There has been growing concern over how state and federal governments can support the increasing population of aging Americans and their need for long-term care. Current insurance funding models cover acute hospitalization and skilled care only, leaving unskilled care needs and homemaker services at the full expense of those in need. Time banking allows individuals to exchange or barter time for goods or services without monetary payment. There is insufficient evidence to determine if members believe time banks to be a viable alternative to support aging-in-place care needs. This phenomenological study explored time banking as a potential vehicle for nonskilled health care support to defray health care costs as one ages. Ostrom's co-production theory provided the theoretical foundation for the research questions, which examined the participants' lived experiences with the role time banks played in their decision to age in place. Face-to-face interviews were conducted with 10 Southern California time bank participants, age 50 years or older. Using a Moustakas-modified van Kaam method and a priori coding emergent themes were extracted. Study findings illustrated that time bank participation did support aspects of nonskilled health care needs and provided members with confident options for aging in place. Study findings also indicated a need for continued collaborations between professional and managerial staff in public agencies, including California's Health and Human Services Agency and time bank users in their communities. Reducing health care costs for taxpayers in any government-funded health insurance model benefits positive social change, and nonskilled health care provider time bank initiatives may be a sustainable alternative for those wishing to age in place.

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Background: Virtual reality (VR) offers potential for enhancing physical activity and engagement among older adults in long-term care (LTC) facilities. This addresses the need for health maintenance and independence. Yet, limited research exists on VR acceptance and its optimization for promoting physical activity. Older adults' VR gaming experiences and the social and contextual factors affecting acceptance are underexplored. This study aims to investigate these unique experiences to inform the design of inclusive VR technology in LTC, enhancing physical activity and well-being. Objectives: My dissertation has two objectives: (1) to examine the individual and social factors that impact the acceptance of VR games among older adults in LTC facilities and (2) to explore LTC residents’ experience with VR games and the meaning they associate with their gaming experience. Methods: To reach these objectives I conducted two studies: (1) a scoping review of 5 articles to identify evidence on older adults' acceptance of physical activity VR games in LTC facilities, describe research designs used, define key acceptance concepts, and identify knowledge gaps for future research and (2) a mixed-methods study, including a series of gaming sessions with 20 older adults residing in a healthcare center followed by a composite questionnaire and semi-structured interviews with 15 older adults and 4 staff members. Results: The scoping review identified a knowledge gap in VR acceptance among older adults in LTC. Varying acceptance levels and inconsistent concept definitions were found, emphasizing the need for an integrated approach combining qualitative and quantitative methods. Only one study used validated tools for assessing acceptance. The quantitative study involved VR gaming sessions with 20 participants aged 65 and older, revealing significant positive correlations between perceived ease of use and Selective Optimization with compensation (SOC) strategies. No significant relationship was found between Technology Acceptance Model (TAM) and Future Time Perspective (FTP). Prior gaming experience led to higher SOC and socioemotional Selectivity (SST) scores, higher game self-efficacy, and increased hedonic motivation. Age and gender had no impact. Participants viewed VR as user-friendly and useful, with positive attitudes toward aging and physically demanding activities. The qualitative revealed themes related to enjoyment, physical activity, social connection, and individual preferences. Staff perspectives addressed relevance, personalization, training, and organizational barriers. The study highlighted the potential benefits of VR gaming for LTC residents, offering insights for technology development. Conclusion: This study offered a comprehensive understanding of VR gaming acceptance among older adults in LTC settings, highlighting the significance of individual and social factors in technology acceptance. Personalized design, support, education, trust, and safety are crucial. Integrating social theories of aging is essential to understand older adults' needs and preferences. Implications for VR design include user-centered approaches, intuitive interfaces, customization, social interaction, and safety considerations. Addressing limitations and biases in future research can promote effective use of VR as a therapeutic tool for older adults in LTC.

Aim: As the ageing population in China increases, support required from family caregivers for older relatives living with long-term health conditions also increases. This being so, this thesis explored the experiences and perceptions of current and prospective family caregivers, under the culture of Xiao (孝; filial piety). Design and Methods: Phase 1 was conducted with 19 Chinese students using 3 focus groups to gain greater familiarity with the culture and inform the main study (Phase 2). Adopting a social constructivist philosophical position, data for Phase 2 were obtained from three generational sub-samples: only-children affected by the One-Child Policy (OCP), parents affected by OCP, and family caregivers in the workforce, totaling 23 participants through virtual in-depth interviews with participants in mainland China. Interviews were translated, transcribed, and analysed using reflective thematic analysis. Findings and Conclusion: Phase 1 confirmed the centrality of the concept of Xiao to attitudes and beliefs around future caregiving for parents. Phase 2 findings’ overarching theme was ‘Competing pressures’, which comprised of three inextricably linked themes: (i) Caregiving beliefs, (ii) Contextual factors, and (iii) Caregiving conditions. Participants expressed meaningful desires to fulfil obligations, reflecting value-based convictions, stemming from their socio-cultural environment. Stressors experienced reveals structural and personal barriers to seeking support. Ultimately, extensive demands and limited coping strategies could diminish meaning in caregiving. This thesis makes a novel contribution on perceptions and experiences of family caregivers of older relatives within China as a collectivist society. Findings have implications for research, policy, and practice, highlighting the need for culturally attuned services to build resilience.

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[pt] Diante do cenário epidêmico das demências e do crescente envelhecimento populacional, esta pesquisa teve como foco o desenvolvimento de produtos e serviços reabilitadores e preventivos do Alzheimer para/com idosos institucionalizados. O objetivo do estudo foi melhorar a cognição e a qualidade de vida dos hóspedes, bem como valorizar seu papel social. Quanto à estrutura, a pesquisa se articulou em 5 etapas: (1) revisão bibliográfica sobre memória, processos cognitivos e Alzheimer; (2) estudo de caso no Bem Viver, que cumulou: observações das atividades, da rotina e das respostas dos idosos aos estímulos aplicados, entrevistas com os hóspedes, funcionários e familiares, e desenvolvimento de conceitos projetuais voltados à criação de produtos e serviços com foco no Alzheimer e na institucionalização; (3) cocriação de artefatos interdisciplinares e multifacetados em parceira com os profissionais da casa, amparada pela ferramenta Card Sorting e por um diagrama interdisciplinar; (4) implementação dos produtos e serviços pelos funcionários da casa nas atividades do Bem Viver; e (5) identificação dos resultados dos estímulos na cognição e na qualidade de vida dos idosos, mediante comparação dos dados coletados no momento inicial e final da pesquisa. No desfecho desta investigação, observou-se que os artefatos em formato aberto e as oficinas foram capazes de melhorar a orientação temporal e as habilidades de escrita e de cálculo de idosos, bem como permitiram despertar a criatividade dos hóspedes, fortalecer os laços de amizade e estimular memórias e funções mentais de indivíduos com os mais variados tipos de demência e perfis cognitivos. / [en] Taking into account the epidemic scenario of dementias and the increased growth of the elderly population, this research consisted of proposing products and services for both recovery and prevention of the Alzheimer s disease among institutionalized elderly. The aim of this study was to enhance cognition and the quality of life of patients, as well as promoting their social role. Regarding structure, this project was organized around 5 stages: (1) a bibliographic review on memory, cognitive processes and the Alzheimer s disease; (2) a case study at the nursing home Centro de Atividades Bem Viver that included observations of activities, routine, and the elderly responses to the stimuli applied; interviews with the guests, employees and relatives; and the development of design concepts for the creation of products and services that focused on the Alzheimer s disease and institutionalization; (3) cocreation of interdisciplinary and multifaceted artifacts in partnership with the instructors of the institution, as well as the support of Card Sorting and an interdisciplinary diagram; (4) implementation of products and services by the staff of the nursing home in the activities at Bem Viver; and (5) identification of results, with respect to cognition and quality of life, by drawing a comparison of the data gathered early and later on. At the end, it was possible to assess that the open-design objects and the workshops improved spatial orientation and also the elderly s writing and math skills, along with the guests creative awakening, the strengthening of friendship ties and the stimulation of memories and mental functions of individuals with different types of dementia and cognitive profiles.

Long-term care facilities (LTCF) were impacted disproportionately by the coronavirus (COVID-19), suggesting their high risk for community-spread pandemics. This three-article dissertation with publications aims to a) aggregate the emerging research evidence of factors for nursing home residents' COVID-19 infections; b) explore hospitalizations due to COVID-19 among emergency admissions and length of hospital stays for long-term care facility (LTCF) residents with dementia; and c). investigate how comorbidity index score mediates the relationship between COVID-19 hospitalization and discharge outcomes among LTCF residents with dementia. This dissertation consists of a three-article format: a mixed-methods systematic review and two retrospective cohort studies. The first study is a systematic review to summarize major factors of nursing home residents' COVID-19 infections over the pandemic period (January 1, 2020, to October 31, 2022) in the United States providing a context for the two empirical studies on COVID-19 hospitalization outcomes for LTCF residents with dementia. The second study is a cross-sectional study and utilizes Texas Inpatient Public Use Data File (PUDF) to compare COVID-19 hospitalization outcomes for LTCF residents with dementia aged over 60 years (n = 1,413) and those without dementia (n = 1,674) during period January 2020 to October 2022. Logistic regression is used to predict emergency admissions and length of hospital stay, with pre-existing conditions mediating the relationship. The third is a cross-sectional study and uses the same dataset and criterion from the second study. Logistic regression, mediation analysis, and moderation analysis are used to investigate the effect of comorbidity index score and health insurance status on the association between dementia status and place of live discharge, while controlling for sociodemographic factors such as age cohort, race, and gender. Findings from the mix-method systematic review of 48 articles yielded evidence to suggest risk factors associated with COVID-19 infections among nursing home residents in the USA by geography, demography, type of nursing home, staffing, resident's status, and COVID-19 vaccination status through 48 articles. The second study found that with COVID-19 hospitalization, a diagnosis of dementia and preexisting conditions was significantly associated with emergency admission (OR = 1.70; 95%CI = 1.40-2.06) and shorter hospital stays (OR = 0.64; 95%CI = 0.55-0.74) when considering, adjusting for confounders such as demographics, health insurance, and lifestyle. In the third study, dementia diagnosis with COVID-19 hospitalization increased the likelihood of discharge to hospice care (OR = 1.44, 95% CI = 1.16-1.80), followed by LTCF (OR = 1.42, 95% CI = 1.23-1.65), but decreased the likelihood of discharge to recovery hospitals (OR = 0.70, 95% CI = 0.52-0.94). The findings highlight the increased risk of COVID-19 hospitalization disparities among individuals with dementia. Targeted health support programs for LTCF residents with dementia would enhance their COVID-19 hospitalization outcomes. Discharge plans for COVID-19 patients with dementia should be customized to their care needs, including hospice care, to minimize healthcare disparities compared to other residents. Further study is needed as to why recovery hospitals are less preferred for live discharge of COVID-19 patients with dementia diagnosis.

在高齡少子化的浪潮下，家庭照顧機能與國家公共長照服務體系之界限逐漸浮現，不論是採稅收制或是社會保險制的國家，均紛紛發動改革，發展新型的照顧服務體系，更有效率地結合社會中各種資源，並且透過報酬支付制度的設計，回應長期照顧需求的多元性，以達成充實長期照顧服務量能、發展創新並符合在地需求之照顧服務。本文以日本介護保險制度自2000年創設以來，在服務供給體系與支付制度上之轉變作為比較對象，觀察其社會價值理念的變遷如何反應到法制設計層面，同時報酬支付制度是如何回應社會現實的需求與政策方向；擬自日本介護保險經驗中萃取值得我國參考借鑑之處，減少台灣長期照顧體系發展過程中可能產生的試誤成本。 本文首先對我國長期照顧服務提供體系之法制發展進行分析，包括釐清長照服務提供之法律關係、長照服務供給體系之構造，以及在長照十年計畫下，政府與民間服務提供者合作模式之建構等；並具體地以數份國內地方政府公布之服務提供契約範本為例，嘗試勾勒出台灣長照服務體系公私協力法律關係之圖像，同時探討我國長照服務提供體系與報酬支付制度現存之問題。 在日本介護保險制度部分，本文歸整介護保險法之制定和改革歷程及其基本構造、初探日本介護保險制度與其他社會保障制度之連動性，並集中分析其服務提供者指定制度之法制設計與問題。接著本文將對比台灣長照體系之發展軌跡與挑戰，分析台日兩國公共長照服務供給體系的幾個議題，包括：總體面的公共長照體系理念變遷、國家資源的公平分配、服務品質之管理等。最末於結論歸納日本介護保險經驗值得我國借鏡或反思之處，並簡評目前我國長期照顧服務法修正，以及長期照顧十年計畫2.0之內涵，是否足以回應社會中的長期照顧需求，並有助於實現在地老化之理想。