Need For Psychosocial Interventions Research Articles

Supporting Carers: Study Protocol of a Meta-Review of Psychosocial Interventions for Carers of People With Cancer.

While there is a clear need for psychosocial interventions that promote the well-being of carers of patients with cancer, the corresponding evidence base is disparate, complex, and difficult for end users to navigate and interpret. Carers remain undersupported with a lack of dedicated, effective, evidence-based programs. We will conduct a meta-review to synthesize this evidence and determine the state of science in this field. This study aims to address the question, "what psychosocial interventions are available to promote the well-being of carers for people with cancer?" A meta-review will synthesize the relevant reviews of psychosocial interventions that have been developed and evaluated with carers for people with cancer. A total of 4 electronic databases (PsycInfo, MEDLINE, CINAHL, and Cochrane Database of Systematic Reviews) will be searched for reviews published between January 2013 and December 2023. A team-based approach will be taken for screening and assessment of the returned records against the eligibility criteria to determine inclusion. Included reviews will be critically appraised using the Joanna Briggs Institute Critical Appraisal Checklist for Systematic Reviews and Research Syntheses. Relevant data on study characteristics, carer and patient populations, intervention details, and psychosocial outcomes will be extracted, synthesized, and the findings will be presented in a narrative format. It is anticipated that the study will be completed by October 2024. Ensuring that carers have access to evidence-based programs that promote their well-being as they care for loved ones is critical. This meta-review will contribute to program development and translation efforts by providing a clear picture of the intervention evidence base of carers of patients with cancer and identifying notable strengths, weaknesses, and gaps across the literature. The findings are anticipated to offer future directions to advance research in the field. PROSPERO (CRD42023403219); https://tinyurl.com/4tnzv49s. DERR1-10.2196/56403.

Development of the Partner Version of the Self-Efficacy to Communicate about Sex and Intimacy (SECSI-PV) Scale in the Context of Cancer Survivorship

Purpose This study aimed to develop the Partner Version of the Self-Efficacy to Communicate about Sex and Intimacy (SECSI-PV) scale. Methods Candidate items derived from the patient version of the instrument were refined with input from an expert panel specializing in sexual health, psychosocial oncology, and instrument development (n = 6). Partners (n = 17) of female cancer survivors participated in cognitive interviews to assess the revised scale’s content validity. Results Transcripts were analyzed qualitatively. Participants endorsed the items as relevant, clear, and appropriate. Conclusions The present work illustrates the iterative development of the SECSI-PV scale. The study highlights the importance of including partners in sexual health discussions and emphasizes the need for psychosocial interventions supporting partners’ confidence communicating about sexuality and intimacy. Additional research is recommended to validate the instrument in larger samples encompassing cancer types that are not sex-based and partners from diverse backgrounds, including sexual and gender minority groups.

Relation between Burnout and Psychosocial Factors in Health Care Providers and Family Caregivers of Patients with Cancer

Abstract Introduction Burnout has been widely studied among oncology health care providers such as nurses and doctors. However, it is a less explored but highly prevalent factor in family caregivers of patients with cancer. Objective The study aimed to understand the construct of burnout among health care providers and family caregivers of patients with cancer, through three objectives: (1) to distinguish burnout between health care providers and family caregivers; (2) to predict burnout based on measurable characteristics, namely, perceived stress, psychological morbidity, well-being, problem-focused coping, emotion-focused coping, and avoidant coping; and (3) to find out the levels of burnout (low, medium, and high) in health care providers and family caregivers. Materials and Methods It is a cross-sectional study conducted among the health care providers and family caregivers of patients with cancer. The measures used in the study were the Professional Quality of Life scale, 12-Item General Health Questionnaire, Perceived Stress Scale, 5-Item World Health Organization Well-Being Index, Brief COPE inventory, and a sociodemographic details form. Results The study found a statistically significant difference in the mean burnout of health care providers (p = 0.027) and family caregivers. Study variables such as perceived stress and avoidant coping positively predicted burnout, whereas well-being and emotion-focused coping negatively predicted burnout. The study also found that a majority of the participants fell into the category of “medium” level of burnout. Conclusion While enhancing well-being and employing adaptive coping styles can act as the mitigating factors to burnout, the existence of stress and maladaptive styles of coping can prove counterproductive in dealing with burnout in work environments. This indicates that there is a need for psychosocial interventions to help the medical professionals deal with the burnout.

Re-visioning and critically emphasizing the need for psychosocial intervention in addressing body image distress in head and neck cancer patients: A review of literature

Head and neck cancers (HNCs) patients undergo extensive debilitating surgeries on the part of their body which is considered as a unique characteristic feature and a central entity to communication and perception, instilling a sense of self: The face. Hereby, alterations and discontinuity in this sense of self lead to fragmentation of body image, thereby shattering the sense of identity and making it difficult for patients to recognize selves and return back to the precancerous identity. Body image dissatisfaction is associated with varied psychosocial adverse outcomes such as anxiety, depression, decreased quality of life affecting social dynamics, romantic relationship distress relating to sexual and intimate health, and excessive efforts spent on appearance-fixing behaviors and the need for constant reassurance. As body image goes way beyond just mere appreciation of self and is a multifaceted, intricate web crucially affecting an individual’s identity and existence, it is of utmost importance that medical health professionals aim at making oncologic treatment a more holistic model which considers a patient’s mental, emotional and physical well-being. Present literature offers a wide scope for studies focused on psychological distress in breast cancer patients; however, limited empirical research has been conducted on body image concerns and the need for psychosocial interventions in HNC patients. A need for an in-depth understanding into this aspect of psycho-oncology will help oncologic intervention to be more patient-centric, providing the benefits of both biomedical and psychosocial skills.

The role of income inequality as an ecological determinant of mental health: A nation-wide multilevel analysis on an Italian sample.

Income inequality, a pivotal determinant of general and mental health, operates through intricate mechanisms at various geographical scales. While established at country or region levels, the impact of lower-level (municipal or neighborhood) inequality remains inconsistent. This study explores the influence of regional- and municipal-level income inequality on individual psychological distress during the COVID-19 pandemic in Italy, employing a multilevel data analysis. In a post hoc analysis of data from the first wave of the pandemic (March to April 2020), three hierarchical levels were considered: individual participants, municipalities, and regions. Depressive and anxiety symptoms were measured using the PHQ-9 and GAD-7 scales, while the Gini coefficient gauged income inequality at municipal and regional levels. The analysis incorporated demographic variables as potential confounders. The study encompassed 21 regions, 3,900 municipalities, and 21,477 subjects. Income inequality at both regional and municipal levels exhibited associations with distress scores, suggesting independent effects. Notably, higher distress scores were identified in southern regions with elevated inequality, despite a more substantial COVID-19 impact in the north. Findings contribute to existing literature by emphasizing the independent impact of lower-level (municipal) and higher-level (regional) income inequality on population psychopathology. The study supports theories suggesting diverse pathways through which inequality at different levels influences health, such as potential associations with healthcare system dysfunction at the regional level and welfare dysfunction at the municipal level. The observed north-south gradient in distress scores highlights the need for psychosocial interventions to alleviate income inequality, especially in historically disadvantaged southern regions. Future research should explore the nuanced interplay between income inequality and various ecological variables to provide a comprehensive understanding of its health impact.

Mild Cognitive Impairment (MCI): Evaluating a new treatment pathway for service users and carers

The prevalence of MCI is increasing in older adults; living with MCI not only negatively affects older people’s daily living and quality of life, but also increases the likelihood of developing dementia in the future. However, not all individuals will progress to dementia, which highlights the importance of developing preventative strategies and appropriate interventions to delay the onset of dementia. Given the current emphasis across the healthcare system on the need for psychosocial interventions that reduce the risk of dementia, the Specialist Dementia and Frailty Service (SDFS) in West Essex has launched a new MCI pathway, which runs as a pilot for one year to offer support for individuals with MCI and their caregivers. The current service evaluation aims to evaluate older people’s and their carers’ experiences of receiving a diagnosis in conjunction with exploring ideas about what they would find helpful in terms of post diagnostic support. Semi-structured interviews were conducted with service users and their carers over the telephone. Service users had received an MCI diagnosis and were either awaiting an intervention from the pathway or had received some form of post diagnostic support. Data was collected through an interview schedule and analysed using thematic analysis (TA). Themes highlighted the varying emotional experiences of receiving the diagnosis, the confusing and ambiguous process of MCI, the helpful and less helpful aspects of the support received, and ideas for future support. Findings from the service evaluation fit with the wider MCI literature and research. Some implications for the memory service are discussed, including individualised support, peer support, additional regular check ins and follow ups from the service, and support for carers.

THE LIVED EXPERIENCES OF DISPLACED AFRICAN SINGLE MOTHERS IN THE AFTERMATH OF FLOODS IN KWAZULU-NATAL

In April 2022, heavy rainfall and flooding took place in most areas of KwaZulu-Natal, South Africa. The floods left a trail of destruction, grief and displacement for the most vulnerable social groups. The condition of African single mothers was of particular concern because of the multiple disadvantages they already face. Based on a qualitative study conducted with 30 displaced single mothers who were purposively selected, the article explores the lived experiences of displaced African single mothers in the aftermath of the KwaZulu-Natal floods. The findings revealed that although temporary shelters were provided for their safety, African single mothers were subjected to various forms of secondary trauma, which aggravated their vulnerability. This suggested a need for psychosocial interventions and a comprehensive emergency plan for single mothers during natural disasters. Based on the strengths perspective, the article recommends intensive social work interventions and strategic resource management amongst community stakeholders and political leaders to ensure the effectiveness and sustainability of support. Keywords: displaced, floods, KwaZulu-Natal, natural disasters, single mothers, social work practice

Excessive daytime sleepiness in nursing technicians: association with sleep quality and memory.

to investigate excessive daytime sleepiness prevalence among nursing technicians and the association with sleep quality and memory. a cross-sectional, inferential study, carried out in a hospital unit in the state of Goiás between December 2020 and January 2021. Assessments were carried out using the Epworth Sleepiness Scale, the Pittsburgh Sleep Quality Index and the Prospective and Retrospective Memory Questionnaire, instruments validated for the Brazilian context. Bivariate and multivariate logistic regression analyzes were performed. the sample consisted of 189 nursing technicians with a 40.9% excessive daytime sleepiness prevalence. In multivariate models, excessive daytime sleepiness was not associated with sleep quality, however there was a significant association with overall memory failures. study results demonstrate a high excessive daytime sleepiness occurrence, an association with overall memory failures and the need for psychosocial interventions for nursing technicians.

The anxiety level of healthcare professionals and hospital support staff during the COVID-19 pandemic

Background/Aim: The coronavirus 2019 (COVID-19) pandemic has placed a significant psychological burden on healthcare professionals. This study aims to identify the anxiety levels of healthcare professionals and non-healthcare personnel during the pandemic. Methods: This cross-sectional study was conducted on healthcare professionals during the pandemic, and we attempted to reach all personnel without setting a specific sample size. Participants completed a survey that included demographic information and the State-Trait Anxiety Inventory (STAI). We compared anxiety scores and working conditions between healthcare and non-healthcare personnel during the pandemic. Results: Our study included 204 personnel, with 45.1% being healthcare professionals and 54.9% non-healthcare professionals. The mean state anxiety score for all participants was 44.7 (10.3). Female professionals, those working in intensive care, and personnel who believed they lacked sufficient protection training had significantly higher mean anxiety scores (P=0.001, P=0.006, P<0.001, respectively). Participants with mild or no problems initiating and maintaining sleep and waking up early had lower mean anxiety scores (P<0.001). There was no statistically significant difference between healthcare professionals and non-healthcare personnel in mean scores (P=0.59). Conclusion: Our study found that all personnel experienced medium-level anxiety during the pandemic, indicating an increased risk for hospital staff. The fact that non-healthcare personnel had similar anxiety scores to healthcare professionals highlights the need for psychosocial interventions to support all hospital staff, regardless of their role in patient care.

‘I don't feel good about myself and sex’: sexual health experiences of women with gynaecological cancer in Ghana

Background/Aims Patients with gynaecological cancer undergoing treatment face numerous challenges, including issues surrounding sexual health. Sexual health is an important aspect of human life, and the negative impact of gynaecological cancer, its treatments and any side effects may cause physical, emotional and psychological distress. In sub-Saharan Africa, sexual health and childbirth form the core of marital relationships; changes in sexual response and function as a result of cancer can lead to dysfunctional relationships. This study explored the sexual health experiences of patients with gynaecological cancer at the Korle Bu Teaching Hospital in Ghana. Methods This study used an exploratory, descriptive, qualitative design. A total of 12 adults with gynaecological cancer (cervical, endometrial and ovarian) were purposively selected from the Korle Bu Teaching Hospital. Data were collected with a semi-structured interview guide through face-to-face or telephone interviews. Data were analysed using thematic analysis. Results Four themes emerged: changes to the sex organ, changes in sex life, anxiety about treatment outcome and coping strategies. The participants had generally had healthy sex lives before being diagnosed with cancer. Psychologically, participants experienced anxiety and lacked interest in sex. Physical effects included bleeding, changes to the female organ and pain. The participants self-stigmatised in the form of low self-esteem and separation. They coped through religious means, family support and health education. Conclusions There is a need for psychosocial interventions in the care of women with gynaecological cancers, including measures to support coping with the physical effects of the condition and its treatment. It is recommended that stakeholders in cancer care are made aware of, and make efforts to include in their care, spirituality, family support and health education.

Can Cardiac Surgery Lead to ICD-11 PTSD and Complex PTSD? Findings of a 5-year Follow-up Study.

Cardiac surgery may lead to various neuropsychiatric conditions, including posttraumatic stress disorder (PTSD). The 11th revision of the International Classification of Diseases (ICD-11) included a new complex posttraumatic stress disorder (CPTSD) disorder in addition to PTSD. This study aimed to explore whether cardiac surgery could be associated with PTSD and CPTSD at a five-year follow-up after cardiac surgery. The study sample comprised 210 patients (mean age 67, 69.5% male) who had undergone cardiac surgery. The self-report International Trauma Questionnaire (ITQ) was used to assess ICD-11 PTSD and CPTSD. The Medical Outcomes Study 36 Item Short Form Health Survey (SF-36) questionnaire was used to measure health-related quality of life (HRQOL). We found 5.2% of cardiac surgery-related probable PTSD and CPTSD at a 5-year follow-up, 1.9% PTSD, and 3.3% CPTSD. Low HRQOL was associated with a high risk for PTSD/CPTSD at follow-up. The results showed that cardiac surgery might have a long-term effect on PTSD and CPTSD symptoms. Patients with low HRQOL are at higher risk of having PTSD/CPTSD risk. The study informs about the need for psychosocial interventions to reduce the impact of cardiac surgery on neuropsychiatric conditions and the improvement of HRQOL.

Mental Health, ART Adherence, and Viral Suppression Among Adolescents and Adults Living with HIV in South Africa: A Cohort Study

We followed adolescents and adults living with HIV aged older than 15 years who enrolled in a South African private-sector HIV programme to examine adherence and viral non-suppression (viral load > 400 copies/mL) of participants with (20,743, 38%) and without (33,635, 62%) mental health diagnoses. Mental health diagnoses were associated with unfavourable adherence patterns. The risk of viral non-suppression was higher among patients with organic mental disorders [adjusted risk ratio (aRR) 1.55, 95% confidence interval (CI) 1.22–1.96], substance use disorders (aRR 1.53, 95% CI 1.19–1.97), serious mental disorders (aRR 1.30, 95% CI 1.09–1.54), and depression (aRR 1.19, 95% CI 1.10–1.28) when compared with patients without mental health diagnoses. The risk of viral non-suppression was also higher among males, adolescents (15–19 years), and young adults (20–24 years). Our study highlights the need for psychosocial interventions to improve HIV treatment outcomes—particularly of adolescents and young adults—and supports strengthening mental health services in HIV treatment programmes.

Predictive influence of personality traits on retirement anxiety among universities staff in Osun State, Nigeria.

Retirement anxiety may occur in retirement-eligible staff, and their reaction may depend on their personality traits. This study examined the predictive influence of five-factor personality traits on retirement anxiety among non-academic staff in some selected universities in Osun State, Nigeria. The study utilized a multistage sampling technique. Two self-administered instruments, Redeemer's University Retirement Anxiety Scale and Mini-International Personality Item Pool were completed by 463 non-academic staff in five selected universities in Osun State, Nigeria. Descriptive statistics (frequency and percentages) and inferential statistics (hierarchical regression, two-sample t-test, and one-way ANOVA) were used to analyze data. The study found a high prevalence rate of retirement anxiety (85.1%) among university staff in Nigeria. In all, 13%, 16%, and 12.5% of the participants showed high levels of retirement anxiety dimensions (personal obligation, financial planning, and social detachment), respectively. Sociodemographic and personality traits jointly accounted for statistically significant (16%, 29%, and 22%) changes in personal obligation (R2 =0.16, P <.01), financial planning (R2 =0.29, P <.01), and social detachment (R2 =.22, P <.01), respectively. Personality traits (extraversion, agreeableness, conscientiousness, and neuroticism) and socio-demographic variables (age, educational level, job tenure, and job status) jointly contributed to the prediction of retirement anxiety dimensions (obligation concerns, financial planning, and social detachment). The findings highlighted the need for psychosocial interventions targeting the at-risk population was highlighted.

Evaluating a Digital Mental Health Intervention (Wysa) for Workers' Compensation Claimants: Pilot Feasibility Study.

This study examines the feasibility and acceptability of an AI-led digital mental health intervention in a Workers' Compensation (WC) program, Wysa for Return to Work. Self-reported demographic data and responses to psychosocial screening questions were analyzed alongside participants' app usage through which four key outcomes were measured: recruitment rate, onboarding rate, retention, and engagement. The data demonstrated a high need for psychosocial interventions among injured workers, especially women, young adults, and those with high severity injuries. Those with more psychosocial risk factors had a higher rate of onboarding, retention, and engagement, and those with severe injuries had higher retention. Our study concluded that Wysa for Return to Work, the AI-led digital mental health intervention that delivers a recovery program using a digital conversational agent, is feasible and acceptable for a return-to-work population.

HIV-related stigma, disclosure and social support: experiences among young pregnant and postpartum women living with HIV in South Africa

ABSTRACT Young pregnant and postpartum women living with HIV (WLHIV) are at high risk of poor antiretroviral therapy (ART) outcomes, which may be driven partly by HIV-related stigma. We conducted in-depth interviews with 20 pregnant and postpartum WLHIV aged 19–24 years to understand how different forms of HIV-related stigma manifest in their lives, as well as their experiences of HIV-status disclosure and social support. Participants described profound levels of perceived stigma in their community, including gossip from other young women and judgement from older adults. Consequently, participants disclosed to a limited number of people to avoid being stigmatised, and disclosure to peers was especially uncommon. However, disclosure in certain situations was described as leading to emotional support and support for ART adherence, and disclosure to older WLHIV resulted in participants having a role model. Finally, participants expressed varied ways in which they accept, speak about, and live with their HIV diagnosis. These data provide a rich understanding of the experiences of HIV-related stigma in this population and point to the need for psychosocial interventions focussed on acceptance and coping with an HIV-positive diagnosis despite profound levels of perceived stigma, as well as navigating decisions around the targets and timing of disclosure. Trial registration: ClinicalTrials.gov identifier: NCT04036851.

Prevalence and factors associated with mild depressive and anxiety symptoms in older adults living with HIV from the Kenyan coast.

IntroductionEmpirical research on the burden and determinants of common mental disorders (CMDs), especially depression and anxiety, among older adults living with HIV (OALWH) in sub‐Saharan Africa is inadequate. To bridge the gap in Kenya we: (1) determined the prevalence of CMDs among OALWH on routine HIV care compared to HIV‐negative peers; (2) investigated HIV status as an independent predictor of CMDs in older adults; and (3) investigated CMD determinants.MethodsIn a cross‐sectional study conducted between 2020 and 2021, the prevalence of CMDs and associated determinants were investigated at the Kenyan coast among 440 adults aged ≥50 years (257 OALWH). The Patient Health Questionnaire and Generalized Anxiety Disorder scale were administered alongside measures capturing biopsychosocial information. Logistic regression was used to examine the correlates of CMDs.ResultsNo significant differences were found in the prevalence of mild depressive symptoms, 23.8% versus 18.2% (p = 0.16) and mild anxiety symptoms, 11.7% versus 7.2% (p = 0.12) among OALWH compared to HIV‐negative peers, respectively. HIV status was not independently predictive of CMDs. Among OALWH, higher perceived HIV‐related stigma, ageism, increasing household HIV burden, loneliness, increasing functional disability, sleeping difficulties, chronic fatigue and advanced age (>70 years) were associated with elevated CMDs. Among HIV‐negative older adults, loneliness, increased medication burden and sleeping difficulties were associated with elevated depressive symptoms. Easier access to HIV care was the only factor associated with lower CMDs among OALWH.ConclusionsOn the Kenyan coast, the burden of moderate and severe CMDs among older adults is low; however, both OALWH and their HIV‐negative peers have a similar relatively high burden of mild depressive and anxiety symptoms. Our results also suggest that determinants of CMDs among OALWH in this setting are predominantly psychosocial factors. These results highlight the need for psychosocial interventions (at the family, community and clinical levels) to mitigate the risks of mild CMDs as they are known to be potentially debilitating.

What is intended by the term "participation" and what does it mean to people living with dementia? A conceptual overview and directions for future research.

Policy continues to emphasise the importance of wellbeing in dementia. However, there is a vital need for psychosocial interventions that can promote positive outcomes to enhance “living well with dementia”. Our developing understanding of what people living with dementia report as being important to them, has resulted in new interpretations of what constitutes wellbeing including constructs such as “growth”, “purpose” and “participation”. These exciting and important constructs are not currently captured by outcome measures within dementia research. This limits our understanding of the value of psychosocial interventions. This paper explores the concept of participation and how continued participation in social life can make a difference to the rights of people living with dementia as citizens. We will firstly consider why participation is important for how we might measure outcomes in dementia research and care. Secondly, we will explore how we might measure participation. Finally, we will consider the value of participation as a psychosocial outcome in future research.

Baseline characteristics of adults with neurofibromatosis enrolled on a psychosocial randomized controlled trial.

Neurofibromatosis (NF) is an incurable genetic neurological condition. Psychosocial interventions that promote resiliency are a promising approach to address the high emotional distress and low quality of life (QoL) associated with NF. However, no studies have examined the psychosocial needs of treatment-seeking adults with NF. Our goal was to explore, using data from the largest efficacy trial of a psychosocial intervention for NF, differences in QoL, emotional distress, resiliency, and pain-related outcomes compared to other chronic medical populations and within subtypes (NF1, NF2, schwannomatosis; SCHW). Enrolled participants (N = 228) were geographically diverse adults with NF and elevated stress. We performed secondary analysis on baseline measures of QoL, emotional distress, resiliency, and pain-related outcomes. We reported descriptive statistics and normative comparisons to understand the psychosocial characteristics of the overall sample and performed between-group analyses to explore differences within NF type. Our sample endorsed worse QoL, emotional distress, resilience, and pain-related outcomes than similar chronic illness populations. Within NF types, participants with NF1 reported lower QoL and resilience compared to those with NF2. Participants with SCHW reported higher pain intensity than those with NF1. Participants with SCHW reported higher pain interference and lower physical QoL compared to those with NF1 and NF2. Our findings support the urgent need for psychosocial interventions targeting deficits in QoL, emotional distress, resilience, and pain-related outcomes in adults with NF. We recommend efforts to enhance sample diversity, prepare clinicians to provide high-levels of support, and attune skills training to each NF type. ClinicalTrials.gov NCT03406208; https://clinicaltrials.gov/ct2/show/NCT03406208 (Archived by WebCite at http://www.webcitation.org/72ZoTDQ6h ).

A Pilot Exploration of the Experiences of COVID-19 Vaccinated Perinatal Women and the Need for Psychosocial Interventions in Rural India.

A Pilot Exploration of the Experiences of COVID-19 Vaccinated Perinatal Women and the Need for Psychosocial Interventions in Rural India.

Adapting the Namaste Care Program for Use with Caregivers of Community-Dwelling Older Adults with Moderate to Advanced Dementia: A Qualitative Descriptive Study.

Family/friend caregivers are highly involved in supporting older adults with dementia who are 65 years of age or older with daily activities, especially when these older adults with dementia are living at home. There is a need for psychosocial interventions for caregivers of older adults with moderate to advanced dementia, as most interventions focus on persons at earlier stages. Namaste Care is a psychosocial, multisensory program intended to enhance quality of life for people with advanced dementia and their caregivers; however, it has not yet been adapted for use in a home setting. In this study, caregivers collaborated in adapting Namaste Care during workshops so that it could be delivered by caregivers of older adults with moderate to advanced dementia at home. Key findings were that Namaste Care resonated with the daily activities of caregivers, but that the intervention required modifications to ensure that it could be tailored to the needs and realities of caregivers and persons with dementia.