1.1 through rehabilitation and optimisation of medications such as

1.1
Introduction

Parkinson’s Disease (PD) is the second most common
neurodegenerative disorder after Alzheimer’s Disease (AD) (Tanner and Goodman,
cited in Gibrat, et al., 2009). It is an
age-related condition and is commonly diagnosed in older adults aged 60 and
above, with some diagnosed as early as before aged 50 (Lonneke & Monique, 2006). PD is postulated to
have an additional strain on both social and economic aspects especially in
countries facing an aging population  (Lonneke & Monique, 2006).

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In a study by Jankovic
& Kapadia (2001), it was identified that there could be an annual decline
of scores, up to 1.58, in the Unified Parkinson’s Disease Rating Scale (UPDRS).
The rate of deterioration also seems to be much more rapid in the early stages
as compared to the advanced stages in the diseases and more so in individuals
with major depressive symptoms (Starkstein, et al.,
1992).
Currently, there is no cure for PD and management has been a multidisciplinary
approach through rehabilitation and optimisation of medications such as
Levodopa (Patil, et al., 2014).

Therefore, due to the debilitating nature of the
neurodegenerative disease, individuals with PD will experience decline in both
motor and non-motor aspects. This places individuals with PD to be at higher
risk of falls (Williams-Gray & Worth, 2016) as well as
conditions such as dementia (Lonneke & Monique, 2006) and depression (Starkstein, et al., 1992) . Due to the
prognosis of the condition, individuals with PD will require a high level of
care, putting them in need for full time carers or worst, institutionalised.

The role of caregiving has traditionally fall on the
shoulders of immediate family members and spouse. However, in recent years, due
to the involvement of more women in the labour force, seeking for alternatives
such as use of foreign domestic workers in eldercare has been much more
prevalent. However, they are at a disadvantaged when caring for the elderly as
compared to that of their family members. Unlike
the immediate family members, foreign domestic helpers had limited to no
interactions with the older adult prior to care (Tan, et al., 2009), making caring more
difficult. Secondly, little is known about the FDW previous eldercare
experience with many employers basing their choice of domestic helpers through
stereotypes such as nationalities and age (Yeoh & Huang,
2010).
And lastly, the market for FDW is huge, resulting in varying background of the
FDWs. Language barrier can then posed as a barrier to understanding the need of
the 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 to
consider the care offered by the foreign domestic helpers.

In current literature, studies have explored on
caregiver burden (Schrag, et al., 2006;
Caap-Ahlgren & Dehlin, 2002) and the level of competency that a
caregiver requires (Given, et al., 2008). However, none have considered
the self-efficacy of a foreign domestic helper when there are multiple barriers
posed in the care of an older adults. Therefore, this review aims to understand
the importance of foreign domestic helper in Singapore’s healthcare scene and
their level of support they received prior to caring for older adults.

1.2 Overview

Varying composite of keywords consisting of
Parkinson’s Disease, caregiver burden, caregiver stress, foreign domestic
workers 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 be
evaluated.

1.3 Change in demographics in Singapore

Compared to two decades ago, Singapore is currently
facing a major change in the population’s demographic. Currently, the country
is experiencing both an aging population and a change in women’s participation
in the workforce.  

Like many developed countries, Singapore is also
facing an aging population. From the year 2000 to 2017, the age pyramid is
starting to take form of an inverted triangle with a median age of 40.5 in 2017
as compared to 34.0 in 2000 (Department of Statistic Singapore, 2017). Due to a change in
demographic to an aging population, there is a need to consider changes to help
and maximise the support for them. These changes will mainly be pertaining to
healthcare needs such as amenities as well as availability of carers. This is
especially important in older adults, as they are prone to hospitalisation and
new onset of disability or functional decline is usually associated with older adults’
post discharge (Boltz, et al., 2012). With a reduction in
functional status, there is a need for older adults to undergo rehabilitation.
However in Asia, family members and older adults would prefer to be cared for
at home rather than relocating to other institution (Wang & Wu, 2016). Hence with a
decline 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 or
daughters-in-law (Jang, et al., 2012). In the similar study, a correlation between proportion of female informal
caregivers and women’s labour force participation, and per capita gross
domestic product (GDP) was noted. For example: country with higher GDP has a
higher percentage of women involved in the workforce, thus resulting in a lower
percentage of informal caregivers and vicely versa.

Austen (2005) reviewed the
demographic change in Singapore and the impact of it. Since achieving independence,
Singapore has put in place policies to restructure her economy by increasing
literacy rate and skills level. This change allows and create oppportunities
for women, to enter into the workforce with a lower barriers to entry. From the
year 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. Coupled
with economic development in the early 1990s, more employment opporuntities
were available for women especially in the Financial, Insurance, Real Estate
and Business Services sector. During the period of 1992 to 2002, Singapore
experienced a 85.6% increase in GDP per capita (World Bank, 2017) with the steepest
increase between 1992 and 1997. Similarly in this period, Singapore also see an
increase in female share of industry job by 2.5%. Relating the findings by
Jang, et al. (2012) to Singapore’s context, as Singapore’s GDP per capita
increases, the number of women in the labour force also increases
proportionately, resulting in a reduction in the percentage of full time
informal caregiver available.

1.4 Healthcare in Singapore

With the change in demographic, there
is a pressing need to manage and come up with alternatives in managing aging
population. In 1989, an Inter-Ministerial Report on The Aging Population (Ministry
of Social and Family Development, 1999) was put together to
cover the challenges and the necessary management needed to help in managing
the upcoming aging population. The healthcare model suggested will rely heavily
upon individual and family support in the management of chronic illness while the
government and community will be the provider of health care.

The Inter-Ministerial report (Ministry
of Social and Family Development, 1999) emphasized that ‘every
Singaporean is personally responsible for his own health and well being’. This
reinforced that individual responsibility start off with ensuring that each and
everyone maintain a healthy lifestyle. Other than the above, subsidised health checks
are also made available, which include comprehensive geriatric health check (Ministry
of Social and Family Development, 1999). In order to
continue maintaining a healthy lifestyle, the older adults are encouraged to retire
at a later age  to minimise the impact of
reduced physical and cognitive function since early retirement is related to
fraility and high mortality (Brockmann, et al.,
2009).

As an individual aged, one tends to rely on their
family for support (Teo, 2008).
This is further reiterated in the Inter-Ministerial Report that ‘the primary
responsibility for caring for the elderly rests with the family’. Singapore, an
Asian country, traditional conservative values still stay. Actions such as
staying with parents especially for the eldest son is deemed as an act of
filial piety. In addition, policies and schemes has also been put in place to
help promote staying together or close to the older adults. For example,
priorities in getting flats are given to married children who are keen in
staying together or close to each other using the Multi-Generation Priority
Scheme and Married Child Priority Scheme respectively (Housing & Development Board, 2017).

The community also known as non-residential
intermediate long-term care (ILTC) plays a part by creating opportunities to
meet the needs of the older people through rehabilitation and socialisation. It
is a long term ‘appropriate and low-cost alternative care’ (Ministry of Social and Family Development, 1999) solution for the
elderly. It comprises of centres set up by the government, Voluntary Welfare
Organisations (VWOs) as well as private organisations which includes day care,
day rehabilitation and senior care centres. The number of non-residential ILTC
has increased from 32 in 2006 to 88 in 2016 (Ministry of Health, 2017). The increase of the
number of non-residential ILTC is in line with the goal whereby older adults
should be cared for at home. Through the community programmes, older adults
will be in the comfort of the community, maximising socialisation and
functional mobility.

Lastly the government will be the over-arching
provider to ensure that the individual, family and community (Ministry of Health, 2017) do their part in
ensuring that the older adults is being cared for out of the institution as
much as possible. In addition, the government are also the one to provide
financial support. As the number of older adults increases, the expenditure of
healthcare increases as well. This is evident from an increase of $6,600.70
million (1.3% of GDP) between 2006 and 2016 (Ministry of Health , 2018) and this amount is
expected to increase to over $13 billion in 2020 (Ministry of Finance, 2015). When comparing this
to the welfare state ‘where ownership is public’ (Moran, 2000)
the healthcare system in Singapore minimise the burden on the government and
ensure that everyone shares the same responsibility.

There are two sides to a coin, thus, even when
everyone shares the same responsibility, the ultimate highest burden of
caregiving for an older adult still falls onto the family aspect. Coupled with
a change in demographic, caring for older adult in a home setting is currently
minimally plausible. Hence, families in fast developing Asian cities are
depending onto foreign domestic workers to care for their older adult in a home
setting (Yeoh & Huang, 2010).

1.5 Foreign Domestic Worker as an option for eldercare

In a statistical report produced by the Ministry of
Health in 2010, 74.2% of the informal caregivers reported having to juggle
between caregiving and work. 84% of the informal caregivers also rely on
external support such as relatives and foreign domestic workers (Zhao, 2011). Having to deal with
both working and caring for their family members, Singaporeans have turn to
employing full-time stay in foreign domestic workers. No doubt that there has
been efforts to get older adults to be engaged in the community level through
building of more facilities and amenities and redirecting more resources into
the community sectors, there are other factors that deter one from being in the
community. Issues such as transportations (Teo, 2008),
the limited operating hours of the centres limiting the picking up of older
adults from centres and the older adult’s perception of being cared for at home
instead of centres (Wang & Wu, 2016) result in one
considering other alternatives. Policies have been put in place to ensure that
every foreign domestic worker can only work for one household as well as
performing household chores only (Ministry of Manpower, 2016), but the poor
establishment of the scope of work has led to employers exploiting them. Hence,
each foreign domestic worker employed can be performing all this task
simultaneously- caring for an elderly, household chores such as cleaning and
cooking as well as caring for the young children. This all-in-one service that
can be provided by a foreign domestic worker outweigh the cost of placing an older
adult in a community centres and yet is beneficial to an employer in the long
run 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 levy
rate of S$60 per month when a foreign domestic worker is employed for eldercare
as compared to S$265 per month in other household (Ministry of Manpower, 2017). This rate of S$60
per month has been reduced drastically from S$250 in year 2006 (Teo, 2008). This has resulted
in an increase of the numbers of foreign domestic workers by 15.9% from 2012 to
2017 (Ministry of Manpower, 2017).

However, this group of newly identified caregivers
received 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 to
eldercare. 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 the
foreign domestic workers and further courses or training for eldercare are
provided at the expense of the employer. With the limited knowledge of
eldercare faced by foreign domestic workers, little is known about their
knowledge as well as confidence in caring for older adults.

As understood, PD is a progressive debilitating
disease whereby there is a need for caregivers in the long run. Currently, studies
have looked into caregiver burden (Caap-Ahlgren
& Dehlin, 2002; Schrag, et al., 2006), type of skills required by
caregivers (Given, et al., 2008) as well as
relationship 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 and
older adult’s confidence in caregiver. This is particularly much more needed in
Singapore’s context where caregiver has evolved from family members to
strangers (foreign domestic helpers) with some even experiencing communication
issues. Moreover, increased in self-efficacy is translated to increase level of
care provided (Crellin, et al., 2014).

In a study by Molloy, et al. (2008), they aimed to find
out if there is a correlation between spousal confidence and ambulatory
activity limitations, patient’s self-efficacy and level of social support
provided. In this study, 109 stroke survivors and their spouse were interviewed
prior to discharge and subsequently 6-weeks after. Other than interviewing both
the patient and spouse, outcome measures such as self-efficacy for ambulation, recovery
and spousal confidence for ambulation using Likert scale was performed. The
studies then yield a result that increase in spousal confidence is associated
with a better than average recovery prior to discharge, however, in the long
run, this can hinder recovery as spouses tend not to request for additional
social support. The study tapped onto the sample (both patient and carers) that
participated 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 the
result of the study by Molloy, et al. (2008) as the intervention group in Johnston, et al. (2007) study were provided
with information about stroke and recovery as well as guidance and
self-management skill and strategies. This was further confirmed by the pilot
study 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 and
comparing the results between Johnston, et al. (2007) intervention and
controlled group can then derive a better understanding of spousal confidence
then.

In a separate study by Taylor, et
al., (1985), confidence of spouse onto patient is classified according to the
level of participation that they were involved in. The participants were
seperated into 3 different groups whereby spouses (wife) will (i) sit in a
waiting room while their husband is undegoing a treadmill test or (ii) observed
husband undergoing treadmill test or (iii) observed their husband undergoing
the test and experience the treadmill test themselves and receive a medical
counselling thereafter. At the end of the study, it was noted that getting
their spouse to experience first hand boost the confidence of wives on their
husband’s cardiac and physical efficacy. However, when comparing to that of
study by Rohrbaugh, et al., (2004), marital quality is a significant factor in
influencing spousal confidence.

1.5 Conclusion

Overall, despite the limited study on spousal
confidence, the three studies reflected that there is a positive relationship between
spousal confidence and self-management and recovery of disease. All three
studies that explored on self-efficacy . With the shift in carer from an
immediate family member to foreign domestic workers, limited research has
explored about their caregiving burden what more with the level of confidence
and self-efficacy that they have in caring for older adults with PD.