1.1 through rehabilitation and optimisation of medications such as

1.

1IntroductionParkinson’s Disease (PD) is the second most commonneurodegenerative disorder after Alzheimer’s Disease (AD) (Tanner and Goodman,cited in Gibrat, et al., 2009). It is anage-related condition and is commonly diagnosed in older adults aged 60 andabove, with some diagnosed as early as before aged 50 (Lonneke & Monique, 2006). PD is postulated tohave an additional strain on both social and economic aspects especially incountries facing an aging population  (Lonneke & Monique, 2006). In a study by Jankovic& Kapadia (2001), it was identified that there could be an annual declineof scores, up to 1.58, in the Unified Parkinson’s Disease Rating Scale (UPDRS).

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The rate of deterioration also seems to be much more rapid in the early stagesas compared to the advanced stages in the diseases and more so in individualswith major depressive symptoms (Starkstein, et al., 1992).Currently, there is no cure for PD and management has been a multidisciplinaryapproach through rehabilitation and optimisation of medications such asLevodopa (Patil, et al., 2014).

Therefore, due to the debilitating nature of theneurodegenerative disease, individuals with PD will experience decline in bothmotor and non-motor aspects. This places individuals with PD to be at higherrisk of falls (Williams-Gray & Worth, 2016) as well asconditions such as dementia (Lonneke & Monique, 2006) and depression (Starkstein, et al., 1992) . Due to theprognosis of the condition, individuals with PD will require a high level ofcare, putting them in need for full time carers or worst, institutionalised. The role of caregiving has traditionally fall on theshoulders of immediate family members and spouse. However, in recent years, dueto the involvement of more women in the labour force, seeking for alternativessuch as use of foreign domestic workers in eldercare has been much moreprevalent. However, they are at a disadvantaged when caring for the elderly ascompared to that of their family members.

Unlikethe immediate family members, foreign domestic helpers had limited to nointeractions with the older adult prior to care (Tan, et al., 2009), making caring moredifficult. Secondly, little is known about the FDW previous eldercareexperience with many employers basing their choice of domestic helpers throughstereotypes such as nationalities and age (Yeoh & Huang, 2010).And lastly, the market for FDW is huge, resulting in varying background of theFDWs. Language barrier can then posed as a barrier to understanding the need ofthe elderly and hence making caring for the elderly more difficult (Yeoh & Huang, 2010).

With an increasing trend of foreign domestic helpers being involved in eldercare(Yeoh & Huang, 2010), there is a need toconsider the care offered by the foreign domestic helpers. In current literature, studies have explored oncaregiver burden (Schrag, et al., 2006;Caap-Ahlgren & Dehlin, 2002) and the level of competency that acaregiver requires (Given, et al., 2008). However, none have consideredthe self-efficacy of a foreign domestic helper when there are multiple barriersposed in the care of an older adults. Therefore, this review aims to understandthe importance of foreign domestic helper in Singapore’s healthcare scene andtheir level of support they received prior to caring for older adults.

1.2 OverviewVarying composite of keywords consisting ofParkinson’s Disease, caregiver burden, caregiver stress, foreign domesticworkers and self-efficacy were entered into the electronic database of PubMed/Medline,AMED and Google Scholar. A total of three studies were generated and will beevaluated. 1.3 Change in demographics in Singapore Compared to two decades ago, Singapore is currentlyfacing a major change in the population’s demographic. Currently, the countryis experiencing both an aging population and a change in women’s participationin the workforce.

 Like many developed countries, Singapore is alsofacing an aging population. From the year 2000 to 2017, the age pyramid isstarting to take form of an inverted triangle with a median age of 40.5 in 2017as compared to 34.0 in 2000 (Department of Statistic Singapore, 2017). Due to a change indemographic to an aging population, there is a need to consider changes to helpand maximise the support for them. These changes will mainly be pertaining tohealthcare needs such as amenities as well as availability of carers. This isespecially important in older adults, as they are prone to hospitalisation andnew onset of disability or functional decline is usually associated with older adults’post discharge (Boltz, et al.

, 2012). With a reduction infunctional status, there is a need for older adults to undergo rehabilitation.However in Asia, family members and older adults would prefer to be cared forat home rather than relocating to other institution (Wang & Wu, 2016). Hence with adecline in functional status, there is a possible need for a full-time carer.Majority of the informal caregiving role are borne by female,either spouse or immediate family members such as adult children ordaughters-in-law (Jang, et al., 2012).

In the similar study, a correlation between proportion of female informalcaregivers and women’s labour force participation, and per capita grossdomestic product (GDP) was noted. For example: country with higher GDP has ahigher percentage of women involved in the workforce, thus resulting in a lowerpercentage of informal caregivers and vicely versa. Austen (2005) reviewed thedemographic change in Singapore and the impact of it. Since achieving independence,Singapore has put in place policies to restructure her economy by increasingliteracy rate and skills level.

This change allows and create oppportunitiesfor women, to enter into the workforce with a lower barriers to entry. From theyear of 1977 to 1997, Singapore has seen an increase of about 376.7% and 1015.8%increase in enrolment to local university and polytechinic respectively. Coupledwith economic development in the early 1990s, more employment opporuntitieswere available for women especially in the Financial, Insurance, Real Estateand Business Services sector. During the period of 1992 to 2002, Singaporeexperienced a 85.6% increase in GDP per capita (World Bank, 2017) with the steepestincrease between 1992 and 1997. Similarly in this period, Singapore also see anincrease in female share of industry job by 2.

5%. Relating the findings byJang, et al. (2012) to Singapore’s context, as Singapore’s GDP per capitaincreases, the number of women in the labour force also increasesproportionately, resulting in a reduction in the percentage of full timeinformal caregiver available.

1.4 Healthcare in SingaporeWith the change in demographic, thereis a pressing need to manage and come up with alternatives in managing agingpopulation. In 1989, an Inter-Ministerial Report on The Aging Population (Ministry of Social and Family Development, 1999) was put together tocover the challenges and the necessary management needed to help in managingthe upcoming aging population. The healthcare model suggested will rely heavilyupon individual and family support in the management of chronic illness while thegovernment and community will be the provider of health care. The Inter-Ministerial report (Ministry of Social and Family Development, 1999) emphasized that ‘everySingaporean is personally responsible for his own health and well being’. Thisreinforced that individual responsibility start off with ensuring that each andeveryone maintain a healthy lifestyle.

Other than the above, subsidised health checksare also made available, which include comprehensive geriatric health check (Ministry of Social and Family Development, 1999). In order tocontinue maintaining a healthy lifestyle, the older adults are encouraged to retireat a later age  to minimise the impact ofreduced physical and cognitive function since early retirement is related tofraility and high mortality (Brockmann, et al., 2009).As an individual aged, one tends to rely on theirfamily for support (Teo, 2008).

This is further reiterated in the Inter-Ministerial Report that ‘the primaryresponsibility for caring for the elderly rests with the family’. Singapore, anAsian country, traditional conservative values still stay. Actions such asstaying with parents especially for the eldest son is deemed as an act offilial piety. In addition, policies and schemes has also been put in place tohelp promote staying together or close to the older adults. For example,priorities in getting flats are given to married children who are keen instaying together or close to each other using the Multi-Generation PriorityScheme and Married Child Priority Scheme respectively (Housing & Development Board, 2017). The community also known as non-residentialintermediate long-term care (ILTC) plays a part by creating opportunities tomeet the needs of the older people through rehabilitation and socialisation. Itis a long term ‘appropriate and low-cost alternative care’ (Ministry of Social and Family Development, 1999) solution for theelderly. It comprises of centres set up by the government, Voluntary WelfareOrganisations (VWOs) as well as private organisations which includes day care,day rehabilitation and senior care centres.

The number of non-residential ILTChas increased from 32 in 2006 to 88 in 2016 (Ministry of Health, 2017). The increase of thenumber of non-residential ILTC is in line with the goal whereby older adultsshould be cared for at home. Through the community programmes, older adultswill be in the comfort of the community, maximising socialisation andfunctional mobility. Lastly the government will be the over-archingprovider to ensure that the individual, family and community (Ministry of Health, 2017) do their part inensuring that the older adults is being cared for out of the institution asmuch as possible. In addition, the government are also the one to providefinancial support. As the number of older adults increases, the expenditure ofhealthcare increases as well. This is evident from an increase of $6,600.

70million (1.3% of GDP) between 2006 and 2016 (Ministry of Health , 2018) and this amount isexpected to increase to over $13 billion in 2020 (Ministry of Finance, 2015). When comparing thisto the welfare state ‘where ownership is public’ (Moran, 2000)the healthcare system in Singapore minimise the burden on the government andensure that everyone shares the same responsibility. There are two sides to a coin, thus, even wheneveryone shares the same responsibility, the ultimate highest burden ofcaregiving for an older adult still falls onto the family aspect. Coupled witha change in demographic, caring for older adult in a home setting is currentlyminimally plausible. Hence, families in fast developing Asian cities aredepending onto foreign domestic workers to care for their older adult in a homesetting (Yeoh & Huang, 2010). 1.5 Foreign Domestic Worker as an option for eldercareIn a statistical report produced by the Ministry ofHealth in 2010, 74.

2% of the informal caregivers reported having to jugglebetween caregiving and work. 84% of the informal caregivers also rely onexternal support such as relatives and foreign domestic workers (Zhao, 2011). Having to deal withboth working and caring for their family members, Singaporeans have turn toemploying full-time stay in foreign domestic workers. No doubt that there hasbeen efforts to get older adults to be engaged in the community level throughbuilding of more facilities and amenities and redirecting more resources intothe community sectors, there are other factors that deter one from being in thecommunity. Issues such as transportations (Teo, 2008),the limited operating hours of the centres limiting the picking up of olderadults from centres and the older adult’s perception of being cared for at homeinstead of centres (Wang & Wu, 2016) result in oneconsidering other alternatives. Policies have been put in place to ensure thatevery foreign domestic worker can only work for one household as well asperforming household chores only (Ministry of Manpower, 2016), but the poorestablishment of the scope of work has led to employers exploiting them. Hence,each foreign domestic worker employed can be performing all this tasksimultaneously- caring for an elderly, household chores such as cleaning andcooking as well as caring for the young children.

This all-in-one service thatcan be provided by a foreign domestic worker outweigh the cost of placing an olderadult in a community centres and yet is beneficial to an employer in the longrun and satisfy the older adult’s desire of being cared for at home. Moreover,to support the model of caring at home, employers will only need to pay a levyrate of S$60 per month when a foreign domestic worker is employed for eldercareas compared to S$265 per month in other household (Ministry of Manpower, 2017). This rate of S$60per month has been reduced drastically from S$250 in year 2006 (Teo, 2008).

This has resultedin an increase of the numbers of foreign domestic workers by 15.9% from 2012 to2017 (Ministry of Manpower, 2017). However, this group of newly identified caregiversreceived minimal training on caregiving for an elderly. In the report by Teo(2008), agency in Singapore only devote 48 hours of the 232-hour course toeldercare. As the maid agency in Singapore are regarded as a business agency(Teo, 2008), agency is not required to provide any form of training to theforeign domestic workers and further courses or training for eldercare areprovided at the expense of the employer. With the limited knowledge ofeldercare faced by foreign domestic workers, little is known about theirknowledge as well as confidence in caring for older adults. As understood, PD is a progressive debilitatingdisease whereby there is a need for caregivers in the long run. Currently, studieshave looked into caregiver burden (Caap-Ahlgren& Dehlin, 2002; Schrag, et al.

, 2006), type of skills required bycaregivers (Given, et al., 2008) as well asrelationship between caregiver and institutionalisation (Chau, et al., 2012; Tan, et al., 2009) and falls (Davey, et al., 2004)but none have looked into the caregiver’s confidence in caring for them andolder adult’s confidence in caregiver. This is particularly much more needed inSingapore’s context where caregiver has evolved from family members tostrangers (foreign domestic helpers) with some even experiencing communicationissues.

Moreover, increased in self-efficacy is translated to increase level ofcare provided (Crellin, et al., 2014).In a study by Molloy, et al.

(2008), they aimed to findout if there is a correlation between spousal confidence and ambulatoryactivity limitations, patient’s self-efficacy and level of social supportprovided. In this study, 109 stroke survivors and their spouse were interviewedprior to discharge and subsequently 6-weeks after. Other than interviewing boththe patient and spouse, outcome measures such as self-efficacy for ambulation, recoveryand spousal confidence for ambulation using Likert scale was performed. Thestudies then yield a result that increase in spousal confidence is associatedwith a better than average recovery prior to discharge, however, in the longrun, this can hinder recovery as spouses tend not to request for additionalsocial support. The study tapped onto the sample (both patient and carers) thatparticipated in the study by Johnston, et al.(2007).

It was not established whether the participants (patient and carer)were in the intervention or the controlled group. This can then affect theresult of the study by Molloy, et al. (2008) as the intervention group in Johnston, et al.

(2007) study were providedwith information about stroke and recovery as well as guidance andself-management skill and strategies. This was further confirmed by the pilotstudy by that the exact intervention replicated by Johnston, et al. (2007)resulted in increase in satisfaction of care by both carer and patients. Hence,the study may then be biased as the sample in Molloy, et al. (2008)study could consist of participants mainly from Johnston,et al.

(2007) intevrention group. Greater clarrification of the sample andcomparing the results between Johnston, et al. (2007) intervention andcontrolled group can then derive a better understanding of spousal confidencethen. In a separate study by Taylor, etal., (1985), confidence of spouse onto patient is classified according to thelevel of participation that they were involved in.

The participants wereseperated into 3 different groups whereby spouses (wife) will (i) sit in awaiting room while their husband is undegoing a treadmill test or (ii) observedhusband undergoing treadmill test or (iii) observed their husband undergoingthe test and experience the treadmill test themselves and receive a medicalcounselling thereafter. At the end of the study, it was noted that gettingtheir spouse to experience first hand boost the confidence of wives on theirhusband’s cardiac and physical efficacy. However, when comparing to that ofstudy by Rohrbaugh, et al.

, (2004), marital quality is a significant factor ininfluencing spousal confidence. 1.5 ConclusionOverall, despite the limited study on spousalconfidence, the three studies reflected that there is a positive relationship betweenspousal confidence and self-management and recovery of disease. All threestudies that explored on self-efficacy . With the shift in carer from animmediate family member to foreign domestic workers, limited research hasexplored about their caregiving burden what more with the level of confidenceand self-efficacy that they have in caring for older adults with PD.