Experiences of family caregivers of people with dementia from a Muslim migrant background in high-income countries: a systematic review and meta-synthesis

Abstract Background The cultural and religious beliefs and values of family caregivers of people with dementia have a profound impact on the use of dementia care services in high-income countries. Yet, little is known about how caregivers of people with dementia from a Muslim migrant background in high-income countries perceive their caregiving journey. Aim To synthesise findings from rigorous qualitative studies on the experiences of family caregivers of people with dementia from a Muslim migrant background in high-income countries. Methods Meta-ethnography of qualitative studies was applied to address the aim. Five databases including MEDLINE, CINHAL, PsycINFO, Web of Science and Scopus were searched. Inclusion criteria were qualitative or mixed study design studies on family caregivers of people with dementia from a Muslim migrant background in a home care setting in high-income countries. Studies were excluded if they used a quantitative research design, were not written in English and were not original studies. Findings In total 17 articles met the inclusion criteria and were included in the study. Meta-synthesis of the data revealed three themes from the life course intersectionality perspective: caregiving as both positive and negative experiences; factors affecting caregivers’ experiences; and coping strategies used by caregivers. Conclusion Caregivers of people with dementia from a Muslim migrant background living in high-income countries have both positive and negative caregiving experiences. However, dementia care services were not tailored to address their care needs and expectations arising from their religious and cultural beliefs.


Introduction
Improved living conditions and medical advances contribute to longevity (United Nations, 2021).However, the increased ageing population is related to growth in the population living with dementia as older age is a risk factor for dementia although dementia is not a normal part of ageing.(World Health organisations, 2021).Currently there are more than 55 million people living with dementia worldwide and the total number of people with dementia (PwD) is projected to increase to 78 million by 2030 and 139 million by 2050 (World Health Organization, 2021).High-income countries show a larger proportion of older people and PwD in their populations compared to low-and middle-income countries but the majority of PwD (or 60%) live in low-and middle-income countries (World Health Organization, 2021).Moreover in high-income countries, the number of people living with dementia from migrant backgrounds, including those from a Muslim background, has increased due to migration since the Second World War (Kenning et al., 2017).
Dementia is a syndrome caused by a variety of diseases and injuries that affects memory and cognitive functions leading to self-care decline and changed behaviour (World Health Organization, 2021).Most PwD require a high level of assistance and are cared for by family caregivers.In 2019, family caregivers of PwD spent an average of 5 h per day on care activities (World Health Organization, 2021).People from minority and migrant backgrounds living in high-income countries have higher tendencies of providing care for family members with dementia at home and are less likely to use formal care services compared to the mainstream culture (Czapka & Sagbakken, 2020;Guo et al., 2019).Such situations are usually attributed to the influence of socio-cultural factors on caregivers from minority and migrant backgrounds, for example collectivism culture or filial piety culture (Kenning et al., 2017).
Studies also revealed that caregivers from a Muslim background, including those from Arab Emirates, are strongly influenced by their religious holy text (Qur'an), which is believed to be a revelation from God dictated to Prophet Muhammad.Sunnah, the Islamic Law, includes sayings, habits, customs and practices of Prophet Muhammad and constitutes a model for Muslims to follow (Daher-Nashif et al., 2021;Hossain & Khan, 2019;Sayegh & Knight, 2013).The Holy texts have ideologies and mandates for Muslims to be dutiful and respectful to their elderly, including parents, which every Muslim must follow (Daher-Nashif et al., 2021;Hossain & Mughal, 2021).Therefore, in high-income countries using formal care services for PwD may be associated with stigma in the Muslim community.
Studies in countries where Muslims are the majority (i.e.Middle East/Arab Emirates, South Asia and Africa) also revealed dementia is perceived as mental illness and a punishment or test from God (Daher-Nashif et al., 2021;Zolezzi et al., 2017).Such beliefs contribute to dementia-associated public stigma (external stigma) and self-stigma (internalised stigma) in caregivers by which they prefer to deal with dementia care privately within a family or seek private advice from Imams of Mosques, or local Islamic scholars (Hamdan, 2007).They are less likely to seek help from other sources (Nguyen & Li, 2020).Therefore, caregivers from a Muslim background in high-income countries are highly susceptible to a higher level of stress, distress and burden compared to other non-Muslim minority migrant groups.
Studies also revealed that caregivers from a migrant background, including Muslims, are engaged in different processes to adapt to the culture of the host country (or acculturation) by which they are willing to use dementia care services if they are culturally and religiously appropriate (Kenning et al., 2017).The underutilisation of dementia care and aged care services by migrant ethnic groups living in high-income countries has been attributed to the lack of ethno-specific care services that meet their care needs, preferences and expectations (Johl et al., 2016;NAESs & Moen, 2015).Considering that Muslim people are strongly influenced by their religious holy texts and Sunnah (Bastos et al., 2018;Daher-Nashif et al., 2021), dementia care services also need to address their unique care needs and preferences.
There are an increasing number of studies focusing on caregivers of PwD from ethnic minority groups, including caregivers from a Muslim migrant background in high-income countries (Mazaheri et al., 2011;Shanley et al., 2012).However, systematic review that has synthesised the findings specific to caregivers from a Muslim migrant background is scarce.The aim of the current systematic review and meta-synthesis is therefore to gather, synthesise, and describe current knowledge about the experiences of family caregivers of PwD from a Muslim migrant background in high-income countries.
To understand the multifaceted nature of family caregiving of Muslim migrants in high-income countries, this study used the intersectional life-course perspective framework (Elder, 1994;Ferrer et al., 2017).This framework brings together lifecourse intersectionality through four dimensions: (1) identifying key events (i.e.dementia care) and their timing; (2) examining locally and globally linked lives; (3) exploring multifaceted factors and how they shape identities; and (4) assessing how systems of domination shape the lives, agency and resistance among caregivers from migrant and minority groups (Ferrer et al., 2017).We adapted this framework to explain the experience of Muslim migrant caregivers that are inextricably influenced by familial, socio-cultural, racial, religious, and other structural factors, and linked to their local and global lives.

Methods
The meta-synthesis of qualitative studies was conducted using meta-ethnography which comprised: development of review questions, literature search strategy, quality appraisal, synthesis, presentation, and discussion of the findings (Atkins et al., 2008;Bettany-Saltikov, 2012;Noblit & Hare, 1988).The protocol of this systematic review was registered with PROSPERO-CRD 42018115734.A PRISMA checklist was developed to improve transparency in the meta-synthesis and systematic review (see Appendix I in Supplemental File).

Search strategy
A systematic search was first conducted by the first author (NN) between 01/07/2017 and 01/08/2017 then updated on 27/07/2020 of five relevant databases: MEDLINE (via Ovid), CINHAL, PsycINFO, Web of Science and Scopus.The grey literature was also searched, and a manual search and reference check of identified papers performed to identify as many relevant studies as possible.A PRISMA flowchart was developed to capture the search process and selection of papers (see Figure 1).The search terms were developed using the population, context, and outcome (PCO) framework (Cooke et al., 2012).All reviewers were involved in the selection of search terms.The review team consulted a librarian specialising in systematic review at Flinders University to clarify the databases and search strategies used.

Inclusion and exclusion criteria
Inclusion criteria were (1) family caregivers of PwD from a Muslim migrant background; (2) dementia care provided at home, (3) studies conducted in high-income countries, and (4) qualitative studies or mixed study design if qualitative data could be extracted.Studies were excluded if they used a quantitative research design, were not written in English and were not original studies.

Search outcome
Citations were retrieved and extracted to EndNote 20 by the first author (NN) for the screening of titles and abstracts.The first database search identified 5201 articles, of which 200 duplicate articles were removed prior to screening.The titles and abstracts of all remaining articles were screened against the inclusion and exclusion criteria by two reviewers (NN and LX) independently and conflicts were resolved through elaborations in regular team meetings.Screening of titles and abstracts resulted in 102 potentially relevant articles.The full texts of the 102 articles were assessed against the inclusion and exclusion criteria by two reviewers (NN and LX) independently.All reviewers participated in regular meetings to discuss and resolve differences in the assessment of eligibility.In total, 17 articles were included in the quality appraisal and all appraised articles were selected for the review (See Figure 1).The updated search identified a further 2670 articles, but no articles matched the selection criteria to be included in the review.

Quality appraisal
Two reviewers (NN and LX) performed critical appraisal for the 17 selected articles independently using the Critical Appraisal Skills Program (CASP) Qualitative Checklist (Critical Appraisal Skills Programme, 2018).Consensus on the critical appraisal was reached in the team through discussions.The CASP contains 10 questions which assess the aim of the research methodology, study design, recruitment data collection, relationship between the researcher and the participants, ethical issues, data analysis, findings and the value of the research.The assessment results in three outcomes: 'yes' , 'no' or 'can't tell' .Ten out of 17 studies met 'yes' in all 10 questions (see Table 1).Three studies did not provide information about ethical approval (Adamson, 2001;Bowes & Wilkinson, 2003;Mackenzie, 2006).Researchers in four studies did not critically reflect on their role in the study and their own influence in forming the research questions, collecting data, recruiting participants, analysing data or their responses to participants (Abojabel & Werner, 2019;Ar & Karanci, 2019;Mukadam et al., 2011;NAESs & Moen, 2015).In addition, two studies did not detail data analysis processes (Adamson, 2001;Bowes & Wilkinson, 2003).We decided to include studies that did not met all 'yes' answers in this review as they nonetheless provided valuable perspectives of caregivers' experiences.

Data extraction, and meta-synthesis
The first author (NN) extracted data from selected studies for analysis using a data extraction form (see Appendix II) and the second reviewer (LX) crosschecked.The meta-synthesis was developed using a table of three level constructs as described by Noblit and Hare (1988).The first level construct includes participant statements from the original studies and original author interpretations, the second level includes the reviewers' comments/interpretations and synthesised themes, and the third level construct includes synthesised findings developed from level 1 and level 2 constructs (see Appendix III).NVivo 12 was used to assist with data recording, coding, developing themes, processing, and performing analysis for meta-synthesis.
The first author (NN) conducted the meta-synthesis, and each procedure was crosschecked by the second author (LX).All reviewers were involved in discussions on the process and outcomes.When four reviewers agreed upon the extracted data, the first author initiated the analysis, including developing themes and sub-themes, and discussed findings with the team.Team discussions continued until all reviewers reached a consensus for data recording, analysis and synthesised findings.

Characteristics of the studies
In total 17 articles were selected for the meta-ethnography.Of the 17 studies, six studies were conducted in United Kingdom (Adamson, 2001;Bowes & Wilkinson, 2003;Mackenzie, 2006;Mukadam et al., 2011;Parveen et al., 2011;Regan, 2016), two in Israel (Abojabel & Werner, 2019;Leichtentritt et al., 2004), three in Australia (Boughtwood et al., 2012;Boughtwood et al., 2011;Shanley et al., 2012), two in Sweden (Mazaheri et al., 2014;Mazaheri et al., 2011), and one respectively in Turkey (Ar & Karanci, 2019), USA (Morhardt et al., 2010), Norway (NAESs & Moen, 2015) and Netherlands (van Wezel et al., 2016).All studies were published between 2001 to 2017.Of the 17 studies, three only included Muslims with the rest including both Muslim and non-Muslim participants.The ethnicity of participants included Arabic, Iranian, Indian, Pakistani, Bangladeshi, Turkish and Moroccan.The vast majority of participants were female adult child caregivers aged between 17 to 90 years.Most participants migrated from south Asian and middle eastern parts of Asia.The characteristics of studies reviewed are summarised in Table 2.More detailed participant demographics are presented in Appendix IV.Meta-synthesis of the data revealed three themes: caregiving as both positive and negative experiences; factors affecting caregivers' experiences; and coping strategies used by caregivers.Additional supportive participant statements relevant to findings are presented in Appendix V.

Caregiving as both positive and negative experiences
Caregivers perceived that their loved ones' diagnosis of dementia was a significant family life event.In most families, caregiving turned out to be an unavoidable and significant part of their family duties, responsibilities and obligation: 'In Arabic culture… the family have an obligation to look after their parents, as their parents brought them up' (Shanley et al., 2012, p. 7).This perception was echoed by caregivers who migrated from a Middle East Asian Muslim country: 'Care for your elderly is what the Islam says' (van Wezel et al., 2016, p.75) and 'My culture doesn't accept changes (of what Islam says)' ( van Wezel et al., 2016, p. 78).Caring for spouses was also emphasised as a caregiver from a south Asian Muslim family said: 'It's your husband, it's something you want to do for him' (Parveen et al., 2011, p. 866).Caring for loved ones was a way to show love: 'It's very tough.You see her deteriorating.But I do it because I love her' (van Wezel et al., 2016, p. 78).Findings indicated that caregivers were motivated to undertake their caregiving roles instantly.
Late diagnosis of dementia was widely reported and caregivers undertook their role long before the diagnosis (See Appendix V) without any dementia education or formal care services (Adamson, 2001;Shanley et al., 2012).Such situations had a negative impact on their emotional wellbeing: 'In the beginning, I used to scream at her (mother) and shout at her, … because I thought she was doing it on purpose' (Adamson, 2001).Caregivers also showed emotional stress: 'What have I done to deserve this punishment?' (Abojabel & Werner, 2019, p. 11).The lack of support also resulted in a sense of burden: 'This (caregiving) is very hard.It's a very difficult disease' (Abojabel & Werner, 2019) and 'It's a burden' (Parveen et al., 2011, p. 867).
Caregivers also experienced psychological stress when they related their caregiving to their religious beliefs: 'I think that having to take care of my father is God's punishment… and it's a very hard punishment' (Abojabel & Werner, 2019); and 'I started asking myself what I had done to deserve this punishment.Why me?I think this is God's punishment for things I did in the past' (Abojabel & Werner, 2019).Findings indicate that caregivers perceived both positive and negative experiences, and religious beliefs influenced a caregiver's role and self-appraisal.
Adapted from Critical Appraisal Skills Programme (CASP, 2018), https://casp-uk.b-cdn.net/wp-content/uploads/2018/03/CASP-Qualitative-Checklist-2018_fillable_form.pdf. Q1: Was there a clear statement of the aims of the research?Q2: is a qualitative methodology appropriate?Q3: Was the research design appropriate to address the aims of the research?Q4: Was the recruitment strategy appropriate to the aims of the research?Q5: Was the data collected in a way that addressed the research issue?Q6: Has the relationship between researcher and participants been adequately considered?Q7: Have ethical issues been taken into consideration?Q8: Was the data analysis sufficiently rigorous?Q9: is there a clear statement of findings?Q10: How valuable is the research?Findings: there is a need for a more strategic and coordinated approach that will support CAlD communities and meet their information needs, expectations and circumstances.
S12 Mazaheri et al.,   Findings: Caregiving for a family member with dementia is a familial duty, especially children are responsible for undertaking this role.Despite the workloads, most caregivers perceived satisfaction from the provision of caregiving.Caregivers also perceived that social support is significant; however, nursing home placement is not culturally and socially appropriate.

Factors affecting caregivers' experiences
Caregivers perceived various factors affecting their experiences, for example cultural norms, religious beliefs, gender, language barriers and financial stress.Cultural norms and religious beliefs inspired them to provide care for their loved ones: 'We have … cultural aspect…where the family have an obligation to look after their parents, as their parents brought them up' (Boughtwood et al., 2011).Religious beliefs also played a strong motivating role: 'From an Islamic point of view, the respect you have for your parents would mean you look after them -that's just what a good Muslim should do' (van Wezel et al., 2016, p. 75).Such a belief was echoed by other caregivers: 'As Muslims, we believe that the road to paradise -is under your mother's feet' (van Wezel et al., 2016, p. 75-76).and 'I am happy to take care of my father.I now have the opportunity to pay them back for all the hard work they did to raise us' (Morhardt et al., 2010).However, cultural and religious factors also prevented caregivers from seeking help: 'I told myself that I prefer not to get help from anyone … not even from the social worker … I prefer doing everything by myself' (Abojabel & Werner, 2019, p. 11).Moreover, these factors prevented them from using formal care services: 'I will never throw him into a nursing home… I will die caring for him but will not take him out of the house' (Leichtentritt et al., 2004, p. 381).For caregivers, putting family members with dementia into a nursing home would be associated with stigma: 'Care alternatives for our elderly outside the family feel for many like they are bringing shame on their whole family' (NAESs & Moen, 2015, p. 1725).
Some caregivers indicated their consideration of formal care services: 'If we cannot resolve the situation ourselves … then a care home could be an option' (van Wezel et al., 2016, p. 77).This was evidence of their acculturation in the host country.However, language barriers were constantly mentioned by those caregivers accessing and using formal care services (Boughtwood et al., 2012;Morhardt et al., 2010).Moreover, they had to act as an interpreter if their loved one could not speak the dominant language of the host country as government funded interpreter services were not available or accessible (Bowes & Wilkinson, 2003;Leichtentritt et al., 2004).In addition, they decided not to use services due to a lack of linguistically congruent care for their loved ones by which they bore higher levels of stress and burden compared to families from the mainstream culture (Boughtwood et al., 2011;Mazaheri et al., 2011).
Gender-based caregiving was evident and most caregivers in the studies reviewed were female (see Table 2).Gender-based caregiving was internalised through family role modelling: 'My mother took care of my grandmother for several years … this becomes part of you … I cannot give you a rationale' (Leichtentritt et al., 2004, p. 378).Only two studies very briefly mentioned financial stress caregivers experienced and they attributed the stress to the cost of health and social care for their loved ones (Boughtwood et al., 2011;Mazaheri et al., 2014).

Coping strategies used by caregivers
Caregivers demonstrated their capabilities and proactive actions (or agency) to cope with various challenges arising from their caregiving experiences.For example, to cope with dementia-related stigma, they chose to hide their caregiver role: 'I wanted to keep the reality of the disease to myself; I wanted to take care of my mother without anyone knowing … not even my closest friends' (Abojabel & Werner, 2019).Such situations contributed to the social isolation of both the caregiver and the PwD: 'People here think he is crazy… This is why I do not let him out of the house…it is not good for the family to be known as having a mental illness among its members' (Leichtentritt et al., 2004, p. 376/77).
Most caregivers perceived complete satisfaction from their caregiving journey despite challenges such as lack of their very own social and family resources and support that they left in their country of origin.For example, 'We are happy to be taking care, we find it rewarding' (Parveen et al., 2011, p. 866) and 'I get a lot of satisfaction from it because I think there's nothing better in the whole world' (van Wezel et al., 2016, p. 78).They adapted to their challenging situation and stayed positive: 'Life is short and I am happy to take care of my father' (Morhardt et al., 2010) and 'Caring for my mother means very much to me' ( van Wezel et al., 2016, p. 79).
Perceived community respect and appreciation for undertaking caregiving helped caregivers stay positive and sustain their journey: 'I can see they (people) look at me (as a carer) with respect and appreciation' (Abojabel & Werner, 2019, p.7).In addition, Islamic rituals, such as praying and seeking support from Allah (through remembrance and invocation), taught many caregivers to be patient, genuine, persistent, perseverant and optimistic throughout their caregiving journey: 'The only thing that kept me going is prayers.I pray every day to God, God has really helped me a lot' (Parveen et al., 2011., p. 868).

Discussion
To our knowledge, this is the first systematic review and meta-synthesis on experiences of family caregivers of persons with dementia from a Muslim migrant background in high-income countries.The intersectional life-course framework we applied to the review enhanced our understandings of multifaceted factors such as familial, social, cultural, and religious beliefs locally and globally and factors arising from the health and social care systems in high-income countries affecting the experiences of Muslim migrant caregivers.Our meta-synthesis highlights that the key life event of becoming a caregiver of a family member with dementia and subsequent caregiving experiences are inextricably linked to religious beliefs, cultural norms and coping strategies.
Our finding indicates caregivers from a Muslim migrant background in high-income countries showed positive thoughts towards dementia care and religious beliefs guided them through hardships.The finding supports that the Qur'an and the Sunnah inform caregivers' actions to overcome challenges in their lives.Respect and care for parents and relatives are emphasised multiple times in the Qur'an for example: 'Be dutiful, gentle, and kind to them and do not be arrogant or rebellious' 19:32)] and 'Do not repel or reproach them, especially when they become old ].Our finding is also in line with a previous study by Daher-Nashif et al. (2021) that Islamic religious texts have a profound positive impact on caregivers for PwD in Middle East Muslim communities.
In a global context, studies revealed that older people in Arab-Muslim communities are respected as the source of blessings, religious faith and sacred sanctuaries; therefore, being dutiful and respectful to them is the fundamental filial virtue (Cipriani & Borin, 2015;Guo et al., 2019).Our review finding on caregivers' motivation in taking their caregiving role supports previous studies.However, our review detailed that both local and global religious and cultural factors affected perceptions in dementia care positively; therefore, caregivers chose to continue despite challenges such as emotional, psychological and physical stress and dementia-related stigma (Mackenzie, 2006;Werner et al., 2012).
We found that most participants in the studies reviewed were female and our finding supports a previous study from Asian and Middle eastern countries where the division of labour, or roles, resources and responsibilities are generally determined by gender (Kabeer et al., 2018).Family caregiving is highly gendered in those countries and failing to do it properly or complaining about the workload for women often triggers family conflicts (Kabeer, 2008;Kabeer et al., 2018).Therefore, it is also possible that to avoid conflict, women living in high-income countries remain adherent to local and global norms.Future studies need to explore the female gender as a factor affecting caregiving experiences in Muslim communities in high-income countries.
Our finding indicated that caregivers deliberately hide their role to avoid dementia-related stigma from their own community.The finding is in line with the study by Johl et al. (2016).Such a passive coping strategy contributes to social detachment, separation and isolation during their caregiving journey (Botsford & Harrison Dening, 2015;Tweed & Conway, 2006).Caregivers' attempts to isolate themselves were also related to their perception that dementia is a mental illness and contributed to self-stigma and lack of help seeking from health professionals (Hossain & Khan, 2019;Mackenzie, 2006).Misunderstandings about dementia reveal the lack of dementia education for Muslim migrant caregivers by which their sense of agency and ability to advocate for dementia care policies, resources and care services to meet the care needs and preferences of their loved ones and themselves in high-income countries are limited (Hossain & Khan, 2019).
We found caregivers from a Muslim migrant background in high-income countries where Muslims are the minority encountered similar and different challenges compared to those from Middle East and North Africa (MENA) countries where Muslims are the majority (Kane et al., 2021).The main similarities both caregivers shared include cultural mores and religious beliefs that motivate caregivers to provide familial care for PwD, the feminisation of dementia care, the lack of dementia care education, dementia stigma, care burden and stigma associated with the use of formal care services (Boughtwood et al., 2012;Boughtwood et al., 2011;Bowes & Wilkinson, 2003;Kane et al., 2021).These similarities are indicators of the global impact on Muslim migrant caregivers (Elder, 1994;Ferrer et al., 2017).Therefore, in high-income countries a life-course perspective to analyse the needs and preferences of Muslim migrant caregivers is imperative when code signing dementia care services for them and those they care for in order to support them to keep PwD at home for as long as they wish.Moreover, difficulties in accessing health and social care for their loved ones were found in our review and a review on MENA countries (Kane et al., 2021).However, factors contributing to the situation differed.In high-income countries, caregivers' language barriers, lack of interpreter services and unfamiliarity with formal care services mainly contributed to the situation (Boughtwood et al., 2011;Shanley et al., 2012).In MENA countries, the lack of availability of dementia care services, caregivers' illiteracy and language barriers of foreign paid domestic helpers were associated with access issues to dementia care (Kane et al., 2021).In addition, in MENA countries, financial stress was constantly mentioned (Kane et al., 2021), but rarely described in the studies we reviewed.This may be due to differences in the welfare systems between high-income and MENA countries (Kane et al., 2021).

Limitations
We only searched English databases and selected studies published in English.Therefore, publication bias existed in this review.Moreover, most studies selected did not focus entirely on caregivers from a Muslim migrant background although they recruited from this caregiver group.It is possible that issues specific to this caregiver group remain under-researched in these studies.Therefore, our review may not have covered all key issues.In addition, this review only included caregivers and findings may not have captured the issues others face in dementia care.Future systematic reviews may consider the inclusion of other stakeholders in the care for PwD from a Muslim migrant background in high-income countries.

Conclusion
This meta-synthesis of qualitative studies identified that Muslim migrant caregivers of PwD in high-income countries experienced both positive and negative caregiving experiences.Positive experiences are mainly connected to their core religious beliefs and cultural norms that caring for family members with dementia is their duty and obligation.Negative experiences are mainly associated with emotional, psychological and physical stress when providing daily care without seeking help outside of the family and social isolation they experienced in the community in high-income countries.The findings have implications.First, policy makers in high-income countries need to invest resources and funding to develop care services tailored to the care needs and expectations of family caregivers of PwD from a Muslim migrant background to address disparities in supporting caregivers of PwD.Second, service providers need to engage caregivers and PwD in co-designing care services and dementia education resources to meet their needs and expectations and encourage updating of these services and resources.Third, further studies are much needed to identify effective approaches to supporting family caregivers of PwD from a Muslim migrant background in high-income countries.

Table 2 .
Summary of the studies.Awareness of and perception toward dementia; causation of dementia (dementia is an ageing process; mental illness and impact of medication); objectification of dementia.Findings: Most participants are aware of the condition of dementia but unaware, unfamiliar, and confused about the symptoms and causes.there is a lack of knowledge about diagnosis, symptoms, and support from professional services.there is a need for information provision and support services.Diagnosis of dementia in minority communities is attached to family and social stigma.the stigma process is highly rooted to religious ideology that affects care-receivers and caregivers.Caregiving is highly traditional in some communities; some consider it as a religious obligation.Carer roles in caregiving (physical care and emotional care experience); family issues (gender matters in caregiving; families' involvement in different levels of caregiving; family conflicts); emotional and personal concerns (grief and loss; lack of time for self; deterioration in the health of the carer; worry about the future; dementia related concerns (behaviour of the PlWD; safety issues).Findings: Carers from CAlD communities in Australia experience the physical and emotional work of caregiving.Perceived traditional, socio-cultural, and familial caregiving rules and practices are key motivations to their caring roles.Most caregivers had caregiving experiences that were positive and gave them a high level of satisfaction, happiness, and peace.At the same time, many caregivers were stressed and worried about the future of the persons with dementia as they daily experienced deterioration. the most terrible moments caregivers experienced when their loved one did not recognize their relationship, and other family members; and relatives and neighbours doubt the caregivers' performance.People from CAlD families are often unfamiliar with the concept of formal services and even when known, family caregiving gets priority over formal services.Families are often reluctant to use formal services as they prefer to keep their loved one at home. the reasons are mostly socio-cultural; however, formal services need to be more CAlD friendly and reliable.
Carers perceived that dementia is a cultural phenomenon and normal ageing process.Dementia caregiving is a cultural and familial obligations.therefore, managing a family member with dementia is perceived to be only the option and outside help is not well accepted until the disease progresses to its last stage, and symptoms becomes unmanageable.Familial, social-cultural, and religion are major contributing factors to motivations for caregiving.Caregivers experience two types of stigma: social stigma and family stigma.Stigma was an unavoidable part of everyday life for caregivers of persons with dementia and affected their emotions, feelings, lifestyle, and quality of care. Findings:

Table 2 .
Continued.Physical health, mental health, diagnosis, accessing care services, isolation, trust, gender, religious adherence, low knowledge, motivation for accessing health and social care services, perception of dementia service, experience of dementia care services, future outlook, and service access.