A qualitative evaluation of the Resources for Enhancing Alzheimer’s Caregiver Health in Vietnam (REACH VN) intervention: a multi-stakeholder perspective

Abstract

Objectives:

The primary goal of this study was to understand attitudes and experiences of a culturally tailored dementia intervention for Vietnamese family caregivers of people living with dementia (PLWD) from the perspectives of family caregivers and other stakeholders.

Method:

We conducted semi-structured qualitative interviews with 53 stakeholders (i.e. family caregivers, interventionists and their supervisors, and other staff and local officials) with direct or indirect knowledge of the intervention, which was delivered in the home over three months by local interventionists. Directed content analysis of the qualitative interview data was performed to identify themes and sub-themes.

Results:

The process-oriented themes suggest that caregivers and interventionists encountered multiple barriers during the intervention process, and amid these challenges, face-to-face intervention was highly preferred among caregivers, and among multiple intervention components, some worked better for caregivers than others. The outcome-oriented themes highlight that participating in the intervention benefited not only caregivers but also health professionals, particularly the interventionists.

Conclusion:

Results highlight the need for further cultural modifications in problem-solving and mood management components, and the potential of the blended format of face-to-face and phone interventions to better fit the sociocultural context and cognitive capacity of most Vietnamese caregivers.

Introduction

The population of older adults, who are 60 and above, has rapidly increased worldwide. According to the World Health Organization (WHO), this population is expected to reach 2.1 billion people by 2050, with approximately 70% of them living in lower- and middle-income countries (LMICs). Aging societies face the undeniable risk of Alzheimer’s disease and related dementias, neurodegenerative brain diseases that impair cognitive functioning at different levels (Gauthier et al., 2022). By 2050, the number of people living with dementia (PLWD) is estimated at 139 million (Alzheimer’s Disease International, 2024). Noticeably, undiagnosed cases may be as remarkable as 75% globally and 90% in LMICs (Gauthier et al., 2022). As anticipated, the proportion of PLWD living in LMICs will account for 63% and 71% of the total PLWD worldwide in 2030 and 2050, respectively (Prince et al., 2013).

Despite the serious risk of dementia, the formal health and social care system in LMICs has been scant, leaving PLWD to be cared for by their family members (Fam et al., 2019; Hinton et al., 2020; Long et al., 2023; Tran et al., 2022). In Vietnam, PLWD being cared for by their families are not only a long-practiced tradition, but also reinforced by its nationwide Law on the Elderly (Vietnam National Assembly, 2010). Approximately 80% of the Vietnamese older adults need some form of care and support in their activities of daily living (ADL), and this group may reach 10 million people in 2030⁹. Among them, 660,000 PLWD are cared for mostly by their families (General Statistics Office of Viet Nam & UNFPA, 2021; Tatarski, 2016; Vietnam Ministry of Health, 2019). That said, a large number of Vietnamese primary and secondary family caregivers have been involved in caregiving duties for PLWD. Due to noteworthy caregiving burden and limited social support (UNFPA & VCCI, 2021; Nguyen et al., 2020), Vietnamese family caregivers have consistently reported consequences on their own and their families, such as time and financial constraints, decreased physical health, strained relationships, and psychological distress (Nguyen et al., 2013; Nguyen et al., 2022; Truong, 2015; Nguyen & Levkoff, 2020), resulting in reduced well-being and quality of life of both caregivers and the PLWD (Nguyen et al., 2013; Truong, 2015; Nguyen et al., 2013).

Although Vietnamese family caregivers confront enormous hardship and are critically in need of formal support, specialized services for them have virtually not existed in the country. Meanwhile, community-based, culturally tailored dementia caregiver interventions have shown their efficacy and effectiveness in supporting dementia caregivers in high-income countries, particularly through increasing their dementia knowledge and caregiving skills, reducing their caregiving burden and psychological distress, and improving their health outcomes and well-being. Similar outcomes have been demonstrated on Vietnamese caregivers in the United States (US) (Hinton et al., 2020; Tran et al., 2022). Among the existing dementia caregiver interventions, the most effective ones have been characterized as person-family centric approaches and multicomponent with comprehensive education, skill-building, stress reduction, and community resource mobilization (Hinton et al., 2020; Committee on Family Caregiving for Older Adults, Board on Health Care Services, Health & Medicine Division, National Academies of Sciences, Engineering, & Medicine, 2016; Sörensen et al., 2002). It has become more pressing to understand whether these interventions work in the specific context of LMICs and how they benefit their family caregivers and other stakeholders.

Serving the long-term purpose of the adaptation of an evidence-based and community-based, culturally tailored dementia caregiver intervention for Vietnamese family caregivers of PLWD, the intervention ‘Resources for Enhancing Alzheimer’s Caregiver Health in Vietnam’ (REACH VN) has been adapted based on the established effectiveness of the ‘Resources for Enhancing Alzheimer’s Caregiver Health’ (REACH) for multicultural populations in the US, as well as Hong Kong citizens (Cheung et al., 2015; Czaja et al., 2018; Martindale-Adams et al., 2017; Schulz et al., 2003), and the ‘Resources for Enhancing All Caregivers Health in the Department of Veterans Affairs’ (REACH VA) for veterans in the US (Nichols et al., 2011; Nichols et al., 2016). This Vietnamese version of the REACH intervention is culturally adapted and multi-component that covering dementia education, caregiver skill-building, and stress reduction using available community resources. The intervention has been provided mostly in the format of face-to-face interaction between an interventionist and a caregiver, standardly in six face-to-face sessions. The REACH VN has been tested multiple times at different scales in Vietnam. The pilot cluster randomized controlled trial (RCT) of nine clusters and 60 family caregivers (Hinton et al., 2020,Tran et al., 2022), followed by a larger cluster RCT with 40 clusters of 350 caregivers in Northern Vietnam (Nguyen et al., 2025), both demonstrate their feasibility and preliminary efficacy.

The promising findings of the feasibility and preliminary efficacy of the REACH VN mark a crucial milestone in the development of community-based, culturally tailored interventions for Vietnamese dementia caregivers. These findings reflect opinions of caregivers, as the intervention recipients, or service users, yet their actual experiences of the intervention delivery, as well as their qualitative assessment of the intervention benefits, remain unknown to interested intervention scholars and policy makers. In addition, existing evidence so far mostly focuses on caregiver ratings, while perspectives of other stakeholders, such as interventionists, monitoring staff, etc., have been barely taken into account. This study, therefore, aims to obtain an in-depth understanding of the real-life experiences of the REACH-VN intervention and its perceived benefits from the perspectives of its stakeholders, including Vietnamese family caregivers for PLWD, interventionists, and other health professionals involved in the intervention delivery.

Methods

Design

This qualitative evaluation study was part of a larger mixed-methods study investigating barriers and facilitators of REACH VN implementation in a community setting through formative evaluation conducted in parallel with the cluster RCT. This study used directed content analysis (Hsieh & Shannon, 2005) to qualitatively evaluate intervention processes and outcomes from the perspectives of multiple stakeholders, including family caregivers, interventionists, and others involved in the intervention delivery. Qualitative process and outcome evaluations can help illuminate how an intervention practically works in a specific sociocultural context (Moore et al., 2015; Morgan-Trimmer & Wood, 2016; Naef et al., 2020).

The intervention

The REACH VN intervention study was registered with clinicaltrials.gov (NCT04542317), and its protocol and outcomes have been previously published (Tran et al., 2022b). The intervention was implemented in three districts with mixed rural and semi-urban areas in a northern province in Vietnam. In this two-arm, cluster RCT, a total of 350 family caregivers of PLWD were randomly assigned to the intervention group or the enhanced control group (175 caregivers in each group). The enhanced control group members received a single dementia educational session at home, which lasted about one hour. Study eligibility included age 18 and above, primary family caregiver of a PLWD, score at least 6 points on the Zarit Burden Interview-4 items (ZBI-4), and consent to participate in the study.

Interventionists (n = 8) were community health workers, nurses, or social workers from the local provincial hospital. The intervention has multiple components, including a risk and need assessment followed by the dementia education, skill-building for mood management and stress reduction, as well as problem-solving using the Caregiver Handbook. The procedure of the intervention delivery included two phases, with the active phase from months 1 to 3, and the maintenance phase from months 4 to 6. During the active phase, typically six face-to-face sessions were conducted at a caregiver’s home within approximately an hour. Interventionists provided a home-visit session to their caregiver every one or two weeks. In the first session, an interventionist assessed the risks and needs of the caregiver and the PLWD, considering their actual living condition at home. In the following five sessions, the interventionists guided caregivers through the Caregiver Handbook for knowledge education and skill building to help them manage their stress and solve prioritized problems. In the maintenance phase, monthly check-in calls were made with caregivers. These calls could last up to 30 min. Consented caregivers received an incentive of $4 (or 100,000 VND) for their screening session completion, and $8 (or 200,000 VND) after each intervention session and outcome assessment visits.

The intervention delivery was monitored in different formats. During the active phase, after each session, interventionists completed a standardized treatment form, such as the Intervention Delivery Form, which was a summary of the session delivery. The form was submitted either as a hard copy or an electronic form on REDCap and regularly checked for its completion. All phone sessions in the maintenance phase were recorded. The interventionists were supervised by a trained monitoring staff from the hospital through biweekly individual phone or Zoom meetings and group consultation.

Researcher characteristics and reflexivity

Following the standards for reporting qualitative research (O’Brien et al., 2014), researchers’ characteristics were examined. Different parties, with distinct roles, were involved in the large-scale, five-year, multiple-round assessments of the mixed-methods study on the process and outcome evaluations of REACH-VN. Key investigators developed and implemented the intervention, as well as led the design of the assessment instruments. They also contracted a renowned independent research institute (PHAD) based in Hanoi to conduct the assessments, including the qualitative data collection in the present study. Additionally, an expert in qualitative health research was contracted separately to conduct the qualitative data analysis independently. The involvement of the three different parties in the qualitative assessment contributes to guaranteeing assessment quality. No conflict of interest was reported among these parties.

The independent qualitative researcher (TN) acknowledged her positionality in conducting data analysis of this study. She is a Vietnamese with advanced training in health research in the US. She has participated in cross-cultural studies on dementia caregiving in the US, Vietnam, and other Asian countries. She has been the principal investigator of multiple studies with Vietnamese family caregivers for PLWD, as well as the independent qualitative consultant of the REACH-VN at different stages. To prevent herself from adopting presumptions about participants, she constantly practiced reflexivity during her analysis (Nguyen, 2025).

Setting, participants, and data collection

The comprehensive intervention the study was approved by Institutional Review Board at University of California, Davis, and Vietnam National Geriatric Hospital. Three groups of participants were recruited, including: Group 1 of family caregivers; Group 2 of interventionists (IV); and Group 3 of other staff, such as interventionist supervisor (IS), local staff (LS), and healthcare leaders (LD).

Based on previous rounds of qualitative assessments, data saturation was often reached within 20 to 30 interviews with caregivers (Nguyen, 2021), and key investigators aimed at 30 family caregivers for the present study. A statistician used statistical software and the list of caregivers who completed their six-month assessment among the total of 350 caregivers in the intervention to randomly select 30 of them to invite to interviews, and six of them refused to participate due to their time constraints. A total of 24 participants (response rate at 80%) agreed to arrange for an interview.

For those who consented to participate in the qualitative study, their interviews were scheduled within three months from their completion of the intervention. All interventionists and interventionist supervisors agreed to participate in a qualitative study. Local officials and leaders, who were directly involved in the implementation of the intervention, were also invited to the qualitative study.

A set of five semi-structured interview guides for CG, IV, IS, LS, and LD was developed by the key investigators. These interview guides included questions on real-life experiences of stakeholders in the intervention in different roles, their perceptions of the intervention benefits, and its delivery effectiveness. The questions aim at information reflecting process and outcome evaluations from different perspectives, particularly stakeholders’ experiences with the intervention delivery and their perceived benefits of the intervention (see Appendix).

All research assistants from the independent research institute were trained to collect informed consent forms and conduct interviews using the interview guides. They could ask follow-up questions, yet not change the order of the question sections. A total of 53 interviews were conducted face-to-face with approved audio recording at caregivers’ homes, or in a private room at non-caregiver participants’ workplace, e.g. a health center or a hospital. An interview often lasted from 30 to 60 min. PHAD’s team also reported their observation of data saturation after completing 24 interviews with caregivers.

Data analysis

All interview recordings were transcribed verbatim, and the transcripts were divided into three sets, including: (i) CG, (ii) IV, and (iii) other staff (IS, LS, and LD). The transcript sets were securely stored in a password-protected folder. The coding process was conducted on the original Vietnamese-language transcripts to preserve the cultural and linguistic authenticity while interpreting the meanings of the texts. In the results, illustrative quotes were translated to support the interpretation.

Directed content analysis (Hsieh & Shannon, 2005; Assarroudi et al., 2018) was adopted to qualitatively evaluate intervention processes and outcomes in the present study. In the preparation phase, the independent researcher (TN), who was in charge of data analysis, immersed herself in data to develop a codebook for formative analysis. An analysis strategy that combined structural coding and thematic coding (Saldana, 2015) to provide a clearer direction for the data analysis process, while allowing data that cannot be grouped into existing themes or categories to be reflected in the analysis results. The structural codes, referring to experiences of the intervention delivery, its perceived feasibility, acceptability, efficacy, benefits, etc., were pre-identified based on a framework and coding system for modifications and adaptations of evidence-based interventions (Stirman et al., 2013), as well as the guidelines for qualitative process and outcome evaluations for health behavior interventions (Moore et al., 2015; Morgan-Trimmer & Wood, 2016; Naef et al., 2020). The defined structural codes were discussed with the intervention research team to reach a consensus before importing them into the NVIVO 12 Plus software for further data coding process. New codes emerging from data were also identified. All the pre-identified and new codes were then grouped and organized to establish key themes reflected in the results. The sample size and the depth of the interviews allowed the saturation of the themes in all three groups. This process mapped on the organization phase of directed content analysis suggested by Assarroudi et al. (2018), in which the authors suggested this phase to be focused on the development and refinement of a coding matrix with predefined main categories and subcategories for data analysis, followed by the establishment of inductively formed main categories and links between generic and main categories (Assarroudi et al., 2018).

Trustworthiness

Multiple methods were adopted to guarantee the trustworthiness and credibility of data analysis (O’Brien et al., 2014). First, three different parties were in charge of the three duties of (i) intervention development and implementation, (ii) data collection, and (iii) data analysis to eliminate the influences of each party on the following step and improve the subjectivity of the assessment. Second, cross-checking between the qualitative researcher (TN) and the co-PI (HN), who was linguistically and culturally competent in health research in Vietnam, was constantly applied during the coding process. HN reviewed the coded outputs and discussed with TN to reach a consensus on the coding outcomes. Third, an audit trail of the coding outcome matrices and data reduction was recorded for review by the key investigator (see Appendix 6 and Table 2). Codes and associated quotations reflecting unpopular opinions of different realities were preserved in the coding outcome matrices to cross-check the accuracy and trustworthiness of the theme establishment (Assarroudi et al., 2018).

Table 2.

Key directed content analysis findings (N = 53).

		Group
Theme	Sub-theme	CG (N = 24)	IV (N=8)	Others (IS, LS, and LD) (N = 21)
Process-oriented theme 1: “Good top-down coordination, yet still multiple challenges to overcome!	Advantages when participating in the intervention		x	x
	Contextual barriers	x	x	x
	Financial and material barriers	x	x	x
	Sensory and cognitive barriers	x	x	x
	Relationship and psychological barriers	x	x	x
Process-oriented theme 2: Direct, face-to-face interaction was irreplaceable!	Perception of received face-to-face intervention	x	x	x
	Perception of potential telephone intervention	x	x	x
Process-oriented theme 3: All intervention components were important, yet we all had our most and least favorite ones!	Content and components most preferred and frequently applied by CG to date	x	x
	Content and components CG find most challenging	x	x
Outcome-oriented theme 1: Caregivers have been much better in many ways!	Benefits of the intervention on CG attitude	x	x	x
	Benefits of the intervention on CG knowledge and skills	x	x	x
	Benefits of the intervention on CG caregiving outcomes	x	x
	Benefits of the intervention on CG health outcomes	x	x	x
Outcome-oriented theme 2: Participating in REACH-VN has truly changed us, health professionals, in a positive way!	Benefits of intervention on healthcare professionals’ (IV, IS) attitude and approach		x	x
	Benefits of intervention on healthcare professionals’ (IV, IS) knowledge and skills		x	x

Notes: CG: Caregivers; IV: Interventionists; IS: Interventionist Supervisors; LS: Local Staff; LD: Healthcare Leaders.

Results

Participant characteristics

Table 1 summarizes the characteristics of 53 participants who participated in the qualitative interviews. The majority of family caregivers were caring for their parents or parents-in-law (eight were caring for their mother, and nine were caring for their mother-in-law), while the rest were caring for their spouse (four were caring for their wife, and three were caring for their husband).

Table 1.

Participant characteristics (N = 53).

Group		Average age (M, SD)	Gender	Other characteristics
1	Caregivers (CG = 24)	62.33 (9.60)	Female: 15 Male: 9	Child caregiver: 17 Spousal caregiver: 7
3	Other staff (n = 21)	45.13 (6.15)	Female: 6 Male: 2	Nurses at the provincial hospital
3	Other staff (n = 21)
3.1	Interventionist Supervisors (IS = 8)	38.67 (8.43)	Female: 6 Male: 2	Former REACH-VN interventionists in the former phase, currently involved in field supervision and program management
3.2	Local staff (LS = 8)	42.40 (6.48)	Female: 4 Male: 4	Health professionals or community workers with a long tenure in the communes
3.3	Healthcare Leaders (LD = 5)	53.20 (4.82)	Female: 1 Male: 4	Healthcare experts and administrative leaders of hospitals at the national, provincial, and district levels.

Notes: M: Mean; SD: Standard deviation.

Key findings

Five themes were identified, including three related to the intervention process and two related to intervention outcomes. The process-oriented themes included: (1) ‘Good top-down coordination, yet still multiple challenges to overcome’; (2) ‘Direct, face-to-face interaction was irreplaceable!’ and (3) ‘All intervention components were important, yet we all had our most and least favorite ones!’ The outcome-oriented themes referred to (4) ‘Caregivers have been much better, in many ways!’ and (5) ‘Participating in REACH-VN has truly changed us, health professionals, in a positive way!’ These themes and their sub-themes in each group were summarized in Table 2.

Process-oriented theme 1: good top-down coordination, yet still multiple challenges to overcome…

In addition to the easy access to the intervention sites, the interventionists and other staff endorsed the human factor as the key facilitator in the implementation of the intervention at the community level. They clearly acknowledge the passion and commitment, as well as the experience and training background of the interventionist team. Additionally, the leading hospital is a national hospital, which is responsible for directing healthcare activities within the Ministry of Health’s healthcare system. It has established a strong connection and direct communication channel with local hospitals, resulting in effective top-down coordination and enthusiastic participation from local healthcare and other community workers. This workforce supported the interventionists to screen, connect to, and build trust and a therapeutic relationship with targeted caregivers in the community.

The local authorities, including the village chairman, village officials, and the village health station, have been very supportive. They often arrange transportation, and the head of the station sometimes personally accompanies us to each household. They are very kind and patient, waiting for us, and even lending us motorcycles for transportation. They also provide guidance and escorts, and the residents are very cooperative, sometimes even lending us their own motorcycles. They are very trusting of us. [IV, female, 47, nurse]

On the other hand, multiple challenges to the implementation and participation in the intervention were acknowledged by all groups. At the beginning of the intervention, interventionists and other staff reported caregivers’ lack of trust and reluctance to participate in the intervention, as they associated it with medical scams, which had happened before in their community when drug companies lured people to buy expensive drugs after letting them try some free services. With the presence and explanation of the respected heads of the village, commune health station, and community associations, caregivers eventually obtained their trust with the interventionist team and agreed to participate in the intervention.

The difficulties and obstacles here are only minimal. Because some people are afraid that this is a program that comes to advise them to buy medicine, like a multi-level marketing program, and it could be a scam, a program that sells low-quality products. So initially, they didn’t cooperate. Then, we, the veterans’ association members, will go in and explain. After that, they participate very highly. [MS, male, 47, community worker]

During the implementation of the intervention, multiple barriers were consistently reported among the three groups. Four key barriers emerged from the data, including: (i) Contextual barriers, such as time constraints and schedule conflicts; (ii) Financial and material barriers; (iii) Sensory and cognitive barriers; and (iv) Relationship and psychological barriers.

Contextual barriers.

Across the three groups, contextual barriers, such as time constraints, emerged as one of the most significant categories. Most caregivers in this rural area were very busy, making it difficult to schedule time to commit to the entire intervention process. Many of them had to take on multiple responsibilities in the family, including income-generating work, tending to farm work, caring for sick family members and young children, etc. Meanwhile, interventionists were also responsible for their official job requirements besides their intervention duty. This situation led to the difficulty scheduling the intervention. There were cases of CG dropping out, unable to complete the intervention process due to time constraints.

People in the local area are mostly agricultural laborers, so the time they must stay at home and attend the intervention sessions, they have very little time; they have to squeeze time to arrange it. So, the main difficulty for people is time. [MS, female, age not revealed, head nurse]

In addition, the interventionists and other staff pointed out that sometimes, they encountered difficulty in traveling and communication. Few caregivers’ homes were quite far and remote to reach, making travel inconvenient and time-consuming. Some caregivers lived in areas with poor phone signal reception, which hinders interventionists’ ability to contact them and schedule appointments.

Financial and material barriers.

Many caregivers reported their limited or no income and poor household economic status. Meanwhile, some action strategies discussed in the intervention might incur costs, such as installing additional support equipment for people with mobility impairments, like bathroom grab bars. Although caregivers understood and agreed with their interventionists that redesigning their homes or installing additional equipment would be beneficial, they were unable to afford these changes.

The difficult part for the interventionist is that after you bring up the issue that needs solutions, but the person’s condition is too difficult. There were cases, to avoid the problem of falling down the stairs, I advised them to make a handrail, but they don’t have the conditions to do it. [IV, male, 45, nurse]

Another challenge we face is dealing with families who lack financial resources. For example, in cases where patients experience incontinence, some families are so poor that they cannot afford diapers. Additionally, not everyone has health insurance to cover regular hospital visits… [IV, female, 37, nurse]

Sensory and cognitive barriers.

All groups consistently acknowledged caregiver sensory and cognitive limitations were significant barriers to the implementation of the intervention. The ability of caregivers to read, understand, and absorb new information was a persistent obstacle throughout the intervention process. As caregivers were in diverse age groups and educational backgrounds, their reading comprehension and learning capabilities varied significantly. Many were older adults with poor eyesight and lacked formal education or a habit of reading books, newspapers, or documents. Some of them were even illiterate. Interventionists shared numerous challenges in guiding or explaining the content of the Handbook to ensure caregivers’ understanding. Many caregivers struggled with reading and comprehending the Handbook, further discouraging them from reading. Interventionists, therefore, dedicated more time to giving direct explanations and guidance to these caregivers, as well as providing supplementary instructions to their children to add further support.

Some caregivers are older adults and cannot read, or they are illiterate. Some are over 70 years old and care for each other. Their children or grandchildren are not at home. When using our materials, they cannot read, or their eyesight is too poor, and they experience eye strain after reading for a short while, so they dislike it. [IV, male, 45, nurse]

It (the Handbook) is easy to understand, but I don’t have time, and my eyesight is bad, so I can’t read. My grandchildren read it, but I only remember it for a while, and then I forget. [CG, female, 65, caring for her husband]

Relationship and psychological barriers.

Barriers related to relationships and power dynamics within the family significantly impacted the intervention process. Many caregivers, typically daughters-in-law, were the primary caregivers, yet lacked a voice within their families and rarely participated in caregiving decisions for relatives with dementia. This created significant challenges for them when attempting to apply the care strategies and techniques learned from the intervention sessions. Sometimes, they had to convey this information to other family members, but their communication skills and position within the family limited the effectiveness of their communication, hindering the desired outcomes of their problem-solving efforts. Due to this issue, many caregivers become very hesitant, reluctant, and even unwilling to try applying new strategies and techniques, fearing that their opinions will not be accepted by other family members.

Another difficulty is that caregivers are often in a lower position within the family, like the youngest child or a daughter-in-law. Their voices within the family are weaker compared to others, and their communication is not clear or coherent. So, when we intervene with the primary caregivers, they face difficulty convincing the family to implement some solutions. This ultimately affects the intervention outcome. [IV, male, 41, nurse]

Another psychological barrier was the reluctance to share family issues with interventionists. With the common mentality of most Vietnamese people, taking care of older members was a family matter, and if problems arose from this care, they often avoided sharing outside of the family due to their fear of being judged. In the early stages of the intervention, most caregivers were very cautious in sharing the problems they faced, especially when those problems were related to family relationships. Dealing with this challenge, interventionists emphasized the importance of being patient and persistent in building trust and supporting caregivers. This barrier was gradually removed in the later sessions of the intervention process.

The interventionist still has to be persistent and collect more information. They also need to be sensitive to understand that this person is hiding something, not telling everything. Then, we can rekindle it so that they can let go of their heavy heart and tell everything they are still hiding, things they can’t tell anyone. [MS, female, age not revealed, head nurse]

Process-oriented theme 2: direct, face-to-face interaction was irreplaceable!

Reflecting upon the process of the intervention delivery, participants from three groups of caregivers, interventionists, and other staff consistently highlighted the importance and significant benefits of the direct, face-to-face interaction in each session. The potential of phone intervention was also brought to discussion to prepare for the case of social distancing, such as during the COVID-19 pandemic. The consensus in their perspectives was that face-to-face sessions were irreplaceable, as they helped create a comforting and humane atmosphere for caregivers to build a trusting relationship and engage in deep conversations with their interventionists. All interventionists considered this approach an advantage to help them build a strong relationship with caregivers and enable them to grasp caregivers’ attitudes and emotions in each session:

When we come to a caregiver’s home, we can assess the level of their cooperation, whether they agree with us or are enthusiastic, and whether they enthusiastically apply the solutions we suggest. Only through direct dialogue and on-site visits can we identify these issues. [IV, male, 41, nurse]

This format allowed caregivers to express their views and emotions freely, especially when discussing sensitive topics, such as conflicts in caregiving between daughters-in-law and mothers-in-law. For most caregivers, the interventionists visiting their homes for a session was a gesture of care and emotional support, which was a crucial need for most caregivers. Caregivers explicitly stated that they greatly appreciated and looked forward to having someone visit their home during the active phase, as one caregiver commented: ‘It’s about feelings, nothing beats real feelings’ [CG, male, 87, caring for his wife].

In addition to the psychological effects, the face-to-face intervention delivery was believed to improve the communication effectiveness between caregivers and their interventionists, enhance caregivers’ learning, and contribute to the overall success of each session. This format also provided interventionists with the opportunity to observe and assess the real-life situations and risks present in caregivers’ living environments. Their accurate assessment critically informed the development and application of tailored intervention plans that fit each caregiver’s needs and condition.

The Handbook might have 10 solutions, but in reality, only two might be suitable for their (caregiver) situation. For example, in one case, the house had a very narrow passageway. It would be more appropriate to bring water to bathe the patient in their room. We have to go there directly. If we just stay in the office and talk about it (on the phone), it wouldn’t be effective. We need to go there directly. [IV, female, 47, nurse]

From the perspective of caregivers, they preferred a face-to-face session for their own learning experience. Most of them commented that they learned better through direct observation and hands-on practice. They wanted to discuss and receive on-the-spot advice when discussing a particular topic related to their dementia care. Furthermore, home delivery of the intervention session allowed interventionists to observe and evaluate caregivers’ real-time progress in their application of learned knowledge and skills in their care strategy and problem-solving.

When we go there directly, the interventionist interacts with the caregiver, and from one session to the next, we can identify whether the caregiver has applied what they learned in the previous session, and how effective it is. [IV, male, 41, nurse]

After the time of social distancing during the COVID-19 pandemic in Vietnam, the option of phone intervention was considered. All stakeholders, including caregivers, interventionists, and other staff, acknowledged its advantages in terms of cost and convenience, yet still preferred face-to-face sessions. They all pointed out that not everyone was suitable for telephone-based interventions. This intervention format required its participants to have a certain level of hearing, speaking, and cognitive ability, as well as technology proficiency, particularly smartphones. Other conditions, such as a stable phone signal, a quiet environment, and the absence of distractions, are also essential for a successful telephone-based intervention. Many caregivers, particularly older ones, highlighted their lack of confidence in engaging in this format. Most caregivers and health professionals suggested a combined format, in which the interventionists would visit each caregiver’s home one or two times to get to know the caregiver, build rapport, assess risks, and provide initial guidance on some basic topics. From subsequent sessions, the interventionists would schedule a time to call the caregivers to provide the remaining intervention content.

Process-oriented theme 3: all intervention components were important, yet we all had our most and least favorite ones!

The REACH VN intervention centered around six key components, including (1) Knowledge education; (2) Stress reduction; (3) Risk assessment; (4) Caregiver handbook; (5) Problem-solving; and (6) Mood management Caregivers and interventionists consistently emphasized that the stress reduction component was favored by almost all caregivers, followed by the knoweldge education and problem-solving skills. The majority of caregivers reported significant caregiving burdens, particularly psychological burden. Interventionists recalled that most of their caregivers complained about being stressed out and tired too often at the beginning of the intervention. At that time, most caregivers were unaware of any simple, feasible methods for reducing their own stress. During the intervention, they learned to apply practical and easy-to-implement stress reduction strategies, such as deep breathing and stretching, and observed noticeable results. This component was also reported to be regularly applied by caregivers even after the intervention ended.

We have done over 40 cases, most CG like the parts they are guided, particularly, the stress reduction. In the first session, they were guided to breathe deeply. After the third or fourth session, until the end of the program, they did that part very well, and they felt it really reduced their stress level to some extent. Also, stretching and muscle relaxation, they practiced them daily and found them comfortable. [IV, female, 43, nurse]

In addition, caregivers and interventionists pointed out that the components of knowledge, education, and problem-solving were endorsed by caregivers. Caregivers clearly acknowledged their lack of knowledge and skills in dementia care. Their key motivation to participate in the intervention was to obtain new, reliable, useful dementia care knowledge and skills. As a result, they were keen on these components:

In terms of caregiving, I personally appreciate all the components, but I particularly favor the knowledge that guides my caregiving. I do not have much knowledge, so I would love to learn from health professionals. There is a wealth of knowledge on YouTube, but I am not sure if they are trustworthy. [CG, male, 72, caring for his wife]

On the other hand, caregivers and interventionists shared the same assessment on the most challenging components for caregivers during the intervention, which were problem-solving and mood management. Although caregivers were highly valued and were engaged in problem-solving, they found it difficult to apply it in different situations. Due to limited sessions and time, caregivers typically received guidance from the interventionist to address one or two priority problems. When new problems arose, many caregivers did not feel well-prepared:

The issue is that when providing care for the patient, there are times when the patient experiences something unexpected, and I’m not prepared to handle it promptly… It means the unexpected situation arises, leaving me unprepared and unable to take proactive measures. [CG, female, 47, caring for her parent]

Also, on the same page with caregivers, interventionists unanimously agreed that the most challenging component of the entire intervention program was mood management. This content was considered quite new and abstract for many Vietnamese people. Many caregivers believed that thoughts were deeply ingrained and unable to change:

Among the six face-to-face intervention sessions, I think session number 3 about Mood Management by changing thoughts, for some cases, is the one that caregivers really had a hard time getting it, it’s a bit abstract. I encountered a case, she said that her mother-in-law and her husband are very cruel, and the husband unfortunately has dementia, and her life is miserable … That belief is ingrained in her subconscious, and she can’t get rid of it. [IV, female, 43, nurse]

Observing one’s own thoughts was not commonly practiced among most caregivers before the intervention. Proposed tools, such as Thought Records and Thought Modification, were found too abstract for many of them, especially those with limited cognitive abilities, to understand. Interventionists tried to overcome this challenge by flexibly explaining and providing culturally tailored examples for their caregivers, instead of rigidly using the Thought Record charts. Still, this was the least favorite component of caregivers from the perspectives of both stakeholder groups.

Outcome-oriented theme 1: caregivers have been much better in many ways!

Caregiver outcome emerged as a dominant theme in the data analysis across all three groups of stakeholders. Four key benefits of the intervention on caregivers were identified, including: (i) obtaining new knowledge and skills; (ii) shifting to a positive attitude; (iii) improving caregiving outcomes, and (iv) improving caregiver health outcomes. First, newly acquired knowledge and skills related to dementia and dementia care were evident. Caregivers highly valued and endorsed the knowledge and skill sets learned from the Caregiver Handbook and the sessions.

I think this program is very meaningful because many people in the district don’t have access to information to know that this is a disease, a manifestation of dementia. For the cases that we intervened in, people were very happy because they found it (the intervention) effective. I think it’s very meaningful and very good. [IV, male, 45, nurse]

Caregiver says: ‘Oh, we feel relieved, our minds are at ease while taking care of our loved ones’. They say that since the interventionists provided them with knowledge, they now know how to care for their loved ones comfortably and well. They no longer label their caregiving difficulty, obstacle, or annoyance. Now, people are content. [LS, female, 32, general practitioner]

Second, through acquiring new knowledge, caregivers significantly changed their perception and attitude toward the PLWD and their caregiving. Having understood that dementia was an illness, and that the behaviors of their relatives were due to the effects of the illness, the vast majority of the caregivers shifted their approach from blaming fate and the patient to becoming more understanding and empathetic towards their relatives. They started acknowledging and accepting their circumstances more calmly and peacefully.

Caregivers understand the illness better; they are more empathetic towards patients, meaning they can let go of thoughts like, ‘Why do I have to endure this? Why do I have to care for this person?’ They have a more positive outlook. And they accept that this disease cannot be cured. Their relative is sick, and doesn’t want to act this way, but their illness is like that. They accept that, and that makes them feel much lighter, and it makes their family life happier, much easier, less arguing, less resentment towards each other, and that has helped them a lot. [IS, Female, age not revealed, head nurse]

Third, with newly obtained knowledge and skills, in most cases, caregivers successfully adopted them in solving problems in their caregiving situations, therefore, improving their quality of care and care effectiveness. Most caregivers shared their experience in using the Caregiver Handbook to search for the information they need at a specific time, such as what to do when their relative kept wandering around or hoarding. As the quality of care improved, their relatives with dementia benefited from the intervention as secondary beneficiaries.

When I participated in the intervention program, I felt very relaxed in managing the illness… I just felt that the patient’s mood and emotions were also more relaxed. I was very encouraged… It’s like giving me more strength to take care of my family and the patient. [CG, male, 63, caring for his wife]

Overall, I find this program very good, very beneficial for the patients and for family members who care for the patients. It helps family caregivers gain the knowledge to provide more attentive and better care for the patients. As far as I’ve seen, that’s the immediate impact. [LS, female, 51, community health worker]

Fourth, along with knowledge and skills in dementia caregiving, part of the intervention centered at providing self-perception and self-care strategies to help reduce caregiver burden and psychological distress. All three stakeholder groups shared their consistent assessment that after the intervention, caregivers successfully prioritized their self-care by actively planning and taking action to care for their own physical and mental health. They learned to solve problems more flexibly and became more attentive to their own health, such as taking time to relax, walk, exercise, and socialize. To all stakeholders, it was evident that caregivers showed better health outcomes, particularly through their self-reported reduced psychological distress and somatic symptoms (e.g. insomnia, headache, etc.).

I feel it’s good for me, primarily, and secondarily, for my grandmother, because I know a lot of knowledge, I learned from that, I learn how to take better care of her, and sometimes it’s also good for my health. Before I didn’t exercise, now I do, every night, for over an hour, I exercise. If I don’t, I feel uncomfortable, I just leave work for a while, delay washing the dishes if needed, so at 7:30, I start exercising until 9. If the interventionist didn’t remind me, I probably wouldn’t go… but when they came, they reminded me, so I followed, applied it, and I felt it was much better.’ [CG, female, 51, caring for her parent]

Outcome-oriented theme 2: participating in REACH-VN has truly changed us, health professionals, in a positive way!

From a broad perspective, most health professionals involved in the implementation of the REACH VN intervention acknowledged its various benefits on all stakeholders besides caregivers, such as interventionists, interventionist supervisors, and local staff, etc.

This REACH program benefits everyone involved, from the interventionists who gain experience, to the supervisors who also gain experience, to the caregivers who receive counseling, books, and the staff at the community level who receive training. It’s a new approach. Previously, we only treated patients. [IS, female, 46, doctor]

Stakeholders agreed that participation in the project helped the nurse interventionists develop valuable new skills. Interventionists were trained in a new approach to support family caregivers of PLWD. Being an interventionist helped them broaden their perspectives and approaches to supporting the health and well-being of those affected by dementia, which not only focused on the patient but also encompassed their family caregivers.

Honestly, joining this program was a complete surprise and a great fortune for me personally. I found the humanity, the community aspect, and the novelty of focusing on another target group besides the patient. Ultimately, the aim is still the patients – the patients receive good care, have good health, and their caregivers have a good understanding of the disease, so the caregivers would be able to care for the patients better. This is a very new target group that we have rarely paid attention to in the past, and this is something I find very good. [IV, male, 41, nurse]

Being in the same line with the current interventionists, former interventionists who were then the interventionist supervisors from the national hospital in this phase shared that they have benefited significantly from both the interventionist and supervisor positions. This personal development was mostly based on exploring and applying a new approach of the intervention with family caregivers, which was different from the scope of their familiar work of medical diagnosis and treatment. As a result, they have a broader and more diverse perspective on supporting patients and families, and they have gained additional knowledge, skill sets, and tools to help them.

I think this project is very good. It’s something new that Vietnam hasn’t had before. We are also very lucky because we are one of the first to have access to a new method and a new approach that we couldn’t have imagined doing. Previously, my work and our team’s work at the hospital focused mainly on treatment and care for patients at the hospital. But the intervention focuses on caregiver stress relief and guidance on behavioral change based on the American model, which we had never heard of before. When we were able to access it, learn about it, and participate in the program, we felt very fortunate because we learned a lot of new knowledge and skills that could help patients and caregivers more. [IS, female, 41, doctor]

As interventionists, health professionals in the program received in-depth training and instruction to enhance their knowledge and skills. The new knowledge and skills were considered not only useful for their professional work at the hospital, but also a source of knowledge to share with their own family and friends in the community. One interventionist described the benefits of ‘stepping out of her comfort zone’ to learn new communication skills as a result of her participation in the project:

We were trained and instructed very thoroughly by the National Geriatric (hospital) on dementia and understand that this project is a very humanitarian scientific research. We have the knowledge and are very confident when we go to work with people in the community. We step out of our comfort zone, gain more knowledge, and our communication skills also improve; we become more confident, more open when communicating with people around us. That’s what I personally gained. [IV, female, 47, head nurse]

The interventionists also reported that participating in the intervention program expanded their social network, increased their understanding of the area and community they worked with, built deeper collaborative relationships with staff at the national hospital, and established new relationships with various stakeholders, including the project’s expert team.

Everyone feels happy and excited about the project because, first, it is an opportunity to enhance their skills as interventionists. Second, they are able to change their work environment. Instead of being confined to the hospital setting, they get to go out, interact with the community, and feel like they are making a greater contribution to the community. Often, this is also a way for them to reduce stress in their lives. [IS, male, 28, specialist in public health]

Discussion

The REACH VN intervention, to the best of our knowledge, is the first culturally tailored, multicomponent intervention targeting family caregivers of PLWD in the community setting in Vietnam (Evans et al., 2024; Hinton et al., 2019). The qualitative findings of this study critically reflect both the process and outcome evaluation of the intervention from the perspectives of multiple stakeholders, including family caregivers, interventionists, and other health professionals, staff, and leaders involved in the intervention delivery. The process-oriented themes suggest that caregivers and interventionists encountered multiple barriers during the intervention process, and amid these challenges, face-to-face intervention was highly preferred among participating caregivers, and among multiple components of the intervention, some worked better for caregivers than others. The outcome-oriented themes, on the other hand, highlight that participating in the intervention benefited not only caregivers but also health professionals involved, particularly the interventionists. These findings add to the scant literature on real-life experiences of multiple stakeholders in a psychosocial intervention for dementia caregivers in an LMIC.

Results from the present study highlighted key barriers to the intervention process at the community level. Four types of barriers emerged from the data, including: (i) Contextual barriers, such as time constraints and schedule conflicts; (ii) Financial and material barriers; (iii) Sensory and cognitive barriers; and (iv) Relationship and psychological barriers. These results are important to the literature on culturally tailored intervention research, as previous studies mostly focus on the assessment of feasibility, efficacy, and effectiveness of the REACH-VN intervention (H. Nguyen et at., 2025; D. Tran et al., 2022a). Very little is known about the practical barriers that caregivers and interventionists encounter and overcome to complete the intervention, and their potential impact on its process and outcomes. Learning about existing barriers critically helps shape the development of new interventions at the community level.

One of the key process-oriented themes emphasizes the importance and benefits of the face-to-face intervention format. All participants from the three groups consistently emphasized that face-to-face interaction was irreplaceable, at least in some first sessions. Similar to what was reported in mental health interventions (Erbe et al., 2017), the face-to-face format showed its strengths in fostering communication and psychological support to help interventionists timely identify and adequately react to caregiver crisis situations. In fact, face-to-face cognitive-behavioral therapy has proven its effectiveness in supporting family caregivers of people with dementia in coping with their complex psychological burden (Nehrig et al., 2019; Töpfer et al., 2023; Töpfer et al., 2024). To Vietnamese people, face-to-face communication plays an important role in education, especially when it involves training in interpersonal problem-solving (Dinh & Nguyen, 2023). In the modern context, where it is challenging for dementia caregivers to fully participate in all face-to-face sessions, stakeholders in the REACH VN intervention all agreed that the blended format of both face-to-face and phone sessions could serve as a potential approach in the future. This finding is in line with the suggestion of existing studies on the acceptability of different intervention formats for dementia family caregivers (Erbe et al., 2017; Töpfer et al., 2023; Töpfer et al., 2024).

The REACH VN intervention adopts the multicomponent approach that combines education, support, skill-building, problem solving, stress reduction, and communication. These approaches have been proven to be most effective among existing dementia caregiver interventions (Hinton et al., 2020; Committee on Family Caregiving for Older Adults, Board on Health Care Services, Health & Medicine Division, National Academies of Sciences, Engineering, & Medicine, 2016; Sörensen et al., 2002), and particularly for Vietnamese family caregivers, who tend to report multiple complex challenges and needs in their adjustment to caregiving (Nguyen et al., 2022; Nguyen & Levkoff, 2020). All stakeholders expressed their appreciation for the diverse components included and shared their consensus on caregivers’ most and least favorite components. Stress reduction was consistently acknowledged as the most preferred and applied component of caregivers, followed by the education component, by both caregivers and interventionists. Vietnamese caregivers explicitly showed their favor of the practical and easy-to-implement stress reduction strategies, such as deep breathing and stretching, and practical skills to care for the PLWD that they had learned in the REACH VN intervention. This finding is supported by the fact that stress reduction interventions (Nehrig et al., 2019; Stoia et al., 2020), as well as structured education programs for family caregivers of PLWD (Nehrig et al., 2019; Spalding-Wilson et al., 2018) have been demonstrated their importance and significance.

Although Vietnamese caregivers agreed that problem-solving and mood management were important, they consistently discussed challenges in learning and applying associated strategies and skills in these components. Managing difficult behaviors in the PLWD is critical to caregivers’ stress reduction and self-efficacy (Spalding-Wilson et al., 2018). In addition, identifying and validating the emotions of not only the PLWD, but also caregivers themselves, has been considered meaningful in minimizing caregiver negative emotions (Spalding-Wilson et al., 2018). Caregivers in the REACH VA intervention in the US also reported a mixed rating of the usefulness of problem-solving skills, while endorsing the effects of emotional transformation (Nehrig et al., 2019). Despite their significance, associated strategies and skills, as well as their tools, such as the Thought Monitoring Chart, were difficult for Vietnamese caregivers to understand, become familiar with, and really apply in their daily lives. It could partly be explained by the fact that Vietnamese adults tend to suppress their emotions and adopt avoidance to cope with stress and interpersonal conflicts (Do, 2022). It is worth noting that most caregivers in this intervention study were older with limited educational background, and most of them had not had the habit to observe their own thoughts and feelings. Further revision of the guidance of these components would be needed to be culturally fit the Vietnamese sociocultural context.

The results of this study suggest that REACH VN benefited Vietnamese family caregivers in many different aspects, showing in their new knowledge and skill obtainment, positive attitude change, improved caregiving outcomes, and better caregiver health outcomes. These outcomes are not only in line with the primary and secondary caregiver outcomes of the intervention, but also consistent with findings of previous studies. Multicomponent psychosocial interventions targeting dementia caregivers have shown their efficacy and effectiveness in reducing caregiver burden, improving their knowledge, care outcomes for the patients, and their own psychological well-being (Brodaty et al., 2003; Nehrig et al., 2019; Spalding-Wilson et al., 2018). Even the quantitative evaluation of the REACH VN intervention in the larger study demonstrated its feasibility and preliminary efficacy in reducing caregiver perceived stress and psychological distress, and their somatic symptoms at three months, and decreased caregiver burden at six months (Nguyen et al., 2025). An important contribution of the present study is the emphasis on the importance of educational and interpersonal strategies in modifying the perception and attitude of caregivers, which significantly contribute to other outcomes.

Another key theme in this qualitative study is positive changes in health professionals participating in the intervention as an interventionist or an interventionist supervisor. Almost all existing studies focus on the benefits and effects of an intervention on family caregivers, its primary beneficiary. A multi-stakeholder intervention needs to take into account of different stakeholders’ perspectives, including health professionals about their own competence (Fortinsky et al., 2014; Zhao et al., 2021). The REACH VN intervention involved the training of health professionals, typically doctors and nurses, to deliver the intervention. It is crucial to understand how being trained and participating in the intervention delivery changed them. Findings of this innovative study suggest positive changes in these groups’ perspectives and approaches in supporting PLWD and their families, expansion in their social networks, improvement in their professional knowledge and skills in dementia care, and improvement in their communication skills and other community skills. In other words, being an interventionist or an interventionist supervisor in the intervention critically paved the way to the capacity building of Vietnamese health professionals involved in the program, which contributed to the long-term effect on supporting PLWD and their family caregivers.

This qualitative study has several limitations, and its findings should be interpreted with caution. Most caregivers who participated in the intervention were caring for a relative with moderate or severe dementia, and their reported caregiver burden was relatively high. Many of the caregivers had limited educational attainment, and some showed challenging cognitive capacity to process complex components, such as problem-solving and mood management, which potentially affected their own assessments. Findings from the perspective of this caregiver group could not fully represent other caregivers. The intervention was conducted in northern Vietnam with specific regional sub-culture, family tradition, and dynamic, and healthcare conditions, which might be different from other regions in Vietnam, such as the central and southern parts of the country.

Conclusion and implications

This qualitative evaluation study suggests that, from multiple perspectives of different stakeholders, the culturally tailored, community-based, multi-component REACH VN intervention showed its significance and important benefits to not only family caregivers of PLWD, but also health professionals involved. Being part of the intervention helped increase caregiver knowledge and skills, positively change their attitude toward dementia and caregiving, improve their caregiving outcomes, as well as their own health outcomes. In addition, involved health professionals in the roles of an interventionist or an interventionist supervisor reported their positive changes in dementia care perspectives and approaches, expanded social networks, improved healthcare knowledge and skills, communication skills, and other community skills. Our study’s results highlight the need for further cultural modifications in some components, such as problem-solving and mood management, to better fit the sociocultural context and cognitive capacity of most caregivers. A blended format of face-to-face and phone interventions was also proposed for future expansion of the intervention at the community level in order to serve the great demand of Vietnamese family caregivers of PLWD.

Supplementary Material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/13607863.2025.2610661.

Data availability statement

Due to the sensitive nature of the research, participants did not agree to their data being shared publicly, so supporting data are not available.