces in clothes in 33 Thinks people are present who aren't.
16
daytime
17 Voids in non-toilet areas < Total Misperception Behaviour

< Total Daily Activities

F Paranoid Behaviour
B Attention/Concentration/Memory 34 Suspicious of family and friends

18 Can't concentrate, pay attention for long 35 Suspicious about money issues
19 Misplaces things more than usual. 36 Accuses others of stealing his or her things
Has difficulty organizing his/her time or daily
20 37 Accuses spouse of infidelity
activities
Forgets activities, conversations of only a Expresses suspicion around taking medica-
21 38
short time before tion.
22 Forgets important everyday information < Total Paranoid Behaviour

< Total Attention/Concentration/Memory

 5

G Judgement/Insight J Sleep/Activity/Sundowning
39 Shows poor judgement in social situations 52 Falls asleep at uncharacteristic times
Gets up and wanders or awakens frequent-
53
40 Shows poor judgement about driving ly at night, more than usual
54 Sleeps more
Poor choices in dressing. (e.g. wears clothes
Behaviour more agitated or impaired in late
42 that are inappropriate for season or temperature, 55
afternoon
wears the same clothes for days).

43 Makes inappropriate sexual advances

44 Shows less self control than usual < Total Sleep/Activity/Sundowning

45 Unable to identify personal safety risks.

< Total Judgement/Insight K Motor/Spatial Problems

Poor coordination seen in limb/finger
56
movements
H Perseveration 57 Slowness of movement

46 Repeats same actions over and over 58 Unsteadiness when walking

Has trouble dressing, especially with but-
47 Repeats same words or phrases 59
tons or shoelaces
48 Repeatedly shouts or calls out 60 Difficulty judging object sizes or how near

< Total Perseveration < Total Motor Spatial Problems

I Motor Restlessness L Language Difficulties

61 Reads far less frequently than previously
49 Desire to pace or walk almost constantly
62 Substitutes some words for others
50 Can't sit still, restless, fidgety.
63 Does not watch or follow television
51 Tries doors, windows.
< Total Motor Restlessness 64 Does not speak unless spoken to. (e.g. Does

65 Often cannot find the right word

66 Trouble pronouncing words.

Does not understand simple commands,
67
Total score explanations
68 Does not produce meaningful speech

< Total Language Difficulties

 6

BURDEN INTERVIEW
The following is a list of statements, which reflect how people sometimes feel when taking care of another person. After each
statement, indicate how often you feel that way; never, rarely, sometimes, quite frequently, or nearly always. There is no right or
wrong answers

C1. Do you feel that your relative asks for more help than he/she needs
0 1 2 3 4
Never Rarely Sometimes Quite Frequently Nearly Always

C2. Do you feel that because of the time you spend with your relative that you don’t have enough time for
yourself?
0 1 2 3 4
Never Rarely Sometimes Quite Frequently Nearly Always

C3. Do you feel stressed between caring for your relative and trying to meet other responsibilities for your
family or work?
0 1 2 3 4
Never Rarely Sometimes Quite Frequently Nearly Always

C4. Do you feel embarrassed over your relative’s behavior?

0 1 2 3 4
Never Rarely Sometimes Quite Frequently Nearly Always

C5. Do you feel angry when you are around your relative?
0 1 2 3 4
Never Rarely Sometimes Quite Frequently Nearly Always

C6. Do you feel that your relative currently affects your relationship with other family members or friends in a negative way?

0 1 2 3 4
Never Rarely Sometimes Quite Frequently Nearly Always

C7. Are you afraid what the future holds for your relative?
0 1 2 3 4
Never Rarely Sometimes Quite Frequently Nearly Always

C8. Do you feel your relative is dependent upon you?

0 1 2 3 4
Never Rarely Sometimes Quite Frequently Nearly Always

C9. Do you feel strained when you are around your relative?
0 1 2 3 4
Never Rarely Sometimes Quite Frequently Nearly Always

C10. Do you feel your health has suffered because of your involvement with your relative?

0 1 2 3 4
Never Rarely Sometimes Quite Frequently Nearly Always
 7

C11. Do you feel that you don’t have as much privacy as you would like, because of your relative?
0 1 2 3 4
Never Rarely Sometimes Quite Frequently Nearly Always

C12. Do you feel that your social life has suffered because you are caring for your relative?
0 1 2 3 4
Never Rarely Sometimes Quite Frequently Nearly Always

C13. Do you feel uncomfortable about having friends over, because of your relative?
0 1 2 3 4
Never Rarely Sometimes Quite Frequently Nearly Always

C14. Do you feel that your relative seems to expect you to take care of him/her, as if you were the only one
he/she could depend on?
0 1 2 3 4
Never Rarely Sometimes Quite Frequently Nearly Always

C15. Do you feel that you don’t have enough money to care for your relative, in addition to the rest of your
expenses?
0 1 2 3 4
Never Rarely Sometimes Quite Frequently Nearly Always

C16. Do you feel that you will be unable to take care of your relative much longer?
0 1 2 3 4
Never Rarely Sometimes Quite Frequently Nearly Always

C17. Do you feel you have lost control of your life since your relative’s illness?
0 1 2 3 4
Never Rarely Sometimes Quite Frequently Nearly Always

C18. Do you wish you could just leave the care of your relative to someone else?
0 1 2 3 4
Never Rarely Sometimes Quite Frequently Nearly Always

C19. Do you feel uncertain about what to do about your relative?

0 1 2 3 4
Never Rarely Sometimes Quite Frequently Nearly Always

C20. Do you feel you should be doing more for your relative?
0 1 2 3 4
Never Rarely Sometimes Quite Frequently Nearly Always

C21. Do you feel you could do a better job in caring for your relative?
0 1 2 3 4
Never Rarely Sometimes Quite Frequently Nearly Always

C22. Overall, how burdened do you feel in caring for your relative?
0 1 2 3 4

Not at all A little Moderately Khá nặng nề Extremely

 8

QUALITY OF LIFE ASSESSMENT WHOQOL-BREF

Please read each question, assess your feelings, and circle the number on the scale that gives the best answer for you for each question

(Please circle the number)

1 2 3 4 5
1. How would you rate your quality of Very poor Poor Neither poor nor Good Very Good
life? good
1 2 3 4 5
2. How satisfied are you with your Very dissatisfied Dissatisfied Neither satisfied Satisfied Very satisfied
health? nor dissatisfied

The following questions ask about how much you have experienced certain things in the last two weeks

(Please circle the number)

3. To what extent do you feel that phys- 1 2 3 4 5

ical pain prevents you from doing Not at all A little A moderate Very much An extreme
amount amount
what you need to do?
1 2 3 4 5
4. How much do you need any medical Not at all A little A moderate Very much An extreme
treatment to function in your daily life? amount amount
1 2 3 4 5
5. How much do you enjoy life? Not at all A little A moderate Very much An extreme
amount amount
1 2 3 4 5
6. To what extent do you feel your life
Not at all A little A moderate Very much An extreme
to be meaningful? amount amount
1 2 3 4 5
7. How well are you able to concen- Not at all A little A moderate Very much Extremely
trate? amount
1 2 3 4 5
8. How safe do you feel in your daily
Not at all A little A moderate Very much Extremely
life? amount
1 2 3 4 5
9. How healthy is your physical envi- Not at all A little A moderate Very much Extremely
ronment? amount

The following questions ask about how completely you experience or were able to do certain

(Please circle the number)

1 2 3 4 5
10. Do you have enough energy for Not at all A little Moderately Mostly Completely
everyday life?

1 2 3 4 5
11. Are you able to accept your bodily Not at all A little Moderately Mostly Completely
appearance?

1 2 3 4 5
12. Have you enough money to meet Not at all A little Moderately Mostly Completely
your needs
 9

(Đề nghị khoanh tròn vào câu trả lời)

1 2 3 4 5
13. How available to you is the infor-
Not at all A little Moderately Mostly Completely
mation that you need in your day-to-
day life?
1 2 3 4 5
14. To what extent do you have the
Not at all A little Moderately Mostly Completely
opportunity for leisure activities?
1 2 3 4 5
15. How well are you able to get
Not at all A little Moderately Mostly Completely
around?

The following questions ask you to say how good or satisfied you have felt about various aspects of your life over the
last two weeks

(Please circle the number)

1 2 3 4 5
16. How satisfied are you with your Very dissatisfied Dissatisfied Neither satisfied Satisfied Very satisfied
sleep? nor dissatisfied

17. How satisfied are you with your abil- 1 2 3 4 5

ity to perform your daily living activ- Very dissatisfied Dissatisfied Neither satisfied Satisfied Very satisfied
ities? nor dissatisfied

1 2 3 4 5
18. How satisfied are you with your ca- Very dissatisfied Dissatisfied Neither satisfied Satisfied Very satisfied
pacity for work? nor dissatisfied

1 2 3 4 5
19. How satisfied are you with your abil- Very dissatisfied Dissatisfied Neither satisfied Satisfied Very satisfied
ities? nor dissatisfied

1 2 3 4 5
20. How satisfied are you with your per- Very dissatisfied Dissatisfied Neither satisfied Satisfied Very satisfied
sonal relationships? nor dissatisfied

1 2 3 4 5
21. How satisfied are you with your sex Very dissatisfied Dissatisfied Neither satisfied Satisfied Very satisfied
life? nor dissatisfied

1 2 3 4 5
22. How satisfied are you with the sup- Very dissatisfied Dissatisfied Neither satisfied Satisfied Very satisfied
port you get from your friends? nor dissatisfied
1 2 3 4 5
23. How satisfied are you with the con- Very dissatisfied Dissatisfied Neither satisfied Satisfied Very satisfied
ditions of your living place? nor dissatisfied
1 2 3 4 5
24. How satisfied are you with your ac- Very dissatisfied Dissatisfied Neither satisfied Satisfied Very satisfied
cess to health services? nor dissatisfied

1 2 3 4 5
25. How satisfied are you with your Very dissatisfied Dissatisfied Neither satisfied Satisfied Very satisfied
mode of transportation? nor dissatisfied

1 2 3 4 5
26. How often do you have negative
feelings, such as blue mood, des- Never Seldom Quite Very Always
pair, anxiety, depression? often often
 10

THE 13-ITEM SENSE OF COHERENCE QUESTIONNAIRE

Here is a series of questions relating to various aspects of your lives . Each question has seven possible answers ,
Please mark the number, which expresses your answer, with number 1 and 7 being the extreme answers

D1. Do you have feeling that you don’t really care about what goes on around you?
1 2 3 4 5 6 7

very seldom
or never Very often
D2. Has it happened in the past that you were surprised by the behavior of people whom you thought you knew well?

1 2 3 4 5 6 7

never happened always happened

D3. Has it happened that people whom you counted on disappointed you?
1 2 3 4 5 6 7

never happened always happened

D4. Until now your life has had:
1 2 3 4 5 6 7

no clear goals or purpose at all very clear goals and purpose

D5. Do you have the feeling that you’re being treated unfairly?
1 2 3 4 5 6 7

very often very seldom or never

D6. Do you have the feeling that you are in an unfamiliar situation and don’t know what to do?
1 2 3 4 5 6 7

very often very seldom or never

D7. Doing the thing you do every day is:

1 2 3 4 5 6 7

a source of deep pleasure and satisfaction a source of pain and boredom

D8. Do you have very mixed-up feelings and ideas?

1 2 3 4 5 6 7

very often very seldom or never

D9. Does it happen that you have feelings inside you would rather not feel?
1 2 3 4 5 6 7

Rất thường
very often xuyên Rất hiếmvery
hoặc khôngor
seldom bao giờ
never

D10. Many people – even those with a strong character – sometimes feel like sad sacks (losers) in certain situations. How often
have you felt this way in the past?
1 2 3 4 5 6 7

never very often

 11

D11. When something happened, have you generally found that:

1 2 3 4 5 6 7

you overestimated or underesti- you saw things in the right propor-

mated its importance tion
D12. How often do you have the feeling that there’s little meaning in the things you do in your daily life?
1 2 3 4 5 6 7

very often very seldom or never

D13. How often do you have feelings that you’re not sure you can keep under control?
1 2 3 4 5 6 7

very often very seldom

POSITIVE ASPECTS OF CAREGIVING

Some caregivers say that, despite all the difficulties involved in giving care to a family member with memory or health
problems, good things have come out of their caregiving experience too. I’m going to go over a few of the good things
reported by some caregivers. I would like you to tell me how much you agree or disagree with these statements. Please
refer to the responses listed on this card

Providing help to care-recipient (CR) has Disagree a lot Disagree a Neither Agree a Agree a lot
little Agree nor little
Disagree

1. Made me feel more useful 1 2 3 4 5

2. Made me feel good about myself 1 2 3 4 5

3. Made me feel needed 1 2 3 4 5

4. Made me feel appreciated 1 2 3 4 5

5. Made me feel important 1 2 3 4 5

6. Made me feel strong and confident 1 2 3 4 5

7. Enabled me to appreciate life more 1 2 3 4 5

8. Enabled me to develop a more positive atti- 1 2 3 4 5

tude toward life
9. Strengthened my relationships with others 1 2 3 4 5
 12

mildly dis-
disagree
disagree

strongly
strongly

agree

agree

agree
agree

mildly
FILIAL PIETY

1. Sons and daughters may protest against being unreasona-

bly scolded by their parents. 1 2 3 4 5 6
2. There is no place under the sun for both oneself and the
enemy of one's father. 1 2 3 4 5 6
3. If there is a reason for doing so, one may rely on an old peo-
ple's home to provide for one's aged parents. 1 2 3 4 5 6
4. Any sacrifice is worthwhile for the sake of filial piety.
1 2 3 4 5 6
5. Sons and daughters should not go to faraway places while
their parents are still living. 1 2 3 4 5 6
6. In choosing a spouse, sons and daughters need not follow
"the parents' command." 1 2 3 4 5 6
7. The main reason for sons and daughters not to do danger-
ous things is to avoid getting their parents worried. 1 2 3 4 5 6
8. Parents should not interfere with their children's freedom to
choose a vocation. 1 2 3 4 5 6
9. The great debt that you have to repay your parents is as
boundless as the sky. 1 2 3 4 5 6
10. "Rearing sons to provide for oneself in one's old age"
should no longer be the main purpose of raising children. 1 2 3 4 5 6
11. No matter how their parents conduct themselves, sons and
daughters must respect them. 1 2 3 4 5 6
12. After the father has passed away, sons and daughters
must conduct themselves according to the principles and
1 2 3 4 5 6
attitudes he followed while he was still living.
13. If there is a quarrel between one's wife and one's mother,
the husband should advise his wife to listen to his mother. 1 2 3 4 5 6

14. After their parents have passed away, sons and daughters
do not necessarily have to finish the business left unfin- 1 2 3 4 5 6
ished by their parents.
15. Spreading one's fame to glorify one's parents" should not
be the most important reason for getting ahead. 1 2 3 4 5 6
16. To worship their ancestors regularly on the proper occa-
sions is the primary duty of sons and daughters. 1 2 3 4 5 6
17. To continue the family line is not the primary purpose of
marriage. 1 2 3 4 5 6
18. Sons and daughters do not necessarily have to seek pa-
rental advice and may make their own decisions. 1 2 3 4 5 6
19. Sons and daughters do not necessarily have to respect the
people respected and loved by their parents. 1 2 3 4 5 6
20. After children have grown up, all the money they earn
through their own labor belongs to themselves, even
1 2 3 4 5 6
though their parents are still living.

21. "There is no crime worse than being unfilial"

1 2 3 4 5 6
22. As a son or daughter, one must obey one's parents no
matter what 1 2 3 4 5 6
 TRƯỜNG ĐẠI HỌC Y HÀ NỘI

KHOA ĐIỀU DƯỠNG—HỘ SINH

- - - o0o - - -

PHIẾU ĐIỀU TRA

CHẤT LƯỢNG CUỘC SỐNG VÀ GÁNH NẶNG CHĂM SÓC CỦA GIA ĐÌNH NGƯỜI BỆNH
SA SÚT TRÍ TUỆ

Nghiên cứu viên: Thạc sỹ Trương Quang Trung

Giảng viên – Khoa Điều dưỡng và Hộ sinh, Trường Đại học Y Hà Nội
Trưởng phòng Điều dưỡng – Bệnh viện Đại học Y Hà Nội
Học viên Sau đại học – Trường Điều dưỡng và Hộ sinh, Đại học Kỹ thuật Queensland
Điện thoại: 0983609905 (Việt Nam) Hoặc +61 415138805 (Australia)
Email: [Link]@[Link]

Tháng 8 năm 2012

 2

Chân thành cảm ơn ông/bà tham gia trả lời câu hỏi. Toàn bộ các câu trả lời của ông/bà sẽ được giữ kín.

Về người thân mà ông/ bà đang chăm sóc

1. Giới tính: Nam (1) Nữ (0) 2. Sinh năm:________________

3. Trình độ học vấn

(1) Mù chữ (4) Phổ thông trung học 4. Là cán bộ hưu trí: Đúng (1) Không đúng (2)

(2) Tiểu học (5) Trung cấp - Cao đẳng

(3) Phổ thông cơ sở (6) Đại học và trên đại học 5. Bảo hiểm y tế : Có (1) Không (2)

6. Nghề nghiệp (trước đây)

(1) Có tay nghề (Giáo viên, nhà khoa hoc, kiến (5) Quân đội, Công an

(2) Buôn bán, doanh nhân (6) Nội trợ

(3) Công nhân (7) Khác
(4) Nông dân - Thuyền chài Ông/bà làm nghề gì:__________

7. Người thân ông/bà đang chăm sóc là

Vợ/chồng (1) Bố/mẹ đẻ (2) Bố/mẹ chồng(3) Họ hàng (4) Khác (5)_________

8. Người thân của ông bà có biểu hiện của bệnh từ năm 20___

9. Người thân của ông bà được chẩn đoán bệnh từ năm 20____

Hỏi về ông/bà:

10. Ngày sinh (ngày/ tháng/ năm) ___/___/19___ Tuổi thực:______ 11. Tình trạng hôn nhân
≤18 tuổi (1) 40 – 49 tuổi (4) (1) Độc thân (3) Ly dị/ Ly thân/ chết
19 – 29 tuổi (2) 50 – 59 tuổi (5) (2) Kết hôn (4) Sống chung
30 – 39 tuổi (3) ≥ 60 tuổi (6)
12. Giới tính: Nam (1) Nữ (0)
13. Trình độ học vấn
14. Tôn giáo
(1) Mù chữ (4) Phổ thông trung học
(1) Đạo Phật (4) Không
(2) Tiểu học (5) Trung cấp - Cao đẳng
(2) Đạo Cơ đốc (5) Khác
(3) Phổ thông cơ sở (6) Đại học và trên đại học
(3) Đạo Thiên chúa ___________

15. Nghề nghiệp (trước đây) 16. Công việc (1) Ổn định

(1) Có tay nghề (Giáo viên, nhà khoa hoc, kiến (5) Quân đội, Công an (2 Tạm thời

(3) Thất nghiệp

(2) Buôn bán, doanh nhân (6) Nội trợ
(3) Công nhân (7) Khác
(4) Nông dân - Thuyền chài Ông/bà làm nghề gì:_________
17. Ông/bà đi từ nhà đến cơ quan mất bao lâu? (Nếu câu 16 trả lời là 3 bỏ qua câu này)
(1) Dưới 10 phút (2) 10 – 30 phút (3) Trên 30 phút

18. Hiện tại ông/bà có mắc bệnh gì không? Có (1) Không (2)
Nếu ông bà có nghĩ rằng mình có vấn đề gì về sức khỏe không? Đó là vấn đề/ bệnh tật gì? _____________________
19. Ông/bà có mắc bệnh mạn tính không? Có (1) Không (2)
Nếu có, là bệnh gì? _______________________________________________________________________________
 3

20. Một tuần, Ông bà chăm sóc người thân bao nhiêu giờ? ____________
< 5 tiếng/tuần (khoảng 1 giờ/ngày và 5 ngày/tuần) 5 – 10 tiếng/tuần(khoảng 2 giờ/ngày và 5 ngày/tuần)
10 – 20 tiếng/tuần (khoảng 4 giờ/ngày và 5 ngày/tuần) 20 – 30 tiếng/tuần (khoảng 6 giờ/ngày và 5 ngày/tuần)
30 – 40 tiếng/tuần (khoảng 8 giờ/ngày và 5 ngày/tuần) 40 – 50 tiếng/tuần (khoảng 10 giờ/ngày và 5 ngày/tuần)
50 – 60 tiếng/tuần (khoảng 12 giờ/ngày và 5 ngày/tuần) > 60 tiếng/tuần

21. Hiện tại đang có bao nhiêu người sống cùng với ông/bà: ____________
22. Thu nhập trung bình hàng tháng của cả gia đình ông bà là (bao gồm của cả vợ chồng ông bà cùng các thành viên trong gia đình)

Dưới 5 triệu đồng/tháng (1) Từ 5 triệu đồng – 10 triệu đồng (2)

Từ 10 triệu đồng – 15 triệu đồng (3) Từ 15 triệu đồng – 20 triệu đồng (4)
Từ 20 triệu đồng – 25 triệu đồng (5) Từ 25 triệu đồng – 30 triệu đồng (6)
Trên 30 triệu đồng (7)

ĐÁNH GIÁ HOẠT ĐỘNG CÁ NHÂN CỦA NGƯỜI BỆNH

Đề nghị ông/bà cho điểm theo các hoạt động tương ứng nhằm xác định mức độ phụ thuộc của người thân của ông/bà trong hoạt
động chăm só[Link]ững hoạt động này được xác định trong khoảng thời gian 5-7 ngày trước đây.

STT Hoạt động Điểm đạt STT Hoạt động Điểm đạt

Ăn uống Sử dụng nhà vệ sinh

0 = Không thể tự ăn được 0 = Hoàn toàn phụ thuộc- đại tiểu tiện tại
1 5 = Cần sự hỗ trợ trong việc ăn uống (cắt nhỏ giường
hoặc cho thức ăn vào thìa..) 7 5 = Cần sự hỗ trợ, nhưng đôi khi có thể
10 = Tự ăn mà không cần hỗ trợ thực hiện được một mình

Tắm 10 = Hoàn toàn độc lập (ra vào nhà vệ

0= Không thể tự tắm, phải có người hỗ trợ sinh, cởi quần, kéo khóa..)
2
Di chuyển (Giữa giường, ghế, xe đẩy và
5 = Tự tắm được, không cần người hỗ trợ
ngược lại)
Chải đầu – Đánh răng 0 = Không thể thực hiện được, không thể
tự ngồi được
0 = Không tự thực hiện được, cần sự hỗ trợ
3 trong chăm sóc bản than 8 5 = Cần nhiều sự trợ giúp (1 – 2 người
nâng đỡ), có thể ngồi được
5 = Tự thực hiện được việc chải đầu, cạo râu,
đánh răng.. 10 = Cần ít sự hỗ trợ
Mặc và thay quần áo 15 = Hoàn toàn độc lập, chủ động

0 = Không tự thực hiện được Đi lại

0 = Không thể đi được hoặc chỉ đi được
4 5 = Cần sự hỗ trợ vì chỉ mặc được một nửa
trong phạm vị < 50 mét
nếu không có sự trợ giúp
5 = Sử dụng xe lăn độc lập, di chuyển
10 = Tự thực hiện được việc mặc và thay trong phạm vi > 50 mét
quần áo (cài khuy, kéo khóa, buộc/ thắt dây..) 9
10 = Đi bộ với sự hỗ trợ của 1 người (lời
Đại tiện nói hoặc hành động) với phạm vi > 50 mét
0 = Không tự chủ (hoặc phải hỗ trợ để thụt 15 = Hoàn toàn độc lập, chủ động (nhưng
tháo phân) có thể sử dụng phương tiện hỗ trợ như
5
5 = Có khi tự chủ, có khi không tự chủ gậy..) với phạm vi > 50 mét
Lên xuống cầu thang
10 = Hoàn toàn chủ động – tự chủ
0 = Không thể thực hiện được
Tiểu tiện
10 5 = Cần sự hỗ trợ (lời nói, hành động, với
0 = Không tự chủ (hoặc phải đặt thông tiểu các phương tiện trợ giúp)
6 và không thể tự kiểm soát)
10 = Hoàn toàn chủ động
5 = Có khi tự chủ, có khi không tự chủ
Tổng cộng (0 – 100)
10 = Hoàn toàn chủ động – tự chủ
 4

ĐÁNH GIÁ HOẠT ĐỘNG HÀNG NGÀY CỦA NGƯỜI BỆNH

Đề nghị đánh dấu X vào các bảng hỏi về các hoạt động/ hành vi mà người thân của ông/bà thực hiện trong vòng 1 tháng gần đây.

A Hoạt động hàng ngày C Hoạt động biểu cảm

Không hứng thú với các hoạt động yêu thích
1 23 Ít hoặc không biểu hiện tình cảm/tâm tính
trước đây (hoặc giảm hứng thú)
Vệ sinh cá nhân kém. (VD như không tắm cho 24 Thay đổi tâm trạng đột ngột không lý do
2 đến khi yêu cầu hoặc mặc nguyên bộ quần báo 25 Thể hiện tình cảm không phù hợp
bẩn và không chịu thay).
Nếu để người đó một mình, họ sẽ không ăn uống 26 Có những nhận xét bi quan khác thường.
3
đúng – đủ
Thực hiện các hoạt động hàng ngày không an toàn
4 < Tổng cộng các hoạt động
nếu không có giám sát
Không thể sử dụng các vật dụng/ phương tiện
5
quen thuộc đúng cách (VD. Điện thoại)
6 Không thể tự quản lý tài chính D Hành vi
7 Không thể làm được các việc nhà. 27 Sử dụng lời lẽ thiếu văn hóa
Dễ bị kích động, dễ cáu giận, buồn hoặc phản
8 Đi lạc ngay trong khu vực quen thuộc của họ 28
ứng thái quá
Phụ thuộc hoàn toàn và yêu cầu nhiều sự trợ 29 Đánh hoặc tấn công người khác
9
giúp hơn bình thường
Mất đi sự khôn khéo/ tinh tế trong trò chuyện, trao < Tổng cộng các hoạt động
10
đổi (VD. Sự hài hước).
11 Khó khăn trong việc xác định thời gian

12 Đi lại không chủ đích E Nhận thức

30 Quả quyết vật/ tài sản trông giống nhau nhưng
13 Dấu các đồ vật
thực chất là khác nhau
31 Quả quyết giống một người trong nhà, nhưng
14 Nhặt nhạnh các vật linh tinh

15 Không nhận ra người thân hoặc bạn 32 Nghĩ rằng đang sống ở một thế giới khác

16 Ỉa/ đái không tự chủ 33 Nghĩ về một người nào đó đã mất

17 Đi vệ sinh không đúng chỗ < Tổng cộng các hoạt động

< Tổng cộng các hoạt động

F Hoang tưởng
B Tập trung/ Chú ý/ Ghi nhớ 34 Nghi ngờ bạn bè hoặc gia đình

18 Không thể tập trung trong thời gian dài 35 Nghi ngờ mất tiền

19 Hay để quên đồ/ vật 36 Buộc tội ai đó lấy đồ vật của mình
Khó khăn trong xác định thời gian hoặc thực hiện
20 37 Buộc tội vợ/ chồng không chung thủy
các hoạt động
Nhanh quên đi việc/ nội dung cuộc nói chuyện
21 38 Nghi ngờ về việc uống thuốc
mới xảy ra
22 Quên những thông tin quan trong hàng ngày < Tổng cộng các hoạt động

< Tổng cộng các hoạt động

 5

G Thẩm định/nhận xét J Ngủ/ nghỉ

Đưa ra những nhận xét không phù hợp về tình
39 52 Ngủ không theo quy luật
huống trong xã hội
Tỉnh dậy và đi lại lung tung hoặc thường xuyên
Có những quyết định không phù hợp khi lái xe 53
40 thức dậy vào ban đêm
(ôtô, xe máy)
54 Ngủ nhiều hơn trước
Lựa chọn trang phục không phù hợp (VD. Mặc
quần áo mùa đông khi đang là mùa hè, trời không
42 55 Dễ bị kích động hoặc tổn thương vào buổi chiều
mưa lại mặc áo mưa, không chịu thay quần áo
nhiều).

43 Có những hoạt động tình dục không phù hợp 55 Dễ bị kích động hoặc tổn thương vào buổi chiều <

44 Khó khăn trong tự kiểm soát bản thân < Tổng cộng các hoạt động
Không thể nhận ra những nguy hiểm với bản
45
thân.
< Tổng cộng các hoạt động K Thời gian/không gian
Hoạt động phối hợp giữa các chi (chân/tay) và
56
ngón tay giảm hoặc yếu

H Lặp lại 57 Giảm hẳn các hoạt động

46 Lặp đi lặp lại một/ nhiều hoạt động 58 Đi lại không vững

Gặp khó khăn khi mặc quần áo, đặc biệt là cài
47 Nhắc đi nhắc lại một từ/ ngữ 59
khuy, kéo phéc-mơ-tuya (khóa kéo)
Khó khăn trong xác định kích thước đồ vật hoặc
48 Liên tục hò hét/ kêu la 60
khoảng cách giữa các đô vật
< Tổng cộng các hoạt động < Tổng cộng các hoạt động

I Vận động L Khó khăn trong ngôn ngữ

61 Đọc chậm hơn bình thường
49 Di chuyển với bước đi đều nhau
62 Vay mượn từ ngữ của người khác
50 Không thể ngồi yên, bồn chồn,
63 Không xem hoặc theo dõi TV
51 Rung/ lắc cửa sổ, cửa ra vào
< Tổng cộng các hoạt động 64
Không nói chuyên trừ khi yêu cầu nói (VD.
Không tham gia vào đối thoại)
65 Thường không thể sử dụng đúng từ/ ngữ

66 Khó khăn trong phát âm.

Không thể hiểu được một yêu cầu, giải thích
67
Điểm tổng đơn giản
68 Không thể nói những câu có ý nghĩa

< Tổng cộng các hoạt động

 6

ĐIỀU TRA VỀ GÁNH NẶNG CHĂM SÓC

Dưới đây là 22 câu hỏi về những cảm giác của người chăm sóc khi chăm sóc người khác. Phần trả lời của mỗi câu hỏi sẽ
được trình bày dưới mức độ: không bao giờ, hiếm khi, đôi khi, khá thường xuyên hoặc thường xuyên. Đề nghị ông/bà
khoanh vào 1 (một) trong các số từ 0 đến 4 tương ứng với câu trả lời của ông/bà. Không có câu trả lời đúng và sai

C1. Ông/bà có cảm thấy người thân đòi hỏi việc chăm sóc nhiều hơn mức họ cần không?

0 1 2 3 4
Không bao giờ Hiếm khi Đôi khi Khá thường xuyên Thường xuyên

C2. Ông/bà có cảm thấy không có đủ thời gian dành cho chăm sóc bản thân mình bởi vì ông/bà dành hết thời
gian cho chăm sóc người thân của mình?
0 1 2 3 4
Không bao giờ Hiếm khi Đôi khi Khá thường xuyên Thường xuyên

C3. Ông/bà có cảm thấy bị stress (áp lực) giữa việc chăm sóc người thân của mình và cố gắng thực hiện đầy
đủ các trách nhiệm đối với gia đình hoặc công việc?

0 1 2 3 4
Không bao giờ Hiếm khi Đôi khi Khá thường xuyên Thường xuyên

C4. Ông/bà có cảm thấy ngượng/ lúng túng về hành vi của người thân mình không?
0 1 2 3 4
Không bao giờ Hiếm khi Đôi khi Khá thường xuyên Thường xuyên

C5. Ông/bà có cảm thấy tức giận khi ông bà ở gần người thân của mình?

0 1 2 3 4
Không bao giờ Hiếm khi Đôi khi Khá thường xuyên Thường xuyên

C6. Ông/bà có cảm thấy người thân của mình đang gây nên những tác động tiêu cực đến mối quan hệ với
các thành viên khác trong gia đình hoặc bạn bè không?
0 1 2 3 4
Không bao giờ Hiếm khi Đôi khi Khá thường xuyên Thường xuyên

C7. Ông/bà có cảm thấy lo lắng về tương lai của người thân mình đang chăm sóc không?
0 1 2 3 4
Không bao giờ Hiếm khi Đôi khi Khá thường xuyên Thường xuyên

C8. Ông/bà có cảm thấy người thân đang phụ thuộc hoàn toàn vào mình không?
0 1 2 3 4
Không bao giờ Hiếm khi Đôi khi Khá thường xuyên Thường xuyên

C9. Ông/bà có cảm thấy căng thẳng khi ông/bà ở gần người thân đang nhận được chăm sóc không?
0 1 2 3 4
Không bao giờ Hiếm khi Đôi khi Khá thường xuyên Thường xuyên

C10. Ông/bà có cảm thấy sức khỏe của mình bị ảnh hưởng bởi vì ông/bà tham gia vào quá trình chăm sóc
người thân không?
0 1 2 3 4
Không bao giờ Hiếm khi Đôi khi Khá thường xuyên Thường xuyên
 7

C11. Ông/bà có cảm thấy mình không có thời gian riêng tư như mong muốn khi chăm sóc người thân không?
0 1 2 3 4
Không bao giờ Hiếm khi Đôi khi Khá thường xuyên Thường xuyên

C12. Ông/bà có cảm thấy hoạt động xã hội của mình bị ảnh hưởng khi chăm sóc người thân không?
0 1 2 3 4
Không bao giờ Hiếm khi Đôi khi Khá thường xuyên Thường xuyên

C13. Ông/bà có cảm thấy không thoải mái về mối quan hệ với bạn bè khi tham gia chăm sóc người thân?
0 1 2 3 4
Không bao giờ Hiếm khi Đôi khi Khá thường xuyên Thường xuyên

C14. Ông/bà có cảm thấy người thân của mình trông chờ việc chăm sóc của mình bởi vì ông/bà là người duy
nhất giúp đỡ họ?
0 1 2 3 4
Không bao giờ Hiếm khi Đôi khi Khá thường xuyên Thường xuyên

C15. Bên cạnh các chi phí cho cá nhân của mình, ông/bà có cảm thấy mình không có đủ tài chính để chăm
chăm sóc người thân không?
0 1 2 3 4
Không bao giờ Hiếm khi Đôi khi Khá thường xuyên Thường xuyên

C16. Ông/bà có cảm thấy mình sẽ không đủ khả năng để chăm sóc người thân của mình lâu hơn nữa không?
0 1 2 3 4
Không bao giờ Hiếm khi Đôi khi Khá thường xuyên Thường xuyên

C17. Ông/bà có cảm thấy mình không thể kiểm soát được cuộc sống của mình kể từ khi người thân mắc bệnh?
0 1 2 3 4
Không bao giờ Hiếm khi Đôi khi Khá thường xuyên Thường xuyên

C18. Ông/bà có khi nào ông bà mong muốn giao việc chăm sóc người thân của mình cho người khác thực
hiện không?
0 1 2 3 4
Không bao giờ Hiếm khi Đôi khi Khá thường xuyên Thường xuyên
C19. Ông/bà có cảm thấy không chắc chắn về việc mình đang làm cho người thân không?
0 1 2 3 4
Không bao giờ Hiếm khi Đôi khi Khá thường xuyên Thường xuyên

C20. Ông/bà có cảm thấy mình phải làm nhiều hơn nữa cho người thân của mình không?
0 1 2 3 4
Không bao giờ Hiếm khi Đôi khi Khá thường xuyên Thường xuyên

C21. Ông/bà có cảm thấy mình thực hiện công việc chăm sóc người thân tốt hơn không?

0 1 2 3 4
Không bao giờ Hiếm khi Đôi khi Khá thường xuyên Thường xuyên

C22. Nhìn chung, ông bà cảm thấy nặng nề khi chăm sóc người thân của mình như thế nào?
0 1 2 3 4
Không nặng nề Một chút Trung bình Khá nặng nề Rất nặng nề
 8

ĐÁNH GIÁ CHẤT LƯỢNG CUỘC SỐNG

Đề nghị Ông/Bà hãy đọc và khoanh vào những câu trả lời phù hợp nhất với bản thân mình

(Đề nghị khoanh tròn vào câu trả lời)

1 2 3 4 5
1. Nhìn chung, ông/bà tự đánh giá chất Rất Kém Kém Không tốt cũng Tốt Rất tốt
lượng cuộc sống của mình là? không xấu
(trung bình)

1 2 3 4 5
2. Nhìn chung, mức độ hài lòng của
ông/bà với tình trạng sức khỏe của Rất không hài Không hài lòng Phân vân/ Hài lòng Rất hài lòng
mình như thế nào? lòng lưỡng lự

Các câu hỏi dưới đây hỏi về mức độ các hoạt động mà ông/bà đã trải qua trong thời gian 2 tuần trước đây.

(Đề nghị khoanh tròn vào câu trả lời)

1 2 3 4 5
3. Về mặt nào đó, ông/bà có thường bị Không bao giờ Hiếm khi Thỉnh thoảng Khá thường Thường xuyên
đau nhức/tê/mỏi cơ thể không? xuyên

4. Ông/bà có thường xuyên phải dùng 1 2 3 4 5

thuốc (thuốc uống đông/tây y; thuốc Không bao giờ Hiếm khi Thỉnh thoảng Khá thường Thường xuyên
tiêm/bôi) để chữa bệnh không? xuyên
1 2 3 4 5
5. Mức độ ông/bà hứng thú với cuộc
sống như thế nào? Hoàn toàn không Có một chút Vừa phải Thích thú Rất thích thú

6. Ông/bà cảm thấy cuộc sống của mình 1 2 3 4 5

có ý nghĩa như thế nào? Hoàn toàn không Một chút Vừa phải Nhiều Rất nhiều

1 2 3 4 5
7. Khả năng tâp trung khi suy nghĩ/làm
Không thể tập Một chút Bình thường Tốt Rất tốt
việc của ông bà như thế nào?
trung

8. Ông/bà có cảm thấy cuộc sống của 1 2 3 4 5

mình an toàn không (an ninh/trật tự)? Hoàn toàn không Có một chút Bình thường An toàn Rất an toàn

9. Ông/bà nhận thấy mức độ trong lành 1 2 3 4 5

của môi trường tự nhiên (nước, Rất không trong Không trong lành Bình thường Trong lành Rất trong lành
không khí, tiếng ồn, rác thải…) nơi lành
mình sống như thế nào?

Các câu hỏi dưới đây hỏi về mức độ hoàn thiện các hoạt động mà ông/bà đã trải nghiệm hoặc ông/bà đã thực hiện
trong thời gian 2 tuần trước đây.

(Đề nghị khoanh tròn vào câu trả lời)

1 2 3 4 5
10. Ông/bà có đủ năng lượng trong các Hoàn toàn Có một chút Vừa phải Nhiều Rất nhiều
hoạt động hàng ngày không? không

11. Ông/bà có cảm thấy hài lòng về 1 2 3 4 5

hình dáng bên ngoài của mình Hoàn toàn Có một chút Bình thường Hài lòng Rất hài lòng
không? không

1 2 3 4 5
12. Ông/bà có đủ tiền để chi trả cho các
nhu cầu sinh hoạt hàng ngày (ăn Không có đủ Có đủ tiền để chi Phân vân/ Đủ tiền để chi Đủ tiền để chi
uống, điện nước,…) ở mức độ nào? tiền để chi trả trả chút ít lưỡng lự trả hầu hết trả tất cả
 9

(Đề nghị khoanh tròn vào câu trả lời)

13. Những thông tin mà ông/bà cần 1 2 3 4 5

cho cuộc sống hàng ngày sẵn có Hoàn toàn Có chút ít Vừa phải Nhiều Rất nhiều
đến mức độ nào? không có

1 2 3 4 5
14. Ông/bà có cơ hội tham gia các hoạt Hoàn toàn Một chút Vừa phải Nhiều Rất nhiều
động vui chơi/giải trí ở mức độ nào? không

15. Khả năng đi lại của ông/bà như thế 1 2 3 4 5

nào? Rất kém Kém Bình thường Tốt Rất tốt

Các câu hỏi dưới đây hỏi về mức độ thoải mái/hài lòng của ông bà về các lĩnh vực khác nhau của cuộc sống của ông/
bà trong thời gian 2 tuần trước đây.

(Đề nghị khoanh tròn vào câu trả lời)

1 2 3 4 5
16. Mức độ hài lòng của ông/bà với giấc Rất không hài Không hài lòng Phân vân/ Hài lòng Rất hài lòng
ngủ của mình như thế nào? lòng lưỡng lự

17. Mức độ hài lòng của ông/bà với các 1 2 3 4 5

hoạt động tự chăm sóc (tắm rửa, Rất không hài Không hài lòng Phân vân/ Hài lòng Rất hài lòng
vệ sinh..) như thế nào? lòng lưỡng lự

1 2 3 4 5
18. Mức độ hài lòng của ông/bà về
năng lực làm việc (Kinh nghiệm, kỹ Rất không hài Không hài lòng Phân vân/ Hài lòng Rất hài lòng
năng…) của mình như thế nào? lòng lưỡng lự

19. Mức độ hài lòng của ông/bà về khả 1 2 3 4 5

năng làm việc của mình như thế Rất không hài Không hài lòng Phân vân/ Hài lòng Rất hài lòng
nào lòng lưỡng lự

1 2 3 4 5
20. Mức độ hài lòng của ông/bà với
quan hệ gia đình và xã hội như thế Rất không hài Không hài lòng Phân vân/ Hài lòng Rất hài lòng
nào? lòng lưỡng lự

21. Ông/bà có hài lòng về đời sống tình 1 2 3 4 5

dục (quan hệ vợ chồng/thái độ âu Rất không hài Không hài lòng Phân vân/ Hài lòng Rất hài lòng
yếm, vuốt ve..) hiện nay của mình? lòng lưỡng lự

22. Ông/bà hài lòng về sự hỗ trợ (kinh 1 2 3 4 5

tế/ sức lực..) của con cái/ bạn bè Rất không hài Không hài lòng Phân vân/ Hài lòng Rất hài lòng
như thế nào? lòng lưỡng lự

23. Mức độ hài lòng của ông/bà với 1 2 3 4 5

điều kiện nhà ở của mình như thế Rất không hài Không hài lòng Phân vân/ Hài lòng Rất hài lòng
nào? lòng lưỡng lự

24. Mức độ hài lòng của ông/bà với khả 1 2 3 4 5

năng tiếp cận các dịch vụ chăm Rất không hài Không hài lòng Phân vân/ Hài lòng Rất hài lòng
sóc y tế ở mức độ nào? lòng lưỡng lự

1 2 3 4 5
25. Ông/bà hài lòng với khả năng di
chuyển/ đi lại của mình như thế Rất không hài Không hài lòng Phân vân/ Hài lòng Rất hài lòng
nào? lòng lưỡng lự

1 2 3 4 5
26. Ông/bà có hay cảm thấy buồn chán, Không bao giờ Hiếm khi Thỉnh thoảng Khá thường Thường xuyên
lo lắng không? xuyên
 10

ĐÁNH GIÁ VỀ KHẢ NĂNG GẮN KẾT—GIẢI QUYẾT VẤN ĐỀ

Dưới đây là những câu hỏi về các sự việc/ sự kiện liên quan đến cuộc sống của ông/bà. Mỗi câu hỏi có 7 sự lựa chọn, đề nghị
ông/bà khoanh vào một (1) trong các số từ 1 đến 7, phù hợp nhất.

D1. Ông/bà có cảm thấy mình thực sự không quan tâm đến các sự việc/ sự kiện đang diễn ra quanh mình?
1 2 3 4 5 6 7

Rất hiếm
Không bao giờ Rất thường xuyên

D2. Với ông/bà, điều này đã bao giờ xảy ra trước đây khi “Hành động của một người nào đó mà ông/bà cho rằng đã
rất hiểu họ làm cho ông/bà ngạc nhiên”?
1 2 3 4 5 6 7

Chưa bao giờ xảy ra Thường xuyên diễn ra

D3. Với ông/bà, điều này đã bao giờ xảy ra trước đây khi người mà ông/bà rất kỳ vọng, làm ông/bà thất vọng
1 2 3 4 5 6 7

Chưa bao giờ xảy ra Thường xuyên diễn ra

D4. Cho đến bây giờ, cuộc sống của ông/bà:

1 2 3 4 5 6 7

Hoàn toàn không có mục đích hoặc Có mục đích hoặc mong
mong muốn rõ ràng muốn rất rõ ràng
D5. Ông/bà có cảm thấy mình bị phân biệt đối xử không?
1 2 3 4 5 6 7

Rất thường xuyên Rất hiếm hoặc không bao giờ

D6. Ông/bà có cảm thấy rằng ông/bà đang gặp phải tình huống hoàn toàn khác biệt và không biết phải làm gì?
1 2 3 4 5 6 7

Rất thường xuyên Rất hiếm hoặc không bao giờ

D7. Đối với ông/bà, việc thực hiện các công việc lặp đi lặp lại hàng ngày là:
1 2 3 4 5 6 7

Thực sự đam mê và hài lòng Thực sự chán nản và buồn tẻ

D8. Đã bao giờ ông/bà có những cảm giác và suy nghĩ rất lộn xộn/ lẫn lộn?
1 2 3 4 5 6 7

Rất thường xuyên Rất hiếm hoặc không bao giờ

D9. Đã bao giờ điều này xảy ra khi “ông/bà mong muốn mình không suy nghĩ và cảm nhận thấy cái gì cả”
1 2 3 4 5 6 7

Rất thường xuyên Rất hiếm hoặc không bao giờ

D10. Rất nhiều người, thậm chí cả những người có cá tính mạnh, đôi khi cảm thấy buồn, chán nản trong một số
tình huống nhất định. Từ trước đến giờ đã bao giờ ông/bà cảm thấy mình gặp hoàn cảnh như vậy chưa?
1 2 3 4 5 6 7

Không bao giờ Rất thường xuyên

 11

D11. Khi một việc gì đó xảy ra, đã bao giờ ông/bà cảm thấy rằng:
1 2 3 4 5 6 7

Mình đã đánh giá quá thấp hoặc quá Mình đã nhận định sự việc đúng
cao tầm quan trọng của việc đó bản chat của nó

D12. Đã bao giờ ông/bà cảm thấy công việc mình làm hàng ngày thực sự không có ý nghĩa?
1 2 3 4 5 6 7

Rất thường xuyên Rất hiếm hoặc không bao giờ

D13. Đã bao giờ ông/bà cảm thấy rằng mình không đảm bảo mọi việc được diễn ra suôn sẻ?
1 2 3 4 5 6 7

Rất thường xuyên Không bao giờ

TÌM HIỂU TÁC ĐỘNG TÍCH CỰC CỦA CHĂM SÓC

Nhiều người chăm sóc nói rằng, bên cạnh những khó khăn khi chăm sóc cho người thân có vấn đề về trí nhớ hoặc mắc
bệnh, có rất nhiều kết quả tốt mà họ có khi thực hiện các công việc chăm sóc này. Tôi sẽ cùng điểm qua một số khía
cạnh chính đã được người chăm sóc trước đây đề cặp đến. Đề nghi ông/bà cho tôi biết mức độ đồng ý/ không đồng ý
với những câu dưới đây. Đề nghị ông/bà khoanh tròn vào các số tương ứng

Khi chăm sóc người thân bị bệnh Hoàn toàn Không Không chắc Đồng ý Hoàn toàn
không đồng ý đồng ý chắn đồng ý

1. Tôi cảm thấy sống có ý nghĩa hơn 1 2 3 4 5

2. Tôi tự đánh giá bản thân tốt hơn 1 2 3 4 5

3. Tôi thấy mình thực sự là cần thiết 1 2 3 4 5

4. Tôi thực sự thấy biết ơn 1 2 3 4 5

5. Tôi thấy mình thật là quan trọng 1 2 3 4 5

6. Tôi cảm thấy mạnh mẽ và tự tin hơn 1 2 3 4 5

7. Tôi nhận ra cuộc sống có giá trị hơn 1 2 3 4 5

8. Tôi có thái độ tích cực hơn về cuộc sống 1 2 3 4 5

9. Quan hệ của tôi với người khác tốt hơn 1 2 3 4 5

 12

Hoàn Không Đồng ý

một Hoàn
toàn Không đồng ý Đồng
TÌM HIỂU VỀ HIẾU NGHĨA không đồng ý một chút ý
toàn
đồng ý
đồng ý chút
1. Con cái có thể phản đối bố mẹ vì bị la mắng vô cớ
1 2 3 4 5 6
2. Không thể sống cùng với kẻ thù của gia đình trong một
mái nhà 1 2 3 4 5 6

3. Dù ngôi nhà của ta có cũ, không đầy đủ tiện nghi, ta vẫn

có thể chăm sóc bố mẹ ở đó nếu ta có ý thức làm việc 1 2 3 4 5 6
này

4. Sự hy sinh cho chữ hiếu là vô giá 1 2 3 4 5 6

5. Con cái không được đi đâu xa khỏi nơi mà bố mẹ minh
đang sinh sống 1 2 3 4 5 6

6. Khi cưới vợ hoặc chồng, con cái phải tuân theo ý của bố
mẹ (Bố mẹ đặt đâu con ngồi đấy) 1 2 3 4 5 6

7. Lý do chính kiến con cái không làm những việc nguy

hiểm là để tránh không làm cho bố mẹ mình phải lo lắng 1 2 3 4 5 6

8. Cha mẹ không nên can thiệp vào sự lựa chọn nghề

nghiệp của con cái 1 2 3 4 5 6

9. Công sức nuôi dưỡng của cha mẹ được ví như trời biển 1 2 3 4 5 6
10. “Nuôi dưỡng con cái để sau này chúng chăm sóc khi về
già” không phải là mục đích chính của việc nuôi dạy trẻ 1 2 3 4 5 6

11. Con cái phải kính trọng bố mẹ mình cho dù họ có đối

xử tốt hay xấu 1 2 3 4 5 6

12. Con cái có trách nhiệm duy trì nếp sống của gia đình đã
được bố mẹ xây dựng từ trước 1 2 3 4 5 6

13. Nếu sự bất hòa/ tranh cãi xảy ra giữa con dâu và mẹ
chồng, người con trai nên khuyên người vợ lắng nghe ý 1 2 3 4 5 6
kiến của mẹ chồng

14. Con cái phải hoàn thành ý nguyện/ công việc mà bố mẹ

họ chưa thực hiện xong 1 2 3 4 5 6

15. Làm rạng rỡ tổ tiên không phải yếu tố quan trọng nhất
cho sự phát triển 1 2 3 4 5 6

16. Trách nhiệm chính của con cái là phải thường xuyên
thờ phụng tổ tiên 1 2 3 4 5 6

17. Nối dõi tông đường không phải là mục đích chính của
việc kết hôn 1 2 3 4 5 6

18. Con cái có thể có những quyết định riêng mà không

nhất thiết phải tìm lời khuyên từ cha mẹ 1 2 3 4 5 6

19. Con cái không nhất thiết phải tôn trọng những người
mà bố mẹ của mình yêu thương và kính trọng 1 2 3 4 5 6

20. Khi con cái trưởng thành, tài sản/ tiền bạc mà họ kiếm
được là của riêng họ ngay cả khi cha mẹ họ vẫn còn 1 2 3 4 5 6
sống

21. Bất hiếu là tội ác lớn nhất 1 2 3 4 5 6

22. Con cái phải vâng lời cha mẹ 1 2 3 4 5 6
 PERCEIVED BURDEN AND QUALITY OF LIFE OF
DEMENTIA CAREGIVERS IN HANOI, VIETNAM IN 2011

Trung Truong Quang1, Elizabeth Beattie2, Karen A. Sullivan3

1
Faculty of Nursing and Midwifery, Hanoi Medical University, Hanoi, Vietnam
2
Dementia Collaborative Research Centre: Carers and Consumers, Queensland University of
Technology, Brisbane, Australia
3
School of Psychology & Counselling, Queensland University of Technology, Brisbane, Australia

ABSTRACT
Dementia, involving a decline in memory and other cognitive functions, is a concern in many
countries and societies and impacts on both sufferers of the disease and their family members.
Dementia was considered as a main cause of burden among mental disorders for male and female
population over 60 year-old in Vietnam in 2008. Family carers of people with dementia experience
many problems themselves related to the carer role that affect their quality of life, such as depression
and lower health status
Objectives
Study aims were to (1) describe carer’s quality of life (QoL) and perceived burden, and (2) explore
the associations between family carers’ characteristics, burden and perceived QoL.
Methods
153 family caregivers of people with dementia in Hanoi, Vietnam participated in a cross-sectional
correlation study in 2011by completed questionnaire including the WHOQOL-BREF (QoL),the
Kingston Standardized Behavioral Assessment (BPSD)and the Zarit Burden Interview.
Results
Moderate to severe burden was found in 25.5% participants, while 33.3% had low or no burden. The
score of WHOQOL-BREE domains correlated negatively with perceived burden. Multiple linear
regressions showed thatthe level of perceived caregiving burden significantly predicted QoL for each

1
Correspondence
Trung Truong Quang
Add: Faculty of Nursing and Midwifery, Hanoi Medical University, 1 Ton That Tung street,
Dongda, Hanoi, Vietnam
Email: [Link]@[Link]
Received: November 21, 2013
Accepted: March 02, 2014
1
Published: April 28, 2014
of four domains of the WHOQOL-BREF, while caregiver’s stable employment was a significant
predictor of QoLin three domains.
Conclusion
QoL among Vietnamese dementia carers in this study was low compared with findings in Western
countries but higher than for dementia caregivers in India. Perceived burden was high in this study
and contributed to predict QoL domains.
Keywords
Quality of Life, dementia caregiver, Vietnam

BACKGROUND

Chronic diseases of aging relate to pathogenic changes in physiological systems and physical
structures that manifest during senescence. Dementia is a particularly concerning disease
because of the decline in memory and other cognitive functions that result in losing of
problem-solving ability and maintenance of emotional control, personality changes,
behavioral problems and the loss of independent capacity to care for the self [1]. The disease
impacts on individuals, families and health-care systems.

Although prevalence of dementia across Vietnam has not been disclosed, dementia was seen
regionally varying from 4.5% [2] to 7.9% [3]of senior people. Dementia was considered as a
main cause of burden among mental disorders for male and female population over 60 year-
old in Vietnam in 2008. Moreover, it was also believed as the second for female or the ninth
for male in over-70-year-oldpopulation among ten leading causes of burden of diseases due
to disability [4]It is clear that the number of persons with dementia in the population will
increase as the percentage of older people in Vietnam is predicted to rise to 11.64% in
2020[5] and dementia diagnoses can be expected to rise proportionally. In addition, the
differential characteristics of health care for elderly people were existed among Vietnamese
areas. The elderly were only offered care from their children when they got sick. The model
of providing self-care was quite popular for older people [6], which suggest that the bulk of
the care required by Vietnamese people with dementia is expected to be borne by family
members.

Caring for people with dementia (PWD) living at home is challenging and usually the
demand is far greater than the supply of care. Care for the carers of PWD should be paid
attention. Dementia caregivers experience problems such as depression and lower health
status. Those problems impact on their QoL as well as their capacity to continue caring.
Factors affecting QoL studied in Western countries
2 include caregiver’s gender [7], health
status of caregivers [8, 9], health status of care-receivers [9, 10], depression [7, 11, 12],
dependency level of care-receivers [13], and caregiver burden [14, 15].Most studies on QoL
and the caregiver burden have been conducted in Western countries; no studies relating to
quality of life of carers of PWD have been conducted in Vietnam. Little is currently known
about these situations in the Vietnamese context and about family dementia carer
responsibilities and experiences when caring for persons with dementia. Furthermore, there
are complications in measuring the QoL and the terms of care-giving and QoL are a relatively
new foci or concern in Vietnam. Therefore, the study on QoL and the care-giving burden
among Vietnamese dementia caregivers is needed and valuable in Vietnam in order to:

1. To describe the perceived QoL of carers and perceived burden of care

2. To explore the associations between family carer characteristics, perceived QoL,

perceived burden of care and care recipient characteristics.

METHODS
Subjects
Family careers of people with dementia met the following criteria for inclusion that are
defined similar in Australia [16] and America [17]:

- Live in area of 10 inner districts of Hanoi during data collection

- Identified as the current primary carer of a person with a medical diagnosis of

dementia

- Care for at least the last three months

- Able to speak and understand Vietnamese

- Provide care for at least one hour/day and two days/week

153 primary caregivers whose family member was diagnosed with dementia living in
communities in the Hanoi area, Vietnam who met the criteria of inclusion, participated in this
study PWD Participants were recruited via an announcement by the Vietnam National
Institute of Gerontology (VNIG) for those patients had diagnosed with dementia.

Methods
Study design: A cross-sectional correlation survey was utilized.

Sample: sample size and sampling

A randomized sampling method was utilized to recruit participants. The list of names with
the contact addresses of the people with dementia and their carers was retrieved from the
3
National Institute of Gerontology based on patient records.
The sample size was calculated according to the formula provided by Lwanga and Lemeshow

[18]:

In which: n: sample size; 1- α: Confidence level; P: Anticipate population proportion; d:

Absolute precision required. With α = 0.05, Z1-/2 = 1.96, P as quality of life at 0.87
withdrawn from the study conducted by Huong, Ha, Nhung, and Chi [19] and d=0.06, n=
121. The absolute precision is defined as “the closeness with which it can be expected to
approximate the relevant population value” [20]. Relevant to this study, with absolute
required precision at 0.06, estimate of quality of life among dementia caregivers might be
varied from 0.81 to 0.93. The theoretical sample size was 121 participants with type I error at
5%. To account for a possible attrition rate of 20%, to increase the external validity and to
reduce the possibility of Type II’s error, an additional 25 participants was recruited for a total
sample of 146 people.
Measures
Caregiver variables
Dementia caregivers’ perceived burden of care was evaluated using the Zarit Burden
Interview (ZBI); a 22 item self-report inventory. Items are evaluated on a 5-point Likertscale
ranging from never to nearly always. Responses to individual items are summed to produce a
total score, ranging from 0 to 88. Higher total scores indicate a higher degree of burden.
According to the cutoffs proposed by Hebert, Bravo, and Preville[21], a ZBI total score of <
21 indicates “little or no burden”, 21 to 40 indicates “mild to moderate burden” , 41 to 60
indicates “moderate to severe burden” and a score >61 indicates “severe burden”.
The Sense of Coherence (SOC) questionnaire was utilized to as a proxy measure of QoL that
included 13 items scored on 7-point Likert scales where each item has two fixed contradicted
responses listed under the endpoint of each item was used. The theoretical total score of SOC
is from 13 (low SOC) to 91 (highest possible SOC). People with a higher score on SOC are
believed to be more confident in managing their situation and knowing how to perform health
promotion.
QoL among dementia caregivers was assessed by employing the WHOQOL – BREF
developed based on the WHOQOL-100 that was tested and validated in the Vietnam context
by [22]. This instrument includes 26 items was rated in a five point-scale in which (1) as
completely unsatisfied, (2) unsatisfied, (3) neither satisfied nor dissatisfied, (4) satisfied, and
(5) very satisfied. WHOQOL-BREF investigates
4 four domains that include Physical,
Psychological, Social relationship and Environment.
PWD related variables
The Barthel Index was used to collect information on the PWD’s ability to perform activities
of daily living (ADLs) [13]. This instrument was first used to assess the independence/
dependence level for ten Activities of Daily Living (ADLs) primarily related to personal care
and mobility in a clinical setting [23]. Barthel Index scores range from 0 (highly dependent)
to 100 (highly independent).
The Kingston Standardized Behavioral Assessment (KSBA) assesses behavioral dementia
symptoms. The KSBA is an informant-based assessment of 68 behaviors (12 categories) that
are common to dementia [24]. Using yes/no format, the caregiver identifies behaviors that
have occurred in past month.
The study instruments were applied in the Vietnamese version by the forward and backward
translation process. Cronbach’s alpha values of mentioned tools in Vietnamese context varied
from 0.89 to 0.5 which indicated a high level of internal consistency for those scales among
Vietnamese dementia caregivers.

Procedure
A list of eligible participants was obtained from the VNIG. A random sampling method
using the SPSS random number generator was used to identify individuals to contact.
Selected participants received 2 formal letters of invitation to participate and consent forms
sent 3 to 5 days apart. Within two weeks after the first letter was sent, recipients were
contacted by phone to determine their interest in participation and, if appropriate, allocate
suitable appointment times. The participants chose a time convenient to them to complete the
study questionnaire.

Data analysis
First, descriptive statistics for major variables were performed. Next bivariate statistics were
calculated across all variables to examine the relationships between Caregiving burden,
quality of life and PWD variables. Finally, multiple-regression was utilized to predict QoL
with the contribution of perceived experiences of caregivers in addition to PWD variables.
The α level of 0.05 was selected for all analysis.

Ethical considerations

The present study was approved by the Ethics Committee of Queensland University of
Technology (QUT Ethics Approval Number 1100001158) and the Hanoi School of Public
Health (HSPH Ethics Approval Number 026/2011/YTCC-HD3).

5
RESULTS

The demographic characteristics of the sample are shown in Table 1. Data for the care recipient
(PWD) and their caregivers is shown. Descriptive statistics (mean and SD) or their non-
parametric equivalents where appropriate, are shown (see Table 1). Table 1 shows that, on
average, caregivers were about 49 years of age, and they were almost twice as likely to be female
than male.

Table 1. Demographic Characteristics of caregivers and PWD (n=153)

n (%) Mean ± SD
Caregivers
Age (in years) 49.25 ± 13.95
Male 56 (36.6)
Relationship to PWD
Spouse 37 (24.2)
Parent 104 (68.0)
Relative 6 (3.9)
Other 6 (3.9)
Stable employment status 88 (57.5)
Caregiver burden (ZBI total score) 30.56 ±14.25
Burden category
Little or no burden 51 (33.3)
Mild to moderate burden 61 (41.2)
Moderate to severe burden 32 (20.9)
Severe burden 7 (4.6)
Sense of Coherence (SOC) 59.82 ±5.94
Quality of Life (WHOQOL-BREF)
Physical 24.12 ±3.9
Psychological 20.85 ±3.14
Social relationship 10.82 ±1.59
Environment 27.05 ±4.13
PWD’s variables
Age (in years) 75.92± 11.63
Female 89 (58.2)
Duration diagnosed with dementia 4.12 ±3.77
Independence with ADLs (Barthel Index) 53.50±30.24
Presence of behaviors characteristic of 27.32 ±10.94
dementia (KSBA score)
ZBI: Zarit Burden Interview; KSBA: Kingston Standardized Behavioral Assessment
In order to investigate the correlation between quality of life and several caregivers’
variables, Pearson correlation coefficients were used (table 2). Significant negative
6
associations were found between quality of life (domains) and caregiver burden (ZBI total
score) and age of carer. Domains of QoL were significantly positive associated with the sense
of coherence (SOC).
Table 2. Pearson correlation coefficients between Quality of life and caregiver variables
WHOQOL-BREF
Physical Psychological Social relationship Environment
Age -0.451** -0.169* -0.102 -0.097
ZBI total score -0.29** -0.447** -0.343** -0.351**
SOC total score 0.153 0.391** 0.443** 0.280**
Note: Significant at * p<0.05, ** p< 0.01
To explore predictors of quality of life, multiple regression was performed. The predictors
that were entered into this analysis were caregiver and care recipient related characteristics.
This analysis showed that perceived burden (Zarit Burden interview total score) was the
strongest predictor of quality of life domains (table 3)

Table 3. Multiple regression analysis for Quality of life

B SE β F R2
WHOQOL-BREF - Physical 23.138*** 33.8
Caregiver’s age -0.153 0.22 -0.506***
Female caregiver 1.531 0.568 0.191***
ZBI total score -0.096 0.020 -0.34**
WHOQOL-BREF – Psychological 17.775*** 39
Caregiver’s age -0.037 0.18 -0.147*
Stable employment 1.707 0.492 0.252**
Duration dementia diagnosis -0.146 0.061 0.171*
ZBI total score -0.072 0.018 -0.304***
SOC score 0.152 0.039 0.274***
WHOQOL-BREF – Social relationship 13.153*** 22.6
Stable employment 0.78 0.277 0.226**
ZBI total score -0.032 0.01 -0.267**
SOC score 0.066 0.022 0.24**
WHOQOL-BREF – Environment 15.164*** 24.5
Stable employment 0.569 0.092 0.308
Duration dementia diagnosis -7.473 1.616 -0.231
ZBI total score 0.273 0.111 0.127
Note: ** p<0.01; *** p<0.001

7
DISCUSSION

Characteristics of participants

Although male caregiver of PWD made up a smaller part compared with female carers,
36.6% vs. 63.4% in this study, this ratio is similar with other studies conducted in Asia
countries, for example in India at 43.3% for men [25], or in Taiwan at 45.6% for male [26].
In this study, more than 2/3 (68%) participants is caring for their parent who is suffering from
dementia. Nearly ¼ (25%) of responders are offering the care for their spouse (husband or
wife). In addition, there were four grandchildren who are caring their grand-parent with
dementia. This findings corroborate with previous researches in Asia countries [27] and it
contradicted with previous studies in Western countries, for example spouse made up major
part at 68% in America [28] or 72.6% in Ontario, Canada [29].
This difference might be related in the theory of Confucianism that caring for parents when
they become older is the major duty of the children, especially the son. They are preserved as
dutiful and loyal. Confucian philosophy has been strongly dominating the Vietnamese culture
for thousands of years [30]. Confucianism defines a system of moral, philosophical and social
norms, virtue and value judgment. Three greatest relationships that a man must uphold are
Ruled to Ruler, Son to Father, and Husband to Wife and three obeying relationships that a
woman must follow include Follow Father, Follow Husband, and Follow Son. A study by
Mok, Lai, Wong and Wan (2007) highlighted that Chinese people with their traditional
culture, customs and religion believed the duty of caring for their family member with the
disease is a norm. Love and support from relatives and family members was extremely
important for those people with dementia [31].
Behavioral profile
Kingston standardized behavioral assessment was used to set the behavioral profile or people
with dementia. The higher score in this this scale, the more problem the people with dementia
receive. According to the cutoffs proposed by Hopkins, Kilik, Day, Bradford, and Rows
[24]behavior profile of people with dementia was categorized based on the Kingston
Standardized Behavioral Assessment total score into level 1 for 5 PWD (3.3%), level 2 for 53
(34.6%), level 3 for 74 (48.4%) and level 4 for 21 (13.7%). It means, in this research, 13.7%
of PWD in the level 4 should consider admitting to professional health care setting. 83%
PWD in the level 2 and 3 should receive the consultation and support services.
Quality of life
As mentioned most of previous studies examined quality of life among dementia caregivers
in the area of health related quality of life. Mean scores of all 4 domain (Physical,
8
Psychological, Social activities and Environment) among responders in this study were much
lower compared with study examined QoL among people with divers disease and conditions
in UK by Skevington and McCrate[32] as well (normal people) on the 4 domains.
Meanwhile, findings in this study are quite similar in results compare with those experienced
by general carers in Skevington and McCrate [32] study. Furthermore, results of this study
are not different with finding from research organized by Cruz, Polanczyk, Camey,
Hoffmann, & Fleck [33] on QoL in general population sample in Brazil. Moreover, means
raw 4 domains scores in this study were higher than those dementia caregivers in New Delhi,
India [25]. Obviously, quality of life among dementia caregivers in this research shows
definitely lower than normal people in UK but comparable with general sample in Brazil.
However dementia caregivers in India or caregivers of mentally illness patients in Taiwan
experienced poorer on QoL than those in this study.
Multiple linear regressions were employed significantly to predict each QoL domains.
Caregiving burden significantly predicted QoL for each of the four domains, while
caregiver’s stable employment was also a significant predictor of QoL excepted physical
domain. Therefore, this study’s findings confirmed previous studies on improving quality of
life by Gavrilova and colleagues [34] on dementia caregivers in Moscow, Russian, Wong,
Lam Chan and Chan [27] on dementia caregivers in Hong Kong, and Fan and Chen [26] on
caregivers of the mentally in Chinese Society.

CONCLUSIONS
QoL among Vietnamese dementia carers in this study was low compared with findings in
Western countries but higher than for dementia caregivers in India.
Significant negative associations were found between quality of life (domains) and caregiver
burden (ZBI total score) and age of carer. Domains of QoL were significantly positive
associated with the sense of coherence (SOC).
Perceived burden was high in this study and contributed to predict QoL domains.

ACKNOWLEDGMENTS

The authors would like to express our heartfelt thanks go to all caregivers of people with

dementia who shared their experiences in Hanoi, Vietnam. Despite of the complexities of the

lives of the informal caregivers with their relative suffering from dementia, they spent the

precious time to commit the interviews and questionnaires. Without those answers, this study
9
would not be possible. We would like to thank our friends, colleagues who provided
supports in many ways for their efforts and enthusiasm encouragement and sharing other

tasks.

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12