Perspectives of Moroccan informal caregivers and occupational therapists informing cultural adaptation of Community Occupational Therapy in Dementia

Abstract

Introduction:

Families of Moroccan descent in the Netherlands face cultural and systemic barriers in accessing dementia care, reflecting broader patterns across ethnic minorities in Europe. This study explored how informal caregivers of Moroccan descent and occupational therapists perceive dementia care needs, and how their perspectives may inform adaptations to the Community Occupational Therapy in Dementia (COTiD) programme to promote more equitable, inclusive dementia care.

Method:

Qualitative data were collected through five semi-structured interviews with informal caregivers and four focus groups involving seven COTiD-trained occupational therapists and six occupational therapists of Moroccan descent. Data were analysed thematically.

Findings:

Three key themes were identified: Families seek optimal dementia care; Families act as managers and decision-makers; and Collaborating through trust and understanding. Cultural agility—the ability to adapt in real time to families’ changing needs, grounded in humility, self-reflection, and mutual learning—emerged as a potentially core professional skill.

Conclusion:

Integrating caregivers’ and occupational therapists’ perspectives highlights cultural agility as central to culturally responsive occupational therapy for Moroccan families. Cultural agility emphasises therapists’ responsiveness to families’ needs and relational dynamics in everyday practice. These insights can inform adaptations of COTiD and support occupational therapists in providing equitable and inclusive dementia care.

Introduction

Ethnic minority groups in the Netherlands, including Moroccan communities, face persistent disparities in dementia care. Moroccan families have a higher risk of developing dementia than the native Dutch population, partly due to elevated rates of cardiovascular disease, diabetes, and depression (Kenning et al., 2017). Despite increasing need, access to dementia services remains limited. Cultural and linguistic barriers, limited awareness of available support, and mistrust toward healthcare providers often result in delayed help-seeking and underutilisation of formal care (Berdai Chaouni et al., 2020; Duran-Kiraç et al., 2022).

Occupational therapists (OTs) play a central role in community-based dementia care across Europe but often struggle to align practice with the cultural values and expectations of diverse families (Fenn et al., 2025). Traditional models of cultural competence—typically focused on acquiring static knowledge of cultural traits—have been criticised for reinforcing stereotypes and oversimplifying diversity (Tervalon & Murray-García, 1998). In response, the occupational therapy (OT) profession increasingly embraces relational, reflexive approaches such as cultural humility, an ongoing practice of openness, self-reflection, and mutual learning, and cultural agility, the ability to adapt flexibly to complex, dynamic cultural contexts (Fenn et al., 2025; Foronda et al., 2016). These shifts reflect broader calls to reimagine dementia care as inclusive and responsive to the lived experiences of marginalised communities. Interventions that overlook cultural context may be less effective in meeting the needs of underserved populations (Ahmad et al., 2022; Shatnawi et al., 2023)

The Community Occupational Therapy in Dementia (COTiD) programme is an evidence-based, home-based intervention implemented in the Netherlands and other European countries. It is designed to enhance meaningful daily activity, coping strategies, and quality of life among people with dementia and their informal caregivers (Graff et al., 2006a, 2010). COTiD combines person- and system-centred approaches, including collaborative goal setting, tailored interventions, and environmental modifications. Although effective, it remains unclear whether COTiD adequately addresses the needs of minority ethnic groups, such as Moroccan families. These families may require not only adapted content but also trust-building approaches rooted in intergenerational, religious, and cultural understanding (Ahmad et al., 2022; Nurunnaher et al., 2023).

This study therefore explores the perceived cultural suitability of the COTiD programme from the perspectives of informal caregivers and occupational therapists—both with and without a Moroccan background. By integrating these perspectives, the study aims to inform culturally sensitive occupational therapy frameworks for dementia care across Europe.

The main research question was: How do informal caregivers and occupational therapists—both with and without a Moroccan background—perceive the suitability of the COTiD programme? And how might the programme be adapted to better reflect the cultural, religious, and lived experiences of people with a Moroccan background living with dementia and their informal caregivers?

To explore this main question, we formulated five sub-questions:

1. What are the perspectives and needs of informal caregivers of people of Moroccan descent living with dementia regarding dementia care and the core components of the COTiD programme?

2. How do COTiD-trained occupational therapists (COTiD-OTs) and occupational therapists of Moroccan descent (MOR-OTs) perceive the cultural suitability of the COTiD programme?

3. How should the COTiD programme be adapted to better align with the needs and preferences of people of Moroccan descent living with dementia and their informal caregivers?

4. What recommendations can improve the quality of community dementia care provided by occupational therapists and other professionals working with migrant families?

5. Which insights from this study can contribute to developing a framework for culturally sensitive interventions for minority ethnic groups?

Methods

Study design

This qualitative, exploratory study examined the cultural suitability of the COTiD programme for people of Moroccan descent living with dementia and their informal caregivers. Focus groups and individual interviews were conducted with three key stakeholder groups: informal caregivers, COTiD-trained occupational therapists (COTiD-OTs), and occupational therapists of Moroccan descent (MOR-OTs). The study design and reporting adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) to ensure methodological rigour and transparency (Tong et al., 2007).

COTiD programme overview

COTiD is an evidence-based, home-based intervention designed to improve daily functioning, mood, and quality of life for people with dementia, while enhancing the coping strategies and sense of competence of their informal caregivers. The programme consists of up to ten sessions delivered over 6–10 weeks by COTiD-trained OTs. It targets both the person with dementia and their caregiver. Sessions include narrative interviews, observations of meaningful activities, and collaborative goal setting. The person with dementia is coached in using personal strategies to perform activities, with environmental adaptations as needed. Informal caregivers receive guidance to manage responsibilities, apply problem-solving techniques, and balance their own needs. A randomised controlled trial in the Netherlands demonstrated its effectiveness (Graff et al., 2006a, 2006b), and the programme has since been implemented in several European countries, including Italy, France, Switzerland, and the United Kingdom (Pozzi et al., 2019; Wenborn et al., 2021).

Participants and recruitment

Participants were drawn from three groups. First, COTiD-OTs were invited via newsletters and a national survey distributed to all OTs registered in the Dutch COTiD network (N = 308). Inclusion criteria included practising OT, COTiD trained, and experience in treating people of Moroccan descent with dementia. In the Netherlands, community-based dementia care is delivered exclusively by qualified occupational therapists; occupational therapy assistants or support workers are not part of this care context. Second, MOR-OTs were recruited through snowball sampling based on referrals from the Dutch COTiD expert group and researchers’ professional networks. Inclusion criteria included current practice in the Netherlands, a Moroccan migration background, and professional or informal experience in dementia care. Third, informal caregivers of Moroccan background were approached via personal networks, social media, and the COTiD expert group. They were eligible if they provided care at least once per week. Exclusion criteria for all participants included inability to provide informed consent or insufficient language proficiency in Dutch, English, or Moroccan Arabic. All participants provided written informed consent.

Data collection

Data collection was conducted in successive phases. An initial online survey sent to all registered Dutch COTiD-OTs helped identify focus group participants and informed the development of the interview guides. Two focus groups were held with both COTiD-OTs and MOR-OTs, followed by individual interviews with informal caregivers. The guides were iteratively refined after each session. Focus groups began with a case vignette of a Moroccan client receiving COTiD, prompting open discussion about experiences, perceived barriers, and possible adaptations. Caregiver interviews focused on daily care routines, interactions with occupational therapists, and the perceived cultural fit of COTiD. Interviews were conducted in participants’ homes or via video call. A neutral interpreter fluent in Moroccan Arabic and Dutch was available for real-time translation when needed and was not involved in data collection or analysis. All sessions were audio-recorded, anonymised, and transcribed verbatim. Interviews lasted between 45 and 90 minutes and were conducted by KB, an occupational therapist trained in qualitative research. A second researcher (LRM) observed focus group sessions, took field notes, and assisted in the refinement of the guides.

Data analysis

Survey findings were used to inform the interview guide. A thematic analysis, informed by the constant comparative method, was conducted once all data collection was completed (Braun & Clarke, 2006; Glaser & Strauss, 1967). Two researchers independently coded transcripts and met regularly with the wider team for peer debriefing. Data collection ceased at thematic saturation. The study adhered to COREQ standards for transparency in qualitative reporting (Tong et al., 2007).

Results

Demographic data

Eighteen participants took part in the study: seven COTiD-OTs, six MOR-OTs, and five informal caregivers. Among the five informal caregivers, three reported experience with occupational therapy in the context of dementia care, while two did not. Table 1 provides a detailed breakdown of demographic information.

Table 1.

Demographic characteristics of the participants.

Category	COTiD-OTs	MOR-OTs	Informal caregivers
Number of participants	7 total - 3 in focus group 1 - 4 in focus group 2	6 total - 4 in focus group 1 - 2 in focus group 2	5 total
Gender	7 females	5 females, 1 male	4 females, 1 male
Age range	34–59 years	22–32 years	20–50 years
Average experience as OT	20 years (range 13–37)	4 years (range 2–10)	—
Average experience as OT with persons with dementia	14 years (range 10–21)	3 years (range 1–8)	—
Work setting	Primary care: 5 in private practice and 2 in home care	Primary care and/or nursing home	—

OT: Occupational therapy.

Thematic findings from qualitative data

Thematic analysis yielded three overarching themes, each capturing distinct perspectives while also revealing shared challenges across participant groups.

Theme 1: Seeking the best care

This theme explores how families of Moroccan descent understand and respond to dementia, focusing on culturally rooted meanings, caregiving norms, and obstacles to accessing formal care. The findings reveal how limited understanding of dementia, expected duty around caregiving, and mistrust of professional care shape care-seeking behaviours. These dynamics affect how and when dementia care is accessed, and how it is perceived.

Experiencing dementia as a challenging concept and source of mental burden

Participants described how dementia was often perceived not as a medical diagnosis but as part of the natural ageing process. Both COTiD-OTs and MOR-OTs noted that families of Moroccan descent tended to avoid using the term ‘dementia’, with MOR-OTs highlighting a general unfamiliarity with the condition’s clinical features. As a result, families struggled to interpret symptoms and experienced emotional strain when fluctuations in cognition generated unrealistic hope.

One caregiver described how this lack of understanding led to repeated disappointment:

In the beginning, my mother drew a lot of hope from the good days. But if you don’t know how this disease works, you develop false hope—and that can be very painful.

(Informal caregiver 1)

OTs and informal caregivers alike observed that these misunderstandings could complicate the emotional adjustment to the illness, and often delayed the search for appropriate support.

Viewing family caregiving as a self-evident responsibility

Caregiving was described as a deeply embedded moral obligation within Moroccan families. Both informal caregivers and MOR-OTs indicated that caring for ageing parents was regarded as a natural, expected duty—one that often made formal care seem unnecessary or even inappropriate. Formal care was sometimes viewed as a sign of neglect or a failure to fulfil familial responsibilities.

Informal caregivers reported willingness to adapt their personal and professional lives to accommodate caregiving tasks, even when this created significant strain. One caregiver reflected:

She is our mother, and we do our best. I do it mainly because I do it with love.

(Informal caregiver 5)

This sense of obligation was intensified by community expectations and social pressure. Participants described how caregiving was often underestimated and emotionally taxing:

It’s harder than people think—mentally as well. Especially when others say: “You must take care of your parents.” But if you work or have a family, it’s very difficult.

(Informal caregiver 3)

Reluctance to seek professional dementia care

Across stakeholder groups, participants described a tendency among Moroccan families to delay seeking formal dementia care. OTs reported that referrals often occurred at later stages of the disease, and informal caregivers explained that professional involvement was rarely considered necessary in the early stages. Underlying this reluctance were cultural expectations around family caregiving, as well as limited awareness of occupational therapy and its relevance to dementia care.

MOR-OTs expressed concern that families, while motivated, often lacked the knowledge or skills to provide adequate care without professional support. COTiD-OTs noted that caregiver overload frequently remained unaddressed, even when OTs attempted to discuss it. One OT reflected:

I saw that the daughters were truly overburdened. I asked, “What can I do for you?” But they didn’t take up the offer.

(COTiD-OT 2-6)

Informal caregivers described a general mistrust of formal care systems, shaped by different healthcare expectations and previous experiences:

Where we come from, if you have a problem, you call a neighbour. You trust that more than a care facility.

(Informal caregiver 5)

Despite initial reluctance, families often responded positively to elements of the COTiD programme, particularly psychoeducation, observation, and practical support. However, some professionals expressed disappointment when families remained hesitant to engage with the full scope of the programme, especially when caregiver needs were left unspoken or unacknowledged.

Experiencing challenges in communication and information provision

Communication barriers further complicated service delivery. OTs described difficulties in identifying family expectations, particularly when language differences interfered with mutual understanding. As one OT explained:

It was difficult to find out exactly what the daughter, mother, and son expected.

(COTiD-OT 2-4)

Both COTiD-OTs and MOR-OTs indicated that families were often unfamiliar with occupational therapy, and referrers seldom explained the role of OT in dementia care. Informal caregivers echoed this, noting that therapists’ contributions were not always clear:

People just nod, and when you’re out the door, it’s “just let it go”—they don’t even know why you were there.

(Informal caregiver 3)

Participants also highlighted challenges in understanding family dynamics. OTs sometimes lacked insight into how decisions were made within the family, particularly when not all members were present during consultations:

I never gained insight into how the daughter and son communicated with each other.

(COTiD-OT 2-4)

Summarising theme 1, the findings indicate that effective dementia care by OTs hinges not only on accessible language but also on timely support and communication attuned to cultural and familial dynamics.

Theme 2: Families as managers and decision-makers

This theme focuses on the central role of families in organising, directing, and mediating dementia care. Participants described care decisions as collective processes, often led by family members who prioritise comfort and continuity. Children of first-generation migrants frequently act as cultural and linguistic intermediaries, supporting their parents’ engagement with health professionals. These findings underscore the importance of recognising family dynamics and intergenerational roles in the provision of occupational therapy.

Families taking the lead in dementia care

Informal caregivers consistently described themselves as the primary coordinators of dementia care within the family. Decision-making processes were initiated and carried out collectively, often prioritising comfort and daily well-being over clinical interventions. OTs observed that families typically defined the scope of professional involvement and expected healthcare professionals to adopt a supporting role.

One OT recalled a goal-setting session in which the family’s focus was clear:

The conversation centred on comfort—like getting a good wheelchair—rather than therapeutic goals.

(COTiD-OT 1-2)

Informal caregivers confirmed that professional advice was frequently discussed privately within the family after appointments, and any disagreement was resolved internally:

When the occupational therapist left, my father would ask what was discussed. If he disagreed, he’d say so—but only after she had gone.

(Informal caregiver 2)

These dynamics reflect a strong preference for family-led care planning, where professionals are seen as resources rather than decision-makers.

Children acting as cultural bridges between parents and professionals

Informal caregivers often assumed the role of mediators between their parents and healthcare professionals. This was particularly important given the limited trust older family members, many of whom were first-generation migrants, placed in formal care. Informal caregivers cited past negative experiences and unfamiliarity with dementia as reasons for parental reluctance to engage with healthcare professionals.

Children frequently acted as interpreters and cultural brokers, helping to ensure mutual understanding during consultations. As one caregiver noted:

We grew up here and have a bit of both cultures.

(Informal caregiver 2)

Caregiver presence during appointments was viewed as essential for fostering trust and facilitating culturally responsive care.

Summarising theme 2, the findings illustrate the multi-layered role of families as coordinators, translators, mediators, and decision-makers in dementia care.

Theme 3: Collaborating through trust and understanding

This theme explores how trust, communication, and cultural understanding shape collaboration between professionals, such as OTs, and Moroccan families in dementia care. Three key categories emerged under this theme: trust as a foundation for collaboration, overcoming language barriers, and cultural competences.

Trust as a foundation for collaboration

Trust emerged as a critical precondition for Moroccan families to engage with professionals in dementia care. Informal caregivers described a deep reliance on their own social networks, driven by limited confidence in healthcare professionals. Both COTiD-OTs and MOR-OTs highlighted that building trust required time, emotional attunement, and cultural sensitivity.

Informal caregivers valued professionals who could connect on a human level:

It’s not only about language comprehension, but about empathy, emotional understanding, and true presence.

(Informal caregiver 4)

OTs shared strategies to foster trust, such as initiating informal, culturally resonant conversations and joining families in everyday rituals like sharing mint tea:

You don’t have to do much during that cup of tea, they will narrate. And then, you basically already have the story.

(COTiD-OT 2-3)

MOR-OTs emphasised that establishing trust often preceded any willingness to accept external support, making it a prerequisite rather than a by-product of care.

Overcoming language barriers

While language was often cited as a barrier, participants noted that cultural misunderstanding and insufficient information were equally relevant. OTs encouraged open, non-judgemental questioning and the use of storytelling to uncover needs and preferences.

Interpreters were frequently used, with families often preferring familiar individuals over professional interpreters:

A good interpreter doesn’t have to be official. It can be a son, daughter, or trusted neighbour—as long as it feels familiar.

(MOR-OT 2-2)

However, language challenges were not always the root issue. One MOR-OT recalled:

It turned out the daughter had simply never received any explanation about dementia or the available aids.

(MOR-OT 1-4)

When verbal communication faltered, OTs found that attentiveness to cultural norms and non-verbal cues often helped sustain meaningful engagement.

Developing cultural competence as a core skill

Participants across all stakeholder groups emphasised the importance of OTs possessing core competencies in intercultural care. These included open-mindedness, adaptability, and critical self-reflection. OTs described cultural responsiveness not as a fixed skillset but as a dynamic, evolving practice shaped by real-time interactions:

It’s about recognising the uniqueness of people and adjusting your behaviour and expectations accordingly.

(COTiD-OT 2-6)

MOR-OTs stressed that these intercultural competences were essential for all OTs:

Occupational therapists with a Moroccan background are scarce. We have to do it together.

(MOR-OT 1-4)

Informal caregivers echoed these points, highlighting the importance of clarity and transparency in therapy goals and methods.

Summarising theme 3, the findings show that across participant groups, cultural competence was viewed not as a fixed body of knowledge but as a reflective, ongoing practice essential to responsive dementia care.

Discussion

This study examined how the evidence-based COTiD programme aligns with, and can be adapted to, the cultural needs of Moroccan families affected by dementia. Drawing on the perspectives of informal caregivers, COTiD-trained occupational therapists, and occupational therapists of Moroccan descent, the study offers a nuanced understanding of how culturally responsive dementia care can be delivered within the structure of an established occupational therapy programme. Findings suggest that no fundamental changes to the content of the COTiD programme are required; instead, adaptation is needed in how the programme is introduced, contextualised, and implemented in practice. By triangulating stakeholder perspectives, the study identifies specific cultural, relational, and informational adaptations that can enhance the programme’s accessibility and relevance. To our knowledge, this is among the first studies to explore the cultural responsiveness of COTiD among Moroccan families in the Netherlands, offering empirically grounded insights relevant to diverse European contexts.

The flexible, person- and system-centred structure of the COTiD programme was perceived as enabling family leadership and timely information-sharing, which may enhance engagement and intercultural competence among OTs. This observation aligns with findings from the COTiD-UK study, which reported that the intervention’s flexibility supported meaningful engagement and collaborative goal setting between OTs, family carers, and people with dementia (Burgess et al., 2021). Ensuring culturally sensitive dementia care requires therapists to adopt a warm, open, and empathetic attitude, supported by skills in intercultural collaboration and family-centred practice. Our findings show that caregiving in Moroccan families is often viewed as self-evident, with family direction playing a pivotal role in care decisions. Children and younger generations often act as interpreters, mediators, and “cultural bridges,” a dynamic consistent with other studies on trust and family leadership in migrant dementia care (Ahmad et al., 2025; Bosma and Smits, 2022), has received limited attention in earlier research. By highlighting these mechanisms, this study extends previous research to the Moroccan-Dutch context.

Comparison with previous studies

Similar to earlier studies, a shift is observed among Moroccan informal caregivers and MOR-OTs toward a more collaborative model of care involving professionals. However, unlike research in other ethnic contexts, this study provides context-specific recommendations for adapting COTiD in the Netherlands. A recurring barrier remains the limited awareness of available dementia services, reinforcing findings from European reviews on information gaps among culturally and linguistically diverse families (Gaviola, 2024). Nevertheless, our results indicate that these barriers are not static: younger generations increasingly engage with formal dementia care while retaining family-led coordination. This generational transition highlights the need for continuous adaptation and co-designed interventions.

Informal, culturally resonant approaches, such as conversations over mint tea, were found to foster trust and help bridge both language and informational gaps. This observation supports emerging evidence on narrative and story-based communication as a culturally sensitive strategy in dementia care (Annac et al., 2025). Clear and accessible communication by referrers, including general practitioners and case managers, remains critical for increasing the uptake of COTiD. Narrative formats may be particularly effective given the cultural importance of storytelling in Moroccan families.

Implications for practice: Cultural agility, competence, and humility

A central implication of this study concerns the role of cultural agility—the capacity to adapt communication and care strategies swiftly and sensitively in cross-cultural contexts (Laferriere and Eberman, 2025). While cultural competence and cultural humility remain essential foundations, agility reflects their dynamic application in practice. Based on participants’ accounts, we interpreted that providing culturally responsive care requires flexibility, rapid adjustment of strategies, and ongoing self-reflection, particularly when working with families whose needs and expectations evolve over time.

Our findings point to specific actions that exemplify this need for agility in practice: adjusting communication styles, creating space for storytelling, navigating family hierarchies with care, and revising goals in response to changing family dynamics. These insights suggest that real-time adaptability—conceptualised here as cultural agility—complements, rather than replaces, cultural knowledge, and represents an important yet often under-recognised skill for occupational therapists in multicultural dementia care (Day et al., 2025; Fenn et al., 2025; Foronda et al., 2016).

Additionally, the study underscores the importance of cultural humility as a core professional attribute. Humility involves lifelong self-evaluation and learning, attentiveness to power imbalances, and respect for each family’s lived experience (Suurmond et al., 2010; Tervalon and Murray-García, 1998). Participants’ reflections highlighted openness to unfamiliar perspectives and a willingness to adapt practice accordingly.

Taken together, these concepts emphasise that cultural competence alone is insufficient. Culturally responsive dementia care in diverse societies requires integrating agility and humility, which enable genuine partnership, mutual learning, and ongoing adaptation of care to families’ lived realities. Occupational therapy education can provide an important foundation for developing cultural agility. Educational programmes should support students in critically reflecting on their own cultural assumptions and in developing communication skills for working with diverse clients and their families and/or social networks. They should also prepare students to adapt assessments and interventions to individuals’ sociocultural contexts, for example through guided reflection and experiential learning. After graduation, occupational therapists should continue to strengthen cultural agility through reflective practice, interprofessional collaboration, and opportunities for continuous professional development supported by institutional policies (Seeleman, 2014).

Strengths and limitations

A key strength of this study lies in its inclusion of multiple stakeholder perspectives, allowing a rich and triangulated understanding of cultural adaptation in dementia care. The focus on Moroccan families—the largest minority ethnic group in the Netherlands—offers in-depth insight into cultural needs and care barriers. These findings may also be transferable to other minority communities and contribute to the development of culturally responsive dementia care frameworks across Europe.

However, several limitations should be noted. Although thematic saturation was reached, the number of informal caregivers (n = 5) was relatively small, potentially limiting the diversity of caregiving experiences, particularly regarding gender, generational roles, and care settings. Moreover, people living with dementia were not directly included, restricting insight into how they perceive occupational therapy and potentially biasing the findings toward caregiver and professional perspectives. This study was also conducted within a single national context and relied on self-reported data, which may limit generalisability.

Despite these constraints, the study provides empirically grounded insights that can inform culturally responsive practice and programme adaptation in dementia care. Future longitudinal and cross-cultural research—including the perspectives of people living with dementia—is needed to examine how caregiving expectations, programme relevance, and cultural dynamics evolve over time.

Conclusion

In conclusion, strengthening cultural agility and humility among occupational therapists, and prioritising genuine, ongoing collaboration with families, are central to achieving accessible and effective dementia care for Moroccan migrant families. This study highlights cultural agility as a conceptual shift beyond traditional notions of cultural competence. Rather than relying on static cultural knowledge about cultural groups, culturally responsive care involves occupational therapists engaging in ongoing reflection and responding flexibly to the evolving needs, expectations, and relational dynamics of families in everyday practice. Strengthening cultural agility therefore requires attention not only in clinical practice but also in occupational therapy education and professional development, where reflective learning and engagement with diverse contexts can support therapists in providing responsive, family-centred, and context-sensitive care. Further research should examine how these cultural adaptations can be implemented in practice and monitor changes in caregiving roles and expectations across generations, to further enhance inclusivity and cultural responsiveness in dementia care throughout Europe.

Key findings

• Moroccan families often view caregiving as a moral duty, which may limit engagement with formal dementia care.

• Trust, empathy, and cultural agility are essential for effective collaboration between occupational therapists and families.

• Family members frequently act as cultural mediators and lead decision-making in dementia support.

What this study adds

• Highlights the importance of cultural agility as a dynamic, relational capacity beyond static cultural knowledge.

• Emphasises the central role of families as decision-makers in dementia care and the implications for occupational therapy practice.

• Offers empirically grounded recommendations to guide culturally responsive adaptation of the COTiD programme.