Different countries or societies have different policies or views regarding elderly care policy. In the United Kingdom (UK), the United Kingdom government has advocated “Building a society for all ages” in (2009). The initiative suggested the followings need to be improved: pension scheme, better public services, improving financial support, engaging with work, and building communities (Building a society for all ages, 2009).

In Hong Kong (2009-2010) recent policy has also mentioned about elderly care. The initiative raised by Hong Kong Government (i.e. 2009-2010 Policy Address) in order to improve the quality of the elderly care include-

1. “Increasing from 50% to 90% the proportion of nursing home places in

existing subsidised contract residential care homes for the elderly;

2. Purchasing, for the first time, vacant places from self-financing nursing homes and care and attention homes; and

3. Making full use of the space in existing subsidised elderly homes to provide more places that offer continuous care” (2009-2010, Policy Address).

Different initiatives, for example, senior citizen card scheme in which elder aged 65 or over can enjoy concessions, privilege offered by Governmental departments (Social Welfare Department, 2009), have already offered for caring the elderly, nonetheless, the impact of global economic tsunami has affected worldwide economical structures and government funded health care provision. Cutting budget is a means commonly used by different governments so as to balancing revenue and expenditure. In the author own experience, having been a nurse in the specialist area of gerontology for seven years, from her observation, budget deficit have already incurred the followings-

Impact on health care staff’s salary is either deducted or remains unchanged. As a result, the overall morale is low and the turnover rate is high.

Impact on budget used for caring the elderly is decreased. Health technology, lifespan of the elderly and expectations from the public are driving forces but budget deficit is a powerful resisting force. Striking a balance between them is a big challenge.

Impact on individual income of the elderly’ parents are also affected. The income of elderly/parental savings is an important factor whether care for their elderly can be achieved, and maintained.

In the author experience a high number of patients cared for in acute care have had a Cerebral Vascular Accident (CVA). According to the statistics conducted by Department of Health, there were 1537 male and 1682 female aged 65 or over, total 3219 patients died with CVA in 2008 (Department of Health, 2008). A concern is that an elderly CVA patient, even though, passed as fit for discharge does not mean the stroke elderly will not need to receive further care or treatments after discharge.

During the period of rehabilitation, different expenditure in taking care of the elderly is necessary. Expenditure is currently commonly spent on the following items,

special diet, supplements (i.e. high protein milk),

dressing materials (if bed sore is developed),

follow-up and medicine fee and anything else.

The above expenditure appears to have less impact on middle and higher social-economical groups. On the one hand, the role played by family carers of the high and middle classes in Hong Kong can be performed by a maid, a private nurse or admitting an elder to a private nursing home. However, it is extravagance to consider the abovementioned ways for taking care of the elderly from the lower social-economical group. This contrast of social-economical status and income raises questions. For example the current status and income of lower social economical groups in Hong Kong is just enough for daily living. Monthly income of the lower class in average is $4023.5 per month (Census and Statistics Department, 2006). How the lower class taking care for their elderly with such income?

The aims and objectives of the dissertation are to mainly examine the role played by family carers in the community care of older patients with CVA and explores whether this family carer can be sustained under the present economic hardship and level of formal support offered by the Hong Kong Government. The structure of the dissertation will have eight parts:

1. Introduction (as stated above)

2. Background information

3. Methodology

4. Method

5. Results

6. Analysis

7. Discussion

8. Conclusion and recommendations

The author is interested in this area of care and previously stated aims informed the following research question: Family care of vulnerable elder patient following Cerebral Vascular Accidents: A literature review of family carers who undertake caring for newly discharged older patients in Hong Kong.

2. Background

Within this chapter the author will establish the background to the dissertation question through exploring the previously stated aims and objectives of

Defining terms and demographic data of the elderly in Hong Kong.

Types of family carer involved with caring for the elderly in Hong Kong.

Clarifying the role of community care.

In addition, an overview will be given in relation to Cerebral Vascular Accidents and how the current global economic recession is affecting healthcare resources and how this may further impact on care of the elderly.

2.1 Demographic data of the elderly

World Health Organization (2010), identified that “most developed world countries have accepted the chronological age of 65 years and above as a definition of ‘elderly’ or older person, but this westernized concepts, does not adapt well to other countries or regions outside of the west (e.g. Hong Kong or Africa) and their respective cultures or societies. In Hong Kong, it is generally accepted that those aged 60 years or above are an older person and the Hong Kong statutory requirement for retirement is also aged 60 years. The following table shows the Hong Kong population by age group in 2009 and sex:

Age Group(End-2009)

Male

Female

60-64

179,000

174,200

65-69

118,100

106,100

70-74

114,900

117,100

75-79

96,600

105,700

80-84

54,100

76,400

>=85

37,600

80,400

(Source: Census and Statistics Department, 2005)

In percentage terms, the elderly represent 18% of the Hong Kong population aged 60 years or above. It is estimated that the population of the elderly in Hong Kong will be up to 22% in 2020 (Census and Statistic Department, 2005). In the UK, the population of the UK is also ageing. Over the last 25 years the percentage of the population aged 65 and over increased from 15 per cent in 1983 to 16 percent in 2008, an increase of 1.5 million people in this age group. This trend is projected to continue. By 2033, 23 per cent of the population will be aged 65 (Office for National Statistics, 2009). In brief, ageing seems a common phenomenon around the World.

The advent of community care frameworks and the increasing role played by family carers are paramount for supporting the discharge of patients back in to the community and the subsequent care provision required. The demographic data of the elderly in Hong Kong supports this increasing demand that will be placed on Hong Kong communities, families, health and social care providers.

2.2. Family carer

The increasing elderly population and role of family carers is an interesting modern phenomenon. A family carer or caregiver has been defined by (Schofield, et al., 1998) as a person who provides any type of physical and/or emotional care at home (Schofield, et al., 1998), go on to state that the dependent or elderly in need of care require 24 hours, 365 days a year care, because of the condition, dependency or frailty often involving physical and/or mental illnesses.

There are different types of family carers, for example, spouses, family members (e.g. adult children), neighbors and friends (Schofield, et al., 1998). From the author own observation, family members are the major caregivers of newly discharged CVA elderly in the lower social economical group, because they may find it hard to afford having additional support, health care services or domestic help (e.g. maid) to help. The role of family carers will often involve responsibility for giving medicines, assisting with meals, and performing care procedures (e.g. bathing). This care may have to be given both day and night and therefore being a caregiver can be a physically exhausting and emotionally stressful task. Carers feel frustrations with day-to-day situations as they work on alone are a typical example.

The work of family carers of elders goes far beyond previously stated role and has already become one of the important primary care members in community care due to two reasons-

The Hong Kong population is aging. The prediction of the population of elderly in the coming future must increase.

The geriatric health care system in Hong Kong is under increasing strain. Health care expenditure is upsurging, workforce shortages in nursing are worsening due to salary and working condition dissatisfactory as well as heavy workload, and the length of time physicians can spend with elder patients is declining. It results that family carers labeled as untrained and undersupported, – constitutes a “shadow workforce,” acting as geriatric case managers, medical record keepers and paramedics.

2.3 Community care

Community care is a primary health care system that provides health-related services within the context of people’s daily lives (Victor, 1997). In addition to government health care services the community care consists of the voluntary, independent, and private sectors. These services becoming very important in the Hong Kong community over the past 30 years as supporting the elderly has shifted from institutional care to care in the community. In Hong Kong, the Social Welfare Department is mainly responsible for implementing community supporting services for the elderly. There are different types of community care for the elderly-

Day care centre.

Home help team.

Enhanced Home and Community Care Services Team.

The first of these, Day care centre is responsible for nursing care, rehabilitation exercise, meal service, respite service, social and recreational activities, transportation service to and from the centre, counselling and referral services. The second is responsible for escort service and household cleaning. The third is responsible for care management, environmental risk assessment and home modifications, 24-hour emergency support (Social Welfare Department, 2005).

2.4 Introduction of Cerebral Vascular Accidents

Cerebral Vascular Accidents can be defined as losing function of the brain due to disturbance of blood supply to the brain (Caplan, 2006). The deaths due to Cerebral Vascular Accidents ranks number four out of ten among the Hong Kong top ten mortality rate. The following table shows the numbers of death in Hong Kong due to Cerebral Vascular Accidents between 2001 to 2009:

2001

2002

2003

2004

2005

2006

2007

2008

2009

CVA

3130

3218

3462

3416

3434

3302

3513

3691

3448

(Source: Department of Health, 2008)

Cerebral Vascular Accidents are also commonly referred to as “strokes”. There are mainly two types of Cerebral Vascular Accidents – ischemic and hemorrhage.

In an ischemic stroke, blood supply to the brain is decreased leading to dysfunction of an area of the brain, say, unable to speak or swallow if medulla oblongata of the brain is affected (Caplan, 2006).

In a hemorrhagic stroke, bleeding from a ruptured vessel can also lead to dysfunction of an area of the brain (Caplan, 2006).

The clinical symptoms of Cerebral Vascular Accidents, in general, are numbness, inability to speak and trouble in movement. Psychologically, depression is not uncommon.

2.5 Economic impact

Difficulty to the family carer in lower socio-economic groups caring for a stroke elderly family member is further deepened by the recent global economic downturn and its impact on individuals (e.g. loss of employment, reduced income). The Hong Kong economy back into recession and cause negative Gross Domestic Product growth, massive employment lay-off, pay-cut, and lack of mandatory unemployment compensation fund the effects on individuals particularly those in lower social economic groups has been considerable. In turn this effecting family income and their ability to care for dependant others such as the elderly in the community.

Interestingly healthcare spending, is steadily increasing under global economic recession. As the expectations from the public are higher and higher, the advance of health technology and the life expectancy of Hong Kong elderly are longer. The increasing demands on healthcare expenditure are unavoidable. As mentioned by The Budget 2010-2011 (The Budget 2010-2011, 2010) which stated that there would be an “allocating about $600 million in the next three financial years to strengthen primary care services” is typical evidence (The Budget 2010-2011, 2010). The big challenge faced by Financial Secretary for Hong Kong and the people of Hong Kong is how to provide support to the lower social-economic group and their dependent stroke elderly with budget restraint during economic recession? The economic recession has already cause inequality in terms of access of health facilities between the lower and higher groups. A study by the Census and Statistics Department released on 18 June 2007 revealed that Hong Kong’s Gini coefficient rose from 0.483 in 1996 to 0.500 in 2006, indicating that Hong Kong has become one of the most unequal developed cities (Census and Statistics Department, 2007). It results the rich can enjoy healthcare with ease, while the poor develop further health problems due to delay consultation of medicine.

The aim of this chapter was to give the background of demographic data of the elderly in Hong Kong, types of family carer and what community care is. The author is interested in this area of care and previously stated aims informed the following research question: Family care of vulnerable elder patient following Cerebral Vascular Accidents: A literature review of family carers who undertake caring for newly discharged older patients in Hong Kong.

3. Methodology

Methodology and method should be well defined and contrasted. Methodology means a component of any scholarly inquiry, as it is in fact a list of practices or experiences which might be applied in the study, and method can be defined as a manner or procedure, which allows systematic and well-organized data collection. Defining the terms ‘methodology’ and ‘method’ is very important in order to avoid combining them, as in scholarly research they have completely different meaning and contexts (Kothari, 2008). On the one hand, positivist and constructivist approach should be well defined too. In positivism, the aim of research is explanation that will result in the ability to predict and control phenomena, either physical or human. The aim of inquiry in constructivism is understanding and reconstructing the constructions or meanings that both the researcher and those being researched hold (Kothari, 2008). In the author study, constructivism is used because the author posed a research question rather than stating a hypothesis and the analysis presented in a narrative format. This section should cover:

Literature reviews as a research methodology

Searching the literature

Critical appraisall of the literature

Thematic analysis of the literature.

3.1 Literature review as a research methodology

The main research methodology of the dissertation is by literature review or constructivism. The dissertation literature review is a review of relevant theory and the most recent published article/journal/thesis/government document on the dissertation topic (Burns & Grove, 2005). Literature review is the best research methodology for the dissertation because of five reasons.

1. To meet the dissertation module requirements.

2. It provides author perfect starting point. Literature review provides an excellent starting point for author beginning to do research in a new area by leading the author to summarise , evaluate, and compare original research in that specific area.

3. It is easy to find related literatures. Literature review gives author easy access to research on a particular issue by selecting high quality articles that are relevant, meaningful, important and summarizing them into one complete dissertation. Up-to-date account and discussion of the research findings can be obtained (Kothari, 2008).

4. Literature review provides author with an up to date explorations and discussion of the research findings in a particular issue. The author will find that in writing a literature review the author with learn about the ways other researchers have constructed their own research topics. Seeing what other researchers have done might help the author understand her own dissertation (Kothari, 2008).

5. Key messages and contradictions can be found out during literature review. Literature review helps the author highlighting key findings (i.e. role play by family carer, the difficulty the lower class of family carer faced and support given by the Hong Kong Government), identifying contributions in the literature and providing a constructive analysis of the methodologies and approaches of other researchers (Kothari, 2008).

3.2 Inclusion/exclusion criteria

Having expressed the author’s thought on why literature review is an appropriate methodology for the dissertation, the importance of searching the literature seriously and precisely will be discussed. The followings should be included when searching the literature- inclusion/exclusion criteria, correct search terms and databases. Explicitly determining the criteria for inclusion and exclusion, in order words, is to determine which articles will be selected for the literature review and which articles will be rejected. An explicit and comprehensive set of the criteria should be established by the author. As a result, any article that comes to light could be included or rejected solely based on those criteria. Furthermore, unclear and ambiguities in the selection or exclusion criteria can result in either useful articles being excluded or poor articles being included. In short, related articles can be simply omitted and the author must be precise about inclusion/exclusion criteria.

3.3 Choosing search terms

Precisely in choosing search terms should not be ignored. The reasons have three.

The numbers of related articles can be confined. Non-specific search or generalized terms, such as health or old are used, resulting in billion of articles appear. Mastering searching strategy can help the author to find out related articles in terms of efficiency. Specific in search terms can greatly decrease unrelated articles appear and increase the chance to find out the desired articles as soon as possible.

Related articles cannot be skipped. Simply imputing generalized search terms, although, abundant articles can be obtained instantly, it is quite easy to miss some related articles when searching from many websites or databases. As a result, sometimes the most appropriate articles cannot be retrieved for literature review.

Time-saving if correct search terms are used. Someone may think that choosing search terms is a trial and error pilot testing. Time consuming is a must. In fact, time can be greatly saved from drifting from book shelf to book shelf or web surfing if planned list of search terms are inputted into a database.

3.4 Database selection

Databases selection should be precise. Obtaining the most valuable and related resources available to the author, top databases such as Medline providing health-related articles should be visited. Visiting irrelevant databases, for example, LexisNexis (delivers articles related to legal, business and tax information worldwide), just time-wasting and nothing related to health issue can be found. Having selected correct databases is not as a whole, but it is the first and important step to decide and find out what databases provide health-related articles. In brief, garbage in, garbage out if imprecise about inclusion/exclusion criteria, search terms or selection of database are performed.

3.5 Variety of critiquing method

Having obtained appropriate articles for literature review, different types of critiquing methods and the importance of critiquing the literature will be described. In this dissertation the critiquing method to be used will be Bray and Rees (1995), a method designed specifically for critiquing research papers. The critiquing framework of Bray and Rees (1995) involve asking 12 questions regarding to research papers. More elaborately, main theme, research design, background and tool of data collection of the research papers must be explored. In addition, major findings, data presentation, ethical considerations and influence to current practice are also explored. In a nutshell, objective assessment and its significance can be reflected.

Another critiquing method- the Critical Appraisal Skills Programme (CASP) is also used. It is a guideline that aims to enable researchers to develop the skills to find and make sense of research evidence helping them to put knowledge into practice. The CASP involves ten questions in order to examine qualitative or quantitative researches. However, researchers need to know about the approach of the studies that are reviewed. Otherwise, questions initially used for critiquing qualitative research may be used for critiquing quantitative research.

3.6 Importance of research critique

Critiquing the literature is a very important step because a research critique is to evaluate the merits of a study and to evaluate its applicability to clinical practice (Burns & Grove, 2005). The author should perform an intellectual and thorough research critique by using one of the critiquing methods in order to judge a study’s strengths, weaknesses, logical links, meaning and significance. As a result, goes beyond summary of a study, all aspects of a study can be carefully appraised.

3.7 Various ways and importance of data analysis

There are different ways of analysing other researchers’ data. Constant comparison is one of the commonly used methods for analyzing data. Researchers variously mainly look at documents and then look for indicators of categories in events/behaviour. Immediately researchers will name and code them on documents for comparing codes to find consistencies and differences.

Data analysis is an important step because the ability to make inferences and predictions based on data is a critical skill the author needs to develop (Fink, 2010). In analysing data, the author can also learn that solutions to some problems depend on assumptions and have some degree of uncertainty. Data analysis is crucial to the development of theories and new ideas. By paying close attention to relationships between and among data sets, the author, therefore, comes to have a deeper understanding of the crucial distinction among data from different papers.

3.8 Ethical implications of literature review

In ethical implications of literature review, there are some ethical issues the author needs to pay attention. When using other researchers’ findings for the author own research, honesty should be committed. It means the author should report data, methods and results and publication status honestly (Fink, 2010). Fabricating or misrepresenting data is totally unacceptable. Deceiving a dissertation supervisor or college is also prohibited. Plagiarism should not be committed too. Plagiarism is easily to be committed if the author uses words from an information resources and does not credit to the original researchers of that information (The University of Hong Kong, 2002). Put it simply, plagiarism is copying the work of another person without proper acknowledgement. On the one hand, information the author used should be collected ethically. More elaborately, the author should respect for intellectual property. In practice, the author should honour intellectual property. Using unpublished data, methods, or results without permission is prohibited. Giving credit to the source of information where credit is due as well as proper acknowledgement for all contributions to research is a must.

Transparent in not claiming the work of others as the author own should be obeyed. To achieve transparent, written declaration should be in the first few pages of the dissertation. The author should declare the dissertation represents the author work, except where due acknowledge is made, and the dissertation has not been previously included in any thesis, paper, or report submitted to this university or other institutions.

4. Methods

This chapter will discuss how to search related literature, databases used and search terms are used for searching as well as why critiquing framework (i.e. Bray and Bees, 1995) is employed.

4.1 Way to searching the literature

Carefully searching the literature should be done for literature review. The literature the author searched is mainly by using a computer. More clearly, the author accesses the Internet, university’s online library, databases and visits local public libraries for finding out related information. In addition, asking for assistance from the author’s well-educated colleagues is also helpful in terms of literature searching.

4.2 Database used

Pubmed Central and Medline is used. The former comprises more than 19 million citations for biomedical articles from Medline and life science journals. Searching desired literature is without difficulty. Credibility (organized by the US Federal Government) and free to download full text are the main reasons the database being selected. The latter database also includes many health-related papers. The database is selected because some local, related study/information (e.g. elderly policy, classification of socio-economic class) can be easily obtained. Also credibility and reliability of theses should not be in doubt.

4.3 Search terms

During searching related articles, the following search terms have been used- “family carer*”, “family caregiver?”, “stroke”, “Cerebral vascular accident”, “Cerebral vascular disease”, “economic impact”, “lower socio-economic class” and “community care”. As a result, limited but related articles/theses have been shown and much time is saved. The following table shows 2 Boolean search tables:

Family carer*

OR

Family caregiver*

AND

Stroke

OR

CVA

OR

Cerebral Vascular Accident

OR

Cerebral Vascular disease

4.4 Inclusion and exclusion criteria

In inclusion criteria, specific terms are highly recommended to be used. The above search terms are concrete example. Operators such as “+”, “AND”, double quotation marks (” “) can help to show exactly wordings the author requests. Furthermore, only English-written and local papers are included because the author is studying an issue of Hong Kong and year 2000 onwards papers are included as they are updated. In exclusion criteria, generalized terms should be avoided, for instance, “health” and “frail”. Operators such as “-“, “NOT”, “AND NOT” limit the author search by returning only the first keyword but not the second, for example, elderly AND NOT frail.

4.5 Critiquing framework

In critiquing framework, Bray & Rees (1995) has been used because of one main reason. The Bray & Rees (1995) help the author developing the necessary skills to make sense of scientific researches, and producing appraisal checklists covering validity and relevance. The author should follow the questions raised by Bray & Rees’s critiquing framework (1995) in order to find out 12 aspects of critiques.

4.6 Thematic analysis

In analyzing data, thematic analysis has been used and how the analysis can be conducted will be shown immediately. The author mainly looks at articles, theses or even background reading to see what themes emerge and what do subjects/people talk about the most? The relationship, how to relate to each other, also should be focused. Any latent emphases should be uncovered too in order to explain an emerging theme. All identifying themes can be presented by using a mind map. In brief, when data is analysed by theme, the author moving forwards and backwards between literature and theses, thematic analysis is conducted.

5. Results

5.1 Number of papers selected and their types

This chapter mainly shows to a reader a summary of the findings of the author critiques. Six papers are found for literature review. Two are quantitative researches (i.e. Economic burden of informal caregivers for elderly Chinese in Hong Kong written by You, H.S., Ho, C. & A, Sham in 2008 and Changing needs of Chinese family caregivers of stroke survivors written by Mak,. K.M., Mackenzine, A. & Lui,. H.L. in 2006). Another one is descriptive-based (i.e. Primary health care in Hong Kong written by Chan, C.Y. in 2006). Three are qualitative researches. All the above articles are selected for the author literature review because the six articles provide appropriate solutions to the topic. For example, the quantitative research provides insight of the financial burden of caregivers.

5.2 Critique of the first paper

The first paper (i.e. The impact of a multidisciplinary stroke education programme on Chinese family carers written by Lee,. S.L., Lui, H.L. & Ann E. Mackenzine in 2005.) will be critiqued by Bray & Rees critiquing framework and the detailed critique can be found in appendix. The following shows the summary grid:

Reference

Lee,. S.L., Lui, H.L. & Ann E. Mackenzine. 2005. The impact of a multidisciplinary stroke education programme on Chinese family carers. Journal of Interprofessional care19(4): 406-407.

Focus

The positive impact of a multidisciplinary stroke education on family carers for stroke survivors

Background

Stroke can cause stroke survivors physically disabled. To care for them in a community, family carers need to do some preparations when they discharge. Multidisciplinary stroke education program is developed and this program is useful for the caregivers.

Terms of reference

To examine the effects of this program on knowledge and satisfaction of family carers

Design

Pre and post-test design is employed

Findings

After attending the program, most of the caregivers understand more in taking care for stroke survivors.

Applicability to practice

Such education program should be highly promoted to target group by nurses (i.e. family carers of stroke survivors)

The summary of the findings of the critique is now given. The focus of the article is