Vignette for the collection of standardised qualitative data on the ability of Long Term Care (LTC) systems to meet the needs of older persons across countries
Aspects in orange represent substitutable elements that allow tailoring of vignettes to different countries, cultures and settings. Descriptions used here are tailored to Singapore.
A common surname of ethnic majority persons in the country
Life expectancy of women at 60 in the country minus 15
The most common living arrangement for this profile in the country
The most common housing type for the median income group in the country
The most common state / town / neighbourhood for the median income group in the country
Country for data collection
The most common form of financial support for older persons. In Singapore, it is a financial transfer from family members under the Many Helping Hands policy. Another example is the state providing pension / social security
Public health financing schemes which are available to the median income group in the country
Stage 1
I’d now like to tell you the story of Mrs Tan, an older woman who is starting to have declines in her physical and cognitive functions. Then I will ask you some questions. Please answer these questions based on Mrs Tan’s perspectives and your understanding of the country’s long-term care system.
Mrs Tan (1) is 72 years old (2). She lives with family (3) in a 2-bedroom flat (4) she owns, located in Hougang (5), Singapore (6). Her husband passed away five years ago. She has some savings and financial support from her children (7). She has been living in the same home for about 40 years and has good relationships in the community. She can manage her daily tasks independently and attend social activities with her friends and family. She has high blood pressure and pain in the joints in the past two years. Currently, she is unable to walk for long, requiring a walking stick for longer distances. She is also getting more forgetful, taking more time to recall important events and frequently misplacing her valuables. Mrs Tan (1) is feeling anxious about losing her ability to manage her tasks on her own. She is eager to maintain her current lifestyle.
Stage 2
OK, now we fast forward to see what happens to Mrs Tan in another three years. The same questions from Stage 1 apply here.
Mrs Tan’s (1) health has become worse. She has fallen three times at home in the last one year. It has become much more difficult to get up from the chair, bed and toilet. She is still able to walk around but moves slowly and feels unsteady. She frequently has to be reminded to take her meals and showers. She also forgets important personal details like her own address and sometimes gets the days wrong. She has since stopped going out for her daily tasks and social activities. Mrs Tan’s (1) children (7) are uncertain about her care arrangement and worried about the cost. Thus far, they have been relying on CPF schemes (8) for health expenses. Mrs Tan (1) prefers to stay home and does not wish to burden her children (7).
Stage 3
I will now tell you the last part of the story. Again, the same questions apply.
It has been eight years and Mrs Tan’s (1) functions and memory have further deteriorated. She needs help in most of her daily activities including bathing, toileting, and dressing. She is starting to have difficulty eating as she constantly needs reminders on when to eat and she spills food and drinks. She is also occasionally quarrelsome and agitated in the evenings and refuses to bathe. Her children (7) are stressed out and in need of more help.
Interview Topic Guide
The same questions and prompts are applied across three stages of the vignette, with stage-specific prompts in italics.
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What care, if any, is available to support Mrs Tan’s needs? This care could include formal services and informal care (family and friends, community).
Stage 1 / 2: What community- based services can Mrs Tan tap into?
Stage 3: What care might support Mrs Tan to still live at home? What residential institutional care is available to Mrs Tan?
What care encourages prevention, reablement or rehabilitation?
Stage 1: What care can Mrs Tan get for her declining mobility /memory issues?
Stage 2: What care can Mrs Tan get to prevent falls or other adverse events?
Stage 3: What end-of-life and/or palliative care services are available and how are these provided? In what ways would care address nutritional needs and continence needs?
What assistance, aids, devices, home modification, technologies or transport might Mrs Tan receive?
What education and support programs are available for Mrs Tan or her caregivers?
Stage 2 / 3: What support or respite care is available and how is this provided?
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How would Mrs Tan and/or her caregivers become aware of the LTC options available to meet her needs?
What is the process to request LTC services that meet Mrs Tan’s needs?
How is Mrs Tan’s eligibility for the service assessed?
Stage 1 / 2 / 3: If Mrs Tan’s needs change, can this service accommodate her changing needs or does she need to reapply for a new service?
How long would Mrs Tan wait for the services she needs?
How would these services differ across urban/rural areas?
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How would Mrs Tan be assessed for whether her needs are met by services?
Stage 1 / 2: How are changes in Mrs Tan’s care needs monitored?
Stage 3: What are the indicators that Mrs Tan might need institutional care?
In what ways are the care strategies Mrs Tan would receive person-centred and goal-oriented? o Stage 3: How is Mrs Tan’s quality of life assessed?
How are Mrs Tan’s needs for mental, emotional, social and spiritual well-being taken care of?
Stage 1 / 2: How will advanced care planning be discussed and documented? Who will introduce this discussion? How is guardianship determined?
What opportunities are there to increase Mrs Tan’s social interactions?
What is the level of family involvement in Mrs Tan’s LTC and the decisions about her care? How does the family communicate with the care providers?
What support would Mrs Tan’s caregiver receive? Is there emotional support for caregivers?
How is Mrs Tan’s care integrated and coordinated with medical and health care?
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What guidelines/systems are in place to prevent and detect the possibility of Mrs Tan experiencing elder abuse?
Stage 1 / 2: What assessments would be made of the home environment?
Stage 3: What assessments would be made of the institutional environment? Is it safe? Is it dementia-friendly? When and how are chemical and/or physical restraints used and are there guidelines for their use?
RECOMMENDATIONS ON HOW TO USE THE VIGNETTE TOOL
Sampling of key informants
Purposively sample experienced long-term care (LTC) experts who have BOTH the experience overseeing ground operations AND system perspective to the LTC sector in the country.
Select key informants representing different settings in the LTC sector: community care, hospital care, residential care, policy making, etc. Prioritise those who have worked across / interacted with various organisations and services.
Format of data collection
Consider using a combination of semi-structured in-depth interviews (IDIs) and focus group discussions (FGDs).
IDIs allow participants more time to reflect more deeply. FGDs stimulate discussion between participants with different disciplinary backgrounds.
Interviewers may first conduct a few exploratory IDIs to map out Mrs Tan’s journey in a diagram, then conduct 1-2 confirmatory FGDs by inviting comments to the diagram.
Interviewers
Have two interviewers. One for scribing and one for leading the interview.
Interviewers should have some basic understanding about health and social care in the country.
Both interviewers to familiarise themselves with the interview guide.
Time management
Aim to keep the interview between 1.5-2 hours.
For more effective time management, prioritise the conversation based on participant’s area of expertise.
Allow participant(s) to take as much time as they need for the first questions (on care needs and available types of care), before asking other questions.
During the interview
For ice breaking, interviewers to self-introduce, explain the purpose of the interview and how the data will be used. Also invite participant(s) to self-introduce and briefly introduce the organisation(s) they are representing, if any.
Show the vignette story stage-by-stage, one stage to a page.
Let the participant(s) have the vignette on paper, for easy reference when answering questions.
Record the interview if possible, and with consent.
Create a relaxed and reflective atmosphere to the interview, by encouraging participant(s) to take time to reflect on what would happen (rather than should) happen to Mrs Tan.
During the interview (continued)
If participant(s) represent(s) certain organisation(s), clarify that the answers should be “based on the Mrs Tan’s perspectives and your understanding of the country’s LTC system” (as per instruction for Stage 1), not based on organisational perspective.
When “should” answers are given, gently bring the conversation back to “would”, and acknowledge the gap.
If the participant(s) ask for more information for the story, lead them into thinking about possible scenarios (“if this happens...”) and the ensuing consequences (“then that will most likely happen...”).
Discuss real-life examples when they provide insight into LTC context. Bring the conversation back to the case of Mrs Tan when sufficient understanding has been established.
If participant(s) is/are going on a roll critiquing the system, acknowledge their frustration then clarify what most commonly does / does not happen in a case like Mrs Tan’s.