Strength for Caregiving

Background: A large proportion of Finnish family caregivers are older adults. Serving as a family caregiver places both psychological and physical strain on the caregiver. As a result, taking care of one's own well-being may be overlooked. Previous studies have shown that up to 40% of family caregivers may be at risk of malnutrition. Inadequate nutrition weakens family caregivers' health and functional capacity, potentially threatening their ability to continue providing care. At present, there is no structured and clearly defined approach to systematically addressing the nutritional status and nutritional needs of family caregivers as part of family caregivers services. Consequently, family caregivers may not receive easily accessible, targeted, and reliable nutritional guidance or materials, even though nutrition is an important factor in maintaining health, functional capacity and the ability to continue caregiving.

Aims: The aim of the Strength for Caregiving project is to promote elderly (≥ 65 years) family caregivers' dietary habits, well-being, and functional capacity through comprehensive nutritional counseling. In addition, the project aims to develop and pilot a nutritional counseling model targeted at family caregivers. The project will also produce nutrition materials for family caregivers.

Methods: The study examines the effectiveness of a 10-month tailored nutritional counseling intervention on well-being, functional capacity, nutritional status and dietary habits among elderly caregivers living in the Satakunta region, Finland. The planned sample size is 100 participants.

The 10-month intervention includes two individual counseling sessions and three group counseling sessions. The individual sessions are conducted by a nutritionist and include a personal nutrition plan. Based on the participants' preferences, the group sessions consist of either nutrition lectures or practical cooking courses.

Study outcomes are assessed at baseline and after 10 months. Outcomes are measured using questionnaires and three-day food records. Nutritional status, weight, blood pressure and muscle strength are measured at the same time points during appointments with research nurse.

Expected outcomes: The project is expected to improve family caregivers' dietary habits, well-being, and functional capacity. The nutrition coaching model will include individual and group counseling, practical cooking courses, and materials for implementing these activities, enabling different organizations and professionals to use the model and continue providing counseling after the project has ended. The materials produced will be publicly available and widely usable after the project.

Discussion: The study will support family caregivers' ability to continue their caregiving role and help reduce nutrition-related health risks. Integrating the nutrition counseling model into family caregiver services in the well-being services county will lay the foundation for long-term change. Openly available materials may help ensure that the project's impact continues beyond the project period.

• Tailored nutritional counselling intervention (Behavioral): The intervention is a 10-month tailored nutritional counselling programme for elderly family caregivers. It includes two individual dietary counselling sessions conducted by a nutrition specialist and three group counselling sessions. The individual counselling sessions include a personal nutrition plan based on the participant's needs. According to participants' preferences, the group counselling sessions consist of either nutrition lectures or practical cooking courses. The intervention aims to improve participants' well-being, functional capacity, and dietary habits.

Primary outcomes

• Mental well-being measured with the World Health Organization-Five Well-Being Index (WHO-5) [Baseline and 10 months]: Psychological well-being of participating informal caregivers will be assessed using the WHO-5 Well-Being Index. The WHO-5 consists of five positively worded items measuring mood, vitality, positive affect, and general psychological well-being during the previous two weeks. Each item is scored on a 6-point Likert scale from 0 to 5, giving a total raw score range of 0-25. The raw score may be multiplied by 4 to obtain a transformed score from 0 to 100, where higher scores indicate better psychological well-being.

Secondary outcomes

• Psychological burden measured with the Zarit Burden Interview, 4-item version (ZBI-4) [Baseline and 10 months]: Psychological burden of participating caregivers will be assessed using the 4-item version of the Zarit Burden Interview. Each item is scored on a 5-point Likert scale from 0 to 4. The total score ranges from 0 to 16, with higher scores indicating greater psychological burden. A score of 8 or higher indicates high caregiver burden.
• Physical functioning measured with the five-times sit-to-stand test and hand grip strength measured with a grip dynamometer [Baseline and 10 months]: Physical functioning and lower-limb muscle strength will be assessed using the five-times sit-to-stand test. Participants rise from a chair and sit down five times as quickly as possible, with arms crossed over the chest. The outcome is the time needed to complete the test, measured in seconds. A longer completion time indicates poorer lower-limb muscle strength and physical functioning. Muscle strength will also be assessed using hand grip strength measured with a grip dynamometer. The outcome is grip strength, with higher values indicating better muscle strength.
• Protein intake measured with a 3-day food diary [Baseline and 10 months.]: Protein intake will be assessed using a 3-day food diary including two weekdays and one weekend day. The outcomes include total daily protein intake and protein intake relative to body weight. Protein intake will be reported as grams per day and grams per kilogram of body weight per day.
• Nutritional status measured with the Mini Nutritional Assessment, long form (MNA) [Baseline and 10 months]: Nutritional status will be assessed using the long form of the Mini Nutritional Assessment. The MNA includes anthropometric measurements, dietary assessment, general health and functioning, and self-perceived health and nutritional status. The maximum score of the long version of the MNA is 30 points. A score of 24-30 points indicates normal nutritional status, 17-23.5 points indicates an increased risk of malnutrition, and a score below 17 points indicates malnutrition.
• Quality of life measured with the 15D instrument [Baseline and 10 months]: Quality of life will be assessed using the 15D instrument which is a self-assessment-based quality of life measure developed, validated, and widely used in Finland. The 15D includes 15 dimensions of health and functioning, each scored on five levels. The responses are combined into a single 15D index score ranging from 0 to 1, where 0 represents death and 1 represents full health. Higher scores indicate better health-related quality of life.

Sex: All, ages: 65 Years to any, accepts healthy volunteers

Inclusion Criteria:

* Born in 1961 or earlier (i.e. aged over 65 years)
* Adequate Finnish language skills
* Able to give informed written consent
* Acting as a caregiver (with or without a formal caregiver contract) in the areas of Pori, Rauma, or Kankaanpää
* Normal cognition (participants with an MMSE score below 24 will be assessed by the responsible physician)

Exclusion Criteria:

* Serious acute illness or inability to act as an informal caregiver
* A condition, ailment, or underlying health risk that is poorly controlled and that participation in the study could exacerbate, or a terminal illness (Consultation of the doctor in charge, if necessary, in unclear cases)
* Born in 1961 or later (i.e. aged under 65 years)
* Substance abuse based on the AUDIT-C score (consultation of the doctor in charge)

• Susanna Kunvik, Principal investigator, Satakunta University of Applied Sciences