This study was granted approval by the institutional review board at the University of Washington (STUDY00009534). Participants in this study gave their verbal or written consent for their involvement. All the data we collected from participants was labeled with a unique study identification number and not the participants’ name or any other information that could identify participants. The contact information of participants was kept in a password-protected file and computer. All data collected from participants were kept confidential and accessible only by our study team. We did not use participants’ names in reports of study findings, REDCap (Research Electronic Data Capture; Vanderbilt University) surveys, or audio recordings of interviews. Instead, we labeled everything with this study’s identification number. We destroyed data that identified participants when we finished recruitment.

Figure 1 [16] illustrates our approach to the cultural adaptation of the STAR-C web-based training modules within the context of the Discover, Design + Build, Test framework. In our previous study, we conducted a qualitative study to gather information about needed cultural adaptations to the web-based training modules for Latino caregivers (the “Discover” phase) [14]. We then used the findings from the qualitative study to brainstorm ideas for preliminary cultural adaptations (the “Design” phase). In this study, we developed low-fidelity prototypes of the culturally adapted STAR-C web-based training modules and tested the prototypes with Latino caregivers (the “Build” phase).

We carried out semistructured qualitative interviews in Washington State with 15 Latino caregivers of people living with dementia who spoke Spanish or English. Caregivers were considered eligible if they self-identified as Hispanic or Latino, were aged 21 years or older, were a child, spouse, or partner, or close friend of someone diagnosed with dementia, lived with the diagnosed individual or within a 5-mile radius, and provided a minimum of 8 hours of weekly care. Our recruitment strategy involved 3 approaches. Initially, we identified potential participants through the electronic health record system at University of Washington Medicine. Additionally, we circulated flyers in both Spanish and English across various locations, including a UW Medicine specialty clinic, a primary care practice-based research network, the Alzheimer Association Washington State Chapter, and local tiendas in Latino communities. Lastly, we used media platforms like local Spanish and English radio stations and newspapers to discuss the impact of dementia on the Latino population and publicize this study.

A member of this study’s team screened for eligibility the individuals who showed interest in joining this study and arranged interviews for those who met the eligibility requirements. Caregivers received a compensation of US $45 for taking part in this study.

In the STAR-C Virtual Training and Follow-up intervention, caregivers receive 1 web-based training module per week for a period of 6-8 weeks. Textbox 1 describes the topics of the web-based training modules. The core components of the intervention include dementia education, strategies for effective communication, Activators-Behaviors-Consequences (ABC) problem-solving, pleasant events, and caregiver support.

We created 3 low-fidelity prototypes of the culturally adapted STAR-C web-based training modules in both English and Spanish for testing among study participants. The low-fidelity prototypes were in the form of videos of recorded presentations with images, text, and voice-over. The videos featured short excerpts from various STAR-C web-based training modules. The first video consisted of educating Latino family caregivers on dementia and problem-solving using the ABC approach. This video explained the STAR-C program, dementia, its causes, walked through each step of the ABC approach for problem-solving in dementia, and concluded with a caregiving example of the ABC approach. The second video featured some modifications, including the addition of information about dementia stages, common behaviors exhibited by people living with dementia, and importance of self-care. We also enhanced the visual aesthetics and design of the lessons to make them more visually appealing and added humor. In the third video, we maintained the core content from the previous versions but incorporated interactive images and examples to increase engagement and interactivity. Figures 2 and 3 provide an example of the low-fidelity prototypes.

Study participants received the low-fidelity prototypes (ie, videos) via text message, WhatsApp Messenger, or email, depending on their preference, and were asked to watch the video at home on their own time prior to the scheduled qualitative interview. A bilingual or bicultural staff member trained in qualitative research techniques conducted interviews from January to August 2022. These interviews were held virtually, and they took place in either Spanish or English based on the participant’s choice. Each interview spanned 30 to 60 minutes in length and was audio recorded and transcribed verbatim by a professional service.

The staff member used semistructured interview guides. For the first 5 interviews, the interview guide asked general questions pertaining to likes and dislikes, queries about the program’s dementia content, examination of the ABC problem-solving strategy, assessment of the provided caregiving example, and a series of questions delving into video accessibility, design, and duration. For the subsequent 5 interviews, we revised the interview guide by adding questions focused on participant preferences, such as whether they preferred watching or listening to the video content, their favored method of receiving the videos, and their ideal video length. Finally, after another subsequent 5 interviews, we revised the interview guide again by incorporating additional inquiries centered around evaluating the images within the videos and improving viewer engagement.

We analyzed the transcripts in their original languages, either Spanish or English, using the qualitative data analysis techniques described by Saldaña [17]. We began by reading through all the transcripts and writing analytic memos to reflect on the content—noting insights, thoughts, and emerging patterns. We then applied deductive codes from a pre-established codebook to the interview transcripts (“protocol coding” [17]). The pre-established codebook was used in a prior qualitative study of STAR-C and was composed of codes representing components of the cultural treatment adaptation framework [14,18]. As an illustration, the codebook contained codes like “Materials and Semantics,” “Cultural Examples and Themes,” and “Therapeutic Framework” to capture cultural adaptations that were needed in the delivery of the intervention. In the next step, we applied inductive second-order codes to capture the details of participants’ feedback (“subcoding” [17]). For example, one of the inductive subcodes under “Materials and Semantics” was “Different BPSD examples” since multiple participants had suggested including in the intervention materials problem-solving examples for different BPSD. Afterward, we grouped the deductive and inductive codes into a smaller number of candidate themes that represented opportunities to improve the cultural adaptations of STAR-C (“pattern coding” [17]). We examined the interrelationship across and within the candidate themes and made refinements to ensure that excerpts within themes cohered and that each final theme was distinct from the others. Finally, we developed a statement to describe each of themes, which are presented in the following section. To manage this coding process, we used Dedoose (version 8.1.8; SocioCultural Research Consultants, LLC).

Table 1 provides the characteristics of Latino caregivers who participated in this study and a description of their caregiving situation. The average age of caregivers was 48.9 (SD 11.1) years, 13 (87%) identified as women, 7 (47%) were the adult children of the people living with dementia, and 12 (80%) provided 35 hours or more of care per week.

The qualitative analysis revealed adaptations that were needed in the (1) delivery of the STAR-C virtual intervention, (2) “dementia education” core component, (3) “ABC Problem-Solving” core component, and (4) “caregiver support strategies” core component. The sections below describe the need for these adaptations from the perspective of caregivers, as well as the changes that were made to the STAR-C web-based training modules in response to caregiver feedback.

Latino caregivers emphasized the importance of seeking assistance and support to alleviate the burdens of caregiving. Many highlighted the value of reaching out to family members or friends when feeling fatigued or overwhelmed, recognizing the need for rest and self-care. A Spanish-speaking caregiver described how the STAR-C program needed to encourage caregivers to take care of their own health and well-being. The caregiver said:

Participants collectively acknowledged the importance of supporting caregivers themselves, not just the care recipients. They emphasized the need for caregivers to take regular breaks and engage in activities that promote mental well-being. For example, a Spanish-speaking caregiver stated:

This comment highlights the importance of recognizing the caregiver’s mental and emotional health as it directly impacts their ability to provide effective care. In response to caregivers’ feedback, we integrated content throughout the various modules (not just the last module) about the importance of caregiver health and well-being. The content emphasizes the need for caregiver rest, support, and self-care, so that caregivers can be better equipped to provide optimal care to their loved ones.

This study’s objective was to test and refine the preliminary cultural adaptations to the STAR-C web-based training modules for Latino caregivers. Our qualitative analysis identified key adaptations required in (1) the delivery of STAR-C, (2) the “dementia education” core component, (3) the “ABC problem-solving” core component, and (4) the “caregiver support strategies” core component. Caregivers expressed a desire for STAR-C videos to be accessible through audio-only formats, and they highlighted the importance of making the videos available on various platforms, including those commonly used in their community. They also emphasized the need for the videos to be easily shareable with family members to enhance communication and caregiving practices. In response, we tailored the narration script to facilitate audio-only access and optimized video formats for widespread accessibility. Moreover, caregivers requested comprehensive education on dementia prevention and understanding the disease’s stages, advocating for expanded content within the “Dementia Education” core component. This resulted in additional content aimed at enhancing caregivers’ understanding of dementia progression and challenges. To further foster empathy, caregivers suggested highlighting the importance of viewing the world from the perspective of individuals living with dementia. Consequently, we incorporated elements emphasizing empathy into the program. Caregivers also sought to incorporate strategies for reducing the risk of developing dementia, leading to the inclusion of content addressing preventive measures. Within the “ABC Problem-Solving” core component, caregivers expressed a need to simplify the “ABC” acronym in Spanish and expand problem-solving examples. We responded by simplifying the acronym and incorporating more problem-solving scenarios to cater to diverse challenges. Additionally, caregivers desired realistic problem-solving examples featuring real interactions between caregivers and persons with dementia. Lastly, caregivers emphasized the importance of caregiver well-being, prompting us to underscore self-care, rest, and seeking support to ensure caregivers’ mental and emotional health is prioritized. These adaptations collectively refine the STAR-C web-based training modules for Latino caregivers and provide a culturally tailored, evidence-based intervention to support dementia caregiving in this community.

Our study identified several key adaptations needed to enhance the cultural relevance and effectiveness of the STAR-C web-based training modules for Latino caregivers. Notably, caregivers expressed a strong desire for videos to be accessible through audio-only formats, a finding that aligns with a study conducted among Hispanic participants from Spain [19], where a similar preference for audio accessibility was observed. The importance of making videos available on various platforms, as highlighted in our study, is also consistent with research where caregivers expressed openness to learning caregiving information from diverse sources and settings [20].

The cultural adaptations identified in this study to enhance the relevance and effectiveness of the STAR-C web-based training modules for Latino caregivers may have applicability to caregivers from other racial and ethnic minority groups as well. For example, collectivist and familism values tend to be strong in Asian cultures that emphasize family and community interdependence [21,22]. As such, making the STAR-C videos easily shareable with family members to facilitate communication and coordinated caregiving practices may also resonate with Asian caregivers.

Furthermore, our study aligns with prior research by emphasizing the need for comprehensive education on dementia prevention and understanding the disease’s stages [20,23]. In a study conducted among various ethnic groups, including Hispanic or Latinos, African Americans, and Asian Americans, it was found that a common lack of knowledge about the early signs of Alzheimer disease existed [23]. This knowledge gap underscores the importance for comprehensive dementia education, a point that resonates with our study’s findings. Additionally, another study similarly stressed the importance of greater education regarding the diversity and spectrum of dementia-related symptoms [20].

Caregivers also strongly advocated for simplifying the ABC acronym in Spanish, adding more problem-solving examples, and demonstrating problem-solving with real individuals. These adaptations align with a study assessing Spanish language health information via videos [24], which found that participants preferred videos featuring increased actor participation, as it enhanced their ability to relate the content to real-life situations.

Our study has limitations worth noting. First, the low-fidelity prototypes of the STAR-C web-based training modules (ie, videos) we used in this study lacked the realistic appearance and comprehensiveness of the full virtual STAR-C program. This may have limited our ability to obtain accurate perceptions and feedback, as caregivers might not have fully understood or engaged with the low-fidelity prototypes as they would have with a higher-fidelity version of the full STAR-C program. As a next step in this research, we plan to pilot test high-fidelity prototypes of the STAR-C web-based training modules. Second, caregivers’ feedback about STAR-C is influenced by their personal preferences and experiences, which may result in us inadvertently prioritizing features or solutions that appeal to the specific subgroup of Latino caregivers participating in this study rather than broader populations of Latino caregivers. We tried to address this limitation by interviewing a diverse group of caregivers including both male and female caregivers (most Latino caregivers tend to be women), caregivers of different ages and family roles (ie, spouse vs child caregiver), and caregivers with different educational backgrounds.

This study addresses a critical gap in the field of dementia caregiving, particularly for Latino caregivers who face unique challenges and disparities in health outcomes. The culturally adapted version of the virtual STAR-C program represents a significant step forward in bridging this gap. Our findings highlight the importance of tailoring interventions to meet the specific needs of Latino caregivers, considering cultural values and beliefs that shape caregiving interactions and experiences. The key adaptations we needed to make to the STAR-C web-based training modules, including accessibility improvements, expanded dementia education, enhanced problem-solving strategies, and a focus on caregiver well-being, underscore the importance of cultural adaptation of evidence-based caregiver interventions for Latino families. While further research is needed to assess the efficacy of these adaptations, we believe that the virtual STAR-C intervention has the potential to improve health care services and health outcomes for Latino people living with dementia and their family caregivers. By addressing the pressing need for culturally adapted evidence-based interventions, we aim to promote more favorable experiences with the intervention and ultimately reduce the health disparities associated with dementia caregiving in this community. This work contributes to the broader mission of advancing health care services for older adults by using technological innovations, serving the interest of health professionals and family caregivers of older adults.