2. Method

In order to address the above objectives, a literature review was conducted using a predetermined inclusion-exclusion criteria and search strategy as outlined below.

#### 2.1 Inclusion and exclusion criteria

The search strategy for the literature review included journal articles and research papers that were published until May 2017. A preliminary search was conducted on this topic to determine the scope of the existing literature, which has revealed a lack of published research in the field of dementia care for migrants and refugees. As a result, no specific boundary was set on the date range of publication, and any relevant article was included in the literature review regardless of its publication date. Articles that were published in English were only included in the search. The keywords used for the literature search were "migrants," "cultural barrier," and "dementia support program," and these search terms were used to explore the cultural barriers faced by migrants in order to access dementia support programs. "Immigrants," "refugees," and "new comers" were also used within the keyword set as migrated population contains immigrants, newcomers, and refugee subgroups. Both "dementia" and "Alzheimer" research related to support programs and care designed for dementia and Alzheimer's disease are often comparable in nature and content, and frequently these two words were used interchangeably. Research regarding both support programs and care services are included in the literature review to encompass all types of barriers faced in regard to access to dementia care and support programs. Research conducted on populations including persons living with dementia, informal and formal caregivers (such as nurses, personal support workers, and other service providers), and dementia program facilitators and coordinators were included in the literature review. Research about barriers to equitable access among certain subgroups such as indigenous people was excluded from this review. Despite the diverse cultural background of indigenous population, this subgroup is not considered migrants.

populations from diverse cultural backgrounds has led to the emergence of the

An Examination of Factors Influencing Equitable Access to Dementia Care and Support…

The most common and impactful factor associated with the access to dementia support programs among migrants was stigma. The Alzheimer's Society of Ireland (2008) reported on two types of stigma, one as external, indicating stigma toward the person by community members, and the other as internal, indicating perceived feelings of shame about themselves that they are "less of a person" because of the symptoms of dementia [16]. Stigma affects the individual with dementia, which includes but is not limited to willingness to seek diagnosis and to seek support once diagnosed and a lack of willingness to participate in research [16]. In some cases, stigma about mental health impairments such as dementia was so deeply rooted that individuals and family members would deny to "recognize the illness" [17]. Data obtained from persons with dementia and family members reported that stigma often prevented them from seeking necessary information or support as "people would gossip about you if something went wrong" and "people don't want to get

In South Asian culture, mental health impairments including dementia are associated with perceived stigma toward the individual and their family members. A great deal of stigma appears to be associated with mental illness in such cultures where open discussion of a relative's mental health issues could cause the family to be stigmatized, with a reduced social standing that could affect later generations, such as interfering with marriage arrangements [15]. South Asian migrants thus appeared to be engaged in "concealment" as a mechanism to protect the reputation of the person with dementia and reputation of their family [15, 18]. The most common explanation for not using any support services among informal caregivers was that seeking support from outside agencies "put an already precarious balance between shame and inner pride in jeopardy" [18]. In Eastern European cultures, stigma associated with dementia also reinforces the tendency to "keep it in the family" instead of seeking support [18] as "going public" about having a family member with dementia is linked with a perceived fear of inviting condemnation from others in the community [18]. This reinforces the behavior of informal caregivers around providing support alone instead of seeking help from social and

Persons with dementia were also identified to be vulnerable to experience stigma associated with chronic and severe mental illness, such as schizophrenia, because they shared a set of similar behavioral symptoms including depression, delusions, hallucinations, and agitation. For instance, researchers from Hong Kong outlined the social consequences of stigma associated with mental illness among Asian culture [19]. Lee and colleagues identified that concealment and anticipated stigmatization had a significant impact on non-compliance with care-seeking behavior. Persons with dementia and their family members attempted to hide their diagnosis from the community and forbid further interaction between the person with the illness and community members in the attempt to hide any shameful incidence [19]. Among Asian Americans such as Chinese and Vietnamese, shame and "loss of face" were identified to contribute to stigmatization associated with dementia [20] where shame was triggered by public display of abnormal behavior. Concealment was adopted to deflect such situations [21], resulting in delays and nonadherence to acquiring external care and

following four themes, which are discussed below.

3.1.1 Stigma associated with dementia

DOI: http://dx.doi.org/10.5772/intechopen.84858

branded as odd or weird" [17].

community support networks.

support.

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#### 2.2 Search strategy and data analysis

An extensive search of the literature was performed using the University of Ontario Institute of Technology (UOIT) library databases, including the PubMed databases and Wiley Library. The search strategy was consistent for every database and was based on the predetermined set of inclusion and exclusion criteria. Only full-text papers published in peer-reviewed journals and proceedings were selected for further review. Editorials, letters, and conceptual papers were excluded. All papers that addressed the keywords and search terms that were relevant to the research topic of interest were retrieved, regardless of their study design.

A total of 4451 research publications resulted from the keyword search from both databases which included peer-reviewed journal articles, eBooks/books, dissertations/thesis, and book chapters. Abstracts that were identified to be relevant to the research question were kept, and full-text papers were retrieved for further review. In the absence of an abstract, full-text papers were retrieved and reviewed for prospective inclusion. Reference lists of selected papers were examined to identify other relevant articles. There were a total of 15 articles included in the final data analysis using a thematic analysis method based on its relevance and the scope of research for data extraction purposes. The data extraction details about these 15 articles are presented in Appendix A. The findings were analyzed and synthesized to identify common themes, methodologies, and research gaps. In addition to the scholarly literature, gray literature found in credible websites were used to obtain information and findings such as statistical data, current approaches, and recommendations from the Alzheimer Society of Canada, Alzheimer's Society of the United Kingdom, and Statistics Canada.
