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Abstract

Background

Studies on caregiving burden in Singapore typically focus on issues at a personal or micro level. There is a paucity of research focused at a meso or macro level on caregiving.

Objective

The purpose of this narrative review is to explore the influence of meso and macro factors on caregiving by informal caregivers of older persons in Singapore.

Method

Studies were identified from sources such as CINAHL, PsycINFO, PubMed, Scopus, Web of Science, Google Scholar, as well as other websites for grey literature. Studies focusing on informal caregivers, defined as family, friends, or foreign domestic workers providing care to an older adult (60 and above) were included. Other inclusion criteria include: (a) studies focusing on meso factors (e.g., social norms, community resource, social network) and/or studies focusing on macro factors (e.g., caregiver support policies, workplace policies, care services policies, or caregiver payment policies), (b) studies with outcome measures on caregivers/caregiving such as burden, gains, or grief, and (c) in Singapore.

Results & Conclusion

A total of 43 studies were included in this review. A range of meso factors influencing caregivers/caregiving were identified. Examples include filial piety, norm of women as caregivers, interventions aimed at helping caregivers, and care services such as day cares. However, the influence of macro level factors (e.g., national level policies) was limited due to a relative paucity of research in this area. Areas for further research were also identified.

Keywords

Caregiving burden older adults Singapore

Introduction

Singapore is a city state that is currently experiencing both an aging population and decreasing fertility rate, hence there will be expectedly fewer young adults looking after an elderly population with increased longevity.¹ Presently, there is an estimated, 210,000 adult caregivers looking after their aging family members in Singapore.² Studies have demonstrated that the cost of caregiving is high, both physically and mentally, and that caregivers in Singapore and Asia have lower quality of life scores compared to their Western counterparts.³ Therefore, there is a need to understand the role of various factors influencing caregiving to address and better support the needs of caregivers.

While there have been numerous studies done on the burden of caregiving in Singapore, these studies typically focus on issues at a personal or micro level. Examples include the impact of caregivers’ competence on burden,⁴ depressive symptoms among caregivers,⁵ care recipients’ factors that correlates with stress in caregivers,⁶ the effect of support from foreign domestic workers on caregiving outcomes,⁷ and the health and psychological conditions of caregivers.⁸ Despite the observations of frontline clinicians on the growing prevalence of issues at these levels, there is a paucity of research focused at a meso (e.g., issues surrounding community resources and social support network) or macro (e.g., national policies relating to caregivers) level on caregiving. Hence, a request to review caregiving studies focusing on meso and macro level factors was made by stakeholders working in healthcare.

As such, the purpose of this review is to explore the influence of meso and macro factors on caregiving by informal caregivers of older persons in Singapore. For the purposes of this review, we defined informal caregivers as anyone caring for the older person in a non-professional capacity. Examples are family members or foreign domestic workers (FDW). Healthcare professionals such as nurses were excluded. This review was guided by a framework developed by Friedemann-Sánchez and Griffin on the economic and health outcomes of informal caregiving.⁹ While other frameworks were considered,¹⁰ we chose to adopt Friedemann-Sánchez and Griffin’s framework due to its strong focus on meso and macro factors, and the linking of these factors to caregivers’ burden/outcome.

Briefly, the framework is organized into three levels: micro, meso, and macro. At the micro level, factors include care recipients’ functional status, resources available to caregivers, and household resources. At the meso level, factors include caregiving social norms, community resources, and social support network. At the macro level, factors include workplace policies, care service policies, and caregiver payment policies. The framework further postulates that factors at the micro and meso level have an influence on one another, and that meso level factors would influence caregiver burden, which influences caregiver outcomes.

Caregiver burden consists of objective factors such as number of caregiving hours or limitations to activities of daily living in care recipients, and subjective factors such as emotional demands, lack of personal time, or family/work imbalances. Meanwhile, caregiver outcomes include economic (e.g., employment or financial strain) and health (e.g., decrease in physical and mental health) outcomes. A slight modification was made to the framework, in that the research team expanded the meaning of caregiver outcomes to include positive outcomes such as competency, coping strategies, gains, mastery, and self-efficacy. This was done to account for the possibility that some meso or macro factors (e.g., adequate community resources or strong social support network) could have positive effects that go beyond the economic or health aspects of caregivers’ outcome. Macro level factors would exert a top-down influence on meso level factors. A figure of the original framework can be found in Figure 1.

Figure 1.

Economic and health outcomes of informal caregiving framework.⁹

Methods

Search strategy

We searched allied health, biomedical, nursing, psychology, and social science electronic databases (CINAHL, PsycINFO, PubMed, Scopus, Web of Science), grey literature search engine (Google Scholar), thesis repository of Singaporean universities (Nanyang Technological University, National University of Singapore, Singapore Management University, Singapore University of Technology and Design), and websites of local organisations involved in elder care (e.g., Agency for Integrated Care, Dementia Singapore) in Feburary 2022. We engaged the assistance of a librarian to conduct the search in electronic databases. The search strategy used terms such as “caregiving”, “foreign domestic workers”, and “Singapore”. We limited our search to literature published from 2010 after consultation with several domain experts, as they opined that the caregiving landscape in Singapore has evolved over time hence any literature published before 2010 would be outdated and less relevant.

Inclusion and exclusion criteria

We applied the PICO framework to formulate our inclusion and exclusion criteria as seen in Table 1.

Table 1.

Inclusion and exclusion criteria.

	Inclusion criteria	Exclusion criteria
Population	Informal caregivers (family, friends, or foreign domestic workers) providing care to an older adult (60 and above)	Formal care by and/or healthcare professionals
Population		Mean age of care recipient is unknown or below 60 (unless care recipients are dementia patients)
Phenomenon of Interest	When one of the following was studied as having an impact or influence on caregivers/caregiving	When micro factors were examined/studied
	Meso factors: Caregiving social norms (e.g., filial piety, women being main caregivers), community resources (e.g., interventions, programs), social support network (formalized networks)	Impact of care recipients’ functional status and household resources on caregivers/caregiving
	Macro factors: caregiver support policies, workplace policies, care services policies, or caregiver payment policies	Caregivers’ personality, coping styles, health, or mental health on caregiving
Context	Singapore	Not in Singapore
Outcomes	Negative outcomes on caregivers/caregiving process: Burdens, caregivers’ health (physical or mental) etc.	Mainly focused on outcomes on care recipients/patients
Outcomes	Positive outcomes on caregivers/caregiving process: Competency, coping strategy, gains, grief, mastery, self-efficacy etc.	Outcomes on formal caregiving/healthcare professionals
Study & publication types	Journal articles (intervention studies such as pilot studies, observational studies etc.)	Studies on scale & instrument development validation
	Grey literature such as: published reports, briefs, or conference proceedings	Commentaries & press releases from organisations
		Grey literature such as: blog posts, news articles
	Publications that collect primary data	Publications that do not collect primary data

Study Selection and data extraction

Four reviewers (JG, KAJ, PL, and TJY) were involved at the title/abstract screening and full-text screening stage. All four reviewers screened the citations independently, and each citation had to be screened by two reviewers. Any disagreements were either resolved via discussion between the two reviewers or consultation with a third reviewer. Data extraction was done by JG, PL, and TJY, guided by the framework from Friedemann-Sánchez and Griffin.⁹

The extraction process is as follows. Each article was first screened to determine if the phenomenon being studied fell under meso or macro factors. For example, a study aiming to understand the reasons of non-use of day care services by caregivers of persons with dementia would be considered as a study with a meso factor,¹¹ as day care services would be considered a form of community resource. In addition, filial piety was indicated as having an impact on caregivers’ decision on not using day care services, which would be considered as a caregiving social norm under meso factors. The findings of the study were extracted into either caregiver burden or caregiver outcome. For instance, the aforementioned study found that usage of day care services was low as the social norm of filial piety meant that caregivers chose not to place their care recipients in the day care, even though it could help alleviate the caregivers’ burden. Screening and data extraction was done in Covidence, a web-based tool.¹²

Results

Summary

A total of 1495 articles were identified using the initial search. After applying the eligibility criteria to the initial screening and full-text screening, 43 articles were included for the review. As some studies had a diverse sample of older adults with different conditions, we were not able to stratify the results using older adults’ health condition. A consort diagram of the review process is in Figure 2.

Figure 2.

Consort diagram.

Meso factors

Meso factors include social norms, available community resources, and social support networks. The social norms found in our review include filial piety and the idea that women should be or are better suited to be caregivers. Community resources pertain to the various organizational resources available to caregivers such as educational talks, the multitude of interventions aimed at caregivers, and the different types of care services available. Social support network comprises both formalized support groups as well as support from religious groups.

Meso factors (social norms)

Filial piety

A total of 13 studies examined or identified filial piety as a factor which impacted caregiving. Caregivers in several studies expressed that they undertook the caregiver role out of filial piety, and some of them saw caregiving as an opportunity to demonstrate their appreciation and love for their parents.^13–18 However, others saw caregiving as an obligation due to societal and/or parental expectations.^11,19,20 Generally, those who were: (a) more likely to prefer caring for the care recipient at home, (b) less likely to hire an FDW, (c) experience some form of positive feelings from caregiving, and (d) see the use of services such as nursing homes as abandonment cited filial piety as a motivating factor.^{11,19,21–23}

The social expectations of being filial can be a source of stress as some caregivers were thrust into the demanding role, or a source of tension between caregivers and their families when other siblings maintained their distance from their parents.^18,20

Women as caregivers

A total of eight studies examined or had participants whose responses related to the theme of women as caregivers. Generally, more women were caregivers compared to men.^24,25 Women felt that their gender meant that they had no choice but to be the caregiver, with some women also stating their unmarried status as another contributing factor.^15,16,18,20 Women have also been observed to react differently than men when family duties interfere with work, suggesting that they may have internalized the norm of being the default caregiver due to their gender.¹⁹ There was also the assumption that caregiving would come naturally to women, leading to FDW taking on caregiving jobs even though they may not possess the relevant skills.²⁶

Meso factors (community resources)

Programs to support caregivers

A total of 21 studies explored the effect of caregiver support programs such as financial assistance or workshops on caregiving. One observation was that most programs available to FDW focused on employment-related matters, with minimal assistance for caregiving-specific matters.²⁶ Family caregivers with the perception that others cannot help them and the preference of keeping issues within the family also led to an avoidance of using such programs.²⁷ A lack of awareness about the assistance provided by community services such as voluntary or religious organizations was reported as well.²⁸ Caregivers also expressed frustrations with approaching governmental and non-governmental welfare organizations for assistance, much due to negative experiences with social service officers and the perception that the outcomes of applying for assistance were arbitrary and unreliable.²⁹

Some programs were also observed to benefit caregivers. Formal talks organized by associations on dementia and support groups helped caregivers cope with the demands of caregiving and have been found to be associated with positive gains in caregiving.^30,31 Similarly, Alzheimer Disease Association (now known as Dementia Singapore) was an avenue for caregivers to acquire knowledge and skills in dementia care, and a source of support.^16,18 Foreign domestic workers caring for frail older adults expressed similar sentiments as well, stating that healthcare professionals from hospitals and home care services were a source of support in teaching them to provide optimal care.³²

14 studies involved an intervention program aimed at helping caregivers, with most of them focusing on reducing caregivers’ burden or anxiety. Overall, the results were mixed. Interventions that had some effects on caregivers’ ZBI scores include: (a) an app-based intervention, (b) using the ZBI as an early identification tool for targeted intervention, (c) rehabilitation for older adults with mild dementia, and (d) an integrated care initiative providing services such as case management and caregiver education.^33–36 Conversely, an arts program aimed at persons with dementia did not have any effect on caregivers’ ZBI scores.³⁷ An overview of the various interventions and their effects can be found in Table 2.

Table 2.

Overview of Intervention Effect for Zarit Burden Interview, Anxiety, and Stress.

Zarit burden Interview
Positive effect	No effect
App-based intervention³³	Arts program³⁷
ZBI as an early identification tool for targeted intervention³⁴
Rehabilitation for older adults with mild dementia³⁵
Integrated care initiative providing services such as case management and caregiver education³⁶
Anxiety and stress
Integrated suite of care services delivered by an inter-disciplinary team³⁸	Mindfulness-based intervention⁴¹
Integrated care intervention with caregiver training³⁹	Dance intervention⁴²
Caring for the Caregiver Program to help caregivers cope and communicate⁴⁰
Aging-in-Place intervention¹³

Interventions that had positive results for anxiety and stress reduction include: (a) an integrated suite of care services delivered by an inter-disciplinary team, (b) an integrated care intervention with caregiver training, (c) a Caring for the Caregiver Program to help caregivers cope and communicate, and (d) an Aging-in-Place intervention.^13,38–40 Conversely, interventions that did not have any effect on caregivers’ anxiety and stress level include a mindfulness-based intervention, and a dance intervention.^41,42 In terms of improving caregivers’ QoL, interventions that had an effect include the Caring for the Caregivers Program, and a dance intervention.^40,42 An after stroke program focusing on fall prevention for stroke patients and education for caregivers did not report any improvements to caregivers’ health or strain.⁴³

An intervention aimed at increasing the utilization of enrichment programs and care services for people with dementia via education and individualized recommendations had many of their participants rejecting the individualized recommendations.⁴⁴ While interventions such as courses on caregiving tips and knowledge about dementia can be helpful for caregivers such as FDW, these efforts may be negated by unsupportive family members.⁴⁵

Care services

A total of 16 studies looked at care services, such as home-based care services, day care centers or nursing homes in Singapore. A trend of underutilizing such services was observed, at times due to filial piety, high cost, poor perception of such services, or these services not meeting caregivers’ needs.^{11,14,15,22,26,28,29,46,47} Studies suggest that the effects of such services were mixed. Observed benefits include (a) reduction in caregiving time, (b) reduction in caregivers’ burden or stress, or (c) providing caregivers with respite.^{20,46,48–50} However, other studies did not find any impact on caregivers.^51,52

Meso factors (social support network)

Social support

Three studies discussed social support and its influence on caregiving. Formalized support groups appear to be beneficial for caregivers, allowing them to learn coping strategies as well as to receive validation for their actions and feelings.^16,30 Support from religious groups have also been reported as a means to ease caregivers’ anxieties.²⁸

Macro factors

Macro factors refer to national level factors such as policies influencing caregiving. Originally, we had intended macro factors to cover policies such as workplace policies, care service policies, and caregiver payment policies. However, these policies were rarely explored in the studies reviewed, except for one report highlighting the lack of paid eldercare leave. Instead, we discovered other national level factors affecting caregivers, such as Singapore’s lockdown in response to COVID-19, and limitations associated with subsidies.

The lack of paid eldercare leave has been highlighted by some caregivers as an issue as it rendered managing both caregiving duties and work challenging.¹⁵ Some caregivers reported that providing care became more difficult due to lockdown measures imposed nationwide in response to the COVID-19 pandemic, with feelings of helplessness and stress increasing as caregivers no longer had access to support services.^24,53 The lack of legal limits on FDWs’ working hours was found to be a likely contributing factor to their high working hours and lack of rest.²⁶ With regards to system level policies on finances, cost of care was identified as another concern for caregivers due to difficulties in qualifying for subsidies, or the limited aid provided by these subsidies.¹⁵ For example, caregivers may only receive one-off subsidies for assistive devices that need to be replaced over time. Qualifying for financial assistance can be challenging as having a job made it more difficult, even if the salary is low.²⁹ Stigma among the public against those with dementia was highlighted as a challenge for caregivers as well, as they were restricted to staying indoors with their care recipient to avoid strife with others caused by the care recipient’s unexpected behavior.^28,47

Discussion

Singapore is a fast-aging society, with increasing caregiving needs for the growing older adult population. While caregiving impacts care recipients and caregivers on the micro-level, the impact of meso- and macro-level factors such as availability of community resources and policies on caregiving in Singapore have not been examined. To our best knowledge, this is the first review to explore the influence of meso and macro factors on informal caregivers of older persons in Singapore.

Filial piety has been cited as a source of motivation for some caregivers, but an obligation or even a source of stress for others. This could partly be due to expectations of social norms and non-caregiving family members keeping a distance from the care recipient, resulting in the caregiver being left with little choice but to take on caregiving duties. While such social norms may be deeply ingrained, previous research on changing other social norms have shown promising results, such as norms associated with gender-based violence, or norms associated with prejudice.^54,55 Hence, it might be worthwhile to explore the possibility of changing unhelpful norms, such as one that expects the responsibilities of caregiving to fall primarily on the eldest children or unmarried daughters. Research might also be needed to help caregivers navigate this unique sense of burden or guilt. Practitioners working with these types of caregivers can try to involve other family members, as well as paying closer attention to these caregivers for signs of burden or stress.

Attempts at designing interventions to alleviate some of the difficulties faced by caregivers generally showed promising results. Further research in this area can focus on examining the cost-effectiveness and longitudinal effects of these interventions, as well as the potential of these interventions to be implemented on a wider scale. For example, the follow-up duration for the study using ZBI as an early detection tool for targeted intervention had a follow up period of 30 days³⁴ Given that caregiving can take years, it is necessary to examine if interventions to reduce caregivers’ difficulties can produce benefits that can be sustained over a longer period. Another intervention involving integrated care by an inter-disciplinary team reported promising results such as decreasing caregivers’ stress and reducing emergency department visits.³⁸ However, the involvement of multiple healthcare and allied health professionals may mean that it is difficult for the intervention to be scaled up, in part due to lack of manpower in the healthcare system. Hence, there might be a need to address this deficit at a national level by offering suitable incentives to healthcare professionals.

Effects of care services appears to be mixed, with some studies reporting benefits for caregivers while other did not. Further research on this topic should explore the reasons behind the lack of positive effect for care services. One speculation is that the additional demands (e.g., advocating, coordinating care, transportation) involved with placing the care recipient in such services could be a source of stress.²⁵ So, a plausible first step would be to explore the direct impact of such demands on caregiver stress, and addressing these demands should an association be found. Given that several studies have also indicated that such services do not meet the needs of caregivers, another research area would be to work with these services to better address the needs of caregivers. Care service agencies and practitioners working here could perhaps reduce caregivers’ stress by identifying and addressing the difficulties caregivers face while using their services. Causes of under-utilization should be a research focus as well, as efforts to improve these services would be wasted if utilization rates continue to remain low.

Formalized support groups and religious groups have been observed to be beneficial for caregivers. However, there is minimal information on such social groups in the studies covered in this review. Further research in this area could be informative, such as the frequency of meetings needed for these groups to be beneficial, or the mechanisms by which these groups exert a positive influence (e.g., providing time away from the care recipient or by providing a listening ear).

Another issue noted in this review pertains to the challenges faced by FDW, who may be assigned care recipients that they are not prepared to look after. There is a lack of caregiving and caregiver support for them, since most FDW-related resources available are focused on employment-related matters instead of caregiving.²⁶ Majority of the research on caregivers in Singapore do not focus on FDW. Hence, there is a knowledge gap on the difficulties encountered by them, which may differ in some areas from those experienced by the family caregivers. However, one difficulty that is known are their high working hours and lack of rest. A national level initiative to address this issue, such as a policy legislating the maximum number of hours a FDW can work each day might be needed.

A notable absence in this review are studies relating to macro factors such as the impact of policies on caregivers/caregiving. Only a small number of studies in our review explored the impact of some of the policies on caregivers/caregiving.^{15,24,26,28,29,47} This highlights the need for further research in this area. For example, although flexible work arrangements is encouraged, take-up remains low.¹⁵ Policy researchers could explore the reasons for low take-up and the challenges caregivers face so that improvements to the national policy on flexible work arrangements can be made. Other possible policy options to explore include the benefits of paid eldercare leave, which has been emphasized by caregivers as an important need and the challenges in implementing them.

Limitations

First, the classification of meso and macro factors is subjective. We have tried to limit this subjectivity through pre-defining the factors at each level (e.g., caregiving social norms), and via discussions among members of the study team. Second, our grey literature search of relevant organizational websites (e.g., AIC) is based on the study team’s own knowledge of organizations in Singapore that are involved with caregiving. Hence, it is plausible that some organizations may have been missed out.

Conclusion

This review set out to explore the influence of meso and macro factors on caregiving by informal caregivers of older persons in Singapore. The influence of meso factors such as filial piety, societal norm of woman as caregivers, community resources, interventions targeted at caregivers, care services, and social support were identified, and recommendations were made for researchers and practitioners. Meanwhile, the information on the influence of macro factors such as policies is limited, making it difficult to identify areas of improvement here. Hence further research in this area is needed.

Footnotes

Acknowledgements

We would like to express our sincere appreciation to Ms Yasmin Lynda Munro at the Nanyang Technological University, Lee Kong Chian School of Medicine Library, for her assistance in the review search strategy and the database searches.

Author contributions

All six authors were involved in the conception of this study. JG, KAJ, PL, and TJY carried out the review with advice and input from PPG and PY. An initial draft was written by JG, and the remaining five authors added their input to the draft.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship and/or publication of this article.

ORCID iD

Jonathan Gao

Availability of data

Data sharing is not applicable to this article, as no data sets were generated or analysed during the current study.

Appendix 1

Title	Title of publication
Last Name of first Author/Organization Name	Last name of the first author, or the name of the organization that published the study/report
Publication year	Year study/report was published
Publication type	Study/report
Aim of study
Sample Size
Caregiver type	Type of caregiver in sample, such as family members, friends, or foreign domestic workers
Care recipients’ health conditions	Health condition of care recipient, such as cancer, dementiaetc.
Meso/Macro factors	Meso level factors
	Caregiving social norms	Norms surrounding who should, or are obligated, to be the caregiver. Examples include adult children being obligated to care for parents because of filial piety or women being expected to be the caregiver due to their gender
	Community resources	Resources and support available to caregivers. Examples include community services provided by religious organisations, care services for dementia patients, or interventions meant to alleviate caregivers’ burden
	Social support network	Formalised social support network (e.g. support groups)
	Others	Other factors that may be considered as meso level factors, but do not fall into any of the above categories
	Marco level factors
	Caregiver payment policies	Policies surrounding the idea of paying caregivers to allow them to remain at home with care recipients
		Care service policies	Policies pertaining to care services
		Workplace policies	Examples include parental leave
		Others	Other factors that may be considered as macro level factors, but do not fall into any of the above categories
Caregiving	Caregivers’ burden (objective)	Refers to objective demands placed on caregivers, such as assisting care recipients with tasks relating to activities of daily living, number of hours spent on caregiving, or cost of care
	Caregivers’ burden (subjective)	Refers to subjective burden experienced by caregivers. Examples include feeling a lack of time for socialising and leisure, feeling that there is an imbalance between family and work, or other emotional demands
	Caregivers’ outcome
	Economic	Refers to outcomes such as changes to caregivers’ employment status, or impacts to caregivers’ financial status (e.g. loss of income or assets)
	Health strain	Refers to outcomes such as caregivers’ physical or mental condition, and includes issues such as anxiety, depression, and grief
	Other outcomes
	Competency	Refers to an individual’s self-assessment within the domain of caregiving, specifically to the self-appraisal of their adequacy and performance as a caregiver
		Coping strategies	Refers to the psychologically protective responses of individuals when experiencing stressful situations
		Gains	Refers to positive outcomes (e.g. personal growth, gains in relationships and spiritual growth)
		Mastery	Refers to an individual’s perceived global sense of control over life situation
		Self-efficacy	Refers to an individual’s belief in performing confidently and capably in specific situations

Appendix 2

Author (Year)	Study & publication type	Sample	Meso/Macro factor
Aloweni (2021)	Journal article (RCT)	44 caregivers who were family of the care recipient	Mindfulness-based intervention did not had an effect on caregivers’ anxiety and stress
Ansah (2013)	Journal article (Modelling study)	N/A	Increase in availability of nursing homes can reduce amount of time spent caregiving
AWARE (2019)	Organizational report (Cross-sectional study)	22 caregivers who were family of the care recipient	Filial piety meant that caregivers were keen to care for their care recipients at home because they felt that being directly involved in care was the best way to fulfil their familial obligations
			Women said that they felt they had no choice but to be their parents’ caregivers because of their gender and unmarried status
			Filial piety, cost and poor quality of long term care services were reasons for not using these services
			Lack of paid eldercare leave an issue as it rendered managing both caregiving duties and work challenging
			Difficulties in qualifying for subsidies, or aid provided is limited
AWARE (2020)	Organizational report (Cross-sectional study)	25 foreign domestic workers	Assumption that caregiving will come naturally to women, even if they may not have the relevant skills
			Resources for foreign domestic workers focus on employment-related matters
			Cost of care services was reason for under-utilization
			Lack of legal limits on FDWs’ working hours likely a contributing factor to their high working hours and lack of rest
Basnyat (2021)	Journal article (Cross-sectional study)	24 caregivers who were family of the care recipient	Belief in filial piety led caregivers to take up the role, and became a source of tension when other family members were seen as not adhering to filial piety
			Unmarried daughters retired or quit their jobs to provide full-time care for their parents
			Alzheimer Disease association was an avenue for caregivers to acquire knowledge and skills in dementia care
Chan (2019)	Journal article (Cross-sectional study)	16 caregivers who were family of the care recipient	Caregivers lamenting that they must be the caregiver due to filial piety
			Daughters expected to be the caregiver
			Day care services used by caregivers to seek respite
Chew (2015)	Journal article (prospective observational cohort study)	55 caregivers	Multimodal cognitive and physical rehabilitation program for care recipient. Improvements in caregivers’ ZBI scores
Eom (2016)	Journal article (longitudinal study)	781 caregivers who were family of the care recipient	More women were caregivers
Ha (2020)	Journal article (Quasi-experimental study)	344 caregivers	Intervention consisting of interdisciplinary members who work together across healthcare settings to provide a comprehensive suite of services. Improvements in caregivers’ ZBI scores
Ha (2020)	Journal article (pre-post study)	266 caregivers who were family or foreign domestic workers	Intervention is assessment and counselling program with individualized recommendations for person with dementia to increase utilization of programs and services. Many participants rejected recommendations
Han (2013)	Journal article (Cross-sectional study)	5 caregivers who were family of the care recipient	Caregivers generally were not receiving any formal assistance, such as support from the family service Centres (FSC) or the community as they preferred to keep issues within the family and think others cannot help them
Heng (2019)	Journal article (Cross-sectional study)	11 foreign domestic workers	Support that healthcare professionals provided to the foreign domestic workers during care training were perceived to be invaluable to provide optimal care
Huang (2016)	Journal article (Cross-sectional study)	16 caregivers who were family of the care recipient	Filial piety, cost, and services not meeting needs were caregivers’ reasons for not using day care services
Keong (2012)	Conference abstract	37 caregivers	An inter-disciplinary team delivers an integrated suite of medical, nursing, rehabilitation, social and personal care services reduce stress for caregivers
Koh (2020)	Journal article (pre-post study)	21 family caregivers	Dance intervention for persons with dementia did not reduce stress for caregivers
Koh (2021)	Journal article (longitudinal study)	214 caregivers who were family or friends of the care recipient	Use of formal services not associated with any impact on caregivers
Koo (2021)	Journal article (longitudinal study)	9 caregivers who were family of the care recipient	Filial piety was closely observed and adhered to by the intergenerational family members, and a motivating factor in caring for the care recipient
			Some of the female interviewees also shared that traditional perceptions of gender-specific support still remained an expectation
			Support group from Alzheimer Disease association a source of support for caregivers
Lee (2021)	Grey literature	1320 caregivers	More women were caregivers
Lee (2021)	Grey literature	1320 caregivers	Lockdown measures imposed nationwide in response to the COVID-19 made caregiving difficult
Leong (2021)	Thesis	195 caregivers who were family of the care recipient	Filial piety seen as an obligation Women internalizing the norm of being the caregiver due to their gender
Leow (2015)	Journal article (RCT)	80 caregivers who were family of the care recipient	Psychoeducational intervention reduces caregivers’ stress
Liew (2010)	Journal article (Cross-sectional study)	334 caregivers who were family of the care recipient	Gains in caregiving associated with participation in support groups
Liew (2020)	Journal article (prospective cohort study)	178 caregivers who were family of the care recipient	Dementia care services attenuated caregivers’ burden
Mehta (2017)	Journal article (Cross-sectional study)	45 caregivers who are family of the care recipients, or foreign domestic workers	Despite the stress experienced in caregiving, the caregivers interviewed underscored the strong sense of filial duty that motivated them to continue to care
Penkunas (2016)	Journal article (Cross-sectional study)	32 caregivers who were family or friends of the care recipient	Filial piety influencing caregivers’ decision to care for older adults at home
Penkunas (2016)	Journal article (Cross-sectional study)		Aging-in-place (AIP) program reduces caregivers’ stress
Ramanathan (2016)	Journal article (Cross-sectional study)	12 caregivers who were family of the care recipient	Filial piety meant that caregivers saw caregiving as an opportunity to demonstrate their love and appreciation for the care they had previously receive from the care recipient. Institutionalisation was a last resort
Ramanathan (2016)	Journal article (Cross-sectional study)	12 caregivers who were family of the care recipient	Filial piety and cost were caregivers’ reasons for not using long term care services
Rozario (2019)	Journal article (Cross-sectional study)	488 caregivers who were family of the care recipient	Caregivers who reported higher levels of filial piety were less likely to hire an FDW than those who reported lower levels
Setia (2011)	Journal article (Cross-sectional study)	30 stakeholders on issues relating to cognitive impairment/dementia. Some of the stakeholders were caregivers	Cost, long waiting lists, and accessibility were some barriers to accessing care services
Setia (2011)	Journal article (Cross-sectional study)		Stigma among the public against those with dementia was highlighted as a challenge
Suen (2018)	Journal article (Cross-sectional study)	19 caregivers who were family of the care recipient	Barriers and gaps in seeking assistance from institutions (e.g., process of obtaining financial assistance appears arbitrary). Main assistance from religious or voluntary welfare organisations
			Difficulties with transporting care recipient to care services, so caregivers do not access such services
			Qualifying for financial assistance can be challenging as having a job made it more difficult, even if the salary is low
Tam (2018)	Journal article (Cross-sectional study)	25 foreign domestic workers	Courses to impart caregiving tips and knowledge about dementia can be helpful for foreign domestic workers but these efforts may be negated by unsupportive family members
Tan (2021)	Journal article (pre-post study)	32 caregivers who were family of the care recipient	Arts program aimed at persons with dementia did not have any effect on caregivers’ ZBI scores
Teoh (2017)	Conference abstract	41 caregivers who were family of the care recipient	Not using support services associated with higher caregivers’ burden
Tew (2010)	Journal article (Cross-sectional study)	266 caregivers who were family of the care recipient	Caregivers prefer to care for relatives in their own home, likely due to filial piety
Towle (2020)	Journal article (pre-post study)	80 caregivers who were family or friends of the care recipient	ZBI as a tool for early recognition of burden and intervention. Improvements in ZBI scores were observed
Tsao Foundation (2020)	Organizational report	N/A	Lockdown measures imposed nationwide in response to the COVID-19 made caregiving difficult

Tuomola (2016)	Journal article (Cross-sectional study)	6 caregivers who were family of the care recipient	Formal talks organized by associations on dementia helped caregivers cope with the demands of caregiving
Tuomola (2016)	Journal article (Cross-sectional study)	6 caregivers who were family of the care recipient	Joining support groups provided caregivers with opportunities to seek validation for feelings and actions
Vaingankar (2013)	Journal article (Cross-sectional study)	63 caregivers who were family of the care recipient	Caregivers were either unsure or expressed lack of knowledge of services provided by voluntary or religious organizations
			Many caregivers were against the idea of long-term residential care due to traditional expectations (e.g., filial piety)
			Poor quality and services, cost, and not meeting caregivers’ needs were reasons for not using care services
			Religious group can be a source of emotional support for caregivers
			Stigma among the public against those with dementia was highlighted as a challenge
Woo (2017)	Journal article (cost analysis study)	51 caregivers	Use of day care centres did not affect informal cost of care
Xiao (2016)	Thesis	40 caregivers who were family of the care recipient	Multi-component intervention with educational information, app, forum. Some improvement in ZBI scores
Xu (2021)	Journal article (pre-post study)	7 caregivers who were family or foreign domestic workers	Fall prevention program for stroke patients did not improve caregivers’ health or strain
Yong (2017)	Conference abstract	444 caregivers	Integrated care for person with dementia and their caregivers through a mobile multidisciplinary team with holistic assessments, interventions and psychosocial support reduce caregivers’ distress
Yu (2016)	Journal article (pre-post study)	3 caregivers	Low take-up and high dropout rates for referrals to day care program
Yu (2016)	Journal article (pre-post study)	3 caregivers	Day care service helped to reduce caregivers’ anxiety and burden, and caregivers had more time to engage in personal activities
Yuan (2021)	Conference abstract	29 caregivers	Caregivers gain positive feelings from being filial

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The influence of meso and macro factors on caregiving of older persons in Singapore: A narrative review

Abstract

Background

Objective

Method

Results & Conclusion

Keywords

Introduction

Methods

Search strategy

Inclusion and exclusion criteria

Study Selection and data extraction

Results

Summary

Meso factors

Meso factors (social norms)

Filial piety

Women as caregivers

Meso factors (community resources)

Programs to support caregivers

Care services

Meso factors (social support network)

Social support

Macro factors

Discussion

Limitations

Conclusion

Footnotes

Acknowledgements

Author contributions

Declaration of conflicting interests

Funding

ORCID iD

Availability of data

Appendix 1

Appendix 2

References