Abstract
In this article, we explore the psychological process through which Vietnamese family caregivers adjust to their role as primary caregivers for their relatives with dementia. The study adopted a constructivist grounded theory approach to collect data with 30 face-to-face, semi-structured interviews with 20 self-identified primary caregivers of older adults with dementia in Vietnam. The core adjustment process, consisting of four stages (Experience, Acknowledgment, Experiment, and Acceptance [EAEA]), to caregiving role emerged from the data. The EAEA process highlights the importance of self-perception, self-perception focused strategies, and acceptance of caregivers and suggests an adjustment process to their “becoming self” in caregiving. The EAEA process was reflected in the transactional relationship with caregiver personal factors (demographic and relational characteristics with care recipients, personal beliefs in and commitments to caregiving, and personal history of caregiving and coping with past adversity) and structural factors (cultural values and norms, social support, and social pressure).
Keywords
Introduction
Dementia, one of the leading causes of disability and dependency among older population aged 60 and above, has recently been acknowledged a global epidemic. According to the World Health Organization (WHO), dementia affects approximately 50-million people worldwide, with two thirds from low- and middle-income countries (LMICs). The annual incidence of dementia is estimated at 10-million cases, which contributes to a projected increase in the total number of people with dementia to 82 million in 2030 and 152 million in 2050 (Dementia, 2019). Older populations from LMICs, especially in South East Asia, are considered to be leading contributors (71%) to these figures (WHO, 2011). As one of the fastest aging countries in the world, with an estimated 30.8% of older adults projected by 2050, Vietnam is expected to experience a doubling of dementia over the next two decades (General Statistics Office & United Nations Population Fund, 2016; WHO, 2011).
The high risk of dementia places intensive burdens on Vietnamese family caregivers, as they are largely responsible for caregiving in their society (B. N. Nguyen et al., 2013; Truong, 2015). Burdens include financial hardship, physical health problems (e.g., sleep disturbance and fatigue), and psychological distress (e.g., anxiety and depression; T. B. Nguyen et al., 2018). The worse the person with dementia’s (PWD) behavioral and psychological symptoms of dementia (BPSD), the higher perceived burden family caregivers report (B. N. Nguyen et al., 2013). High perceived burden, lack of confidence in caregiving management, and limited medical and social supports negatively impact well-being and quality of life of Vietnamese family caregivers (B. N. Nguyen et al., 2018; Truong, 2015). In the past few years, the Vietnamese government started acknowledging dementia caregiving burden as one of the greatest concerns to public health (Tatarski, 2016). Although many scholars share consistent insights on the kinds of burdens Vietnamese family caregivers experience, very little is known about how they adjust to their caregiving role in their context.
Caregiving experiences are critically shaped by caregivers’ sociocultural contexts. In Vietnam, caregiving practice deeply reflects the Confucianism-based culture, which highly values filial piety and familism (Dam et al., 2006; Truong, 2015). Cultural foundation not only shapes social norms and expectation toward family members but also influences Public Laws. For example, the Law on the Elderly explicitly declares that the responsibility of caregiving for older adults, particularly those with sickness, is on their children and grandchildren (The Law on the Elderly, 2010). Vietnamese family caregivers typically carry out intensive care duties with little effort to seek help outside of their families. Even if caregivers wanted to obtain help outside their families, recent studies have found very limited supports available in either the formal health care or social care systems (B. N. Nguyen et al., 2013; Truong, 2015). Given the fact that dementia is one of the most challenging chronic conditions that family caregivers face, the Vietnamese sociocultural context may create more barriers for caregivers to adjust to their caregiving roles than those from other societies less Confucianism-based. The important role of cultural mechanisms in shaping caregivers’ adjustment, practice, and health outcomes has been identified in other countries, such as China, Singapore, Japan, Korea, and India (Hashizume, 2010; Tuomola et al., 2016; Win et al., 2017).
In health research, caregiving has been described as a dynamic “process of change” that “unfolds over time” (Montgomery & Kosloski, 2013, p. 135). The adjustment process of family caregivers to their caregiving role refers to their psychological process of “making sense of, coming to terms with, and adapting to changes in functioning, typically loss of function” of their loved ones following the onset of dementia (Ownsworth & Gracey, 2010). As coping plays a central role in this process, many researchers describe the adjustment process from a stress and coping perspective, as the caregiver adapts to the progressive changes in the PWD’s cognitive, behavioral, and physical symptoms, leading to changes in caregiving challenges over time (Lazarus & Folkman, 1984; Pearlin et al., 1990). Many studies have adapted Lazarus and Folkman’s (1984) stress and coping model which consists of (a) stressors, (b) cognitive appraisal, (c) coping strategies, and (d) adaptation outcomes across different contexts and populations, for example, with Latino and Taiwanese family caregivers (Huang et al., 2006; Montoro-Rodriguez & Gallagher-Thompson, 2009; Pinquart & Sörensen, 2005).
Researchers examining the coping processes of family caregivers also emphasize the importance of person–environment relationship (Basinger et al., 2015; Hinrichsen & Ramirez, 1992; Lazarus, 1993). This theory suggests that there is a “dynamic, mutually reciprocal, and bidirectional relationship” between caregivers and their environment (structural factors; Lazarus & Folkman, 1984, p. 293), which changes over time, given the changes in stressors that accompany the dementia caregiver’s journey. Most existing studies, however, address coping strategies for caregiving distress very broadly, with little focus on any specific sources of stress, leading to the lack of specific strategies to cope with individual stressors (Gilhooly et al., 2016). As Vietnamese family caregivers face various sources of stress rooted in their socioeconomic, cultural, religious, and spiritual beliefs (Meyer et al., 2015; Truong, 2015; Yeo et al., 2002), further studies are needed to address these specific stressors.
Taken together, existing theories do not provide an adequate framework to explain the psychological processes Vietnamese family caregivers go through as they adjust to their caregiving role in their own sociocultural context. This study responds to the knowledge gap that calls for studies to examine the psychological adjustment process incorporating both caregivers’ internal processes (e.g., cognitive appraisal), as well as structural factors that facilitate or hinder person–environment relationship. The key research questions of the study are the following:
Method
Research Design
This study adopted constructivist grounded theory (Charmaz,1997, 2014), which provides a powerful approach for researchers to integrate a new theory that explains the lived experiences of diverse participants from their perspectives, taking into account their own context and culture (Liu et al., 2015; McCalman et al., 2013; Mendez-Luck et al., 2016; Waterworth et al., 2016). Figure 1 presents a flowchart of the study’s research process. A preliminary literature review helped refine study aims, research questions, and conceptual framework. Theoretical sampling and constant comparative methods were applied to refine the recruitment and interview process, as well as to support the saturation of theoretical categories, with data collection and preliminary analysis conducted iteratively over the course of 7 months, following guidelines of Charmaz (2014) and Ng and Hase (2008).
Research process flowchart.
Ethical Considerations
The study protocol in both English and Vietnamese was approved by the University of South Carolina’s Institutional Review Board (IRB) and the Vietnam’s National Geriatric Hospital (NGH), from where participants were recruited. This protocol was consistent with Vietnam’s Law on the Elderly (valid since 2009) on reporting elder abuse and referring caregivers in need to health care and social services. At the beginning of the first interview of each participant, the principal investigator (PI) handed him or her a Vietnamese informed consent and explained the study procedures. For each completed interview, a participant received a $15 honoraria. The PI removed all identifiable information of participants from the transcripts and assigned them identification numbers that matched with the audio recordings and transcripts of their interviews. Only the PI could access the data, which were securely stored in a password-protected computer.
Setting and Participants
Setting
Participant recruitment took place in the Department of Neuropsychiatry and Alzheimer’s Disease at the NGH in Hanoi, Vietnam. The Department has four psychiatrists, 15 nurses, and a nurse assistant, who run the Dementia Program, which was funded by the government with the purpose of providing quality and affordable medical treatment for older adults clinically diagnosed with dementia. The program covers from 50% to 100% of the medical bills of only patients using health insurance. The NGH is one of a few health care facilities in Vietnam using Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000) to diagnose dementia. On a yearly basis, the Department provides medical treatment to approximately 130 out-patients with dementia (B. Nguyen, personal communication, March 19, 2017). Medical treatment consists of medications, such as Aricept and Razadyne (Galantamine), and monthly checkups. No other therapies or other interventions were available for either patients or their caregivers at the time of the study.
Participant recruitment
Participants were recruited using purposive sampling (Charmaz, 2014; Guest et al., 2006) and a two-step recruitment process with the support and supervision of the Dementia Program’s participating health professionals. First, psychiatrists and nurses contacted family caregivers of patients with diagnosis of dementia in the program to explain the study. Recruitment flyers were distributed around the hospital. Family caregivers who were interested in study participation agreed for the psychiatrists and nurses to give the PI their phone numbers. Second, the PI made phone calls to interested caregivers to explain further about the study protocol and screen their eligibility for participation. Inclusion criteria included the following: (a) aged 18 or older; (b) self-identified as primary family caregiver who had provided direct, hands-on, and substantial day-to-day care (minimum 20 hr/week) for a family member clinically diagnosed with dementia; (c) had taken care of the relative with dementia for at least 1 year consecutively; (d) had no self-declared cognitive disability; and (e) could communicate in Vietnamese. A total of 20 caregivers met the inclusion criteria, and all were invited to set up a time and location for the interviews.
Participant characteristics
Twenty caregivers participated in the study, 65% female and 35% male (see Table 1 for sociodemographic characteristics). Their average age was 61 (SD = 13). Most of the caregivers were married (90%), retired (65%), taking care of their spouses (65%), and living in urban areas (65%). A half of participants held a college degree or higher. All respondents self-identified as the primary family caregiver to the PWD and estimated spending an average of 7 hr a day (SD = 2) on caregiving. Two of the caregiver respondents were taking care of the same PWD. They both defined themselves as primary caregivers, but with different scope of care duties. The PWD’s wife focused on providing hands-on, direct care, whereas his son-in-law was responsible for medication management and treatment decision-making. Most caregivers found it difficult to estimate their caregiving duration as they already lived with and cared for the PWD for many years before a dementia diagnosis was made.
Characteristics of Caregivers and Care Recipients.
Note. N = the total number; n = the specific number in each category; SD = standard deviation; N/A = non-applicable; NGH = National Geriatric Hospital.
The 20 caregivers were thus taking care of 19 PWD (42% female, 58% male), who were all clinically diagnosed with Alzheimer’s Disease and enrolled in the NGH Dementia Program for government-funded medical treatment. PWD’s average age was 73 (SD = 8), had demonstrated dementia symptoms for on average of 5 years (SD = 4.4), and had been enrolled in the Dementia Program for an average of 30 months (SD = 30.5). Less than a third of PWD (31.6%) held a college degree, with the rest having a primary (26.3%), secondary (26.3%), or high school diploma (15.8%).
Data Collection
Prior to data collection with eligible family caregivers, two pilot interviews were conducted to test the feasibility and cultural appropriateness of the interview protocol. Using personal networks and word of mouth, the PI recruited and interviewed two people who self-identified as family caregivers of relatives with memory impairment. The PI reviewed the audio records, field notes, and memos from the pilot interviews to revise questions in the interview protocol. These documents were not included in the data analysis presented in this article.
After the interview protocol was revised, the PI started collecting and analyzing data iteratively as suggested by principles of theoretical sampling (Charmaz, 2014; Corbin & Strauss, 2014; Creswell, 2012). Long-term caregivers, who shared rich stories with multiple transitions across stages of the adjustment process, were asked to participate in follow-up interviews for further exploration of their experiences. Out of 10 participants invited for a follow-up interview, two refused due to scheduling conflicts. Among eight caregivers who accepted the invitation, six of them were interviewed one more time, and two, who reported challenging caregiving situations and complex emotional states, were interviewed an additional two times.
Data collection took place over a 7-month period. After the first 10 caregivers were interviewed, the PI started preliminary data analysis by reviewing digital records and transcripts, field notes, and reflective memos. Analytic memos were also written to develop initial codes and themes emerging from exiting data. This process helped refine the recruitment strategy for new participants and inform new interview questions for the follow-up interviews. An addition of 20 interviews were conducted, including the 10 follow-up interviews. Theoretical sampling ceased after the 30th interview when the PI found theoretical saturation, that is, no new findings emerged from the data (Charmaz, 2014; Corbin & Strauss, 2014; Creswell, 2012).
As the study aimed to explore participants’ perspectives grounded in their sociocultural context, the interviews were conducted inductively using an interview guide that consisted of four sections, following the guidelines of Charmaz (2014), as the follows:
Grand tour question: “Tell me about your experience of caring for your relative.”
Intermediate questions, for example, “Why did you take your relative to the hospital? What did you think after learning about the problems/diagnosis of your relative from the doctor? What are your daily care routines? What are the biggest challenges in caregiving and why? What do you do to get through the day?” Depending on the response of each participant and the flow of the conversation, deeper and more detail-oriented questions were probed.
Basic demographic questions.
Ending questions, for example, “Is there anything else you think I should know to understand your caregiving experience better? Is there anything you would like to ask me?”
In follow-up interviews, the PI asked about participants’ current events, changes in their mood, attitudes, coping, and coping outcomes, and their perceived reasons for the changes. Overall, the PI conducted 30 face-to-face, semi-structured interviews with 20 eligible participants. The average time of an interview was 58 min, ranging from 30 to 97 min. Interviews took place at participants’ homes or the hospital, depending on their preferences. All interviews were audio recorded and transcribed verbatim in the original language of Vietnamese by a professional Vietnamese transcriber. Demographic information was recorded in a Microsoft Excel Sheet for the purpose of data analysis. Field notes, including observation notes, reflective, and analytic memos were used to supplement and triangulate data for analysis and synthesis.
Data Management and Analysis
Data analysis was conducted iteratively with data collection. Audited interview transcripts and memos were uploaded, managed, and coded with the program MaxQDA12. Data analysis was conducted on the original Vietnamese-language transcripts to help protect cultural and linguistic authenticity in meaning interpretation and enhance the internal validity of the results (Haidar, 2013; Shibusawa & Lukens, 2004). The two Vietnamese American committee members who advised the study randomly selected audited transcripts for validity checks regarding language translation in the quotes and result synthesis. These validity checks reduced any validity threats associated with language translation and meaning interpretation.
Interview transcripts were analyzed using the three-phase coding procedure, which includes initial coding, focused coding, and theoretical coding (Charmaz, 2014; Strauss & Corbin, 1990). In the initial coding phase, the PI conducted line-by-line coding to construct initial categories, followed by the second phase of focused coding, in which the most significant and frequent codes and categories were examined throughout all transcripts. In the last phase of coding, theoretical coding, the PI selected core categories and subcategories to develop an integrative theory to explain the adjustment process of family caregivers to their caregiving roles. Theoretical sorting, constant comparative strategies, and diagramming were also adopted to support theory integration (Charmaz, 2014; Ng & Hase, 2008).
Results
The model of the psychological process that Vietnamese family caregivers went through to adjust to their caregiving role in dementia care is shown in Figure 2. This model consists of two key components. First, at the core of the model is the psychological adjustment process of caregivers, which is an iterative cycle of four stages, including (a) Experience, (b) Acknowledgment, (c) Experiment, and (d) Acceptance (the EAEA process). Second, the looping arrow boxes around the EAEA process represent caregiver personal and structural factors, as well as their interactions with each other and with the core EAEA process. These interactions could lead to, for example, caregivers’ active or passive acceptance of their caregiving role.
The model of the adjustment process to the caregiving role.
This model provides a framework for understanding the core essential experiences of Vietnamese family caregivers in a flexible, iterative fashion. It is important to note that, first, acceptance is the result of a learning process evolving over time. As caregiving situations evolved, family caregivers continued to learn and develop their skill set to adapt and accept the situation. Second, not all family caregivers reached the last stage of acceptance. For example, a long-term caregiver revealed her feeling of “being trapped” and could not accept her primary caregiver role for her mother-in-law. Third, neither is the EAEA process a linear process, with rigid stages of progression. Because each caregiver had a different life experience depending on their background and context, their adjustment process varied, often not progressing uniformly from one stage to another.
The “Experience, Acknowledgment, Experiment, and Acceptance (EAEA)” Process
Experience (E)
At the beginning of the adjustment process to the caregiving role, family caregivers started experiencing their loved ones’ early symptoms without much knowledge of dementia. This stage was often marked by unusual signs or changes in their loved ones’ cognitive abilities, emotions, and/or behaviors. Most caregivers recalled exactly when their relatives did not act like “they used to before” and began to act like “a new different person.” For example, a spousal caregiver marked the starting point of their journey with dementia when her husband did not help her carry their luggage at the airport. There was a wide range of time when caregivers started to seek medical assessment at the hospital for their loved one’s symptoms, anywhere from a few months to a few years. Before a clinical diagnosis was made, most caregivers lived with doubts, uncertainty, worries, and often times incorrect attributions about their relatives’ condition. Common assumptions were “being confused” as a consequence of the aging process, brain damage, physical injuries, or psychological distress.
After learning about the diagnosis of dementia, most caregivers approached their caregiving role willingly to fulfill their social responsibility of a spouse or an adult child, as they often said, “It is a spouse’s/child’s responsibility.” Caregivers tended to focus on key tasks post diagnosis, that of medication management, activities of daily living (ADLs; for example, bathing, dressing), and instrumental activities of daily living (IADL; for example, cooking, shopping). Different from caring for patients at the early stage with less severe BPSD, caregiving for those in advanced stages of dementia required a tremendous amount of time and effort. Caregivers for those patients often described intensive ADLs care, including feeding, bathing, shaving, brushing teeth, and even scrubbing them with soap when they put toilet waste on their body. A spousal caregiver summarized, “I take care of him from the smallest things.” Hands-on caregiving could be challenging, as patients would at times violently attack their caregivers, as they did not want to follow caregivers’ lead.
Acknowledgment (A)
In the second stage of the adjustment process, most family caregivers came to a clear acknowledgment of their caregiving situations, including caregiving demands, challenges, and available resources to support their caregiving. At a more profound level, many caregivers developed an awareness of their identity, that is, their self as a caregiver.
Acknowledgment of caregiving demands, challenges, and resources
As PWDs’ dementia symptoms progressed over time, caregivers clearly acknowledged their increasingly intensive workload, time constraints, social isolation, and financial burdens. It became increasingly hard to balance their multiple roles in their family, community, and society, as well as to solve escalating role conflicts. Conflicting role demands were particularly challenging for long-term female caregivers, who were under high pressure and expectations to perform a variety of roles, such as wife, mother, sister, daughter, and often employee, along with their primary caregiver role. One female caregiver summarized the following: Caregiving is very tough, very stressful . . . I went to teach, took care of my family business, and my father. When I looked after him in the hospital, I run the business on the phone. I was so busy and exhausted. My health was considerably affected. I have just applied for an early retirement.
Dealing with caregiving demands and challenges, caregivers became aware of different sources of social support. Most caregivers considered both nuclear and extended family as the primary and most important informal social support during their adjustment process to the caregiving role. Family caregivers also placed trust in and endorsed health professionals in the Dementia Program at the NGH, which was the only formal and specialized geriatric care available to them, as other health care services did not exist.
Acknowledgment of the self in caregiving (self-perception)
Along the journey of dementia care, caregivers became aware of and reconstructed their identity and the sense of self. Tough caregiving situations tended to lead to their double-identity crises. The first identity crisis happened when caregivers acknowledged the identity loss of their loved ones, who showed severe dementia symptoms, such as uncontrollable toileting behaviors, spitting, and biting. Caregivers no longer recognized their loved ones and failed to reconnect the patient to the parent/spouse they had known before. A spousal caregiver shared the follows: He used to be a true gentleman. Now with this disease (AD), I feel so pity for him. He was so handsome, but now, he lost 70-80% of that charming look . . . I am really sad. How can I feel happy with that? We were a happy couple before. When my coworkers saw us together, they said: “Wow, look at them, they are such a sweet couple. They always hold each other’s hand, lovingly look into each other’s eyes. They love each other so much!” They even said that. But now, it is not like that anymore.
The second identity crisis was the loss of identity and self-erosion of the caregivers themselves. Most caregivers associated their identities and sense of self with their loved ones’ identities. Observing the loss of self of their loved ones contributed to the loss of self of caregivers. For example, a female participant described herself as “a dementia caregiver, a family doctor, and even a maid” for her ill husband, while stating her “disconnection to the role of a wife.” She also reported her sadness at the loss of intimacy with her spouse, and multiple negative emotions, such as being upset and frustrated. Like many other caregivers, she kept revisiting the former image of her husband and envisioned that her life would have been “perfect” and “endlessly happy” if her husband had not developed dementia, despite the fact that he had lived with dementia for more than 10 years. Comparing their loved ones to their predementia selves disconnected the caregiver from the present and contributed to their inability to move toward acceptance of their caregiving role.
Critically in the stage of acknowledgment, Vietnamese family caregivers learned about their identity (the self) in caregiving by constantly reflecting upon their complex beliefs, emotions, and behavioral reactions while providing direct, hands-on care for their loved ones. These reactions, as immediate responses to specific caregiving situations, were located on a wide spectrum, constantly swinging between the very negative and the very positive (Figure 3). On the negative side, family caregivers often passively expressed the “have-to-take-it” and “what-if” attitudes, with negative emotions, such as “worried,” “pitiful,” “sad,” and “stifled.” A few long-term caregivers of PWD in advanced stages reported more extreme emotions, such as feeling “miserable,” “depressed,” and even “feeling like dying.” Some caregivers admitted to “ignoring” their loved ones and their behaviors, and just “crying” at the situation. Caregivers were able to clearly and honestly recall and describe their negative reactions: Too depressed. I cried too much, and sometimes I screamed and yelled at him. I was a devoted traditional woman, a role model for my husband and my children, but now sometimes I become a nasty woman. Angry, then I even cursed him. I was very depressed and felt like my head was about to explode and I just wanted to die . . . Keep being like this, keep giving care like this, I may die soon. To be honest to you, sometimes, I just want to tell him: “I would rather have you die!” I was too hopeless and resentful.
Spectrum of key beliefs/perception/attitude, emotions, and behaviors of caregivers.
The comments of many family caregivers also fell into the positive side of the spectrum. These caregivers revealed a gradual development of understanding and empathy for their loved ones with dementia and “acceptance” of the illness and caregiving situation. The most common responses were, for example, “looking on the positive sides,” “planning for future,” and “finding joys/rewards in caregiving.” All of these complex, extensive states of beliefs, emotions, and reactions fostered caregivers to acknowledge and reconstruct their identity and sense of self.
Experiment (E)
Caregivers entered the stage of experiment with different strategies to adapt to caregiving situations. They engaged in two types of strategies, one being caregiving task-focused, and the other being self-perception focused, depending on the two types of acknowledgment of caregiving nature and the self as discussed above.
Caregiving task-focused strategies
Although all caregivers clearly acknowledged the challenging and demanding nature of dementia caregiving, they adopted different strategies to meet the increasing care needs of their loved ones. Common strategies included adjusting their schedule and lifestyle, even quitting their jobs, to devote more time to caregiving, and actively learning about dementia and new caregiving skills and techniques from doctors, friends, books, news, and the internet. In addition to medication management, most caregivers set up a balanced diet for PWD with fresh, organic, and plant-based food choices, combined with supervised walking every day. They closely observed any changes in their loved ones’ symptoms, which they shared with their doctors, and adjusted caregiving routines accordingly. Caregivers also learned to communicate with their relatives more effectively by being aware of the meaning of their behaviors and symptoms, speaking slowly in short sentences, and patiently negotiating with them to help them take medication and to finish their meals. Many caregivers creatively came up with new activities for PWD, such as coaching them to go grocery shopping, read a book for 15 min, write in a diary, make a phone call to a friend every day, and attend community events.
As caregivers were mostly self-taught, their creative strategies came from their rich understanding, empathy, love, and tremendous time and effort spent on direct, hands-on care for their relatives with dementia every day. Many caregivers positively revealed that they took caregiving as a chance to renew their bond with their loved ones, reinforce their family connectedness and tradition, and learn new skills. Multiple spousal caregivers shared that caregiving gave them an opportunity to pay back for the love and support they had received before from their spouses, and “start our love anew,” as a male caregiver commented. Adult children caregivers also discussed that caregiving helped bring their siblings together to spend more time with their parents. Experiments with new caregiving tasks-focused strategies, in other words, could lead to positive and fulfilling experiences for family caregivers.
Self-perception focused strategies
Caregivers developed new strategies for caregiving based on their acknowledgment of their newly evolving self-perceptions. The key strategy shared by most caregivers was “thought training.” First, caregivers refocused their thinking to transform their perceptions and attitudes toward their situation, rather than immediately blaming and reacting to the PWD’s symptoms, which they began to accept were not under their control. A male caregiver pointed out that Patients (with dementia) will always be patients. There is nothing else they can do. It is all about caregivers . . . It all depends on our mindset. We create our own mindset. We can update new information to learn which would work for us and which would not.
Second, caregivers practiced observing and reflecting upon their thoughts, particularly in chaotic and difficult situations. Third, they guided themselves to switch their thoughts into a more positive and constructive mode to be consistent with their moral values. As a spousal caregiver recalled, “Sometimes, a thought came to my mind, like: ‘If you die soon, we will not have to suffer any longer’. But then, my conscience guided me not to think like that anymore.”
This thought training was a constant learning process, and often challenging. Family caregivers kept practicing this strategy along with the more task-focused strategies. A spousal caregiver was open about his caregiving journey for his wife: Before, there were times I was so angry, so mad. I tried to take care of her, but she hit me. I could not stand that, and I hit her back. I even punched her. I am honest to you. But then, I reflected upon that, and I tried to control myself: “No, it is not OK! I should not have done that.” I stopped doing that because I told myself: “She hit me because she did not know anything anymore. I should be gentle to her, negotiate with her, not hit her.” After becoming aware of that, I stopped reacting to her by hitting her back around a year ago. I just pity her because she has been sick. She had no idea what she was doing.
The development of their newly evolving self-perceptions led caregivers to adopt new perspectives around self-care. Long-term caregivers of relatives with advanced dementia learned about the importance of respite and self-care after reflecting upon their frequent negative emotional and behavioral reactions toward the PWD and caregiving situations. A long-term caregiver shared his thought about how he reclaimed self-care: I try to be nicer to myself. If my children visit me, I tell them to stay with their mother for a while so that I can travel to somewhere nearby. For my own sanity. Caregivers like me need to keep our mind light and content. It is very dangerous if we are sad and depressed, because we may be sick. I see that already. I have my own strategies to take care of myself and improve my life in order to take better care of her.
From caregivers’ perspectives, reclaiming self-care would improve health outcome of both caregivers and PWD. Different from novice caregivers, who did not pay attention to self-care at the beginning stage of their caregiving journey, long-term caregivers clearly acknowledged this need when they reached the point of burnout and serious deteriorating health. A 10-year caregiver commented that self-care helped her “relieve stress” and “free herself” from “going crazy” with her stressful caregiving. Adopting new strategies to spend personal time to relax helped caregivers shift their thoughts away from the negative side to the more constructive, positive side of the spectrum. As a result, they started experiencing more positive emotions, which contributed to their acceptance of their caregiver role, their caregiving situation, and their new self-identity as a caregiver.
Acceptance (A)
In the final stage of the psychological adjustment process, acceptance emerged as the most frequent and significant key category identified across all the interviews, and typically presented as passive or active acceptance. Caregivers who associated dementia with their loved one’s fate, and caregiving burdens with their own fate, presented passive acceptance. A female caregiver commented, “Because it is my fate, I accept it.” They were less active in their caregiving strategies as they perceived that “there was nothing else to do” to improve the situations or their feelings associated with the situations. They maintained their caregiving duty with the goals of “getting through it” and “getting it done” on a daily basis.
On the other hand, most family caregivers actively accepted their caregiving role, situation, and their new “self.” Their active acceptance was based on a set of realistic, practical, and constructive views, and strategies for feasible action plans. These caregivers demonstrated such perspectives in how they approached their overall lives and their performance in caregiving. Caregivers with active acceptance described life as a combination of unpredictability, risks, and misfortunes, as well as joys, hope, and chances for personal growth. They acknowledged and came to term with the fact that dementia was a difficult condition to deal with and their relatives’ symptoms would progress overtime. Therefore, they approached caregiving demands and challenges as part of their ordinary life: I accept it. When I decided to take my father-in-law to live with us, I already accepted the challenges going with it. My life routine was interrupted at first, but I will get used to it eventually . . . I am content. Being born, getting old and sick, and passing away are the rules of life that each of us will experience. As a child, I try my best to take care of him. When he passes away, I may cry, but I cannot keep crying for the rest of my life.
These caregivers turned their caregiving experiences into life lessons and learned to appreciate and show their gratefulness for small achievements in daily care. They were also more realistic in assessing their caregiving abilities, that is, being able to distinguish what was within and out of their control, and content with their limitations: We cannot predict anything, so don’t worry about it. What will come will come. I only try to do what under my control . . . It does not matter if I worry or not. I only focus on what I know and take the best care of my wife to help her improve as much as possible. I do not think too much, just do my best. If she eats well and sleeps well, that is a successful day.
As the caregivers stopped blaming and victimizing themselves over their limitations in caregiving, they found room for improvement and growth, in both their knowledge and patience. A spousal caregiver expressed, “I take what life gives me. I accept everything and try my best to live with a positive attitude. Living with a burden in my heart just makes it harder. I learn to live with adversity.” This attitude released family caregivers from extreme negative emotions and allowed them to experience caregiving in a more positive, fulfilling way. It did not mean caregivers who progressed to the active acceptance stage never experienced negative feelings during the day-to-day caregiving activities. They were able, however, to embrace their feelings, both positive and negative, and to learn to make peace with their inner self.
All caregivers who reached the stage of active acceptance shared the same pattern of actively making practical and feasible plans for future, including plans for worst case scenarios, while finding joys and rewards in everyday caregiving, and focusing on the present. They were also flexible and more willing to accept changes in their relatives’ symptoms and caregiving plans: “If her illness gets worse tomorrow, I will adapt my caregiving routine to meet her needs. I do what I can. What I cannot do, I accept that too.” Caregiver with active acceptance tended to report better psychological well-being and health outcomes, unlike caregivers who did not accept their situations. Those caregivers often expressed having destructive self-concepts, such as “a nasty women,” negative emotions, such as “feel like dying,” and being depressed.
Personal Factors Influencing the EAEA Process
Demographic and relationship characteristics
Demographic and relationship characteristics influenced the adjustment process of Vietnamese family caregivers to their caregiving role to a small extent. Participants differed in terms of socioeconomic backgrounds, including age, gender, educational level, employment status/type of job, and geographic area of residence. One third of participants lived in rural areas where they did not have access to high-quality health care services. To receive the specialized services at the NGH, many rural caregivers and their relatives had to travel long distances every month, causing them significant amounts of money and time. This challenge became more critical among caregivers who were retired and lived on a tight budget. Not all retired caregivers had retirement pensions, as a few were farmers and still worked on their farms or in a part-time job to support themselves and the PWD. These challenges influenced their experience of the illness and hands-on care, as well as their acknowledgment of caregiving demands and resources, and their experiments with task-focused strategies.
The relationship of primary caregivers with their loved ones appeared to be more critical than demographic characteristics in shaping the EAEA process. Caregivers who were children (direct bloodline) or spouses tended to take on the role as a primary caregiver without hesitation or resistance to fulfilling their filial or marital obligations. However, a caregiver who took care of her mother-in-law with advanced dementia exhibited negative emotions toward assuming the caregiver role, as she reported feeling “trapped” with caregiving duty, as her sisters-in-law refused to assume this role.
Personal beliefs and commitments
Personal beliefs of Vietnamese family caregivers included their beliefs of family responsibility in caregiving and religious and/or spiritual beliefs, which were shaped by the Confucianist and Taoist cultural values and social norms commonly accepted in the Vietnamese societies (see below, for more on cultural values and social norms). Caregivers holding values of family responsibility/obligation in caregiving, affection, and gratitude (between husband and wife), and filial piety (between children and parents) tended to take on the role and carry it out willingly. These values and beliefs led caregivers to strongly hold on to their commitments to care for their relatives with dementia. These commitments were associated with their moral codes, identity, and social reputation as a moral person and a role model in their families and community.
Spiritual beliefs also contributed to caregivers’ acceptance of their role and caregiving situations. Even though most caregivers did not associate with any specific religion, they expressed their spiritual beliefs to some extent, particularly, their Buddhist beliefs in karma and the crucial practice of compassion and good deeds. They used these beliefs to explain their commitment to caregiving. Family caregivers with strong spiritual beliefs tended to focus on changing their own negative perceptions and attitudes toward their loved ones with dementia and their difficult situation, leading to a deeper understanding of their “selves” and acceptance of their situation. Their beliefs also directed them to pray and do good for others, including continuing to care for their loved ones with dementia, and to collect good karma and find peace for themselves.
Personal history of caregiving and coping with adversity
Most caregivers had confronted multiple adversities in their lives. Two thirds of caregivers were 55 and above, and most of them had directly or indirectly experienced the effect of the Vietnam War. Living with poverty, hunger, physical injuries, chronic diseases, as well as loss of family members and war trauma were common among these older caregivers. A female caregiver shared the following: I was an orphan since I was so little. My mother passed away when I was 12, my father had passed away before I could even remember his face. I learned to take care of myself since then. I had suffered a lot during my childhood, especially from hunger. Getting out of poverty, I feel so lucky and positive. It is all in my head. I tell myself: If I keep thinking, it will only make me suffered. If I let it go and keep working, I will overcome it.
In addition, some younger female caregivers experienced different types of psychological difficulties stemming from marriage and family conflicts, including separation, divorce, and family disconnection. Overall, many of the family caregivers were traumatized with a number of different major events in their lives. Confronting these adversities fostered caregivers to develop their coping skills and resilience: “Since I was born, I have been living with so many sufferings. So now I can live with all kinds of suffering because I see suffering a normal part of life.” Caregivers who experienced the most challenging situations, for example, war traumas, all revealed significant sources of strengths and resilience to cope with caregiving challenges.
Most female caregivers shared rich experiences of caregiving for other family members, which maps onto the cultural values of familism, self-sacrifice, and the social norms expected of female family members in the Vietnamese society. Many of these women became regular unpaid caregivers for other family members who were in need of care over the course of their lives. For example, a female caregiver shared about her experiences: I always take care of others. I took care of my sisters-in-law when they gave birth, of my dying relatives in the hospital . . . I have lived a very rough life since very young. I had to run to the forest with my family when (American) airplanes dropped bombs in my hometown. From the age of eight or nine, I started taking care of my mother when she was pregnant. I was always working and helping my mother to take care of other siblings. I did not have time to play, I had no childhood and no younghood.
Experiencing multiple adversities and caregiving demands from other family members, Vietnamese family caregivers gradually developed their resilience and coping skills. They still confronted negative thoughts, emotions, and behaviors when the PWD’s symptoms rapidly progressed, but they gradually enhanced their sense of self in caregiving and learned to move toward the positive side of the spectrum. They also actively accepted the illness of their loved ones, their caregiving role, and uncertain life situation. On the other hand, other caregivers who had not experienced major adversity tended to reveal more negative thoughts, emotions, and behaviors, as well as to deny the reality of the illness and caregiving situation.
Structural Factors Influencing the EAEA Process
Cultural values and social norms
Confucianism-based values of filial piety for adult children, and affection and gratitude among spouses both established moral standards for family members to undertake the role to fulfill their social responsibilities and expectations of a filial child or a devoted spouse. A female caregiver commented on the caregiving norm in her community: “Whenever a parent is sick, children will voluntarily take care of him/her.” Taking on the role of primary caregiver for a PWD was also considered a method to “save face” or protect social pride and reputation of the whole family. Under these social expectations, most caregivers found no other way than accepting their roles, regardless of their attitudes and emotions. Although most family caregivers accepted their role willingly with pride and honor, a few caregivers expressed obligational or passive acceptance.
In addition, Buddhist beliefs of karma (laws of cause and effect) and sowing and reaping good deeds for the whole family is a way of life to most Vietnamese people regardless of their religious status and affiliation. Consistent with Buddhist beliefs of karma, many caregivers shared that suffering from dementia and from the hardship of dementia caregiving were the effects of bad actions that the PWD and caregivers had committed in the past lives. Therefore, enduring caregiving duties with their difficulties was a way for caregivers to pay back the “debts” and sow new good deeds in this life. Even though they still experienced multiple negative emotions associated with their daily caregiving activities, they accepted their situation and tried to “get by.” Buddhist beliefs contributed to shape not only passive acceptance but also active acceptance, depending on the interpretations of each caregiver.
Social pressure
Cultural values and social norms, including gender norms, also contributed to social pressure and judgment, inhibiting caregivers’ psychological adjustment process, as they created conflicts and difficult feelings in the development of caregivers’ evolving self-perceptions. Throughout the caregiving process, family caregivers explored different layers of their “inner selves” and identities. Many caregivers had to constantly face challenging caregiving situations, and sometimes questioned their love and commitment to their loved ones, particularly after their immediate and violent reactions to the PWD, such as hitting back. A female caregiver expressed her frustration and resentment due to the lack of empathy and full of judgment from her neighbors, despite her great effort to take care of her husband with late dementia: When my neighbors heard me yelling at my husband, they thought I treated him badly . . . I am angry when they judge me like that . . . I just wanted to tell them that no one wanted to be like that. It is difficult to explain for myself.
Caregivers in these situations went through their own identity crises of “the persons they thought they were” versus “the persons they have become.” A spousal caregiver compared her former self as a “loving, devoted woman” to her “becoming nasty woman” under the intensive burdens of caregiving for more than 10 years. Family caregivers like her already struggled to come to term with their new “selves.” Outside pressure and judgment would likely make their adjustment to their new “selves” more difficult.
Social support
Social support included both formal support from the NGH and informal support from their nuclear and extended families, friends, and neighbors. Family caregivers received social support in different forms, including tangible support (money and supplements for the PWD), help with hands-on care regarding ADLs and IADLs, informational support from those who were knowledgeable in medical care, and emotional support from family and friends during the caregiving process.
The availability and frequency of social support a family caregiver received impacted how he or she progressed across stages of the EAEA process. Caregivers with multiple sources and forms of social support had better means to cope with caregiving demands. For example, caregivers living in big cities with more options of services, such as housemaid, could obtain more time for self-care, whereas rural dwelling caregivers, with strong support of extended families, found it easier to ask for help with hands-on care. Caregivers with good social support tended to actively accept their caregiving role and situation with better action plans. Caregivers who did not receive adequate social support, particularly from their families, often struggled during each stage of the adjustment process. They tended to experience more negative than positive emotions, and found it harder to balance between the two sides of the spectrum and learn to really accept their caregiving role and situation as part of their new found reality.
In summary, the adjustment process to the caregiving role of Vietnamese family caregivers has different layers with multiple associated factors. Family caregivers did not only adjust to their role, caregiving situation and demands, but also to their new “selves” and identity. The adjustment process, in other words, is a process to explore the self at more profound levels. This process placed family caregivers in difficult situations that required them to constantly acknowledge “the persons they thought they were” and “the persons they have become” in often times chaotic and problematic situations. This process also fostered their ability to come to terms with the complex perceptions, emotions, and behaviors they experienced, as well as their ability to accept their situation and embrace their “becoming selves.”
Discussion
This study contributes to the literature on the adjustment of dementia caregivers to their caregiving role, not only in the Vietnamese context, but also in other countries with similar religious and cultural values. The four-stage EAEA process and its associated factors at both personal and structural levels are consistent with well-known stress and coping models (Lazarus & Folkman, 1984; Pearlin et al., 1990) that have been widely adopted to study different racial and ethnic groups in different countries, such as United States, Australia, China, Singapore, and Vietnam. Similarly to these models, study results emphasize the cognitive and psychological processes in which Vietnamese family caregivers acknowledged and assessed their stressful situations, their own beliefs, emotions, and competences to manage their caregiving situations. Consistent with previous studies (Cooper et al., 2008; Davis et al., 2014; Gilhooly et al., 2016; Hashizume, 2010), family caregivers experimented with different strategies to deal with complex demands of caregiving, including caregiving-related problems, their emotions and relationship with the PWD and others in the family. The study results also highlight the iterative process of the four stages that Vietnamese family caregivers went through, as caregiving constantly changed along with the progression of dementia, with caregivers continuing to learn and adapt to the new situation.
One of the key features of this grounded theory study is that the results inductively emerged from data and reflected participants’ own perspectives. Several qualitative studies have explored the adjustment process of dementia family caregivers (e.g., Butcher et al., 2001; Silverberg, 2006; as cited in Butcher et al., 2001) relying on stress and coping models, mostly that of Lazarus and Folkman (1984). These studies focused narrowly on help seeking from formal health services in Western contexts and did not include caregivers from diverse sociocultural backgrounds. This study extends prior research in two important ways, by examining how caregivers from societies with strong Confucianist and Buddhist beliefs adjust psychologically to their caregiving role and by focusing on help seeking from both formal and informal systems of care.
Perhaps the most unique contribution of this study to the literature is the insights regarding caregivers’ self-perceptions, that is their acknowledgment of the self in caregiving, self-perception focused strategies, and acceptance as the core concepts of the psychological adjustment process. This study suggests that the adjustment process to the caregiving role happens at different layers, with the first layer being their adjustment to the illness condition of their loved one and caregiving demands; the second layer, when caregivers went through the journey to come to term with the “loss of self”; and the double identity loss, happening often to both PWD and the caregiver, and also to learn to accept and embrace “the becoming of the self” as primary caregivers. This stage of acknowledgment reveals deeply what caregivers learned about their own beliefs/perception/attitudes, emotions, and behaviors. Particularly, the acknowledgment of the self in caregiving (self-perception) in the EAEA model clearly portrays the coexistence and swinging pattern between the two sides (negative and positive) of the spectrum of caregivers’ states. Caregivers rarely stayed on one side of the spectrum, such as solely negative or positive thoughts, emotions, and behavioral reactions. Indeed, they went through and learned about their shift in worldview and the complex, divergent states in their stream of emotions. These results add an important contribution to the caregiving literature as they demonstrate the importance of the development of newly evolving self-perception in the long adjustment journey.
Building upon self-perception of family caregivers, the results of this study emphasize self-perception focused strategies that are unique from existing studies. Previous studies have focused on examining the coping process, strategies, and techniques with regard to help-seeking from formal supports, such as professional health care services (Butcher et al., 2001; Levkoff et al., 1999). In addition to examining help seeking from informal care systems, this study focuses on specific strategies for self-awareness. Those strategies contributed significantly to their acceptance of the illness, caregiving situation, and primary caregiving role in the family, as well as a higher awareness of their inner strengths, self-confidence, personal growth, and abilities for skill enhancement (Aneshensel et al., 1995; Furlong & Wuest, 2008).
Acceptance emerged as both the most significant theme and the final stage of the adjustment process of Vietnamese family caregivers. Although acceptance of destiny has been identified as a key concept in the coping process of other Asian family caregivers with Confucianist, Taoist, and Buddhist values (Tuomola et al., 2016), this study extends the insights from prior studies by identifying two different types of acceptance, that of passive and active acceptance. Different from passive acceptance, which was often associated with less hope and minimal action plans, active acceptance referred to the acceptance of life situations with their duality and uncertainty, and with active action plans to respond to newly emerging situations. Active acceptance is similar to the concept of true acceptance found among people coping with traumas in the Western contexts (Feldman & Kravetz, 2015). True acceptance refers to the adoption of a realistic view to live with all aspects of life, including its uncertainty and fragility, while maintaining hope that enables people to act and achieve their goals for life improvement.
This study highlights the role of personal factors in shaping the adjustment process of family caregivers. Similar to previous studies, the role of caregivers’ demographics, relationship with PWD, as well as beliefs and commitments to caregiving, were found to be critical in their adjustment process (Bielsten et al., 2018; Caron & Bowers, 2016; Huang et al., 2006; Pinquart & Sörensen, 2005). More importantly, this study emphasizes the role of personal history of caregiving and coping with past adversity in family caregivers’ acceptance of their caregiving role. This relationship is consistent with the concepts of “posttraumatic growth,” “psychological gains,” and “inner strengths” in existing literature on trauma coping in Western contexts (Feldman & Kravetz, 2015).
At the structural level, this study reveals the importance of social support, cultural values and norms, and social pressure as both facilitators and barriers to the psychological adjustment process of Vietnamese dementia caregivers. These results are consistent with much literature examining the role of social support and cultural mechanisms in caregiving experiences (Feldman & Kravetz, 2015; Huang et al., 2006; Knight & Sayegh, 2010). Feldman and Kravetz (2015) suggest that social support is one of the most important factors shaping the adjustment process and acceptance of people going through adversity. In the context of Vietnamese culture, family is identified as the primary social support that facilitates caregiving by providing sources of support with caregiving tasks, emotions, and so on. Family, on the other hand, also inhibits caregiving when it becomes a source of pressure and stress, especially for women. These results are consistent with general studies, as well as studies on Vietnamese American (Meyer et al., 2015), and Chinese dementia caregivers (Tuomola et al., 2016), reflecting the dominant influence of culture across geographic settings.
Limitations
Despite important contributions, this study has several limitations. First, the sample size of this study is relatively small and quite homogeneous, with a total of 20 primary family caregivers recruited from the same Dementia Program at the NGH in Northern Vietnam. One can assume that these participants would be more knowledgeable in dementia compared with those who had not taken their relatives to the hospital for dementia diagnosis and treatment. The results of this study, therefore, cannot take into account experiences of either Vietnamese family caregivers who did not know about dementia clinically, or receive medical care from professional health care providers, or from other parts of the country with different subcultures. On the other hand, the sample size and homogeneous characteristics of participants in this study are appropriate for reaching theoretical saturation in a grounded theory study (Guest et al., 2006).
Second, language translation may create a challenge for the meaning transfer of the results. Data collection and analysis were conducted in Vietnamese, whereas result synthesis was conducted in English. Some specific terms and proverbs were challenging to convey fully from Vietnamese to English due to cultural differences. On the other hand, conducting data analysis in the original language and having validity checks with two committee members help improve cultural and linguistic authenticity in the meaning transfer of the data, and reduce possible threats to validity in data analysis and synthesis (Haidar, 2013; Shibusawa & Lukens, 2004).
Third, the rapport built between the PI and the participants, as well as the possible “therapeutic effect” of the interviews might have influenced their adjustment process to some extent (Morecroft et al., 2004). For example, one long-term female caregiver who was interviewed three times over the 6-month period emphasized the lack of understanding, empathy, and emotional support from her family. She commented on the effect of the interviews as a channel for her to be open and express her feelings freely. Within 6 months, this caregiver showed significant progress toward acceptance of her situations. The interviewing effect and the rapport between the PI and the caregiver may have possibly played a part in her adjustment process. Therefore, the results of the study also need to take into consideration this effect.
Implications
The results of this study call for future study to deepen the understanding of “the self” and inner strengths of family caregivers in adjusting to the hardships of their caregiving situations. The need for these studies becomes more pressing in the changing context of the demographic transitions in various LMICs, and the corresponding changes in family dynamics due to migration trends from rural to urban areas. Different from most participants in this study, who had experienced tremendous hardships earlier in their lives, such as the Vietnam War and famine, the coming generation of caregivers in those countries will represent very different cohorts and life experiences. Future studies on experiences of this new group of caregivers in their sociocultural context are much needed.
The study results help inform practical implications for family caregivers in dementia care not only in Vietnam but also in other LMICs with similar sociocultural contexts. First, by illustrating the portraits of family caregivers with their challenges and needs to adjust to the demanding roles, the study results advocate for the needs of new policies, interventions, and services targeting this group. Currently, medical services for older adults with dementia are very limited, and services for family caregivers are almost nonexistent in most LMICs. Caregivers, therefore, need to be considered a specific clientele in hospitals and community, where they should be able to access appropriate resources, such as social workers, counselors, and support groups. Second, the new interventions and services need to be built upon the concepts of caregivers’ self-perceptions, resilience, and cultural values. Most available interventions for family caregivers in Western settings focus on the training of specific caregiving skills, such as feeding and bathing, while leaving out the critical components of caregivers’ self-perceptions. The results of this study suggest that caregivers would benefit from culturally competent interventions that help them constructively reflect on their self-perceptions and develop practical, positive self-perception focused strategies to actively accept caregiving situation and roles.
Conclusion
In summary, given the critical knowledge gap in understanding Vietnamese family caregivers in dementia care, this study sought to learn about the psychological process through which they adjust to their caregiving role in their own sociocultural context. By attending to the nexus of individual experience, transactional relationship, and cultural context, this research may provide an important new framework for examining transition into the caregiving role in other similar sociocultural contexts, as well as more generally. The specific results regarding the role of the “self” in caregiving (self-perception), self-perception focused strategies, and acceptance of caregiving role, provide unique contribution to the existing literature examining resilience and coping attributes of family caregivers. Not only do these results have implications for cross-cultural studies, they can also inform interventions development targeting resilience for diverse family caregivers in a broader context.
Footnotes
Acknowledgements
We would like to thank Drs Huong Nguyen, Teri Browne (University of South Carolina), Thanh Tran (Boston College), and Hongtu Chen (Harvard University) for their critical feedback on the first draft of this manuscript.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was partially supported by a SPARC Graduate Research Grant from the Office of the Vice President for Research at the University of South Carolina.
