Lived Caregiving Experience of Foreign Domestic Workers (FDWs) for those with Terminal Illness in Singapore: A Secondary Qualitative Data Analysis

Lived Caregiving Experience of Foreign Domestic Workers (FDWs) for those with Terminal Illness in Singapore: A Secondary Qualitative Data Analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Lived Caregiving Experience of Foreign Domestic Workers (FDWs) for those with Terminal Illness in Singapore: A Secondary Qualitative Data Analysis Jing Yi Lee, Karen Liaw, Angel Lee, Hong Choon Oh, Foong Ling Ng, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4088516/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 21 Nov, 2025 Read the published version in BMC Palliative Care → Version 1 posted 3 You are reading this latest preprint version Abstract Background Due to societal changes associated with evolving family structures in Singapore, the reliance on foreign domestic workers (FDWs) for elderly caregiving is increasing. While involving FDWs in caregiving has proven effective in moderating family caregivers' burden and benefiting patients' health outcomes, their caregiving experiences of FDWs are not always ideal. Existing studies on FDWs' caregiving experiences have mainly focused on elder care. However, palliative care, being more specialised and intense, poses unique challenges. Given high caregiver burden experienced in caring for non-cancer patients with terminal illnesses, this study aims to explore FDWs' experiences in caring for non-cancer patients at their end of lives in Singapore. Method A qualitative secondary analysis was conducted on 15 transcripts from a study related to a non-cancer palliative care program. The analysis used an adapted model combining the Informal Caregiving Integrative Model (ICIM), Inherent Tension of Caregiving Model, and Risk and Resistance Model (RRM) of Adjustment model. FDWs' experiences were categorized into five caregiving profiles based on perceived burden and benefits characterised by Pristavec. Results Based on caregiver experience profiling characteristics by Pristavec, one was classified under “intensive domestic helper”, while two others were classified as “relationship”. Nine had a “balanced” profile and three others were classified as “satisfied” FDWs. Common caregiver outcomes like psychological stress and physical fatigue were observed across different profiles. Each profile highlighted unique caregiving experiences, emphasizing the significance of individual coping strategies, clear personal boundaries, and positive mindsets in mitigating the impact of caregiving demands on FDWs' wellbeing. Conclusion This study provides valuable insights into FDWs' caregiving experiences of non-cancer patients with terminal illnesses. The findings suggest the need for tailored services or interventions to enhance FDWs' coping abilities. Future research could focus on developing caregiver support programs specifically designed for FDWs caring for individuals with terminal illnesses. Foreign domestic workers caregiving end-of-life qualitative palliative care Figures Figure 1 Background The World Health Organization estimated that 56.8 million people need palliative care worldwide[ 1 ]. This number is expected to grow with rapidly aging societies. Thus, to facilitate a sustainable and accessible palliative care system for the patients and their families across the world, WHO proposed for palliative care services to be integrated into the community aside from the mainstream institutions. As patients who are receiving palliative care spend most of their time in the comfort of their homes instead of institutionalized care settings, there is an increasing reliance on family caregivers to provide care at home[ 2 , 3 ]. This imposes significant physical and emotional burden for family caregivers, with ever increasing burden as the patients continue to deteriorate throughout their disease trajectory [ 4 , 5 ] Similar to the global trend, demands for palliative care continues to grow in Singapore with emphasis on community-based services. Approximately 8800 persons with terminal illness were reported to be receiving palliative care in 2022 [ 6 ]. As care delivery to older adults shifts from institutions to the community, families take on the huge responsibility of caregiving to fulfil filial obligations expected of the Asian society[ 7 ]. In several societies and cultures, women often assumed the role of informal caregivers for elderly and family members with disabilities or chronic medical conditions[ 8 ]. However, societal changes associated with evolving family structures with higher women employment and decreasing birth rates have posed challenges for family members to assume responsibility as sole caregivers [ 9 ]. In Singapore, it is increasingly common to hire foreign domestic workers (FDW) as alternative caregivers particularly when it comes to providing physical aspects of care [ 9 ]. A FDW is a full-time migrant worker usually hired to perform domestic duties. FDWs are typically females and live together with their employers. Majority of these domestic workers are from neighbouring countries including Indonesia, Philippines, and Myanmar[ 10 ]. While they are normally tasked to do domestic chores, many are hired to provide round-the-clock physical caregiving to older adults[ 10 ]. One in every five households employs FDWs in Singapore, and approximately 50% of the employers hired FDWs specifically to care for older adults at home[ 11 ]. Involvement of FDWs has been demonstrated to moderate the effects of family caregivers’ care burden and is beneficial for patients’ health outcomes. Spousal caregivers with FDW assistance reported to be significantly less distressed as compared to those without[ 12 ].Singaporean older adults with FWD assistance experienced positive health outcomes in terms of physical function, memory, behaviors, and mood [ 13 ]. Furthermore, older adults with FDW assistance were found to be 70% less likely to be admitted into institutional care within one year [ 14 ]. It was also found that the presence FDWs could moderate the depressive symptoms among Singaporean caregivers of patients with dementia through provision of emotional support and practical assistance in daily caregiving tasks [ 9 ]. Though employers of FDWs may have benefited from deployment of FDWs to support caregiving, a local study found that many FDWs lacked physical rest and social support for them to feel recharged. They also reported feeling stressed while caring for older adults with behavioral issues[ 14 ]. The stress of caring for older adults with behavioural issues, juggling between caregiving and domestic chores, is made worse by language barriers and long working hours (i.e., an average of 20 hours per day caring for care recipient), depriving them of rest time[ 16 ]. Compared to Indonesians FDWs, Filipino and Burmese FDWs were found to have experienced significantly higher caregiver burden[ 17 ]. This is problematic and warrants attention for long term sustainability of FDWs as caregivers for elderly [ 17 ]. Having a good and trusting relationship between FDWs and employers, sufficient social interaction and adequate respite were found to be beneficial for the wellbeing of FDWs [ 10 ]. Additionally, self-efficacy of FDWs, less disruptive behaviour of the elderly, ability to communicate with employers and care recipients and desirable living conditions were known to moderate FWD stress well[ 18 ]. While existing studies offered insights into the caregiving experiences and challenges faced by the FDWs, they focus on elder care, which is distinct from palliative care. Elder care focuses on addressing the unmet needs of older adults to cope with declining functions due to frailty or chronic conditions [ 19 ]. Conversely, patients requiring palliative care have advanced illnesses that are irreversible, where focus is on quality of life and symptom control. As they deteriorate, care intensity increases, negatively affecting the caregivers’ physical and mental health and social wellbeing [ 5 , 18 – 22 ]. Currently, specialized palliative home care services focus on cancer patients as the prognosis of non-cancer advanced illnesses is less certain [ 25 ]. Nevertheless, non-cancer patients with advanced illness also experience distressing symptoms impacting their quality of life at the end-of-life[ 26 , 27 ]. Recognizing this, the palliative care focus has expanded beyond cancer conditions in Singapore [ 6 ]. Caregiver burden was notably higher among those caring for non-cancer patients with advanced illness compared to those caring for cancer patients due to multiple co-morbidities and increased care dependence[ 28 ]. While caregiver burden is acknowledged, most existing work in this area focuses on supporting family caregivers with little attention on FDWs caring for patients at the end-of life[ 10 ]. This study aims to explore FDWs’ caregiving experiences caring for non-cancer patients at the end-of-life in Singapore. Understanding the unique caregiving journey experienced by FDWs can aid the development of services or interventions that can improve the coping abilities of FDWs and the quality of care they provide in the end-of-life context. Methods Data Collection This study is a qualitative secondary analysis of the realist evaluation of the Violet Programme (ViP), a palliative care initiative for non-cancer patients with advanced illnesses[ 29 ]. FDWs caring for patients enrolled in the ViP were conveniently sampled, and 15 anonymized transcripts of their interviews were used in this study. Initial contact with employers was made through a text message, inviting FDWs for an interview about their caregiving experiences. Once employers agreed to the participation, a follow-up phone call was made to the employer to further explain the study.. Out of 31 invitations sent, 54.84% of FDWs agreed to participate (n = 17), 35.48% declined (n = 11), and the rest did not respond. Common reasons for declining included busy caregiving duties and employer discomfort with the interview. Semi-structured interviews were conducted in English (n = 3), Bahasa Indonesia (n = 6), and Burmese (n = 8) between October 2022 and October 2023. Each interview, lasting 30 to 45 minutes, were conducted either at the FDWs' homes or over Zoom teleconferencing, guided by an interview guide. Notes were taken, and interviews were recorded. Interviewers, assigned based on language, had no prior interaction with the FDWs Informed consent was obtained, and interviews were conducted in FDWs' preferred languages. English interviews with the Filipino domestic helpers were facilitated by JY (Female, BPsychSci (Hons)), EH (Male, MA), and CT (Female, MScR); Indonesian interviews were facilitated by MN (Female, MPH); and lastly, Burmese interviews were facilitated by two Burmese-speaking interviewers, NEE (Female, PhD), and MT (Female, PhD) Though some interviews were in non-English languages, All recordings were transcribed into English, including the non-English interviews. Study subject numbers were used for anonymity. Audio recordings and transcripts were securely stored with password protection. Data saturation was discussed among the researchers involved in the interviews. Contextual Framework The study utilized a framework that combined the Informal Caregiving Integrative Model (ICIM)[ 30 ], key determinants from the Inherent Tension of Caregiving[ 31 ], and additional mediators from the Risk and Resistance Model (RRM) of Adjustment [ 32 ] to guide the analysis of transcripts (refer to Fig. 1). This comprehensive framework considers caregiver demands and resources holistically, encompassing physical and psychosocial characteristics, as well as the caregiving environment's impact on various outcomes. Unlike other models that focus on a two-dimensional process without exploring mediating factors, the ICIM framework delves into the complex and dynamic processes mediating the impact of demands and resources on caregiver strain. Following this combined framework, determinants were identified by assessing caregiving demands, considering the duration, intensity, and care recipients' physical and psychological conditions. Various resources within FDWs' self, social, and work environments were recognized to aid in coping with caregiving demands [ 30 ][ 30 ]Sociodemographic, psychological factors, and physical state were considered as caregiver characteristics playing a role in stress buffering[ 33 , 34 ]. Social support, professional support, role recognition, and facility availability were identified as resources within social and work environments [ 31 ]. To understand the relationship between resources, demands, and caregiving outcomes, key mediators such as appraisal, relationship quality, coping styles, and intrapersonal variables (self-efficacy and locus of control) were examined[ 31 ]. Appraisal involves the caregiver's positive or negative assessment of the caregiving experience, acting as a cognitive process mediating between caregiving stressors and outcomes [ 35 ]. Relationship quality refers to the closeness between caregiver and patient and can influence caregiving experience and burden Coping strategies and self-efficacy play crucial roles in regulating stress experienced by caregivers [ 30 , 36 ]. Locus of control, representing the extent of control individuals feel over life events, is associated with lower vulnerability to stress among caregiver [ 37 ]. Finally, the study assessed caregiver outcomes, including impacts on physical and psychological wellbeing, such as psychological distress, positive emotions, anxiety, and quality of life, along with adverse care recipient outcomes. Data Analysis NVivo was used to code the data deductively and inductively by JYL, MN & KL. Framework analysis of the transcripts was guided by the combined framework. New themes that emerged from the analysis were also included into the framework inductively. After coding the transcripts, memos were written for each transcript. In the memo, the care recipient’s characteristics, and a summary of the helper’s caregiving experience (i.e., the challenges and resources the helper had, and the caregiving outcomes) were described. Then, based on the written memos, the transcripts were categorized based on the profiles of caregiving experienced identified by Pristavec et al [ 38 ].According to the magnitude of burden and benefits perceived by the caregiver in various domains (i.e., emotional, interpersonal, cognitive, physical, and social; FDWs experienced was categorized into five types of caregiving experience. Table 2 shows the five different domestic helpers’ caregiving profiles adapted from Pristavec et al. Results Study Participants by Caregiving Experience Profile Based on profiling characteristics described by Pristavec, one FDW was profiled as having an intensive caregiving experience, while the experiences of 2 FDWs were classified as relationship. Nine FDWs had a balanced caregiving experience and 3 FDWs described their experience as satisfied. It is noteworthy that none of the interviewed FDWs reported having a dissatisfied experience. Table 2 provides a detailed overview of the demographics of FDWs based on their caregiving experience profiles. Caregiving Experience This study revealed unique caregiving experiences, varied level of demands and available resources. Table 3 summarises intensity of demands, coping styles, intrapersonal processes, quality of relationship, outcomes and their relationship as experienced and described by FDWs. Intensive Caregiving Experience The demands from family members and the care recipients exerted significant negative impact on the physical and psychological wellbeing of the FDW, primarily manifested through strained relationships. The continual requests from the care recipient's family members, pulling the FDW away from her care recipient, caused initial confusion, physical discomfort and sense of helplessness due to overwhelming demands. Additionally, violent tendencies from both the care recipients and their family members strained the relationship , causing distress for the FDW. Overall, these demands had an adverse effect on the FDW's physical and psychological health. " She (recipient’s wife) would hit me ... Of course, my feelings was hurt .. When I’m doing something, she would bug me to do something else .... I got stressed. I considered jumping down ... (C024) "I was stressed because I had to be wary of him (care recipient)... When I was around him, I would start sweating ... He was someone else’s father so when he hit me, I didn’t dare to be angry." (C024) In order to cope with the distress, the FDW sought normalization of her experiences through her social support system and exerted a locus of control to moderate her Quality of Life (QoL). Seeking advice from friends who had similar caregiving experiences helped her address specific issues related to care. Over time, the FDW gained confidence to stand firm on her beliefs about appropriate care, even in the face of conflicting opinions from the care recipient's family. " Sometimes, when I have something I want to know, I asked my friends (for their experience). That other time, when there was a lot of phlegm, I asked if they had the same experience. When he shouts, I also asked my friend if her patient shout. She said “People with dementia are like this too. They shout too. " (C024) Relationship Caregiving Experience Profile FDWs' experiences were characterized by trusting and family-like relationships with both the care recipient and employer. Generally, they maintained open communication and had a sense of agency in their caregiving role. Viewing care recipients as family, FDWs expressed sympathy, leading to minimal perceived burden. They valued dedicated rest time/days. Despite facing significant demands and cultivating family-like relationships, FDWs remained unaffected personally. This was attributed to their skill in establishing a clear personal boundary, which acted as a buffer against emotional and demanding aspects. This boundary also facilitated their adaptation to caregiving situations, with challenges seen as inherent to their job and not affecting them personally. "The difficult part was at nighttime. If he screamed, couldn’t sleep, or when he was in pain… that one was the most difficult for me . Difficult because I pitied him… But it’s part of the job, what to do. " (C035) "I mean , just consider it as common thing ... This is the risk of looking after an elderly... Because I’m a carefree person . I think that it is normal for my boss to scold me, I don’t care . That’s why if someone is not mentally prepared, more than being “crazy”, (I suggest not to) work overseas... I enjoy working here very much, if not I would have been gone back . " (C035) "Since I was in Singapore, I’ve changed a few employers, and this one is the nicest one ... A lot of relaxing time . (…) (It is) law from MOM... since last January, helpers from any country have to be given off-day at least once or more in a month , the main thing is that there’s off-day given. Previously, don’t expect any of that. It was like crazy , really… (I) didn’t get any off-day." (C035) The ability to adapt increased FDWs' sense of control and self-efficacy, allowing them to optimize caregiving tasks and handle emergencies calmly. Healthcare professional-provided education and training further improved FDWs' self-efficacy, instilling confidence in employers who trusted them with caregiving responsibilities. "(He’s) very heavy... But I already have the trick, so now I don’t need to lift him . (…) I had an idea to push upwards his legs. Well, just like that. Because when he lies down, he often slips down, so his legs must be lifted. The bed is the same as the one in the hospital, it can be positioned vertical and horizontal. So, I put it in horizontal position then I pushed upwards his legs. Well, only like that. So, it’s easy, I don’t need help (anymore) . (C035) Balanced Profile FDWs with a balanced experience reported moderate caregiving burden and high benefits. Compared to those with intensive or relationship-based experiences, they faced fewer intensive demands from other family members. Despite managing household chores alongside caregiving, their ability to prioritize and manage time proved beneficial. Autonomy granted by employers empowered them to control their priorities. These FDWs utilized a range of resources, including social support and family-like relationships, both within and outside the workplace. Training and consistent support from healthcare professionals facilitated their assimilation into caregiving duties, contributing to adaptability and resilience. “Maybe sometimes at 4pm when it’s time to rest, then I rest . If it’s not 4pm yet and the work is not done , even if I’m tired, I will continue to work . I manage my own schedule" (C036) "Usually, I share with my friends. We share about work , or anything, like if we have family or friend problems , we share and discuss them”. (C038) " I talk to my employer . Since we don’t have other people around us, so she chose to trust to me, I chose to trust her . I can share to her . She’s open to me, I’m open to her . That’s our relationship as an employer and a worker." (C021) "... I learned from the nurse and practiced it. Then now to me... taking care of (name of care receipient) is like normal already because I am used to it ... " (C032) Positive appraisal and adaptability were notable in handling stress. FDWs viewed caregiving challenges as manageable, adapting to their duties with a positive mindset. Despite exhaustion, they remained emotionally composed and continued to perform well. Positive beliefs about themselves and their employers boosted confidence in difficult situations. As they came into terms that that every job has its stressors and challenges, FDWs learnt to enjoy the caregiving process despite difficulties faced " Many things change when taking care of the grandmother , but despite this, I feel that it’s manageable . Whatever happens to the grandmother , I no longer get emotional and I just try my best . " (C021) "Well, having a job (of course) sometimes I feel tired … (I’m a) human. But I’m used to it … My job is just like this . " (C022) "No , we can’t feel stressed . Must learn to enjoy it . Working comes with some level of stress, not always comfortable but just have to go through it . Can’t say it is heavy. " (C018) " You need to be brave if you are not doing anything wrong . You don’t need to be scared. You need to be confident. If you make mistakes you have to admit your mistakes and apologize for them. Now whatever they are going to say, I will respond as best I can. If they like me, they will keep me, if not they will dismiss me. That’s all on my mind . " (C027) Empathy was a distinct theme for those with a balanced experience, stemming from close relationships. Interestingly, Relationship profile individuals showed sympathy but not empathy, possibly due to a clear personal boundary . FDWs expressed empathy for care recipients and understanding for employers facing challenges. Despite perceiving caregiving as manageable, FDWs acknowledged the risks and uncertainties associated with caring for the elderly. Many were unsure about continuing as caregivers after their contracts ended. "I love (X) so much. I care for her for so long already... Every time I see her, I cry because of her bed sores. I know it’s painful... every time I clean ah... Then I tell her, “So sorry Ma(ma), I know, I know it’s painful. I know how you feel.” (C032) "… My boss is kind-hearted… He knows what I have to deal with…because Ah Gong is quite difficult to handle. (My employer) does not demand me to do other chores (…) (He has) never gone out, poor him… He really (cares) about Ah Gong, his father. (…) If Sir seemed stress out, I would just keep quiet, " (C034) "After my contract ends, maybe 50:50, I would probably prefer to do domestic chores ... There is a higher risk taking care of elderly , we never know when he/she will fall , we don’t know what is ahead . There is a definitely a higher risk." (C018) Satisfied Profile FDWs exhibiting satisfied profile showed similarities with those in Balanced profile concerning demands, resources, and coping strategies. Those with satisfied profile exhibited notable adaptability, a positive outlook, a well-defined personal boundary and self-efficacy, all of which prove advantageous in managing stressors in the caregiving environment and positively impacting the QoL of FDWs. Similar to other profiles, caregiving demands arising from conditions and characteristics of care recipients are present, often causing distress. Nevertheless, positive mindset and attitude of FDWs seemed to assist them in establishing a clear personal boundary, which, in turn, proves beneficial in mitigating experienced stress. Despite facing caregiving challenges, FDWs expressed contentment in being able to support their families back home. On the flip side, an excessively positive mindset sometimes leads to a reluctance to share personal feelings with others, even when social support is available. Some FDWs believed that stress would naturally dissipate without discussing it with others. Enhancing the self-efficacy of FDWs with the Satisfied profile was cited as achievable through caregiver training, education, employer instructions, and guidance from healthcare professionals. Additionally, FDWs proactively seek help from professionals when needed. " I don’t feel stressed because I choose to live happily … Since the grandmother is having dementia and bedridden. There are moments when she pinches and stuff like that. But I can’t do anything about it. I have to be understanding . " (C030) "I don’t feel upset… There’s nothing to feel upset about . (…) I send my salary back to my family. My parents don’t cause me any stress either. Since there’s no reason to. We’re not rich but there’s nothing (to feel stressed about) . " (C030) " When I’m stressed, I don’t talk . I don’t want to talk. (…) I have people I can call, (but) I don’t want to talk ... [I: If you don’t talk , does it go away? The stress.] Bit by bit . " (C026) “ I have less stress because of nurses’ instructions and I have more confidence . I really like them. I don’t have to be afraid of them and I can tell them everything and they are really friendly . " (C031) Moreover, the motivation to provide care also plays a role in the adaptability of FDWs with the Satisfied profile, a factor not observed in other profiles. For instance, one FDW shared that her enthusiasm for caring for the elderly stems not from passion but from her religious beliefs. " I’m used to looking after them. In Taunggyi, we believe that we can receive blessing from taking care of elderly… from Christian religion belief .. " (C030) Discussion This study, a secondary analysis of the ViP realist evaluation explored FDWs' caregiving experiences for non-cancer patients at the end-of-life in Singapore. FDWs were categorized into Intensive, Relationship, Balanced, or Satisfied profiles based on their caregiving experiences. Common caregiver outcomes like psychological stress and physical fatigue were observed across Intensive, Balanced, and Satisfied profiles, aligned with existing evidence on caregivers of palliative patients facing high distress and exhaustion over time[ 39 ]. Distinctly, burnout emerged as an outcome unique to the Intensive profile, where caregiving demands were not well-regulated by coping skills and cognitive processes, supporting prior research associating maladaptive coping skills with burnout [ 40 ]. Our findings concurred with the ICIM framework by Gérain and Zech [ 30 ], suggesting that caregiver burnout occurs when negative impacts outweigh positive ones. In the Intensive profile, caregiving demands, stemming from a violent-tempered care recipient and family, strained relationships, causing extreme stress and even suicidal ideation. Interestingly, despite challenging care and interpersonal demands akin to the Intensive profile, those with Relationship profile reported no adverse caregiving outcomes. This could be attributed to the clear personal boundaries observed in this profile, acting as a buffer against incoming interpersonal demands. This aligns with findings from Cross et al.[ 41 ], emphasizing that caregivers who maintain an emotional and psychological distance cope better with caregiving demands. The Balanced profile, unlike the Intensive and Relationship profiles, did not report interpersonal demands from care recipients' family members. Leveraging on extensive resources and coping styles, FDWs in the Balanced profile effectively managed and regulated caregiving demands. This supports the role strain theory, suggesting that effective utilization of existing resources helps individuals cope with role demands[ 42 ]. Similarly, the Satisfied profile, free from interpersonal demands, showed a higher quality of life due to effective adaptation skills, clear personal boundaries, and a positive mindset. This aligns with previous findings that suggested that caregivers who adopt positive reframing and actively change their mindset experience lower stress and find more positive meaning in their caregiving journey [ 43 ]. In summary, each profile demonstrated unique caregiving experiences, emphasizing the importance of individual coping strategies, clear personal boundaries, and positive mindsets in mitigating the impact of caregiving demands on FDWs' wellbeing. Strengths and Limitations of the Study The strengths of this study lie in the efficient use of existing data from the realist evaluation of the Violet Programme, a non-cancer home palliative programme. and inclusion of diverse samples of FDWs from different backgrounds (i.e., Filipinos, Indonesians, and Burmese) that made up 3 largest groups of FDWs in Singapore. Furthermore, our interrater reliability was within acceptable range and the analysis was guided by a comprehensive framework. However, there is inherently selection bias as FDWs recruited had participated willingly and with the permission of their employers and very likely had positive caregiving experiences. Only one FDW was profiled as an Intensive domestic helper in this study. It is possible that the experience shared may not be representative of this profile as other determinants or processes may not have been captured in the single interview. Although a comprehensive framework was used to analyse the data, individual contributing models were not developed specifically for paid caregivers in the home setting. ICIM and RRM were developed for family caregivers while Inherent Tension of Caregiving framework was developed for formal caregivers working in a healthcare system. Lastly, the current study did not assess power differential which may have the potential to influence the employer-FDW relationship and the FDWs’ sense of agency. Singapore has adopted a sponsorship system that is similar to the Kafala system for migrant workers coming to Singapore to work, requiring the employers to pay a sum of $ 5000 as security bond[ 42 ]. This influences the employers to exercise their power over the FDWs through strict disciplining and micromanagement in at least one of aspects of the FDW’s life (daily routine, social circle, or movement) to prevent forfeiting the bond. Some examples of strict disciplining include having rules and regulation, planning their work schedules, controlling whom they can socialise with, supervise their mobility during their day off. Out of fear of losing their jobs or being deported, FDWs tend to be compliant and try to maintain good relationships with their employers despite being mistreated, perpetuating a sense of helplessness among these FDWs. This could potentially affect their overall mental health due to the suppression of negative feelings. Therefore, future research can consider examining or assessing power differentials when exploring the relationship between the FDWs and their employers and its relationship with FDWs’ locus of control and wellbeing. Implications and Recommendations for Future Research To the best of our knowledge, this is the first study integrating ICIM, the Inherent Tension of Caregiving and RRM frameworks to explore the caregiving experiences of FDWs in Singapore. The study has also provided an insight into the various types of demands, resources, mediating factors, caregiving outcomes, and the relationship between these components for the different caregiver profiles. Insights into the different caregiver profiles, identifying resources and mediating factors of FDWs and types of demands, can be used both as an intervention to build resilience while fostering effective coping skills and as a preventative measure by guiding FDWs to act early on anticipated potential challenges to ease their caregiving journey. Future research can concentrate on developing support programs for caregivers, specifically targeting foreign domestic workers (FDWs) caring for palliative care recipients. Meanwhile, insights from this study can inform the design of services or interventions aimed at enhancing FDWs' coping abilities which may in turn influence the quality of care they deliver in end-of-life situations. An essential aspect of such research would involve investigating the impact of these services or interventions on caregiver burden and the quality of care provided to recipients. Additionally, future research should explore power differentials between FDWs and their employers, examining how these variations influence FDWs' locus of control and overall wellbeing. Given the potential selection bias during recruitment, where only one FDW represented the Intensive profile, future studies seeking to replicate this research using the combined framework may consider expanding to direct recruitment of FDWs through all palliative services in Singapore. This approach may enhance the chances of recruiting FDWs with Intensive profiles and possibly Dissatisfied profiles as well. To take it one step further, it may also be beneficial to recruit and interview FDW and employer dyads to obtain comprehensive views of employer-employee relationship and how it affect caregiving burden. Conclusion This study provides valuable insights into the caregiving experiences of FDWs caring for non-cancer patients with an advanced illness. It enhances understanding of FDWs' demands and resources, highlighting the role of coping abilities and cognitive resources, such as self-efficacy and locus of control, in regulating demands and buffering stress. Those who had Balanced and Satisfied experiences demonstrated diverse coping styles and resources, enabling effective management of caregiving demands and stress regulation. In contrast, those with Intensive experience faced high demands with limited coping resources, potentially leading to negative caregiver outcomes. The study identified the importance of strong personal boundaries in the Relationship profile, creating emotional distance and facilitating better adaptation to caregiving situations. These findings offer insights for the development of services or interventions aimed at enhancing FDWs' ability to cope with stress. Future research could focus on the creation of caregiver support programs specifically tailored for FDWs caring for care recipients with advanced illnesses. Declarations Ethical approval and consent to participate The SingHealth Centralised Institutional Review Board (CIRB) reviewed our study protocol (CIRB Ref: 2020/3039) and determined that the application does not require further ethical deliberation because this is a programme evaluation project. Study team members signed a confidentiality agreement to guarantee the privacy of all information. To maintain confidentiality of the research participants, analysis was conducted only on de-identified data. Consent for publication Not applicable Availability of data and materials Data is available upon request from corresponding author Competing interests KL, AL, KLH are directly involved in the provision of care for individuals enrolled in ViP. All authors declared no financial competing interest. Funding This work was supported by 10th Singapore Millenia Foundation (SMF) grant awarded by Temasek Foundation, Singapore. Funders have no role in the design of the study and writing the manuscript. Authors’ contributions LJY and MN conceptualized and designed this study. LJY, MN and KL analysed data. LJY andMN drafted the first and final version of the manuscript. All authors read, provided suggestions for revision and approved the final manuscript. Acknowledgement The authors wish to thank the participants who shared their experiences, Nang Ei Ei Khaing and Mon Hnin Tun for helping to conduct interviews in Burmese language. References WHO. Why Palliative Care Is an Essential Function of Primary Health Care. World Health Organ. 2018;:1–20. Martín JM, Olano-Lizarraga M, Saracíbar-Razquin M. The experience of family caregivers caring for a terminal patient at home: A research review. Int J Nurs Stud. 2016;64:1–12. Yuan Q, Zhang Y, Samari E, Jeyagurunathan A, Tan GTH, Devi F, et al. 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Psychol Health. 2016;31:1293–310. Sharma N, Chakrabarti S, Grover S. Gender differences in caregiving among family - caregivers of people with mental illnesses. World J Psychiatry. 2016;6:7. Yuan Q, Zhang Y, Samari E, Jeyagurunathan A, Tan GTH, Devi F, et al. The impact of having foreign domestic workers on informal caregivers of persons with dementia – findings from a multi-method research in Singapore. BMC Geriatr. 2022;22:305. Tam W, Koh G, Legido-Quigley H, Ha N, Yap P. I Can’t Do This Alone: a study on foreign domestic workers providing long-term care for frail seniors at home. Int Psychogeriatr. 2017;30:1–9. Study Finds That Family Caregivers of Singapore Elderly Who Rely on Foreign Domestic Workers Fare Better. https://globalhealth.duke.edu/news/study-finds-family-caregivers-singapore-elderly-who-rely-foreign-domestic-workers-fare-better . Accessed 10 Jan 2024. Chong AML, Kwan CW, Chi I, Lou VWQ, Leung AYM. Domestic Helpers as Moderators of Spousal Caregiver Distress. Journals Gerontology: Ser B. 2014;69:966–72. Østbye T, Malhotra R, Malhotra C, Arambepola C, Chan A. Does support from foreign domestic workers decrease the negative impact of informal caregiving? Results from Singapore survey on informal caregiving. J Gerontol B Psychol Sci Soc Sci. 2013;68:609–21. Chau PH, Woo J, Kwok T, Chan F, Hui E, Chan KC. Usage of Community Services and Domestic Helpers Predicted Institutionalization of Elders Having Functional or Cognitive Impairments: A 12-Month Longitudinal Study in Hong Kong. J Am Med Dir Assoc. 2012;13:169–75. Heng J, Fan E, Chan EY. Caregiving Experiences, Coping Strategies and Needs of Foreign Domestic Workers Caring for Older People. J Clin Nurs. 2018;28. Heng JL, Fan E, Chan EY. Caregiving experiences, coping strategies and needs of foreign domestic workers caring for older people. J Clin Nurs. 2019;28:458–68. Ha N, Chong M, Choo R, Tam W, Yap P. Caregiving burden in foreign domestic workers caring for frail older adults in Singapore. Int Psychogeriatr. 2018;30:1–9. Bai X, Kwok TCY, Chan NYT, Ho FKY. Determinants of job satisfaction in foreign domestic helpers caring for people with dementia in Hong Kong. Health Soc Care Community. 2013;21:472–9. Abdi S, Spann A, Borilovic J, De Witte L, Hawley M. Understanding the care and support needs of older people: a scoping review and categorisation using the WHO international classification of functioning, disability and health framework (ICF). BMC Geriatr. 2019;19. Chan CY, De Roza JG, Ding GTY, Koh HL, Lee ES. Psychosocial factors and caregiver burden among primary family caregivers of frail older adults with multimorbidity. BMC Prim Care. 2023;24:36. Chua C, Wu JT, Wong Y, Qu L, Tan Y, Neo P, et al. Caregiving and Its Resulting Effects—The Care Study to Evaluate the Effects of Caregiving on Caregivers of Patients with Advanced Cancer in Singapore. Cancers (Basel). 2016;8:105. Onyeneho CA, Ilesanmi RE. Burden of Care and Perceived Psycho-Social Outcomes among Family Caregivers of Patients Living with Cancer. Asia Pac J Oncol Nurs. 2021;8:330–6. Teixeira L, Borges M, Abreu D, Ribeiro K, Shimano S, Patrizzi L. Caregivers of older adults in palliative care: level of burden and depressive symptoms. Fisioterapia em Movimento. 2022;35. Zubaidi ZSA, Ariffin F, Oun CTC, Katiman D. Caregiver burden among informal caregivers in the largest specialized palliative care unit in Malaysia: a cross sectional study. BMC Palliat Care. 2020;19. Ushikubo M. Nurses’ Perceptions Regarding End-of-life Care for Individuals with Non-cancer Diseases on Non-invasive Positive Pressure Ventilation-dependent: A Qualitative and Descriptive Study. Indian J Palliat Care. 2023;29:1–6. Evans CJ, Bone AE, Yi D, Gao W, Morgan M, Taherzadeh S, et al. Community-based short-term integrated palliative and supportive care reduces symptom distress for older people with chronic noncancer conditions compared with usual care: A randomised controlled single-blind mixed method trial. Int J Nurs Stud. 2021;120:103978. Moens K, Higginson IJ, Harding R. Are there differences in the prevalence of palliative care-related problems in people living with advanced cancer and eight non-cancer conditions? A systematic review. J Pain Symptom Manage. 2014;48:660–77. Pop RS, Mosoiu DV, Puia A, Tint D. Comparison of the Burden Evolution of the Family Caregivers for Patients With Cancer and Nononcological Diseases Who Need Palliative Care: A Prospective Longitudinal Study. Palliat Med Rep. 2023;4:161–8. Nurjono M, Liaw K, Lee A, Vrijhoef HJM, Koh LH, Tan M et al. A Study Protocol of Realist Evaluation of Palliative Home Care Program for Non-Cancer Patients in Singapore. Int J Integr Care. 2022;22. Gérain P, Zech E. Informal Caregiver Burnout? Development of a Theoretical Framework to Understand the Impact of Caregiving. Front Psychol. 2019;10. Czuba K. Understanding Formal Caregivers and Work Stress An Interpretive Description Study. Mercurio-Riley D, Lee GK, Chronister J, Swigar EA. Psychosocial Adjustment of Spousal Caregivers of Patients With Chronic Pain: A Model of Risk and Resistance Factors. Sage Open. 2013;3:2158244013512130. Dill J, Erickson RJ, Diefendorff JM. Motivation in caring labor: Implications for the well-being and employment outcomes of nurses. Soc Sci Med. 2016;167:99–106. Sheldon K. The self-determination theory perspective on positive mental health across cultures. World Psychiatry. 2012;11:101–2. Pot AM, Deeg DJH, van Dyck R, Jonker C. Psychological distress of caregivers: the mediator effect of caregiving appraisal. Patient Educ Couns. 1998;34:43–51. Leung D, Chan H, Chiu P, Lo R, Lee L. Source of Social Support and Caregiving Self-Efficacy on Caregiver Burden and Patient’s Quality of Life: A Path Analysis on Patients with Palliative Care Needs and Their Caregivers. Int J Environ Res Public Health. 2020;17:5457. Contador I, Fernández-Calvo B, Palenzuela D, Miguéis S, Campos F. Prediction of burden in family caregivers of patients with dementia: A perspective of optimism based on generalized expectancies of control. Aging Ment Health. 2012;16:675–82. Pristavec T. The Burden and Benefits of Caregiving: A Latent Class Analysis. Gerontologist. 2019;59:1078–91. Oechsle K, Ullrich A, Marx G, Benze G, Heine J, Dickel L-M, et al. Psychological burden in family caregivers of patients with advanced cancer at initiation of specialist inpatient palliative care. BMC Palliat Care. 2019;18:102. Low J, Bhar S, Chen W. Exploring the relationship between co-worker and supervisor support, self-confidence, coping skills and burnout in residential aged care staff. BMC Nurs. 2022;21. Cross AJ, Garip G, Sheffield D. The psychosocial impact of caregiving in dementia and quality of life: a systematic review and meta-synthesis of qualitative research. Psychol Health. 2018;33:1321–42. Goode WJ. A theory of role strain. Am Sociol Rev. 1960;25:483–96. Cheng S-T, Mak EPM, Lau RWL, Ng NSS, Lam LCW. Voices of Alzheimer Caregivers on Positive Aspects of Caregiving. Gerontologist. 2016;56:451–60. Kantachote K. Micromanagement of foreign domestic workers in Singapore: The influence of state regulations and laws. Heliyon. 2023;9:e17679–17679. Tables Table 1: Caregiving Experience Profiles as described by Pristavec et al Profiles of caregiving experience Description Dissatisfied domestic helper Domestic helper perceives high burden in emotional, interpersonal, and physical domains; but perceives absent benefits in their caregiving journey. Intensive domestic helper Domestic helper perceives high burden in emotional, interpersonal, physical, and social domains. Perceived burden is highest compared to the other profiles. Moderate benefits are likely to be reported across emotional, interpersonal, and cognitive domains. Relationship domestic helper Domestic helper perceives low burden, but burden may be limited to interpersonal (employer/care recipients argue, get on their nerves, strained relationship). She perceives high benefits, but similarly limited to interpersonal and emotional domains (e.g., seeing benefits from their relationships with the employer/care recipient). Benefits perception is at relatively lower levels than Satisfied Caregivers. Balanced domestic helper Domestic helper perceives moderate burden in emotional, interpersonal, and physical domains. However, she does not perceive social burden because caregiving does not appear to interfere with their social activities. She perceives high benefits in emotional, interpersonal, and cognitive domains. Satisfied domestic helper Domestic helper perceives absent burden and perceives high benefits across emotional, interpersonal, and cognitive domains. Table 2. Demographics of FDWs by caregiving profiles Dissatisfied ( n = 0) Intensive ( n = 1) Relationship ( n = 2) Balanced ( n = 9) Satisfied ( n = 3) Age (Mean, SD) - 23 34 *only 1 data 31.33 (4.04) *only 3 data 30 *only 1 data Nationality (%) Filipino - 0 (0.00%) 1 (50.00%) 2 (22.22%) 0 (0.00%) Indonesian - 0 (0.00%) 1 (50.00%) 5 (55.56%) 0 (0.00%) Burmese - 1 (100.00%) 0 (0.00%) 2 (22.22%) 3 (100%) Duration of caregiving [year], (Mean, SD) - 2 4.13(4.42) 3.68(4.89) 3.53(2.16) Table 3 Intensive Relationship Balanced Satisfied Intensity of demands ++++ ++ +++ ++ Adaptability - Regulates demands, coping and cognitive resources and relationships facilitated by prior experience in caregiving/training, and personal coping processes. Coping styles Positive mindset and attitude - - Facilitated adaptability and regulated caregiving demands Facilitated adaptability, regulated caregiving and interpersonal demands Clear personal boundary - Facilitated adaptability, regulated caregiving and interpersonal demands Confiding to others - - Linked to social support Reluctance to share feelings to others Linked to appraisal - Linked to physical wellbeing (fatigue) Linked to positive mindset Personal rest time Similar – entertainment engagement and going out - Similar – entertainment engagement and going out Setting priorities Linked to autonomy but does not regulate demands - Regulates demands - Cognitive processes Appraisal Negative – facilitates the hesitancy to share - Positive – facilitates adaptability, buffering demands and helping to regulate stress - Sympathy Similar across these three profiles – feeling pity towards the patient - Empathy - - Present – facilitated by having close relationships and commitment to care - Locus of control Regulates demands Similar across profiles – facilitated by self-efficacy, close relationship with employer (i.e., empowerment) Self-efficacy Similar across profiles – strongly linked to having caregiver training/education and professional healthcare support Relationship quality Relationship with and care recipient Strained Family-like Close Communication barrier Relationship with employer Friendly (w/ empowerment) Trusting Family-like (w/ empowerment) Friendly (w/ empowerment) Relationship with other parties Varied (depends) Friendly Varied (depends) Friendly Care recipient outcomes Improved quality of life Facilitated by locus of control - - - Caregiver outcomes Physical well-being (fatigue, pain) √ - √ - Psychological well-being (stress) √ - √ √ Burnout √ - - - Improved quality of life - - - Facilitated by positive mindset Perspective: Future choices - - Prefers to do house chores after contract ends - Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 21 Nov, 2025 Read the published version in BMC Palliative Care → Version 1 posted Editor assigned by journal 19 Mar, 2024 Submission checks completed at journal 18 Mar, 2024 First submitted to journal 12 Mar, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4088516","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":281251973,"identity":"b3a8b028-3348-48a6-adcd-0ed2369f688c","order_by":0,"name":"Jing Yi Lee","email":"","orcid":"","institution":"Changi General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jing","middleName":"Yi","lastName":"Lee","suffix":""},{"id":281251974,"identity":"7cd46a71-d26f-47b7-b440-015b1064314e","order_by":1,"name":"Karen Liaw","email":"","orcid":"","institution":"St. Andrew’s Community Hospital","correspondingAuthor":false,"prefix":"","firstName":"Karen","middleName":"","lastName":"Liaw","suffix":""},{"id":281251975,"identity":"1150a8a9-299f-451a-9133-9e0a03ff7429","order_by":2,"name":"Angel Lee","email":"","orcid":"","institution":"St. Andrew’s Community Hospital","correspondingAuthor":false,"prefix":"","firstName":"Angel","middleName":"","lastName":"Lee","suffix":""},{"id":281251976,"identity":"1f7f57c1-a267-48bf-bc92-d70390f124ba","order_by":3,"name":"Hong Choon Oh","email":"","orcid":"","institution":"Changi General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Hong","middleName":"Choon","lastName":"Oh","suffix":""},{"id":281251977,"identity":"9e6e09d3-3d96-4c07-b8fd-4ad4a27e21c7","order_by":4,"name":"Foong Ling Ng","email":"","orcid":"","institution":"Changi General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Foong","middleName":"Ling","lastName":"Ng","suffix":""},{"id":281251978,"identity":"9d7e279e-1277-46d9-b44d-74a76e10b5b4","order_by":5,"name":"Milawaty Nurjono","email":"data:image/png;base64,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","orcid":"","institution":"Changi General Hospital","correspondingAuthor":true,"prefix":"","firstName":"Milawaty","middleName":"","lastName":"Nurjono","suffix":""}],"badges":[],"createdAt":"2024-03-13 02:26:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4088516/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4088516/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12904-025-01936-7","type":"published","date":"2025-11-21T15:58:48+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":53184608,"identity":"7522c338-0334-4ee6-8a6c-58ca2b7d4b62","added_by":"auto","created_at":"2024-03-21 16:06:16","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":386408,"visible":true,"origin":"","legend":"\u003cp\u003eFigure legend not available with this version.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4088516/v1/0a2b458f12218bcf2528e1d6.jpeg"},{"id":96650944,"identity":"4152a21d-b740-4546-af5f-609bc11a61b1","added_by":"auto","created_at":"2025-11-24 16:12:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2313053,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4088516/v1/bb29e679-527c-44b6-b1f9-310b37accf8b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Lived Caregiving Experience of Foreign Domestic Workers (FDWs) for those with Terminal Illness in Singapore: A Secondary Qualitative Data Analysis","fulltext":[{"header":"Background","content":"\u003cp\u003eThe World Health Organization estimated that 56.8\u0026nbsp;million people need palliative care worldwide[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. This number is expected to grow with rapidly aging societies. Thus, to facilitate a sustainable and accessible palliative care system for the patients and their families across the world, WHO proposed for palliative care services to be integrated into the community aside from the mainstream institutions. As patients who are receiving palliative care spend most of their time in the comfort of their homes instead of institutionalized care settings, there is an increasing reliance on family caregivers to provide care at home[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. This imposes significant physical and emotional burden for family caregivers, with ever increasing burden as the patients continue to deteriorate throughout their disease trajectory [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eSimilar to the global trend, demands for palliative care continues to grow in Singapore with emphasis on community-based services. Approximately 8800 persons with terminal illness were reported to be receiving palliative care in 2022 [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. As care delivery to older adults shifts from institutions to the community, families take on the huge responsibility of caregiving to fulfil filial obligations expected of the Asian society[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. In several societies and cultures, women often assumed the role of informal caregivers for elderly and family members with disabilities or chronic medical conditions[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. However, societal changes associated with evolving family structures with higher women employment and decreasing birth rates have posed challenges for family members to assume responsibility as sole caregivers [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In Singapore, it is increasingly common to hire foreign domestic workers (FDW) as alternative caregivers particularly when it comes to providing physical aspects of care [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA FDW is a full-time migrant worker usually hired to perform domestic duties. FDWs are typically females and live together with their employers. Majority of these domestic workers are from neighbouring countries including Indonesia, Philippines, and Myanmar[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. While they are normally tasked to do domestic chores, many are hired to provide round-the-clock physical caregiving to older adults[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. One in every five households employs FDWs in Singapore, and approximately 50% of the employers hired FDWs specifically to care for older adults at home[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eInvolvement of FDWs has been demonstrated to moderate the effects of family caregivers\u0026rsquo; care burden and is beneficial for patients\u0026rsquo; health outcomes. Spousal caregivers with FDW assistance reported to be significantly less distressed as compared to those without[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].Singaporean older adults with FWD assistance experienced positive health outcomes in terms of physical function, memory, behaviors, and mood [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Furthermore, older adults with FDW assistance were found to be 70% less likely to be admitted into institutional care within one year [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. It was also found that the presence FDWs could moderate the depressive symptoms among Singaporean caregivers of patients with dementia through provision of emotional support and practical assistance in daily caregiving tasks [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThough employers of FDWs may have benefited from deployment of FDWs to support caregiving, a local study found that many FDWs lacked physical rest and social support for them to feel recharged. They also reported feeling stressed while caring for older adults with behavioral issues[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The stress of caring for older adults with behavioural issues, juggling between caregiving and domestic chores, is made worse by language barriers and long working hours (i.e., an average of 20 hours per day caring for care recipient), depriving them of rest time[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Compared to Indonesians FDWs, Filipino and Burmese FDWs were found to have experienced significantly higher caregiver burden[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. This is problematic and warrants attention for long term sustainability of FDWs as caregivers for elderly [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Having a good and trusting relationship between FDWs and employers, sufficient social interaction and adequate respite were found to be beneficial for the wellbeing of FDWs [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Additionally, self-efficacy of FDWs, less disruptive behaviour of the elderly, ability to communicate with employers and care recipients and desirable living conditions were known to moderate FWD stress well[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhile existing studies offered insights into the caregiving experiences and challenges faced by the FDWs, they focus on elder care, which is distinct from palliative care. Elder care focuses on addressing the unmet needs of older adults to cope with declining functions due to frailty or chronic conditions [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Conversely, patients requiring palliative care have advanced illnesses that are irreversible, where focus is on quality of life and symptom control. As they deteriorate, care intensity increases, negatively affecting the caregivers\u0026rsquo; physical and mental health and social wellbeing [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan additionalcitationids=\"CR19 CR20 CR21\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCurrently, specialized palliative home care services focus on cancer patients as the prognosis of non-cancer advanced illnesses is less certain [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Nevertheless, non-cancer patients with advanced illness also experience distressing symptoms impacting their quality of life at the end-of-life[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Recognizing this, the palliative care focus has expanded beyond cancer conditions in Singapore [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Caregiver burden was notably higher among those caring for non-cancer patients with advanced illness compared to those caring for cancer patients due to multiple co-morbidities and increased care dependence[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. While caregiver burden is acknowledged, most existing work in this area focuses on supporting family caregivers with little attention on FDWs caring for patients at the end-of life[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. This study aims to explore FDWs\u0026rsquo; caregiving experiences caring for non-cancer patients at the end-of-life in Singapore. Understanding the unique caregiving journey experienced by FDWs can aid the development of services or interventions that can improve the coping abilities of FDWs and the quality of care they provide in the end-of-life context.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n \u003ch2\u003eData Collection\u003c/h2\u003e\n \u003cp\u003eThis study is a qualitative secondary analysis of the realist evaluation of the Violet Programme (ViP), a palliative care initiative for non-cancer patients with advanced illnesses[\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e]. FDWs caring for patients enrolled in the ViP were conveniently sampled, and 15 anonymized transcripts of their interviews were used in this study. Initial contact with employers was made through a text message, inviting FDWs for an interview about their caregiving experiences. Once employers agreed to the participation, a follow-up phone call was made to the employer to further explain the study.. Out of 31 invitations sent, 54.84% of FDWs agreed to participate (n\u0026thinsp;=\u0026thinsp;17), 35.48% declined (n\u0026thinsp;=\u0026thinsp;11), and the rest did not respond. Common reasons for declining included busy caregiving duties and employer discomfort with the interview.\u003c/p\u003e\n \u003cp\u003eSemi-structured interviews were conducted in English (n\u0026thinsp;=\u0026thinsp;3), Bahasa Indonesia (n\u0026thinsp;=\u0026thinsp;6), and Burmese (n\u0026thinsp;=\u0026thinsp;8) between October 2022 and October 2023. Each interview, lasting 30 to 45 minutes, were conducted either at the FDWs\u0026apos; homes or over Zoom teleconferencing, guided by an interview guide. Notes were taken, and interviews were recorded. Interviewers, assigned based on language, had no prior interaction with the FDWs Informed consent was obtained, and interviews were conducted in FDWs\u0026apos; preferred languages. English interviews with the Filipino domestic helpers were facilitated by JY (Female, BPsychSci (Hons)), EH (Male, MA), and CT (Female, MScR); Indonesian interviews were facilitated by MN (Female, MPH); and lastly, Burmese interviews were facilitated by two Burmese-speaking interviewers, NEE (Female, PhD), and MT (Female, PhD)\u003c/p\u003e\n \u003cp\u003eThough some interviews were in non-English languages, All recordings were transcribed into English, including the non-English interviews. Study subject numbers were used for anonymity. Audio recordings and transcripts were securely stored with password protection. Data saturation was discussed among the researchers involved in the interviews.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n \u003ch2\u003eContextual Framework\u003c/h2\u003e\n \u003cp\u003eThe study utilized a framework that combined the Informal Caregiving Integrative Model (ICIM)[\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e], key determinants from the Inherent Tension of Caregiving[\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e], and additional mediators from the Risk and Resistance Model (RRM) of Adjustment [\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e] to guide the analysis of transcripts (refer to Fig.\u0026nbsp;1). This comprehensive framework considers caregiver demands and resources holistically, encompassing physical and psychosocial characteristics, as well as the caregiving environment\u0026apos;s impact on various outcomes. Unlike other models that focus on a two-dimensional process without exploring mediating factors, the ICIM framework delves into the complex and dynamic processes mediating the impact of demands and resources on caregiver strain.\u003c/p\u003e\n \u003cp\u003eFollowing this combined framework, determinants were identified by assessing caregiving demands, considering the duration, intensity, and care recipients\u0026apos; physical and psychological conditions. Various resources within FDWs\u0026apos; self, social, and work environments were recognized to aid in coping with caregiving demands [\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e][\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e]Sociodemographic, psychological factors, and physical state were considered as caregiver characteristics playing a role in stress buffering[\u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e]. Social support, professional support, role recognition, and facility availability were identified as resources within social and work environments [\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e\n \u003cp\u003eTo understand the relationship between resources, demands, and caregiving outcomes, key mediators such as appraisal, relationship quality, coping styles, and intrapersonal variables (self-efficacy and locus of control) were examined[\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e]. Appraisal involves the caregiver\u0026apos;s positive or negative assessment of the caregiving experience, acting as a cognitive process mediating between caregiving stressors and \u003cstrong\u003eoutcomes\u003c/strong\u003e [\u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e]. Relationship quality refers to the closeness between caregiver and patient and can influence caregiving experience and burden Coping strategies and self-efficacy play crucial roles in regulating stress experienced by caregivers [\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e]. Locus of control, representing the extent of control individuals feel over life events, is associated with lower vulnerability to stress among caregiver [\u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e]. Finally, the study assessed caregiver outcomes, including impacts on physical and psychological wellbeing, such as psychological distress, positive emotions, anxiety, and quality of life, along with adverse care recipient outcomes.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n \u003ch2\u003eData Analysis\u003c/h2\u003e\n \u003cp\u003eNVivo was used to code the data deductively and inductively by JYL, MN \u0026amp; KL. Framework analysis of the transcripts was guided by the combined framework. New themes that emerged from the analysis were also included into the framework inductively. After coding the transcripts, memos were written for each transcript. In the memo, the care recipient\u0026rsquo;s characteristics, and a summary of the helper\u0026rsquo;s caregiving experience (i.e., the challenges and resources the helper had, and the caregiving outcomes) were described. Then, based on the written memos, the transcripts were categorized based on the profiles of caregiving experienced identified by Pristavec et al [\u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e].According to the magnitude of burden and benefits perceived by the caregiver in various domains (i.e., emotional, interpersonal, cognitive, physical, and social; FDWs experienced was categorized into five types of caregiving experience. Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e shows the five different domestic helpers\u0026rsquo; caregiving profiles adapted from Pristavec et al.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n \u003ch2\u003eStudy Participants by Caregiving Experience Profile\u003c/h2\u003e\n \u003cp\u003eBased on profiling characteristics described by Pristavec, one FDW was profiled as having an intensive caregiving experience, while the experiences of 2 FDWs were classified as relationship. Nine FDWs had a balanced caregiving experience and 3 FDWs described their experience as satisfied. It is noteworthy that none of the interviewed FDWs reported having a dissatisfied experience. Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e provides a detailed overview of the demographics of FDWs based on their caregiving experience profiles.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n \u003ch2\u003eCaregiving Experience\u003c/h2\u003e\n \u003cp\u003eThis study revealed unique caregiving experiences, varied level of demands and available resources. Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e summarises intensity of demands, coping styles, intrapersonal processes, quality of relationship, outcomes and their relationship as experienced and described by FDWs.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\n \u003ch2\u003eIntensive Caregiving Experience\u003c/h2\u003e\n \u003cp\u003eThe demands from family members and the care recipients exerted significant negative impact on the physical and psychological wellbeing of the FDW, primarily manifested through strained relationships. The continual requests from the care recipient\u0026apos;s family members, pulling the FDW away from her care recipient, caused initial \u003cem\u003econfusion, physical discomfort and sense of helplessness\u003c/em\u003e due to overwhelming demands. Additionally, \u003cem\u003eviolent tendencies from both the care recipients and their family members strained the relationship\u003c/em\u003e, causing distress for the FDW. Overall, these demands had an adverse effect on the FDW\u0026apos;s physical and psychological health.\u003c/p\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;\u003c/em\u003e \u003cstrong\u003eShe (recipient\u0026rsquo;s wife) would hit me\u003c/strong\u003e... \u003cem\u003eOf course, my feelings was\u003c/em\u003e \u003cstrong\u003ehurt\u003c/strong\u003e.. \u003cem\u003eWhen I\u0026rsquo;m doing something, she would bug me to do something else\u003c/em\u003e.... \u003cstrong\u003eI got stressed. I considered jumping down\u003c/strong\u003e... \u003cem\u003e(C024)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;I was\u003c/em\u003e \u003cstrong\u003estressed because I had to be wary of him\u003c/strong\u003e \u003cem\u003e(care recipient)... When I was around him, I would start\u003c/em\u003e \u003cstrong\u003esweating\u003c/strong\u003e... \u003cem\u003eHe was someone else\u0026rsquo;s father so when he hit me, I didn\u0026rsquo;t dare to be angry.\u0026quot; (C024)\u003c/em\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003cp\u003eIn order to cope with the distress, the FDW sought normalization of her experiences through her social support system and exerted a locus of control to moderate her Quality of Life (QoL). Seeking advice from friends who had similar caregiving experiences helped her address specific issues related to care. Over time, the FDW gained confidence to stand firm on her beliefs about appropriate care, even in the face of conflicting opinions from the care recipient\u0026apos;s family.\u003c/p\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;\u003c/em\u003e \u003cstrong\u003eSometimes, when I have something I want to know, I asked my friends (for their experience).\u003c/strong\u003e \u003cem\u003eThat other time, when there was a lot of phlegm, I asked if they had the same experience. When he shouts, I also asked my friend if her patient shout. She said \u0026ldquo;People with dementia are like this too. They shout too. \u0026quot; (C024)\u003c/em\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e\n \u003ch2\u003eRelationship Caregiving Experience Profile\u003c/h2\u003e\n \u003cp\u003eFDWs\u0026apos; experiences were characterized by trusting and family-like relationships with both the care recipient and employer. Generally, they maintained open communication and had a sense of agency in their caregiving role. Viewing care recipients as family, FDWs expressed sympathy, leading to minimal perceived burden. They valued dedicated rest time/days. Despite facing significant demands and cultivating family-like relationships, FDWs remained unaffected personally. This was attributed to their skill in establishing a clear personal boundary, which acted as a buffer against emotional and demanding aspects. This boundary also facilitated their adaptation to caregiving situations, with challenges seen as inherent to their job and not affecting them personally.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;The difficult part was at nighttime. If he screamed, couldn\u0026rsquo;t sleep, or when he was in pain\u0026hellip;\u003c/em\u003e \u003cstrong\u003ethat one was the most difficult for me\u003c/strong\u003e. \u003cem\u003eDifficult because\u003c/em\u003e \u003cstrong\u003eI pitied him\u0026hellip; But it\u0026rsquo;s part of the job, what to do.\u003c/strong\u003e\u003cem\u003e\u0026quot; (C035)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;I mean\u003c/em\u003e, \u003cstrong\u003ejust consider it as common thing\u003c/strong\u003e... \u003cem\u003eThis is the risk of looking after an elderly... Because\u003c/em\u003e \u003cstrong\u003eI\u0026rsquo;m a carefree person\u003c/strong\u003e. \u003cstrong\u003eI think that it is normal for my boss to scold me, I don\u0026rsquo;t care\u003c/strong\u003e. \u003cem\u003eThat\u0026rsquo;s why if someone is not mentally prepared, more than being \u0026ldquo;crazy\u0026rdquo;, (I suggest not to) work overseas...\u003c/em\u003e \u003cstrong\u003eI enjoy working here very much, if not I would have been gone back\u003c/strong\u003e.\u003cem\u003e\u0026quot; (C035)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;Since I was in Singapore, I\u0026rsquo;ve changed a few employers, and\u003c/em\u003e \u003cstrong\u003ethis one is the nicest one\u003c/strong\u003e... \u003cstrong\u003eA lot of relaxing time\u003c/strong\u003e. \u003cem\u003e(\u0026hellip;) (It is) law from MOM... since last January, helpers from any country\u003c/em\u003e \u003cstrong\u003ehave to be given off-day at least once or more in a month\u003c/strong\u003e, \u003cem\u003ethe main thing is that there\u0026rsquo;s off-day given.\u003c/em\u003e \u003cstrong\u003ePreviously, don\u0026rsquo;t expect any of that. It was like crazy\u003c/strong\u003e, \u003cem\u003ereally\u0026hellip; (I) didn\u0026rsquo;t get any off-day.\u0026quot; (C035)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eThe ability to adapt increased FDWs\u0026apos; sense of control and self-efficacy, allowing them to optimize caregiving tasks and handle emergencies calmly. Healthcare professional-provided education and training further improved FDWs\u0026apos; self-efficacy, instilling confidence in employers who trusted them with caregiving responsibilities.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;(He\u0026rsquo;s) very heavy... But\u003c/em\u003e \u003cstrong\u003eI already have the trick, so now I don\u0026rsquo;t need to lift him\u003c/strong\u003e. \u003cem\u003e(\u0026hellip;) I had an idea to push upwards his legs. Well, just like that. Because when he lies down, he often slips down, so his legs must be lifted. The bed is the same as the one in the hospital, it can be positioned vertical and horizontal. So, I put it in horizontal position then I pushed upwards his legs. Well, only like that.\u003c/em\u003e \u003cstrong\u003eSo, it\u0026rsquo;s easy, I don\u0026rsquo;t need help (anymore)\u003c/strong\u003e. \u003cem\u003e(C035)\u003c/em\u003e\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003eBalanced Profile\u003c/h2\u003e\n \u003cp\u003eFDWs with a balanced experience reported moderate caregiving burden and high benefits. Compared to those with intensive or relationship-based experiences, they faced fewer intensive demands from other family members. Despite managing household chores alongside caregiving, their ability to prioritize and manage time proved beneficial. Autonomy granted by employers empowered them to control their priorities. These FDWs utilized a range of resources, including social support and family-like relationships, both within and outside the workplace. Training and consistent support from healthcare professionals facilitated their assimilation into caregiving duties, contributing to adaptability and resilience.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Maybe sometimes at 4pm\u003c/em\u003e \u003cstrong\u003ewhen it\u0026rsquo;s time to rest, then I rest\u003c/strong\u003e. \u003cem\u003eIf it\u0026rsquo;s not 4pm yet and the work is not done\u003c/em\u003e, \u003cstrong\u003eeven if I\u0026rsquo;m tired, I will continue to work\u003c/strong\u003e. \u003cem\u003eI manage my own schedule\u0026quot; (C036)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;Usually, I share with my friends.\u003c/em\u003e \u003cstrong\u003eWe share about work\u003c/strong\u003e, \u003cem\u003eor anything, like if we have\u003c/em\u003e \u003cstrong\u003efamily or friend problems\u003c/strong\u003e, \u003cem\u003ewe share and discuss them\u0026rdquo;. (C038)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;\u003c/em\u003e \u003cstrong\u003eI talk to my employer\u003c/strong\u003e. \u003cem\u003eSince we don\u0026rsquo;t have other people around us, so\u003c/em\u003e \u003cstrong\u003eshe chose to trust to me, I chose to trust her\u003c/strong\u003e. \u003cstrong\u003eI can share to her\u003c/strong\u003e. \u003cstrong\u003eShe\u0026rsquo;s open to me, I\u0026rsquo;m open to her\u003c/strong\u003e. \u003cem\u003eThat\u0026rsquo;s our relationship as an employer and a worker.\u0026quot; (C021)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;...\u003c/em\u003e \u003cstrong\u003eI learned from the nurse and practiced it.\u003c/strong\u003e \u003cem\u003eThen now to me...\u003c/em\u003e \u003cstrong\u003etaking care of (name of care receipient) is like normal already\u003c/strong\u003e \u003cem\u003ebecause\u003c/em\u003e \u003cstrong\u003eI am used to it\u003c/strong\u003e...\u003cem\u003e\u0026quot; (C032)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003ePositive appraisal and adaptability were notable in handling stress. FDWs viewed caregiving challenges as manageable, adapting to their duties with a positive mindset. Despite exhaustion, they remained emotionally composed and continued to perform well. Positive beliefs about themselves and their employers boosted confidence in difficult situations. As they came into terms that that every job has its stressors and challenges, FDWs learnt to enjoy the caregiving process despite difficulties faced\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;\u003c/em\u003e \u003cstrong\u003eMany things change\u003c/strong\u003e \u003cem\u003ewhen taking care of the grandmother\u003c/em\u003e, \u003cstrong\u003ebut despite this, I feel that it\u0026rsquo;s manageable\u003c/strong\u003e. \u003cem\u003eWhatever happens to the grandmother\u003c/em\u003e, \u003cstrong\u003eI no longer get emotional and I just try my best\u003c/strong\u003e.\u003cem\u003e\u0026quot; (C021)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;Well, having a job (of course)\u003c/em\u003e \u003cstrong\u003esometimes I feel tired\u003c/strong\u003e\u003cem\u003e\u0026hellip; (I\u0026rsquo;m a) human.\u003c/em\u003e \u003cstrong\u003eBut I\u0026rsquo;m used to it\u003c/strong\u003e\u003cem\u003e\u0026hellip;\u003c/em\u003e \u003cstrong\u003eMy job is just like this\u003c/strong\u003e.\u003cem\u003e\u0026quot; (C022)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;No\u003c/em\u003e, \u003cstrong\u003ewe can\u0026rsquo;t feel stressed\u003c/strong\u003e. \u003cstrong\u003eMust learn to enjoy it\u003c/strong\u003e. \u003cem\u003eWorking comes with some level of stress, not always comfortable but\u003c/em\u003e \u003cstrong\u003ejust have to go through it\u003c/strong\u003e. \u003cem\u003eCan\u0026rsquo;t say it is heavy. \u0026quot; (C018)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;\u003c/em\u003e \u003cstrong\u003eYou need to be brave if you are not doing anything wrong\u003c/strong\u003e. \u003cem\u003eYou don\u0026rsquo;t need to be scared. You need to be confident. If you make mistakes you have to admit your mistakes and apologize for them. Now whatever they are going to say, I will respond as best I can.\u003c/em\u003e \u003cstrong\u003eIf they like me, they will keep me, if not they will dismiss me. That\u0026rsquo;s all on my mind\u003c/strong\u003e.\u003cem\u003e\u0026quot; (C027)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eEmpathy was a distinct theme for those with a balanced experience, stemming from close relationships. Interestingly, Relationship profile individuals showed sympathy but not empathy, possibly due to a \u003cstrong\u003eclear personal boundary\u003c/strong\u003e. FDWs expressed empathy for care recipients and understanding for employers facing challenges. Despite perceiving caregiving as manageable, FDWs acknowledged the risks and uncertainties associated with caring for the elderly. Many were unsure about continuing as caregivers after their contracts ended.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;I love (X) so much. I care for her for so long already... Every time I see her, I cry because of her bed sores. I know it\u0026rsquo;s painful... every time I clean ah... Then I tell her, \u0026ldquo;So sorry Ma(ma), I know, I know it\u0026rsquo;s painful. I know how you feel.\u0026rdquo; (C032)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;\u0026hellip; My boss is kind-hearted\u0026hellip; He knows what I have to deal with\u0026hellip;because Ah Gong is quite difficult to handle. (My employer) does not demand me to do other chores (\u0026hellip;) (He has) never gone out, poor him\u0026hellip; He really (cares) about Ah Gong, his father. (\u0026hellip;) If Sir seemed stress out, I would just keep quiet, \u0026quot; (C034)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;After my contract ends, maybe 50:50, I would probably\u003c/em\u003e \u003cstrong\u003eprefer to do domestic chores\u003c/strong\u003e... \u003cem\u003eThere is a\u003c/em\u003e \u003cstrong\u003ehigher risk taking care of elderly\u003c/strong\u003e, \u003cem\u003ewe never know when he/she will fall\u003c/em\u003e, \u003cstrong\u003ewe don\u0026rsquo;t know what is ahead\u003c/strong\u003e. \u003cem\u003eThere is a definitely a higher risk.\u0026quot; (C018)\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003eSatisfied Profile\u003c/h2\u003e\n \u003cp\u003eFDWs exhibiting satisfied profile showed similarities with those in Balanced profile concerning demands, resources, and coping strategies. Those with satisfied profile exhibited notable adaptability, a positive outlook, a well-defined personal boundary and self-efficacy, all of which prove advantageous in managing stressors in the caregiving environment and positively impacting the QoL of FDWs. Similar to other profiles, caregiving demands arising from conditions and characteristics of care recipients are present, often causing distress. Nevertheless, positive mindset and attitude of FDWs seemed to assist them in establishing a clear personal boundary, which, in turn, proves beneficial in mitigating experienced stress.\u003c/p\u003e\n \u003cp\u003eDespite facing caregiving challenges, FDWs expressed contentment in being able to support their families back home. On the flip side, an excessively positive mindset sometimes leads to a reluctance to share personal feelings with others, even when social support is available. Some FDWs believed that stress would naturally dissipate without discussing it with others. Enhancing the self-efficacy of FDWs with the Satisfied profile was cited as achievable through caregiver training, education, employer instructions, and guidance from healthcare professionals. Additionally, FDWs proactively seek help from professionals when needed.\u003c/p\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;\u003c/em\u003e \u003cstrong\u003eI don\u0026rsquo;t feel stressed\u003c/strong\u003e \u003cem\u003ebecause\u003c/em\u003e \u003cstrong\u003eI choose to live happily\u003c/strong\u003e\u003cem\u003e\u0026hellip; Since the\u003c/em\u003e \u003cstrong\u003egrandmother is having dementia\u003c/strong\u003e \u003cem\u003eand bedridden. There are moments when\u003c/em\u003e \u003cstrong\u003eshe pinches\u003c/strong\u003e \u003cem\u003eand stuff like that. But I can\u0026rsquo;t do anything about it.\u003c/em\u003e \u003cstrong\u003eI have to be understanding\u003c/strong\u003e.\u003cem\u003e\u0026quot; (C030)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;I don\u0026rsquo;t feel upset\u0026hellip;\u003c/em\u003e \u003cstrong\u003eThere\u0026rsquo;s nothing to feel upset about\u003c/strong\u003e. \u003cem\u003e(\u0026hellip;) I send my salary back to my family. My parents don\u0026rsquo;t cause me any stress either. Since there\u0026rsquo;s no reason to.\u003c/em\u003e \u003cstrong\u003eWe\u0026rsquo;re not rich but there\u0026rsquo;s nothing (to feel stressed about)\u003c/strong\u003e.\u003cem\u003e\u0026quot; (C030)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;\u003c/em\u003e \u003cstrong\u003eWhen I\u0026rsquo;m stressed, I don\u0026rsquo;t talk\u003c/strong\u003e. \u003cem\u003eI don\u0026rsquo;t want to talk. (\u0026hellip;)\u003c/em\u003e \u003cstrong\u003eI have people I can call, (but) I don\u0026rsquo;t want to talk\u003c/strong\u003e... \u003cem\u003e[I: If you don\u0026rsquo;t talk\u003c/em\u003e, \u003cstrong\u003edoes it go away? The stress.] Bit by bit\u003c/strong\u003e.\u003cem\u003e\u0026quot; (C026)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;\u003c/em\u003e \u003cstrong\u003eI have less stress because of nurses\u0026rsquo; instructions and I have more confidence\u003c/strong\u003e. \u003cem\u003eI really like them. I don\u0026rsquo;t have to be afraid of them and\u003c/em\u003e \u003cstrong\u003eI can tell them everything and they are really friendly\u003c/strong\u003e.\u003cem\u003e\u0026quot; (C031)\u003c/em\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003cp\u003eMoreover, the motivation to provide care also plays a role in the adaptability of FDWs with the Satisfied profile, a factor not observed in other profiles. For instance, one FDW shared that her enthusiasm for caring for the elderly stems not from passion but from her religious beliefs.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;\u003c/em\u003e \u003cstrong\u003eI\u0026rsquo;m used to\u003c/strong\u003e \u003cem\u003elooking after them. In Taunggyi, we believe that we\u003c/em\u003e \u003cstrong\u003ecan receive blessing from taking care of elderly\u0026hellip; from Christian religion belief\u003c/strong\u003e..\u003cem\u003e\u0026quot; (C030)\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003e This study, a secondary analysis of the ViP realist evaluation explored FDWs' caregiving experiences for non-cancer patients at the end-of-life in Singapore. FDWs were categorized into Intensive, Relationship, Balanced, or Satisfied profiles based on their caregiving experiences. Common caregiver outcomes like psychological stress and physical fatigue were observed across Intensive, Balanced, and Satisfied profiles, aligned with existing evidence on caregivers of palliative patients facing high distress and exhaustion over time[\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDistinctly, burnout emerged as an outcome unique to the Intensive profile, where caregiving demands were not well-regulated by coping skills and cognitive processes, supporting prior research associating maladaptive coping skills with burnout [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Our findings concurred with the ICIM framework by G\u0026eacute;rain and Zech [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], suggesting that caregiver burnout occurs when negative impacts outweigh positive ones. In the Intensive profile, caregiving demands, stemming from a violent-tempered care recipient and family, strained relationships, causing extreme stress and even suicidal ideation.\u003c/p\u003e \u003cp\u003eInterestingly, despite challenging care and interpersonal demands akin to the Intensive profile, those with Relationship profile reported no adverse caregiving outcomes. This could be attributed to the clear personal boundaries observed in this profile, acting as a buffer against incoming interpersonal demands. This aligns with findings from Cross et al.[\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e], emphasizing that caregivers who maintain an emotional and psychological distance cope better with caregiving demands.\u003c/p\u003e \u003cp\u003eThe Balanced profile, unlike the Intensive and Relationship profiles, did not report interpersonal demands from care recipients' family members. Leveraging on extensive resources and coping styles, FDWs in the Balanced profile effectively managed and regulated caregiving demands. This supports the role strain theory, suggesting that effective utilization of existing resources helps individuals cope with role demands[\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSimilarly, the Satisfied profile, free from interpersonal demands, showed a higher quality of life due to effective adaptation skills, clear personal boundaries, and a positive mindset. This aligns with previous findings that suggested that caregivers who adopt positive reframing and actively change their mindset experience lower stress and find more positive meaning in their caregiving journey [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn summary, each profile demonstrated unique caregiving experiences, emphasizing the importance of individual coping strategies, clear personal boundaries, and positive mindsets in mitigating the impact of caregiving demands on FDWs' wellbeing.\u003c/p\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and Limitations of the Study\u003c/h2\u003e \u003cp\u003eThe strengths of this study lie in the efficient use of existing data from the realist evaluation of the Violet Programme, a non-cancer home palliative programme. and inclusion of diverse samples of FDWs from different backgrounds (i.e., Filipinos, Indonesians, and Burmese) that made up 3 largest groups of FDWs in Singapore. Furthermore, our interrater reliability was within acceptable range and the analysis was guided by a comprehensive framework.\u003c/p\u003e \u003cp\u003eHowever, there is inherently selection bias as FDWs recruited had participated willingly and with the permission of their employers and very likely had positive caregiving experiences. Only one FDW was profiled as an Intensive domestic helper in this study. It is possible that the experience shared may not be representative of this profile as other determinants or processes may not have been captured in the single interview. Although a comprehensive framework was used to analyse the data, individual contributing models were not developed specifically for paid caregivers in the home setting. ICIM and RRM were developed for family caregivers while Inherent Tension of Caregiving framework was developed for formal caregivers working in a healthcare system.\u003c/p\u003e \u003cp\u003eLastly, the current study did not assess power differential which may have the potential to influence the employer-FDW relationship and the FDWs\u0026rsquo; sense of agency. Singapore has adopted a sponsorship system that is similar to the Kafala system for migrant workers coming to Singapore to work, requiring the employers to pay a sum of \u003cspan\u003e$\u003c/span\u003e5000 as security bond[\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. This influences the employers to exercise their power over the FDWs through strict disciplining and micromanagement in at least one of aspects of the FDW\u0026rsquo;s life (daily routine, social circle, or movement) to prevent forfeiting the bond. Some examples of strict disciplining include having rules and regulation, planning their work schedules, controlling whom they can socialise with, supervise their mobility during their day off. Out of fear of losing their jobs or being deported, FDWs tend to be compliant and try to maintain good relationships with their employers despite being mistreated, perpetuating a sense of helplessness among these FDWs. This could potentially affect their overall mental health due to the suppression of negative feelings. Therefore, future research can consider examining or assessing power differentials when exploring the relationship between the FDWs and their employers and its relationship with FDWs\u0026rsquo; locus of control and wellbeing.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eImplications and Recommendations for Future Research\u003c/h2\u003e \u003cp\u003e To the best of our knowledge, this is the first study integrating ICIM, the Inherent Tension of Caregiving and RRM frameworks to explore the caregiving experiences of FDWs in Singapore. The study has also provided an insight into the various types of demands, resources, mediating factors, caregiving outcomes, and the relationship between these components for the different caregiver profiles.\u003c/p\u003e \u003cp\u003eInsights into the different caregiver profiles, identifying resources and mediating factors of FDWs and types of demands, can be used both as an intervention to build resilience while fostering effective coping skills and as a preventative measure by guiding FDWs to act early on anticipated potential challenges to ease their caregiving journey.\u003c/p\u003e \u003cp\u003eFuture research can concentrate on developing support programs for caregivers, specifically targeting foreign domestic workers (FDWs) caring for palliative care recipients. Meanwhile, insights from this study can inform the design of services or interventions aimed at enhancing FDWs' coping abilities which may in turn influence the quality of care they deliver in end-of-life situations. An essential aspect of such research would involve investigating the impact of these services or interventions on caregiver burden and the quality of care provided to recipients.\u003c/p\u003e \u003cp\u003eAdditionally, future research should explore power differentials between FDWs and their employers, examining how these variations influence FDWs' locus of control and overall wellbeing. Given the potential selection bias during recruitment, where only one FDW represented the Intensive profile, future studies seeking to replicate this research using the combined framework may consider expanding to direct recruitment of FDWs through all palliative services in Singapore. This approach may enhance the chances of recruiting FDWs with Intensive profiles and possibly Dissatisfied profiles as well. To take it one step further, it may also be beneficial to recruit and interview FDW and employer dyads to obtain comprehensive views of employer-employee relationship and how it affect caregiving burden.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study provides valuable insights into the caregiving experiences of FDWs caring for non-cancer patients with an advanced illness. It enhances understanding of FDWs' demands and resources, highlighting the role of coping abilities and cognitive resources, such as self-efficacy and locus of control, in regulating demands and buffering stress. Those who had Balanced and Satisfied experiences demonstrated diverse coping styles and resources, enabling effective management of caregiving demands and stress regulation. In contrast, those with Intensive experience faced high demands with limited coping resources, potentially leading to negative caregiver outcomes. The study identified the importance of strong personal boundaries in the Relationship profile, creating emotional distance and facilitating better adaptation to caregiving situations.\u003c/p\u003e \u003cp\u003eThese findings offer insights for the development of services or interventions aimed at enhancing FDWs' ability to cope with stress. Future research could focus on the creation of caregiver support programs specifically tailored for FDWs caring for care recipients with advanced illnesses.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe SingHealth Centralised Institutional Review Board (CIRB) reviewed our study protocol (CIRB Ref: 2020/3039) and determined that the application does not require further ethical deliberation because this is a programme evaluation project. Study team members signed a confidentiality agreement to guarantee the privacy of all information. To maintain confidentiality of the research participants, analysis was conducted only on de-identified data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData is available upon request from corresponding author\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eKL, AL, KLH are directly involved in the provision of care for individuals enrolled in ViP. All authors declared no financial competing interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by 10th Singapore Millenia Foundation (SMF) grant awarded by Temasek Foundation, Singapore. Funders have no role in the design of the study and writing the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLJY and MN conceptualized and designed this study. LJY, MN and KL analysed data. LJY andMN drafted the first and final version of the manuscript. All authors read, provided suggestions for revision and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors wish to thank the participants who shared their experiences, Nang Ei Ei Khaing and Mon Hnin Tun for helping to conduct interviews in Burmese language.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWHO. Why Palliative Care Is an Essential Function of Primary Health Care. World Health Organ. 2018;:1\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMart\u0026iacute;n JM, Olano-Lizarraga M, Sarac\u0026iacute;bar-Razquin M. The experience of family caregivers caring for a terminal patient at home: A research review. Int J Nurs Stud. 2016;64:1\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYuan Q, Zhang Y, Samari E, Jeyagurunathan A, Tan GTH, Devi F, et al. 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Palliat Med Rep. 2023;4:161\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNurjono M, Liaw K, Lee A, Vrijhoef HJM, Koh LH, Tan M et al. A Study Protocol of Realist Evaluation of Palliative Home Care Program for Non-Cancer Patients in Singapore. Int J Integr Care. 2022;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eG\u0026eacute;rain P, Zech E. Informal Caregiver Burnout? Development of a Theoretical Framework to Understand the Impact of Caregiving. Front Psychol. 2019;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCzuba K. Understanding Formal Caregivers and Work Stress An Interpretive Description Study.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMercurio-Riley D, Lee GK, Chronister J, Swigar EA. Psychosocial Adjustment of Spousal Caregivers of Patients With Chronic Pain: A Model of Risk and Resistance Factors. Sage Open. 2013;3:2158244013512130.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDill J, Erickson RJ, Diefendorff JM. Motivation in caring labor: Implications for the well-being and employment outcomes of nurses. Soc Sci Med. 2016;167:99\u0026ndash;106.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSheldon K. The self-determination theory perspective on positive mental health across cultures. World Psychiatry. 2012;11:101\u0026ndash;2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePot AM, Deeg DJH, van Dyck R, Jonker C. Psychological distress of caregivers: the mediator effect of caregiving appraisal. Patient Educ Couns. 1998;34:43\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLeung D, Chan H, Chiu P, Lo R, Lee L. Source of Social Support and Caregiving Self-Efficacy on Caregiver Burden and Patient\u0026rsquo;s Quality of Life: A Path Analysis on Patients with Palliative Care Needs and Their Caregivers. Int J Environ Res Public Health. 2020;17:5457.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eContador I, Fern\u0026aacute;ndez-Calvo B, Palenzuela D, Migu\u0026eacute;is S, Campos F. Prediction of burden in family caregivers of patients with dementia: A perspective of optimism based on generalized expectancies of control. Aging Ment Health. 2012;16:675\u0026ndash;82.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePristavec T. The Burden and Benefits of Caregiving: A Latent Class Analysis. Gerontologist. 2019;59:1078\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOechsle K, Ullrich A, Marx G, Benze G, Heine J, Dickel L-M, et al. Psychological burden in family caregivers of patients with advanced cancer at initiation of specialist inpatient palliative care. BMC Palliat Care. 2019;18:102.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLow J, Bhar S, Chen W. Exploring the relationship between co-worker and supervisor support, self-confidence, coping skills and burnout in residential aged care staff. BMC Nurs. 2022;21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCross AJ, Garip G, Sheffield D. The psychosocial impact of caregiving in dementia and quality of life: a systematic review and meta-synthesis of qualitative research. Psychol Health. 2018;33:1321\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGoode WJ. A theory of role strain. Am Sociol Rev. 1960;25:483\u0026ndash;96.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCheng S-T, Mak EPM, Lau RWL, Ng NSS, Lam LCW. Voices of Alzheimer Caregivers on Positive Aspects of Caregiving. Gerontologist. 2016;56:451\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKantachote K. Micromanagement of foreign domestic workers in Singapore: The influence of state regulations and laws. Heliyon. 2023;9:e17679\u0026ndash;17679.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTable 1: Caregiving Experience Profiles as described by Pristavec et al\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.77870216306157%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eProfiles of caregiving experience\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"67.22129783693843%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDescription\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.77870216306157%\" valign=\"top\"\u003e\n \u003cp\u003eDissatisfied domestic helper\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"67.22129783693843%\" valign=\"top\"\u003e\n \u003cp\u003eDomestic helper perceives high burden in emotional, interpersonal, and physical domains; but perceives absent benefits in their caregiving journey.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.77870216306157%\" valign=\"top\"\u003e\n \u003cp\u003eIntensive domestic helper\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"67.22129783693843%\" valign=\"top\"\u003e\n \u003cp\u003eDomestic helper perceives high burden in emotional, interpersonal, physical, and social domains. Perceived burden is highest compared to the other profiles. Moderate benefits are likely to be reported across emotional, interpersonal, and cognitive domains.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.77870216306157%\" valign=\"top\"\u003e\n \u003cp\u003eRelationship domestic helper\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"67.22129783693843%\" valign=\"top\"\u003e\n \u003cp\u003eDomestic helper perceives low burden, but burden may be limited to interpersonal (employer/care recipients argue, get on their nerves, strained relationship). She perceives high benefits, but similarly limited to interpersonal and emotional domains (e.g., seeing benefits from their relationships with the employer/care recipient). Benefits perception is at relatively lower levels than Satisfied Caregivers.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.77870216306157%\" valign=\"top\"\u003e\n \u003cp\u003eBalanced domestic helper\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"67.22129783693843%\" valign=\"top\"\u003e\n \u003cp\u003eDomestic helper perceives moderate burden in emotional, interpersonal, and physical domains. However, she does not perceive social burden because caregiving does not appear to interfere with their social activities. She perceives high benefits in emotional, interpersonal, and cognitive domains.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.77870216306157%\" valign=\"top\"\u003e\n \u003cp\u003eSatisfied domestic helper\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"67.22129783693843%\" valign=\"top\"\u003e\n \u003cp\u003eDomestic helper perceives absent burden and perceives high benefits across emotional, interpersonal, and cognitive domains.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 2. Demographics of FDWs by caregiving profiles\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"602\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.5%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"15.666666666666666%\" valign=\"top\"\u003e\n \u003cp\u003eDissatisfied\u003c/p\u003e\n \u003cp\u003e(\u003cem\u003en\u003c/em\u003e = 0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.166666666666666%\" valign=\"top\"\u003e\n \u003cp\u003eIntensive\u003c/p\u003e\n \u003cp\u003e(\u003cem\u003en\u003c/em\u003e = 1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.666666666666668%\" valign=\"top\"\u003e\n \u003cp\u003eRelationship\u003c/p\u003e\n \u003cp\u003e(\u003cem\u003en\u003c/em\u003e = 2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.666666666666666%\" valign=\"top\"\u003e\n \u003cp\u003eBalanced\u003c/p\u003e\n \u003cp\u003e(\u003cem\u003en\u003c/em\u003e = 9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.333333333333334%\" valign=\"top\"\u003e\n \u003cp\u003eSatisfied\u003c/p\u003e\n \u003cp\u003e(\u003cem\u003en\u003c/em\u003e = 3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.5%\" valign=\"top\"\u003e\n \u003cp\u003eAge (Mean, SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.666666666666666%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.166666666666666%\" valign=\"top\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.666666666666668%\" valign=\"top\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003cp\u003e*only 1\u0026nbsp;data\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.666666666666666%\" valign=\"top\"\u003e\n \u003cp\u003e31.33 (4.04)\u003c/p\u003e\n \u003cp\u003e*only 3 data\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.333333333333334%\" valign=\"top\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003cp\u003e*only 1\u0026nbsp;data\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.5%\" valign=\"top\"\u003e\n \u003cp\u003eNationality (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.666666666666666%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"14.166666666666666%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"17.666666666666668%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"14.666666666666666%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"14.333333333333334%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.5%\" valign=\"top\"\u003e\n \u003cp\u003eFilipino\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.666666666666666%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.166666666666666%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0.00%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.666666666666668%\" valign=\"top\"\u003e\n \u003cp\u003e1 (50.00%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.666666666666666%\" valign=\"top\"\u003e\n \u003cp\u003e2 (22.22%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.333333333333334%\" valign=\"top\"\u003e\n \u003cp\u003e0\u0026nbsp;(0.00%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.5%\" valign=\"top\"\u003e\n \u003cp\u003eIndonesian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.666666666666666%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.166666666666666%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0.00%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.666666666666668%\" valign=\"top\"\u003e\n \u003cp\u003e1\u0026nbsp;(50.00%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.666666666666666%\" valign=\"top\"\u003e\n \u003cp\u003e5 (55.56%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.333333333333334%\" valign=\"top\"\u003e\n \u003cp\u003e0\u0026nbsp;(0.00%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.5%\" valign=\"top\"\u003e\n \u003cp\u003eBurmese\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.666666666666666%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.166666666666666%\" valign=\"top\"\u003e\n \u003cp\u003e1 (100.00%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.666666666666668%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0.00%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.666666666666666%\" valign=\"top\"\u003e\n \u003cp\u003e2\u0026nbsp;(22.22%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.333333333333334%\" valign=\"top\"\u003e\n \u003cp\u003e3 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.5%\" valign=\"top\"\u003e\n \u003cp\u003eDuration of caregiving [year],\u0026nbsp;(Mean, SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.666666666666666%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.166666666666666%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.666666666666668%\" valign=\"top\"\u003e\n \u003cp\u003e4.13(4.42)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.666666666666666%\" valign=\"top\"\u003e\n \u003cp\u003e3.68(4.89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.333333333333334%\" valign=\"top\"\u003e\n \u003cp\u003e3.53(2.16)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 3\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"614\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.70731707317073%\" colspan=\"2\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"17.5609756097561%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eIntensive\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.447154471544716%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eRelationship\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.5609756097561%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eBalanced\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.723577235772357%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSatisfied\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.70731707317073%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eIntensity of demands\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.5609756097561%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e++++\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.447154471544716%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e++\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.5609756097561%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e+++\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.723577235772357%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e++\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.70731707317073%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdaptability\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.5609756097561%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50.73170731707317%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eRegulates demands, coping and cognitive resources and relationships facilitated by prior experience in caregiving/training, and personal coping processes.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.097560975609756%\" rowspan=\"6\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCoping styles\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.609756097560975%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePositive mindset and attitude\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.5609756097561%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.447154471544716%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.5609756097561%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eFacilitated adaptability and regulated caregiving\u0026nbsp;\u003cbr\u003e\u0026nbsp;demands\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.723577235772357%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eFacilitated adaptability, regulated caregiving and interpersonal demands\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"32.10702341137124%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eClear personal boundary\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"36.12040133779264%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.77257525083612%\" valign=\"top\"\u003e\n \u003cp\u003eFacilitated adaptability, regulated caregiving and interpersonal demands\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.6046511627907%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eConfiding to others\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.930232558139537%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.410852713178294%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"42.054263565891475%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eLinked to social support\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.6046511627907%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eReluctance to share feelings to others\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.930232558139537%\" valign=\"top\"\u003e\n \u003cp\u003eLinked to appraisal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.410852713178294%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.930232558139537%\" valign=\"top\"\u003e\n \u003cp\u003eLinked to physical wellbeing (fatigue)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.124031007751938%\" valign=\"top\"\u003e\n \u003cp\u003eLinked to positive mindset\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.6046511627907%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePersonal rest time\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.930232558139537%\" valign=\"top\"\u003e\n \u003cp\u003eSimilar \u0026ndash; entertainment engagement and going out\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.410852713178294%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"42.054263565891475%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eSimilar \u0026ndash; entertainment engagement and going out\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.6046511627907%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSetting priorities\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.930232558139537%\" valign=\"top\"\u003e\n \u003cp\u003eLinked to autonomy but does not regulate demands\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.410852713178294%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.930232558139537%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cbr\u003e\u0026nbsp;Regulates demands\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.124031007751938%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.097560975609756%\" rowspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCognitive processes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.609756097560975%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAppraisal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.5609756097561%\" valign=\"top\"\u003e\n \u003cp\u003eNegative \u0026ndash; facilitates the hesitancy to share\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.447154471544716%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.5609756097561%\" valign=\"top\"\u003e\n \u003cp\u003ePositive \u0026ndash;\u0026nbsp;facilitates adaptability, buffering demands and helping to regulate stress\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.723577235772357%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.640776699029125%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSympathy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"60.19417475728155%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eSimilar across these three profiles \u0026ndash; feeling pity towards the patient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.16504854368932%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.6046511627907%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eEmpathy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.930232558139537%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.410852713178294%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.930232558139537%\" valign=\"top\"\u003e\n \u003cp\u003ePresent \u0026ndash; facilitated by having close relationships and commitment to care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.124031007751938%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.6046511627907%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eLocus of control\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.930232558139537%\" valign=\"top\"\u003e\n \u003cp\u003eRegulates demands\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"60.46511627906977%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eSimilar across profiles \u0026ndash; facilitated by self-efficacy, close relationship with employer (i.e., empowerment)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.640776699029125%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSelf-efficacy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"81.35922330097087%\" colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003eSimilar across profiles \u0026ndash; strongly linked to having caregiver training/education and professional healthcare support\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.097560975609756%\" rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eRelationship quality\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.609756097560975%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eRelationship with and care recipient\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.5609756097561%\" valign=\"top\"\u003e\n \u003cp\u003eStrained\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.447154471544716%\" valign=\"top\"\u003e\n \u003cp\u003eFamily-like\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.5609756097561%\" valign=\"top\"\u003e\n \u003cp\u003eClose\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.723577235772357%\" valign=\"top\"\u003e\n \u003cp\u003eCommunication barrier\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.6046511627907%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eRelationship with employer\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.930232558139537%\" valign=\"top\"\u003e\n \u003cp\u003eFriendly (w/ empowerment)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.410852713178294%\" valign=\"top\"\u003e\n \u003cp\u003eTrusting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.930232558139537%\" valign=\"top\"\u003e\n \u003cp\u003eFamily-like (w/ empowerment)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.124031007751938%\" valign=\"top\"\u003e\n \u003cp\u003eFriendly (w/ empowerment)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.6046511627907%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eRelationship with other parties\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.930232558139537%\" valign=\"top\"\u003e\n \u003cp\u003eVaried (depends)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.410852713178294%\" valign=\"top\"\u003e\n \u003cp\u003eFriendly\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.930232558139537%\" valign=\"top\"\u003e\n \u003cp\u003eVaried (depends)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.124031007751938%\" valign=\"top\"\u003e\n \u003cp\u003eFriendly\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.097560975609756%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCare recipient\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eoutcomes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.609756097560975%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eImproved quality of life\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.5609756097561%\" valign=\"top\"\u003e\n \u003cp\u003eFacilitated by locus of control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.447154471544716%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.5609756097561%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.723577235772357%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.097560975609756%\" rowspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCaregiver outcomes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.609756097560975%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePhysical well-being (fatigue, pain)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.5609756097561%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026radic;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.447154471544716%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.5609756097561%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026radic;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.723577235772357%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.6046511627907%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePsychological well-being (stress)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.930232558139537%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026radic;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.410852713178294%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.930232558139537%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026radic;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.124031007751938%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026radic;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.6046511627907%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eBurnout\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.930232558139537%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026radic;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.410852713178294%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.930232558139537%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.124031007751938%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.6046511627907%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eImproved quality of life\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.930232558139537%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.410852713178294%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.930232558139537%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.124031007751938%\" valign=\"top\"\u003e\n \u003cp\u003eFacilitated by positive mindset\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.6046511627907%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePerspective: Future choices\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.930232558139537%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.410852713178294%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.930232558139537%\" valign=\"top\"\u003e\n \u003cp\u003ePrefers to do house chores after contract ends\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.124031007751938%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-palliative-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pcar","sideBox":"Learn more about [BMC Palliative Care](http://bmcpalliatcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pcar/default.aspx","title":"BMC Palliative Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Foreign domestic workers, caregiving, end-of-life, qualitative, palliative care","lastPublishedDoi":"10.21203/rs.3.rs-4088516/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4088516/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eDue to societal changes associated with evolving family structures in Singapore, the reliance on foreign domestic workers (FDWs) for elderly caregiving is increasing. While involving FDWs in caregiving has proven effective in moderating family caregivers' burden and benefiting patients' health outcomes, their caregiving experiences of FDWs are not always ideal. Existing studies on FDWs' caregiving experiences have mainly focused on elder care. However, palliative care, being more specialised and intense, poses unique challenges. Given high caregiver burden experienced in caring for non-cancer patients with terminal illnesses, this study aims to explore FDWs' experiences in caring for non-cancer patients at their end of lives in Singapore.\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e \u003cp\u003eA qualitative secondary analysis was conducted on 15 transcripts from a study related to a non-cancer palliative care program. The analysis used an adapted model combining the Informal Caregiving Integrative Model (ICIM), Inherent Tension of Caregiving Model, and Risk and Resistance Model (RRM) of Adjustment model. FDWs' experiences were categorized into five caregiving profiles based on perceived burden and benefits characterised by Pristavec.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eBased on caregiver experience profiling characteristics by Pristavec, one was classified under \u0026ldquo;intensive domestic helper\u0026rdquo;, while two others were classified as \u0026ldquo;relationship\u0026rdquo;. Nine had a \u0026ldquo;balanced\u0026rdquo; profile and three others were classified as \u0026ldquo;satisfied\u0026rdquo; FDWs. Common caregiver outcomes like psychological stress and physical fatigue were observed across different profiles. Each profile highlighted unique caregiving experiences, emphasizing the significance of individual coping strategies, clear personal boundaries, and positive mindsets in mitigating the impact of caregiving demands on FDWs' wellbeing.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThis study provides valuable insights into FDWs' caregiving experiences of non-cancer patients with terminal illnesses. The findings suggest the need for tailored services or interventions to enhance FDWs' coping abilities. Future research could focus on developing caregiver support programs specifically designed for FDWs caring for individuals with terminal illnesses.\u003c/p\u003e","manuscriptTitle":"Lived Caregiving Experience of Foreign Domestic Workers (FDWs) for those with Terminal Illness in Singapore: A Secondary Qualitative Data Analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-21 16:05:59","doi":"10.21203/rs.3.rs-4088516/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorAssigned","content":"","date":"2024-03-19T07:56:14+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-03-18T13:19:10+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Palliative Care","date":"2024-03-13T02:23:28+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-palliative-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pcar","sideBox":"Learn more about [BMC Palliative Care](http://bmcpalliatcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pcar/default.aspx","title":"BMC Palliative Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0eae64c6-aec5-432e-b3a4-9f5452af81ca","owner":[],"postedDate":"March 21st, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-11-24T16:09:52+00:00","versionOfRecord":{"articleIdentity":"rs-4088516","link":"https://doi.org/10.1186/s12904-025-01936-7","journal":{"identity":"bmc-palliative-care","isVorOnly":false,"title":"BMC Palliative Care"},"publishedOn":"2025-11-21 15:58:48","publishedOnDateReadable":"November 21st, 2025"},"versionCreatedAt":"2024-03-21 16:05:59","video":"","vorDoi":"10.1186/s12904-025-01936-7","vorDoiUrl":"https://doi.org/10.1186/s12904-025-01936-7","workflowStages":[]},"version":"v1","identity":"rs-4088516","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4088516","identity":"rs-4088516","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}