Abstract
Objective
To: (1) compare the effectiveness of the ‘Usual iSupport’ and ‘Tailored iSupport’ programs on carers' quality of life (QoL); self‐efficacy; and their care recipients' QoL; and (2) explore carers' acceptance of and adherence to the programs, satisfaction with the support, recruitment and retention rates, and staff training rate in a 6‐month trial.
Methods
An internal pilot randomised controlled trial nested in a large effectiveness implementation trial.
Results
In total, 78 carers enrolled in the trial. Most carers were female (66% or 85%), with a mean age of 65.6 years. We detected a statistically significant difference of mean score in mental health‐related QoL (3.44 [95% CI: .53, 6.35]; p = .02); self‐efficacy for responding to changed behaviours (9.02 [95% CI: 1.24, 16.81], p = .02); and self‐efficacy for controlling upsetting thoughts (8.83 [95% CI: 1.14, 16.51]; p = .03) between the ‘Usual iSupport’ group and the ‘Tailored iSupport’ group at 6 months post‐intervention. The recruitment and retention rates were 17% and 100%, respectively. Carers in the ‘Tailored iSupport’ group completed 16.5 iSupport units, attended 4.5 peer support meetings and rated their satisfaction with the support highly. The staff training rate was 36%.
Conclusions
This internal pilot study identified improved mental health‐related QoL, self‐efficacy for controlling upsetting thoughts, and for responding to changed behaviours in the ‘Tailored iSupport’ group. The recruitment rate was low, but the retention rate was high, and carers showed adherence to the intervention.
Keywords: caregivers, dementia, feasibility study
Practice impact.
This feasibility study identified an excellent retention rate of Chinese carers in the trial. However, the recruitment rate was low; thus, future trial needs to allocate a sufficient time to achieve a sample size. The intervention effects identified in the trial need to be confirmed in a fully‐powered study.
1. INTRODUCTION
Carers from culturally and linguistically diverse (CALD) communities in Australia have experienced difficulties in obtaining dementia care education in their preferred language due to structural discrimination in the social care system. 1 , 2 Remaining in such a situation significantly limits their ability to maintain health and well‐being for themselves and their care recipients. 3 The World Health Organization (WHO) developed the iSupport for Dementia program, a self‐guided psychoeducation program for informal carers of people with dementia. 4 The program enables carers to self‐care to reduce their stress and care for people with dementia (File S1). 4
Before this study, we followed the WHO iSupport program adaptation guideline to translate the program into a simplified Chinese language iSupport version and a traditional Chinese language iSupport version in collaboration with researchers from greater China. 5 We also followed the WHO guideline to undertake a qualitative study to culturally adapt the two Chinese versions to the Chinese‐Australian community and reported the findings. 5 Approval from the WHO for these two Chinese iSupport versions was acquired through the peer review process according to the adaptation guideline. In addition, we undertook a randomised controlled trial (RCT) to evaluate the effectiveness and cost‐effectiveness of an online multicomponent Chinese iSupport intervention to meet stakeholders' expectations for using the intervention to address challenges in supporting Chinese carers. 6 In this study, we name the online multicomponent Chinese iSupport intervention the ‘Tailored iSupport’ program, which includes these main components: (1) self‐guided study using one of the Chinese iSupport manuals based on preference; (2) facilitator‐enabled monthly carer peer support meetings; and (3) needs‐based facilitator support for carers to access care services. 6 The ‘Tailored iSupport’ program showed effects on carers' mental health‐related quality of life (QoL), self‐efficacy for controlling upsetting thoughts about caregiving and distress reactions to changed behaviours of people with dementia compared with the usual care. 6
On the completion of the Chinese iSupport program RCT in Australia, stakeholders recommended the need to embed the evidence‐based ‘Tailored iSupport’ program in aged care services. 2 Access the Chinese iSupport program to perform self‐guided learning (hereafter: The ‘Usual iSupport’ program) was expected. 2 Chinese carers' expectations for different iSupport program interventions reflect their diverse needs in dementia care. The ‘Usual iSupport’ program has been implemented in most WHO member countries as a single component intervention. 7 , 8 , 9 The intervention lasted 3 months 7 , 8 or 6 months 9 and the outcomes were measured at baseline, 3 and 6 months post‐baseline. However, a full powered RCT using the ‘Usual iSupport’ program in the UK showed no effects on carers' mental health, quality of the caregiving relationship, dementia knowledge and the QoL of people with dementia compared with usual care. 9 The results were attributed to carers' low‐level engagement in the iSupport program, as evidenced by an average of four login times during the 6‐month intervention period. A similar finding was also reported in iSupport RCTs conducted in India and Portugal. 7 , 8 In contrast, one study identified that facilitator‐enabled needs assessment using the ‘Risk Appraisal Measure’ could enable carers to identify their care needs and motivate them to take action to meet their needs. 10 Furthermore, peer support was viewed as an effective strategy to connect carers with peers to overcome social isolation and support each other. 11 Randomised control trials to compare the ‘Usual iSupport’ program and the ‘Tailored iSupport’ program are much needed to generate evidence‐informed support for carers.
Recruiting and retaining carers to psychoeducation programs were challenges due to various factors affecting their participation in the program, such as overloaded carer responsibilities and difficulties in reaching carers. 11 In the India iSupport trial, researchers reported a 45% recruitment rate and a low retention rate of 36% in a 3‐month iSupport trial. 7 However, the Portuguese iSupport trial reported a higher recruitment rate of 66% and a higher retention rate of 74%. The better results were attributed to support from health and social care professionals at Alzheimer's Associations who referred carers to the program. 8 In the UK iSupport trial, the researchers reported a low recruitment rate of 15% but a 91% retention rate in a 6‐month intervention period. 9 The high retention rate was attributed to the use of e‐coaches to resolve IT issues. 9 Embedding evidence‐based practice in aged care requires organisational support by training and supporting staff. However, due to the ongoing shortage of aged care staff in Australia, 12 , 13 barriers existed in staff training. Adherence to the trial protocol in a real‐world care setting is also a concern. 14
The aims of the study were to: (1) compare the effectiveness of the ‘Usual iSupport’ program and ‘Tailored iSupport’ program on carers' QoL (primary outcome); self‐efficacy; and their care recipients' QoL (secondary outcomes); and (2) explore carer recruitment rate, carers' acceptance of and adherence to the programs, satisfaction with the support and staff training rate in a 6‐month trial.
2. METHODS
2.1. Study design
We conducted an internal pilot RCT nested in a large hybrid type II effectiveness implementation trial. This study design is appropriate when recruitment, retention, attrition or randomisation are uncertain and need to be explored within the main RCT. 15 We followed the CONSORT2010 statement: extension to randomised pilot and feasibility trials (File S2) to report the study. 16 We registered the main RCT prospectively in the Australia New Zealand Clinical Trials Registry (ACTRN12623000323628). We have also published the trial protocol elsewhere. 17
2.2. Setting, participants and ethics approval
Ethics approval was obtained from Flinders University Human Ethics Committee (project number: 5819). This trial was undertaken in three Chinese‐ethno‐specific aged care organisations in two states in Australia, which distributed a carer recruitment flyer via regular newsletters to their clients, carer support groups and their organisations' websites. Carers who were interested in the programs were directed to contact a researcher to assess their eligibility and sign written informed consent before baseline data collection. By the end of the project, each participant received $100 as appreciation for their commitment to the trial.
Carers were included in the trial if they were aged 18 years or older and cared for a relative with dementia at home at least twice a week. We also included caregivers who cared for relatives without a formal diagnosis of dementia if their care recipients had cognitive impairment using the AD8 Dementia Screening Interview. 18 Carers were excluded if they self‐reported severe mental health conditions, terminal illness, or were involved in other research projects.
2.3. Intervention
2.3.1. The ‘Tailored iSupport’ intervention
Carers in the ‘Tailored iSupport’ group were assigned to a trained iSupport facilitator appointed by the participating organisations through an internal selection process. We worked with these organisations to develop selection criteria and a job description for the facilitators. In general, they were staff employed by the participating organisations, expressed interest in supporting carers of people with dementia, held a bachelor's degree (or higher) in nursing or social care areas, and had at least 2 years of experience in the care of people with dementia. The selection process ensured that the facilitators could deliver the intervention to carers to achieve the expected outcomes. Carers participated in the following activities remotely for 6 months: (1) The facilitator supported carers in using the Chinese version of the ‘Risk Appraisal Measure’ 10 to assess their individualised care needs and gain advice on learning modules/units or care services that would meet their care needs; (2) Carers engaged in self‐study using the iSupport Manual; (3) The facilitator organised monthly meetings with carers using WhatsApp or WeChat, lasting 45–60 min; (4) The facilitator sent weekly text messages extracted from the iSupport manual via WeChat or WhatsApp to engage carers in the program; and (5) The facilitator encouraged carers to contact them to gain need‐based support.
2.3.2. The ‘Usual iSupport’ intervention
The direct care staff was trained by the iSupport facilitator to introduce the iSupport manuals and resources to carers who were assigned to the ‘Usual iSupport’ group, using an ‘Introduction to iSupport leaflet’ developed by the project team. Carers in the group engaged in self‐guided dementia skill training using either the simplified Chinese language iSupport manual or the traditional Chinese language iSupport manual without facilitator support and without carer peer support activities.
2.4. Outcome measures
2.4.1. The effectiveness of the ‘Usual iSupport’ and the ‘Tailored iSupport’ programs
All scales we used in this study were translated into Chinese (Mandarin) and validated in greater China where our Chinese‐Australian carers came from. We also tested the validity in our previous RCT and detailed the validity indexes of these scales in our published study protocol for the present study. 6 , 17
Mental health‐related QoL and physical health‐related QoL of carers
We used the Chinese language version of the 12‐Item Short‐Form Health Survey (SF‐12) 19 to measure mental and physical health‐related QoL.
Revised scale for caregiving self‐efficacy
We used the Revised Scale for Caregiving Self‐Efficacy to measure self‐efficacy. 20 This instrument has three domains: self‐efficacy for obtaining respite, responding to changed behaviours and controlling upsetting thoughts about caregiving.
Quality of life of people with dementia
We applied the QoL in Alzheimer's Disease (QOL‐AD) proxy to determine the QoL of people with dementia. 21
2.4.2. The feasibility of the trial
Recruitment rate of carers
We measured the recruitment rate using the proportion of carers enrolled and the estimated total number of carers of people with dementia or cognitive impairment in the three participating organisations.
Carers' acceptance of the iSupport programs
We monitored the retention of carers in the trial as evidence of their acceptance of the two programs.
Carers' adherence to the iSupport programs
We collected carers' self‐reported completion of iSupport units and their attendance at peer support meetings in a 3‐ and 6‐month survey as their adherence to the programs.
Carers' satisfaction with the ‘Tailored iSupport’ program
We employed a self‐developed ‘Carer's satisfaction with support questionnaire’ which included 10 statements about activities delivered by the facilitator. The questionnaire was co‐developed with and agreed upon by representatives of industry partners and carers to audit intervention fidelity.
Staff training rate
We measured the proportion of direct care staff who participated in the training sessions provided by the iSupport facilitators among the total number of direct care staff in the participating organisations.
2.5. Sample size calculation
Sample size calculation was not required for an internal pilot RCT. According to Eldridge et al., 10 participants in each study arm are appropriate to test the feasibility of the effectiveness of the interventions based on medium effect sizes for the primary outcome. 16
2.6. Randomisation
Carers were randomly assigned to the ‘Usual iSupport’ program or the ‘Tailored iSupport’ program after the baseline data collection. We used block randomisation to ensure equivalent conditions of the two groups in spouse carers versus non‐spouse carers and people with similar stages of dementia in each group. The group assignment was performed by a researcher who had no knowledge of or contact with the carers in the trial.
2.7. Data collection
We collected data via the carers' self‐administered survey at baseline, 3 and 6 months post‐intervention. Carers were offered either an online survey via Qualtrics or a hardcopy survey via preaddressed and prepaid mail, based on their preferences. We also collected information about clients with dementia or cognitive impairment, as well as the total number of direct care staff and staff who participated in training sessions related to the trial via an organisational survey.
2.8. Data analysis
We applied an intention‐to‐treat method based on group assignments. We filled missing values using multiple imputations. We entered the data into IBM SPSS version 29 for data analysis. A biostatistician who was blind to the group assignments performed data analysis. Descriptive statistics were used to summarise the demographic information of carers and people with dementia. We applied a multivariate mixed‐effects linear regression model to compare the primary and secondary outcomes between the two groups. This data analysis method enabled us to capture both fixed effects, including group effect, time effect and group × time interaction. The random effects estimated the variability in the intercept to measure repeated outcomes across the three time points of data collection. We applied the two‐sided test for all analyses. We set the level of significance at p < .05.
3. RESULTS
3.1. Socio‐demographic information of participants
A total of 78 carers met our inclusion criteria and were enrolled in the trial. The recruitment took 6 months between May and October 2023. We randomly assigned carer participants to the ‘Usual iSupport’ group (n = 38) or the ‘Tailored iSupport’ group (n = 40). All carers completed the 6‐month follow‐up (Figure 1) in April 2024. Most carers were female (n = 66, 85%) and spouse carers (n = 56, 72%) and the mean age was 65.6 years. Most carer participants were in the less than 65 years age group (53%). Seven carers (9%) were in the 85 years and older group. The demographic characteristics of carers are detailed in Table 1. Just over half of people with dementia were females (n = 44, 56%), with a mean age of 82 years, half of whom were in the early or moderate stages of dementia.
FIGURE 1.
Study flow diagram.
TABLE 1.
Demographic characteristics of carers and people with dementia.
| Characteristics | Total (n = 78) | Tailored (n = 40) | Usual (n = 38) | p |
|---|---|---|---|---|
| A. Carers | ||||
| Gender: n (%) | ||||
| Male | 12 (15) | 3 (8) | 9 (24) | .048 a |
| Female | 66 (85) | 37 (93) | 29 (76) | |
| Age (years): mean (SD) | 65.6 (12.5) | 65.2 (11.6) | 66.1 (13.5) | .64 b |
| Age group (years): n (%) | ||||
| <65 | 41 (53) | 23 (58) | 18 (47) | .43 a |
| 65–74 | 18 (23) | 8 (20) | 10 (26) | |
| 75–84 | 12 (15) | 6 (15) | 6 (16) | |
| ≥85 | 7 (9) | 3 (8) | 4 (11) | |
| Relationship with patient: n (%) | ||||
| Spouse | 56 (72) | 28 (70) | 28 (74) | .72 a |
| Non‐spouse | 22 (28) | 12 (30) | 10 (26) | |
| Marital status: n (%) | ||||
| Married | 57 (73) | 28 (70) | 29 (76) | .53 a |
| Unmarried/divorced/widowed | 21 (27) | 12 (30) | 9 (24) | |
| Live in the same house: n (%) | ||||
| No | 38 (49) | 22 (55) | 16 (42) | .26 a |
| Yes | 40 (51) | 18 (45) | 22 (58) | |
| Religious beliefs: n (%) | ||||
| Yes | 29 (37) | 17 (43) | 12 (32) | .36 a |
| No | 48 (62) | 23 (58) | 25 (66) | |
| Employment status: n (%) | ||||
| Employed | 23 (30) | 13 (33) | 10 (26) | .55 a |
| Unemployed/retired | 55 (71) | 27 (68) | 28 (74) | |
| Education level: n (%) | ||||
| High school and below | 26 (33) | 13 (33) | 13 (34) | .87 a |
| Above high school | 52 (67) | 27 (68) | 25 (66) | |
| Financial pressure: n (%) | ||||
| Yes | 39 (50) | 24 (60) | 15 (40) | .07 a |
| No | 39 (50) | 16 (40) | 23 (61) | |
| Hours on care weekly: median (IQR) | 48.0 (21.0, 136.5) | 49 (22.8, 89.3) | 42 (18.0, 168.0) | .70 b |
| Family members' help: n (%) | ||||
| Yes | 19 (24) | 8 (20) | 11 (29) | .32 a |
| No | 58 (74) | 32 (80) | 26 (68) | |
| B. People with dementia | ||||
| Gender | ||||
| Male | 34 (44) | 16 (40) | 18 (47) | .51 a |
| Female | 44 (56) | 24 (60) | 20 (53) | |
| Age (years), mean (SD) | 81.7 (8.4) | 82.0 (8.5) | 81.3 (8.5) | .69 b |
| Religious beliefs | ||||
| Yes | 28 (36) | 12 (30) | 16 (42) | .33 a |
| No | 49 (63) | 28 (70) | 21 (55) | |
| Education level | ||||
| High school and below | 51 (65) | 26 (65) | 25 (68) | .81 a |
| Above high school | 26 (33) | 14 (35) | 12 (32) | |
| Stages of dementia a | ||||
| Mild | 37 (47) | 20 (50) | 17 (45) | .65 a |
| Moderate | 41 (53) | 20 (50) | 21 (55) | |
Note: Mild dementia was based on MMSE score 24–21; Moderate dementia was based on MMSE score 10–20; Due to missing data, the total percentage was not 100% in some variables.
χ 2 test.
Mann–Whitney U‐test.
3.2. Effectiveness of the two iSupport programs
We detected a statistically significant difference of mean score in mental health‐related QoL (3.44 [95% CI: .53, 6.35]; p = .02); self‐efficacy for responding to changed behaviours (9.02 [95% CI: 1.24, 16.81], p = .02); and self‐efficacy for controlling upsetting thoughts about caregiving (8.83 [95% CI: 1.14, 16.51]; p = .03) between the ‘Usual iSupport’ group and the ‘Tailored iSupport’ group at 6 months post‐intervention (Table 2).
TABLE 2.
Effectiveness of the two iSupport programs on carers and people with dementia at 3 and 6 months.
| Outcome measures | Groups | Baseline | 3 M | 6 M | TG vs UG differences at 3 M (95% CI) | p | TG vs UG differences at 6 M (95% CI) | p |
|---|---|---|---|---|---|---|---|---|
| Carer QoL: PCS | TG | 36.3 | 38.1 | 42.3 | −.2 (−4.07, 3.70) | .93 | 1.9 (−1.98, 5.79) | .33 |
| UG | 41.4 | 38.3 | 40.4 | |||||
| Carer QoL: MCS | TG | 40.9 | 38.6 | 47.2 | −1.4 (−4.3, 1.50) | .34 | 3.4 (.53, 6.35) | .02 a |
| UG | 41.5 | 40.0 | 43.8 | |||||
| CSE: respite | TG | 52.7 | 58.5 | 72.1 | −1.2 (−11.55, 9.22) | .83 | 5.4 (−4.95, 15.82) | .30 |
| UG | 53.6 | 59.7 | 66.7 | |||||
| CSE: behaviours | TG | 55.5 | 59.0 | 69.7 | 3.3 (−4.51, 11.07) | .41 | 9.0 (1.24, 16.81) | .02 a |
| UG | 54.5 | 55.8 | 60.7 | |||||
| CSE: upsetting | TG | 60.6 | 53.8 | 70.8 | −.7 (−8.34, 7.04) | .87 | 8.8 (1.14, 16.51) | .03 a |
| UG | 61.29 | 54.40 | 62.0 | |||||
| QoL of people with dementia | TG | 2.3 | 2.2 | 2.1 | −.0 (−.20, .19) | .96 | −.1 (−2.27, .12) | .44 |
| UG | 2.3 | 2.2 | 2.2 | |||||
| UG | N/A | .4 | .4 |
Note: Adjusted for confounding variables, including gender, age, relationship with people with dementia, marital status (yes or no), living in the same household with people with dementia or not, religion, employment status (yes or no), education level (12 year or above), financial pressure and family members' help (yes or no).
Abbreviations: CSE, caregiver self‐efficacy; IG, tailored iSupport group; M, months; MCS, mental composite summary score; PCS, physical composite summary score; QoL, quality of Life; UG, usual iSupport group.
The mean difference is statistically significant in the mixed‐effect linear regression model.
We did not identify a statistically significant difference in the mean score of carers' physical health‐related QoL, their self‐efficacy for obtaining respite and the QoL of people with dementia between the ‘Usual iSupport’ group and the ‘Tailored iSupport’ group at 6 months post‐intervention (Table 2). We did not identify any statistically significant differences in outcome measures between the two groups at 3 months post‐intervention (Table 2). We did not identify any unintended consequences.
3.3. The feasibility of the trial
The three organisations provided care services to 470 older people living with dementia or cognitive impairment, and all of them had nominated family carers (Table 3). However, only 135 (29%) carers were interested in the trial, and 78 carers met the eligibility criteria and were enrolled in the trial. Thus, the recruitment rate was 17%. All carers completed the 6‐month follow‐up, a 100% retention rate.
TABLE 3.
Carer recruitment rate and staff training rate.
| Org. | Carers of people with dementia | Carers interested | Carers recruited | Recruitment rate (%) | Staff training sessions | Staff trained | Total direct care staff | Training rate (%) |
|---|---|---|---|---|---|---|---|---|
| Org. 1 | 150 | 48 | 34 | 23 | 4 | 70 | 200 | 35 |
| Org. 2 | 300 | 67 | 38 | 13 | 4 | 54 | 160 | 34 |
| Org. 3 | 20 | 20 | 6 | 30 | 3 | 20 | 40 | 50 |
| Total | 470 | 135 | 78 | 17 | 11 | 144 | 400 | 36 |
Note: Org. = a participating organisation.
The three organisations employed over 400 direct care staff members. Of those, 144 attended one of the 11 training sessions provided by the five iSupport facilitators to enable them to introduce the ‘Usual iSupport’ program to carers. Thus, the training rate was 36% over a 6‐month period (Table 3). The training sessions were flexible, lasting 15–30 min.
Carers in the ‘Tailored iSupport’ group completed an average of 16.5 units, while carers in the ‘Usual iSupport’ group completed an average of 10 units at 6 months post‐intervention. The mean difference between the two groups was statistically significant (6.35 [95% CI: 1.17, 11.52]; p = .02) (Table 4). Furthermore, they attended an average of two peer support meetings at 3 months and 2.5 at 6 months post‐intervention. The mean difference between three and 6 months was statistically significant (.52 [95% CI: .27, .78]; p < .001). In addition, they rated their satisfaction with support as 4.8 out of 5 at 3 months and 4.7 out of 5 at 6 months post‐intervention (Table 4).
TABLE 4.
Carers' adherence to and satisfaction with care services in the two iSupport programs at 3 and 6 months.
| Outcome measures | Groups | Baseline | 3 M | 6 M | Within‐group effect | Between‐group effect | |||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| 3 M vs baseline differences at (95% CI) | 6 M vs baseline differences at (95% CI) | p | TG vs UG differences at 3 M (95% CI) | p | TG vs UG differences at 6 M (95% CI) | p | |||||
| Completion of learning units | TG | N/A | 12.8 | 16.3 | N/A | 3.5 (−1.0, 8.0) | .13 | 3.0 (−8.7, 2.7) | .30 | 6.4 (1.2, 11.5) | .02 a |
| UG | N/A | 9.9 | 10.0 | N/A | .1 (−5.2, 5.9) | .99 | |||||
| Attending peer support meetings | TG | N/A | 2.0 | 2.5 | N/A | .5 (.3, .8) a | <.001 | N/A | N/A | ||
| UG | N/A | N/A | N/A | N/A | |||||||
| Satisfaction with support | TG | N/A | 4.8 | 4.7 | N/A | −1.0 (−.3, .1) | .23 | N/A | N/A | ||
| UG | N/A | N/A | N/A | N/A | N/A | ||||||
The mean difference is statistically significant in the mixed‐effect linear regression model.
4. DISCUSSION
4.1. Characteristics of carers
In this pilot RCT, we found most carers (85%) were female, with nearly half of them 65 years or older, including 9% in the 85 years or older age group. The demographic characteristics of carers in our study are in line with a national study that confirms the traditional role of women in the care of family members with health conditions in a society, 22 although the proportion of female carers in our sample is higher than the national average of 75%. The findings underscore the need to provide tailored support for older female carers in the Chinese‐Australian community by considering their needs and preferences in the programs.
4.2. Intervention effectiveness
We found improved carers' mental health‐related QoL at 6 months post‐intervention in the ‘Tailored iSupport’ group compared to the ‘Usual iSupport’ group. This finding supports our previous RCT that tested the effects of the ‘Tailored iSupport’ program in comparison with a usual care group. 6 Our finding differs from feasibility iSupport RCTs in India and Portugal, where researchers reported no effects on the QoL of carers. 7 , 8 The low adherence to studying the iSupport manual, as reported in these RCTs, might have contributed to the lack of intervention effects on carers' QoL. 7 , 8 Our findings align with two systematic reviews which reported intervention effects of psychoeducation on carers' well‐being and mental health. 23 , 24 Our findings also support a systematic review and meta‐analysis by Sun et al. 25 that reported intervention effects of peer support groups on carers' QoL.
Our finding of improved self‐efficacy for controlling upsetting thoughts about caregiving concurs with our previous RCT that compared the ‘Tailored iSupport’ group and the usual care group. 6 However, we also identified improved self‐efficacy for responding to changed behaviours that we did not detect in the previous RCT. 6 This may be due to the use of the ‘Risk Appraisal Measure’ 10 by the facilitator in the present RCT to identify and meet the carers' individual needs. Our findings on improved self‐efficacy differ from those of the India iSupport RCT, which reported no effects but align with other psychoeducation and peer support interventions. 23 , 26
While the absolute differences in mental health‐related QoL, self‐efficacy for responding to changed behaviours and controlling upsetting thoughts may appear modest, they are clinically meaningful in the context of caregiving for people with dementia. 27 These changes were observed in an at‐risk population, primarily older carers with high caregiving demands, where even small improvements can translate into better coping, reduced distress and sustained caregiving capacity. Importantly, these gains were achieved over a 6‐month period using a relatively low‐resource intervention embedded in existing aged care services. The improvements in self‐efficacy are particularly relevant, as previous research has linked caregiver self‐efficacy to improved positive appraisal and QoL of carers. 28 The findings on improved QoL for carers will inform policymakers, dementia and aged care organisations, and clinicians to adapt the evidence‐based iSupport program in routine care services for the benefits of carers of people with dementia.
We did not detect any improvement in self‐efficacy for obtaining respite. This finding aligns with that of our previous RCT. 6 The lack of availability and accessibility of respites for people with dementia from CALD communities, as reported in a recent consultation with stakeholders in Australia, may have contributed to this finding. 29 Moreover, we did not identify any intervention effects on QoL in people with dementia. This finding aligns with those of the UK iSupport RCT. 9 and may be attributed to the lack of interventions for people with dementia in our RCT. A recent longitudinal RCT that tested dyadic intervention on people with dementia and carers in the United States reported improved QoL of people with dementia, which underscores the need to add this intervention on people with dementia to optimise outcomes.
4.3. Feasibility of embedding the iSupport programs in aged care services
Our recruitment rate is lower than those in the Indian and Portuguese RCTs, but close to the UK RCT. 7 , 8 , 9 However, our retention rate was higher than those in India, Portugal and the UK iSupport RCTs. This may be due to the trust relationships between carers and staff in the three Chinese‐ethno‐specific aged care organisations, which were reported in a previous study. 2 Our finding aligns with the Portuguese iSupport study, in which all carers referred by health or social care professionals at Alzheimer's Associations completed a 6‐month follow‐up. 8 In contrast, carers recruited online had a 58% retention rate. 8 Previous studies have reported that the lack of digital literacy in carers hinders them from completing the iSupport program. 8 , 9 We trained facilitators and direct care staff to support carers in accessing the iSupport program online, which may have contributed to the high retention rate.
The average completion of the iSupport unit in our trial was higher than that reported in the Indian RCT. Carers' regular contact with trained facilitators and peers in our study may have contributed to better adherence to the iSupport program, as evidenced by the significant difference in completion of the iSupport units between the two groups. Our findings support previous studies showing that opportunities to interact with facilitators/coaches and peers to share learning experiences enhance carers' engagement and adherence to psychoeducation. 11
In our study, carers rated the support provided by facilitators highly, which is evidence that facilitators adhered to the intervention protocol from carers' perspectives. Moreover, iSupport facilitators achieved a 36% staff training rate in our study, which is higher than the 28% dementia care training rate among staff in a national survey study. 13 Our finding on staff training supports other studies showing that organisational commitment is important in embedding evidence‐based practice in real care settings. 30
5. BENEFITS AND LIMITATIONS
This internal pilot study embedded in a large implementation RCT has demonstrated some benefits. First, it showed improved QoL for carers of people with dementia. Second, it demonstrated improved carers' confidence in dementia care (or self‐efficacy) by which they are more likely to sustain home‐based care for their loved ones living with dementia. Third, the feasibility of training strategies for direct staff to deliver the ‘Usual iSupport’ program to carers will enable the ‘Usual iSupport’ intervention to be embedded in routine care services for the benefits of people with dementia who use aged care services. Fourth, the study enabled the team to test the fidelity of the intervention as per the study protocol and act accordingly. In addition, the internal pilot study enabled the inclusion of the data in the main study.
This study also had some limitations. First, as an internal pilot study, the RCT did not achieve an adequate sample size; thus, the intervention effects reported in the trial need to be tested in a fully powered RCT. Second, the trial was undertaken in a few Chinese‐ethno‐specific aged care organisations in Australia. Therefore, the findings on the feasibility of the trial may not be generalisable to other aged care organisations. Future implementation trials need to be extended to a wider CALD community to test and modify the feasibility of the implementation strategies based on the real situation in these communities.
6. CONCLUSIONS
This internal pilot study identified improved mental health‐related QoL, self‐efficacy for controlling upsetting thoughts about caregiving, and self‐efficacy for responding to changed behaviours in the ‘Tailored iSupport’ group compared with carers in the ‘Usual iSupport’ group. Moreover, we found a relatively lower recruitment rate but a higher retention rate of carers in our study compared with other iSupport RCTs. In addition, carers and facilitators in the study adhered to the intervention protocol. The findings have implications for policy‐makers, dementia care organisations and clinicians working with people with dementia and their carers to embed the evidence‐based ‘Tailored iSupport’ program in dementia care services to optimise the benefits for people with dementia and their carers. The findings on the feasibility of strategies to deliver the ‘Usual iSupport’ program and the ‘Tailored iSupport’ program will inform future implementation studies to scale up multiple language iSupport programs in other CALD communities in Australia and thus address equitable support for all carers of people with dementia from CALD communities.
FUNDING INFORMATION
This study is funded by the Aged Care Research & Industry Innovation Australia (ARIIA), the Australian Government (grant number: R2GAP00032), the Australian Nursing Home Foundation, Chinese Australian Services Society and Chinese Welfare Services of SA.
CONFLICT OF INTEREST STATEMENT
No conflicts of interest declared.
Supporting information
File S1
File S2
ACKNOWLEDGEMENTS
We would like to acknowledge carers and Aged Care Research & Industry Innovation Australia (ARIIA) staff who contributed to the study. Open access publishing facilitated by Flinders University, as part of the Wiley ‐ Flinders University agreement via the Council of Australian University Librarians.
Xiao L, Cheng A, Xie C, et al. A feasibility study on embedding the usual Chinese iSupport and tailored Chinese iSupport programs in aged care services. Australas J Ageing. 2025;44:e70072. doi: 10.1111/ajag.70072
DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available upon reasonable request to the Corresponding author (lily.xiao@flinders.edu.au).
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
File S1
File S2
Data Availability Statement
The data that support the findings of this study are available upon reasonable request to the Corresponding author (lily.xiao@flinders.edu.au).