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Article

Unseen Strength: Dementia, the COVID-19 Pandemic, and the Resilient Hearts That Never Stopped Caring

by
Alice Yip
1,*,
Jeff Yip
2,
Zoe Tsui
1 and
Ka Man Rachel Yip
1
1
S.K. Yee School of Health Sciences, Saint Francis University, 2 Chui Ling Lane, Tseung Kwan O, New Territories, Hong Kong, China
2
Hong Kong Institute of Paramedicine, Hong Kong, China
*
Author to whom correspondence should be addressed.
COVID 2025, 5(6), 93; https://doi.org/10.3390/covid5060093
Submission received: 25 May 2025 / Revised: 13 June 2025 / Accepted: 17 June 2025 / Published: 18 June 2025
(This article belongs to the Section COVID Public Health and Epidemiology)
Review Reports Versions Notes

Abstract

:
This qualitative study explored the motivations for, and resilience of, family caregivers visiting family members with dementia in residential care homes (RCHs) in Hong Kong during the COVID-19 pandemic. Data for this qualitative descriptive study was obtained through audio-recorded, semi-structured, in-depth interviews with 25 family caregivers of individuals with dementia in RCHs. Following transcription, a thematic analysis was performed on the verbatim data. Three main themes emerged: (a) virtue of respect and filial piety; (b) family expectations and hopes; and (c) from red flags to resilience and rebuilding stronger relational bonds. The findings elucidate family caregiver motivations and resilience during RCH visits, offering crucial insights for healthcare policymakers. This can inform the design of care services and support to bolster the resilience of both caregivers and their relatives with dementia amidst ongoing global health-system pressures.

1. Introduction

The COVID-19 pandemic, a global health crisis of unprecedented scale, has had a disproportionately severe impact on older people. A report from the Centre for Health Protection concerning the COVID-19 pandemic in Hong Kong indicated that between January 2020 and January 2023, a total of 12,266,467 individuals tested positive for the SARS-CoV-2 virus through nucleic acid assays, supplemented by 1,880,112 positive identifications from Rapid Antigen Tests [1]. The study of Mueller et al. (2020) reported that adults over 65 years of age experienced a high rate of hospitalization and death [2,3]. Dementia serves as a broad classification for a range of advancing neurological conditions. These conditions are characterized by a decline in behavioral, cognitive, and social functions, leading to a significant need for caregiver assistance in everyday life [4,5]. According to the World Health Organization (WHO), the 57 million people worldwide living with dementia in 2021 was predicted to rise to 78 million by 2023, a trend predominantly affecting older individuals and consequently pressuring their family caregivers into making difficult decisions about relocating relatives to residential care homes (RCHs) [3,6,7].
The COVID-19 pandemic cause great distress in Hong Kong’s RCHs, creating a ‘perfect storm’ of dependence. The 2022 Omicron wave was particularly fatal due to extremely low initial vaccination rates among the frail, older population living in crowded conditions [8]. This led to explosive outbreaks, with individuals in RCHs accounting for roughly 60% of all COVID-19 deaths in Hong Kong in 2022. Understaffed and unequipped for quarantine, these institutes were overburdened. Prolonged visitor bans also caused severe social isolation and loneliness, compounding the crisis for vulnerable residents [8,9].
Older people with dementia often experience frailty, increasing their vulnerability [10]. COVID-19 infection worsens their cognitive and behavioral symptoms, leading to higher risks of mortality and other health issues. This places a significant burden on family caregivers, who worry about severe, long-term complications and face increased stress due to reduced support [11,12]. Therefore, caregivers of family members with dementia may arrive at the difficult decision to seek placement in RCHs. This choice often stems not from a diminished wish to have their loved one living with them, but rather from the progression of cognitive impairment, which can make providing comprehensive and safe care at home increasingly challenging for them [13,14]. RCHs can offer a more specialized and supportive environment to meet the complex needs associated with dementia. The truth of this might lie in the observation that family caregivers continue to visit their loved ones in RCHs both often and on a regular schedule. Compared to those caring for family members without dementia, caregivers of people with dementia report a higher incidence of mental, physical, and behavioral health issues, as well as a greater caregiving burden [15].
Resilience, a complex and multi-dimensional concept, is commonly defined in ways that highlight its role in fostering positive adaptation despite significant life challenges: as a personal trait suggesting inherent qualities that help an individual to withstand adversity; as a dynamic process involving ongoing adaptation and resource utilization to navigate stressors over time; and as a positive outcome demonstrating successful adaptation or ‘bouncing back’ despite exposure to significant adversity [15,16,17]. Acknowledging the limitations of an individualistic conceptualization of resilience, a sociocultural perspective provides a more comprehensive and exact framework, interpreting how socioeconomic status, cultural norms, supportive social ecologies, equitable resource distribution, and culturally attuned support systems collectively structure the context wherein resilience is cultivated, manifested, and operationally defined, and thereby enhancing the imperative to bolster community cohesion, redress systemic inequities, and promote cultural practices conducive to enhanced well-being [18,19]. Reduced anxiety and depressive symptoms, along with an improved quality of life, healthier lifestyle choices, and greater investment in self-care, are characteristic of caregivers who possess a high degree of resilience [20,21].
Within the Chinese cultural context, a deeper understanding of caregiver resilience is predominant, as the significant stressors implicit in caregiving can precipitate severe family conflict or lead to situations where caregivers, feeling overwhelmed and incapable, may give up their responsibilities, resulting in the placement of their family members in RCHs [22,23,24]. Nevertheless, a notable gap exists in the literature concerning the driving forces behind sustained visitation to individuals with dementia residing in RCHs, particularly within cultural contexts shaped by Chinese traditions. Notwithstanding the valuable perspectives offered by studies on the significance of familial visitation to individuals with dementia, such research has been predominantly situated within RCHs in Western countries [25,26]. This geographical and contextual focus is noteworthy, as the incidence of in-home caregiving for family members with dementia is considerably higher in Asian nations shaped by Chinese cultural values [27]. While previous studies have explored the resilience of Chinese family caregivers, a critical gap exists: no research has yet synthesized these findings through an extensive review focusing specifically on the resilience of caregivers in Hong Kong from Chinese cultural perspectives, particularly during the COVID-19 pandemic. This study aimed to understand the motivations for, and resilience of, family caregivers visiting family members with dementia in RCHs in Hong Kong.

2. Methods

2.1. Study Design

This qualitative descriptive study involved conducting semi-structured interviews via telephone or videoconferencing (e.g., Zoom) with family caregivers of individuals with dementia living in RCHs. Employing a qualitative methodology, the use of flexible interviews enabled the acquisition of a comprehensive understanding of the lived experiences of participants. The reporting practices aligned with Tong et al.’s (2007) criteria for qualitative research, thus promoting the rigor and validity of the study [28].

2.2. Participants

A convenience sampling strategy was employed to recruit participants. To be eligible for inclusion, individuals were required to be family caregivers, aged 18 years or older, residing in Hong Kong, and capable of communicating in Cantonese, Putonghua, or English. The primary inclusion criterion specified that the care recipient—the family member—must have a formal diagnosis of dementia and be a current resident in a Hong Kong RCH. Recruitment sites encompassed a diverse range of RCHs, including non-profit, self-financing, and subvented institutions. Recruitment occurred via referrals from RCH staff and social media. Participants, comprising family caregivers, were recruited in Hong Kong through convenience sampling utilizing various social medica platforms (e.g., Facebook, Instagram, WeChat).

2.3. Data Collection

To capture participants’ caregiving experiences related to visiting family members with dementia in RCHs during the COVID-19 pandemic, individual semi-structured interviews were conducted (Table 1). Data collection for this purpose occurred between March 2021 and January 2022. Hong Kong responded to the COVID-19 pandemic declaration by implementing several key preventive measures. These included vaccination passes, quarantine policies, and social distancing, all aimed at differentiating individuals with a higher risk of coronavirus disease. To ensure consistency in data collection and interpretation, a single researcher conducted all interviews in Chinese. This researcher (A.Y.), a qualitative scholar experienced in studies involving older adults and their family caregivers, obtained written permission for each audio-recorded interview. The interviews, lasting approximately 40–60 min each, were then transcribed verbatim. The process for each interview included the generation of field notes.

2.4. Analysis Strategy

All audio recordings were transcribed word for word. To ensure the integrity of these transcripts, a comparison was conducted between the transcribed text and the source interview material, the latter having been organized into a uniform format [29,30,31]. A thematic analysis of the transcribed interview data was undertaken by three authors (A.Y., J.Y., Z.T.) working independently, for the purpose of recognizing, validating, and revealing themes [28]. The categorization and grouping of the notes were executed iteratively across six distinct phases: (i) acquiring data familiarity; (ii) setting up starting codes; (iii) analyzing for thematic content; (iv) interpreting the identified themes; (v) conceptualizing and identifying themes; (vi) generating the report. The process of understanding the motivations and experiences of family members and caregivers visiting relatives with dementia in RCHs involved reading each transcript multiple times. Data relevant to several categories was assigned to all appropriate classifications and incorporated into the analysis. The authors deepened their comprehension of the transcribed information by revisiting the original transcripts and consulting scholarly works on the experiences of those caring for a relative with dementia in an RCH. To ensure coding consistency and accuracy, the second author (J.Y.) independently reviewed the coded text within each thematic category. Subsequently, illustrative quotations were reallocated to the most suitable subthemes to achieve a more refined classification. The final conceptualization and delineation of themes and subthemes, along with their respective definitions, were established through a consensus-based discussion among all authors. The quotations featured were carefully chosen to represent key aspects of the dominant themes and their related subthemes. The final analysis was translated by bilingual experts, whose fluency in English guaranteed linguistic precision. To enhance the rigor and objectivity of the analytic process, any interpretive discrepancies or disagreements arising among the authors during data analysis were systematically addressed. This involved engaging an external expert with established proficiency in qualitative research methodologies. This expert facilitated a series of deliberative discussions, which continued iteratively until a complete consensus regarding thematic interpretations and coding decisions was achieved by all members of the research team. Data were collected and analyzed accordingly, with this dual process persisting until no new significant themes emerged, signifying data saturation. This point of saturation was identified following the engagement of the 25th participant.

2.5. Rigor

To establish the trustworthiness of this research, the methodological approach comprehensively adhered to the rigorous criteria set out by Lincoln and Guba [32]. To enhance the confirmability of the research findings, two members of the research team (A.Y. and J.Y.) systematically maintained analytical memos and engaged in reflexive journaling throughout the study. The study’s procedural framework involved participant recruitment through convenience sampling, analytical validation via peer debriefing, and process documentation by means of an audit trail. The representation of diverse social backgrounds among participants served to diversify the study cohort and bolster the trustworthiness inherent in the research design and execution. To enhance the analytical review, peer debriefing involved engaging in detailed discussions about the analysis with researchers specifically chosen for their expert knowledge of qualitative studies. Moreover, the utilization of a consistent, standardized format for interview transcripts served to guarantee transcription accuracy [29,30].

2.6. Ethical Considerations

Ethical approval for the present study was secured from the Research and Ethics Committee of Caritas Institute of Higher Education (Reference: HRE210104) prior to its commencement. All participants were provided with comprehensive information regarding the nature and objectives of the research, and subsequently gave their voluntary informed consent, which was formally documented via signed consent forms.

3. Results

Twenty-five family caregivers of individuals with dementia in RCHs were selected and agreed to participate in individual interviews with the aim of exploring what motivated them to visit their relative with dementia who had been transferred to an RCH in Hong Kong. We enrolled 11 male and 14 female family caregivers between the age of 28 and 92, with an average age of 50.4, in this study. Eleven participants were in full-time employment, and twelve participants were unemployed or retired. The participants had different frequencies of visits to their relatives with dementia in RCHs: eight participants made one to three visits per month, eight participants made four to five visits per week, and nine participants made six to seven visits per week. An outline of the information of the participants is listed in Table 2. Three themes of interviews were identified, and are summarized below (Table 3).

3.1. Theme 1: Seeking Clarity and Safety Through Pandemic Training

In line with Confucian beliefs, many participants recognized that visiting relatives residing in RCHs constituted a familial responsibility. This filial response stemmed from their familial relationship with the individual, such as husband, wife, parent, grandmother, or grandfather. These individuals not only adhered to societal expectations within their community, but also conformed to traditional, deeply ingrained personal expectations inherent in Chinese culture.

3.1.1. Affected by Confucian Beliefs

The participants, all of whom were of Chinese ethnicity, were predominantly influenced by Confucian beliefs characteristic of traditional Chinese communities. Participants articulated a sustained concern for their relatives, which was reportedly demonstrated through diligent attention to the relatives’ daily personal hygiene and support for their established daily routines. Essentially, they persisted in providing all the requisite support to ensure their relatives’ comfort and convenience, notwithstanding the relatives’ transfer to and ongoing residence in the RCH. One son said,
“Even if my mother is living with advanced dementia and may no longer recognize me, she remains my mother—the woman who gave me life. This connection feels profoundly natural and essential. She lovingly cared for me when I was young, and I am committed to visiting her at her residential home at least three times a week before COVID-19… Her health is fragile, as her son, I embrace caring for her as my heartfelt responsibility. My dedication won’t waver, bringing peace and preventing guilt. I do this wholeheartedly, ensuring no regrets when she passes, knowing I did everything I could with love and dedication.”
(Son, P02)
Several participants reported an inability to dedicate sufficient time to the care of their relatives prior to their admission to the RCH. Consequently, these individuals engaged in visits to the RCH with a frequency that reportedly exceeded what they felt they could realistically manage. This increased visitation appeared to serve as a compensatory behavior, aimed at alleviating personal stress and mitigating feelings of guilt that may have arisen from their previous inability to provide direct care.
“I empathize with my mom, knowing older individuals prefer not to be in residential homes. It pains me that others might misunderstand; my demanding work prevents home care, causing helplessness and sorrow. Frequent visits comfort me. During one, I changed her soiled towels, pillowcases, and bedsheet, ensuring her comfort at best I could, wanting to provide care despite limitations.”
(Son, P15)
Another participant posited that their presence within the RCH served as a positive inducement, potentially motivating care staff to provide a more attentive or enhanced standard of care for their relatives. This level of engagement could demonstrate to the staff of the RCH that the participant remained attentive regarding their relative’s needs, thereby fostering an environment where the provision of appropriate treatment and care was more consistently ensured. For instance, Participant 09, whose grandmother was diagnosed with early-stage dementia, expressed the following:
“My assessment is that this residential facility’s care standard falls short of expectations. On several occasions, I’ve observed healthcare workers raising voices or speaking harshly to residents. Securing appropriate local accommodation for my grandmother was challenging and finding a suitable alternative has not yet been possible. Consequently, I visit approximately every three days to monitor the care she is receiving and ensure her needs are adequately addressed. Despite directly requesting workers refrain from using raised voices with my grandmother, this issue persists. Furthermore, engaging social work staff regarding these concerns has not yielded discernible improvement or a formal response.”
(Granddaughter, P09)
Confucian principles regarding familial roles and responsibilities appear to exert a significant influence on the dyadic care practices and mutual support exhibited by spouses in their usual interactions. Illustratively, a 92-year-old male participant reported making daily visits to his wife who was diagnosed with early-stage dementia and resided in an RCH. He articulated that,
“My marriage is enduring, lifelong partnership with profound reciprocal obligation. I view my commitment as repaying a ‘life debt’ to my wife, perhaps from a past life, believing we were destined. My devoted care for her now settles this ‘love debt’ without complaint. I am convinced it’s my duty to provide her with the most comprehensive, dedicated care.”
(Husband, P21)

3.1.2. Mitigation or Affliction

Participants often reported grappling with significant frustration and guilt as they witnessed the ongoing deterioration of their loved ones’ physical and cognitive abilities due to dementia, particularly concerning the decision for them to reside in an RCH. All participants regularly visited their family members at the RCH, though their approaches to providing care differed: some participants were deeply involved, personally providing most aspects of care, while others took a more supervisory role, relying on the RCH staff for the day-to-day care of their family members.
However, some participants articulated a persistent yet altered relationship with their spouse who was afflicted by dementia and its associated physical and cognitive impairments. These participants stated that the progressive deterioration in their spouse’s health led to a perceived decrease in the intimacy that had previously characterized their marital bond. One husband presented his feelings regarding the loss of conversation and communication with his wife, who was in the late stages of dementia. Nevertheless, he also expressed a degree of relief knowing that his wife was being cared for by the staff at the RCH. He said,
“Everything about our forty-year marriage as husband and wife is gone. There is no longer any interaction between us. There is nothing to carry on, because you (wife) cannot talk, nor to communicate and share your experience with me … I am not in good health now. It is good to know you have appropriate caring services for daily living in RCH. I feel relieve knowing this is a good place for you to stay.”
(Husband, P17)
For some participants, the fact of their spouse with dementia being in long-term care at the RCH led to feelings of loss and loneliness due to separation. Traditional Chinese culture emphasizes lifelong commitment, causing some to mentally perceive their spouses as having already gone, despite them being physically present in the RCH. One wife said,
“As his wife, I will stay with him for a lifetime. There’s a Chinese idiom, ‘Married to a chicken—follow the chicken,’ which means I’ll follow the man I married. The staff at RCH take care of everything. All I do is visit him frequently, sometimes feeding him, and sometimes not. I like to keep doing this. However, now our lives are separated if you understand what I mean. In fact, I feel I already lost him some time ago.”
(Wife, P05)
Conversely, some participants worried about the care their family members received at the RCH, viewing clean living conditions as a sign of good service. To ensure quality care and for peace of mind, these participants visited their loved one at the RCH frequently. Some reported visiting their family member in the RCH more than six times per week before the COVID-19 pandemic. The daughter of an elderly lady with middle-stage dementia who lived in an RCH stated,
“To ease my guilt, I visit my mom every week before COVID. During these visits, I often check if her hair, eyes, and dentures are clean, and I also trim her fingernails.”
(Daughter, P18)

3.2. Theme 2: Family Expectations and Hopes

Participants hoped that frequent visits to family members in RCHs could slow dementia’s decline, especially given common staff shortages in Hong Kong. They believed their consistent care, including reinforcing familiar habits like routines, food, and exercise, might delay deterioration and support their loved ones’ health.

3.2.1. Support for Nutritional Deficits

Individuals with dementia often experience deterioration in their appetite and eating habits, causing family concern about food in RCHs. Consequently, families may bring appealing, nutritious food for relatives in these facilities. Swallowing difficulties (dysphagia), due to diminished muscle strength, are common. To improve nutritional status, some families encourage relatives to perform swallowing exercises during visits, aiming to enhance their eating capabilities. This proactive approach by families highlights their dedication to their relatives’ well-being and quality of life.
Participants described sometimes bringing handmade, preferred food to boost relatives’ appetites, stating that the RCH staff provided plain meals, not what the residents with dementia desired, impacting their desire to eat and their overall well-being.
“My mother does not sleep much and is not eating well. When she does not eat, she’s not getting the good stuff her body needs from food. This makes me very worried about her health.”
(Daughter, P08)
Guided by cultural beliefs, some participants described using specific healthy foods to supplement diets, aiming to improve their relative’s nutrition or digestive problems. For example, one described preparing Chinese herbal medicine and fruit for her father with middle-stage dementia to help him to meet his nutritional needs.
“My dad smiles contentedly after eating the food I provide. To address his ailments, I bring Chinese medicine like Ginseng if he’s unwell, and fruit for constipation, which he enjoys.”
(Daughter, P25)
Following hospital discharge, some residents with dementia require nasogastric tube feeding due to swallowing difficulties, impacting their nutritional status. However, families often prefer their loved ones in RCHs to eat independently. Consequently, relatives described dedicating visiting time to assisting with swallowing practices, being concerned that RCH staff might lack sufficient time, highlighting a preference for active self-care over passive feeding. One participant, who had a grandmother with late-stage dementia, stated,
“My grandma, fed only by nasogastric tube due to swallowing difficulties, could not eat orally. I hoped to improve her swallowing, so I helped her practice with mántou (steamed bread), and she succeeded! During each visit, I assisted her with swallowing exercise. Now she eats independently! Doctors and nurses supported removing the tube, encouraging her self-feeding. Aware that RCH staff might lack time for this intensive practice, I committed to personally helping my grandma with her training … Separated by COVID restrictions, I longed to see my grandma. My pain was eased by profound respect for the heroic RCH staff who became our family’s protective shield.”
(Granddaughter, P23)

3.2.2. Support for Physical Deficits

Participants indicated that frequent visits could enhance the comfort of their relative and facilitate ongoing monitoring of their relative’s health status. Some participants attempted to engage in tactile interaction or shared activities with their relative. Furthermore, family members expressed a strong willingness to actively assist with their relative’s daily routines, a sentiment exemplified by one daughter whose father had been diagnosed with early-stage dementia:
“I help Daddy clean his dentures, wash his face, and shave. Because his skin is dry and can get hurt easily if he scratches, I always bring him some lotion to apply.”
(Daughter, P12)
Moreover, participants reported engaging in activities designed to enhance the mobility of their relative. Some participants aimed to reduce the deterioration of their relative’s physical condition by assisting them in increasing active physical mobility and augmenting muscle strength.
“The home seems short-staffed, so residents sit a lot, which can weaken muscles. Walking is good for Mom’s early memory problems. So, when I visit, I always help her walk because she needs support. This keeps her moving and can help her memory.”
(Daughter, P18)

3.2.3. Support for Cognitive Deficits

To bolster memory function in residents with dementia, participants reported developing interventions involving either cognitive stimulation or rehabilitation, with the aim of reducing or retarding the memory deterioration typically observed during the progression of the condition. One daughter, who was worried about her father with early-stage dementia, said,
“If I do not visit my father two to three times a week, I am convinced his cognitive abilities would decline rapidly. When I visit, bringing him snacks and engaging in conversation, it compels him to respond and communicate. This interaction, at the very least, provides him with crucial verbal stimulation, and I hope it might slow the decline of his memory. If I were to stop these visits, I am deeply afraid he could enter a vegetative state, and his physical condition would progressively deteriorate.”
(Daughter, P19)

3.3. Theme 3: From Red Flags to Resilience and Rebuilding Stronger Relational Bonds

Participants noted dementia’s decline: memory loss, anxiety, and aggression. Displaying resilience, families frequently visited loved ones in RCHs, believing that this would improve conditions and foster harmony. With this consistent support, they aimed to strengthen their relatives’ ability to cope with increasing difficulties, helping them to adapt and maintain well-being. Such efforts highlight families’ resilience in enhancing their loved ones’ quality of life despite the disease’s progression.

3.3.1. Support for Emotional Deficits

Participants visited family members in RCHs to ease emotional distress from dementia symptoms like memory loss, anxiety, and confusion (e.g., handling money). One participant expressed her helplessness and wanted to comfort her relative in an RCH who was suffering from early-stage dementia. The daughter described,
“Although my father no longer recognized me, he’d nervously ask RCH staff, “Has my daughter come to visit?” I sobbed, feeling deep sorrow. During COVID-19 pandemic, there was a lot of regulations for me to follow for my visitation. I will keep visiting to ease him mind and bring him comfort, hoping to make him feel at ease despite his confusion.”
(Daughter, P19)
A grandson said that he would visit his grandmother in the RCH one to three times each month before the COVID-19 pandemic:
“I remember, before COVID, whenever I visited my grandmother, she would hold my hand. She would often accuse ‘Mrs. Yuen’ in the next bed of being a ‘bad lady.’ She claimed Mrs. Yuen got her, ate her biscuits, and stole her towel and “Red fish” (a $100 note). In fact, staff never gave her money. Each time, I had to listen to her story and comfort her.”
(Grandson, P03)

3.3.2. Resolving Conflicts

Aggression among residents with dementia in RCHs can test co-residents’ resilience—their crucial ability to adapt for peaceful coexistence. Families explained that they used behaviors to reduce conflict, but this raised resilience concerns: could others truly accept and help those with dementia to cope, ensuring well-being for all involved?
“Grandpa’s nervous doubts and communication issues test his resilience. When misunderstanding others, his anxiety can lead to conflict, showing his struggle to cope with confusion and maintain peaceful connections despite his internal state and the challenges of his condition.”
(Granddaughter, P04)
One son said,
“Knowing my mom’s brain damage can cause rudeness, I proactively manage potential conflict. I comfort her, explain her illness to others who may not understand, and apologize in advance on her behalf to foster understanding and prevent distress for everyone involved … Due to COVID-19 restrictions, I could not visit my mom. Our only way to connect was through an iPad, so I could see her, but not face-to-face.”
(Son, P24)

4. Discussion

The findings of this study detail the essential nature of family caregivers’ visits to relatives with dementia in RCHs, including the meaning they attribute to these visits and their motivations for undertaking them. The findings of this study align with the existing literature, enhancing the recognized importance of maintaining the quality of care for individuals with dementia [33,34,35]. This includes an awareness of their multifaceted needs, and a desire among caregivers to alleviate the burdens associated with the progressive stages of the disease. Crucially, however, this study also highlights the unique influence of Chinese cultural values, particularly the centrality of family boding, in shaping these caregiving perspectives and experiences [36].
In this study, nearly all the participants visited family members at RCHs with the primary hope of slowing the degenerative process. Their efforts focused on maintaining their family member’s physical capabilities, memory, and nutritional well-being. During these visits, families actively participated in mentally stimulating activities with the residents and provided assistance to help them improve their daily activities, especially during the COVID-19 pandemic. The reports of participation in self-care activities by family members of cognitively impaired RCH residents show similarities to some other studies, with health promotion being the main goal for visits to typically cognitive residents [13,37,38]. Providing a consistent and supportive environment, involving offering emotional security or assistance in resolving conflicts, was reported to be the main motivation for visits. Studies highlight that family caregivers of RCH residents make efforts to keep visiting relatives with cognitive decline in order to serve as advocates for them [39,40,41]. Family caregivers, particularly those adhering to Chinese cultural norms, often experience considerable stress stemming from the disruptive behaviors of the individuals they care for [42]. To boost residents’ nutrition, when family members of RCH residents with cognitive impairment visit, they often bring food that is personalized to individual requirements, for instance, softer-textured meals for those who have difficulty chewing or swallowing [43,44].
Trust in RCH staff emerged as a critical factor influencing families’ perceptions of care quality, especially during the COVID-19 pandemic, when family caregivers felt they had no choice, that everything was out of their control, and that they had no say in the caring interventions for their family member in the RCH. Some participants explicitly stated that their concerns stemmed from a lack of trust, fearing that this could lead to the abandonment or persecution of their family member, whose cognitive impairments made them vulnerable. Echoing these concerns, studies also mention issues of trust in staff’s ability to manage dementia care needs appropriately [45,46]. The significance of trust is further highlighted by research showing its positive association with family satisfaction with care and more favorable evaluation of physician–family communication [47,48,49]. By improving how information is communicated and shared, RCHs can increase the trust that family members have in their staff, which is fundamental to providing excellent care for residents with dementia. In the context of the COVID-19 pandemic, timely and understandable explanations of preventive measures, such as changes to daily routines or visitation policies, helped families to feel more secure and confident in the care their loved ones received amidst unprecedented challenges [50,51].
Central to Chinese cultural understanding is filial piety, which serves as the bedrock of all moral and societal values [52,53]. This core principle has long dictated the strong sense of responsibility and mutual obligation observed in the relationship between parents and children, as well as between spouses. Consequently, before the COVID-19 pandemic, the active care and regular visitation of family members were deeply established social norms. While the pandemic period necessitated significant adjustments to how these duties could be fulfilled—often shifting in-person visits to virtual connections or modified care routines to ensure safety—the fundamental expectation of familial support persisted. In the period following the most acute phase of the pandemic, there was a widespread effort to return to and reaffirm these established practices of care and visitation, sometimes integrating new lessons learned about flexible support [54,55].
The resilience of Chinese family caregivers, as indicated by participants in this study and consistent with broader research, appears to be deeply rooted in Confucian ethics and unique Chinese cultural characteristics that foster strong family adaptation during crises such as a loved one developing dementia [56,57]. This cultural framework encourages family members to actively adapt and overcome such challenges by diligently fulfilling their duties and responsibilities to care for their relatives, a commitment observed to persist throughout the COVID-19 pandemic and into the period that followed. Importantly, and in line with findings from other studies, the level of this resilience among Chinese family caregivers was found to be significantly correlated with their overall life fulfillment, their experiences of worry and anxiety about family members, and the extent of the burden they perceived their caregiving role to have [15,58].
The escalating global prevalence of dementia, particularly its rapid increase in China, necessitates the strengthening of family-based support systems [59,60]. International public polices, such as Germany’s provision of paid leave for family caregivers and the World Health Organization’s goal for 75% of countries to offer carer support and training, provide adaptable models [61,62,63,64,65]. Multi-component societal intervention is urgently required to enhance psychological well-being for Chinese families [66,67]. In the Chinese context, this could mean integrating psychoeducation with culturally adapted practices like mindfulness and peer-support groups, an approach that has proven to be effective in Hong Kong for reducing caregiver distress [68,69]. Good practices like person-centered care, which focuses on an individual’s life story and preferences, can be aligned with cultural values such as filial piety [66,67,68,69,70]. This study elucidates the motivations of Chinese family caregivers visiting relatives in RCHs, disclosing how their perspectives foster positive attitudes and resilience. It also highlights the need for further studies on the emerging needs of those with dementia following public health crises like the COVID-19 pandemic.

Limitations

This study has several limitations that warrant consideration. A primary limitation is the sampling frame, which did not proportionally represent all four types of RCHs in Hong Kong. This may restrict the generalizability of the findings. Furthermore, data were collected during the acute crisis of the COVID-19 pandemic, a context that likely influenced caregiver responses. The necessary shift to remote data collection may also have impacted data quality. The remote nature of interviews conducted via telephone and videoconference can disrupt rapport-building and limit the observation of non-verbal cues, potentially affecting the depth of participant responses. Future studies could mitigate these effects by intentionally building rapport at the outset of interviews and utilizing video to capture visual cues. While some research suggests that remote and in-person methods can yield comparable data, ensuring participants have adequate technology and a private space is crucial. These context-specific findings highlight the need for future research using more comprehensive sampling and data collection strategies.

5. Conclusions

This study concludes that during COVID-19, Chinese cultural beliefs enhanced the resilience of family caregivers when visiting relatives with dementia in RCHs. This fostered better relationships and awareness of the importance of holistic care, including nutrition. These insights urge policymakers to improve care services and support for both populations, especially for further public health crises, by providing more competent and culturally sensitive support systems.

Author Contributions

Conceptualization, A.Y. and J.Y.; methodology, A.Y.; validation, A.Y., J.Y. and Z.T.; formal analysis, J.Y., A.Y. and Z.T.; investigation, A.Y.; resources, A.Y.; data curation, A.Y. and J.Y.; writing—original draft preparation, A.Y.; writing—review and editing, A.Y., J.Y., Z.T. and K.M.R.Y.; project administration, A.Y. and Z.T. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

The study was conducted in accordance with the Declaration of Helsinki, and was approved by the Research and Ethics Committee of Caritas Institute of Higher Education (HRE210104, 3 February 2021).

Informed Consent Statement

Informed consent was obtained from the participants to participate in the study. In addition, all participants were assured that their shared experience and interview content would be reported anonymously in international journals.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Acknowledgments

The authors thank the research participants for their time dedicated to this study.

Conflicts of Interest

The authors declare no conflicts of interest.

References

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Table 1. Interview guide for individual interviews.
Table 1. Interview guide for individual interviews.
No.Probing Questions
1.Could you share some of the reasons that bring you visit your family member here at the residential care home (RCH)?
2.Could you share what it was like for you when visiting the RCH throughout the COVID-19 pandemic?
3.When you think about the RCH, what aspects or qualities stand out to you most positively? Perhaps you could share a specific instance from the COVID-19 pandemic that highlighted this for you.
4.Could you describe what a typical visit with your family member at the RCH looks like? What sorts of activities or interactions do you usually have? Perhaps you could share a specific example of how a visit went during the COVID-19 pandemic.
5.Did they suffer from the disease themselves?
6.What were some of the main difficulties or problems you faced during your visits? Can you give an example of a challenge that arose during the COVID-19 pandemic period.
7.How do you feel when you think about your family member and his/her dementia?
8.Thinking about any challenges you faced during your visits, how did you manage those, and what do you think could improve the visit experience overall or prevent such difficulties?
Table 2. Characteristics of participants (N = 25).
Table 2. Characteristics of participants (N = 25).
Mean (Min–Max)n(%)
Age50.4 (28–92)
Gender
  Male 11(44)
  Female 14(56)
Education level
  None 1(4)
  Primary 4(16)
  Secondary 3(12)
  Tertiary 17(68)
Employment
  Employed 11(44)
  Self-employed 2(8)
  Unemployed/Retired 12(48)
Marital status
  Single 7(28)
  Married 16(64)
  Divorced 2(8)
Relationship to family member with dementia
  Grandmother/Grandfather 7(28)
  Mother/Father 10(40)
  Wife/Husband 7(28)
  Sister/Brother 1(4)
Frequency of visit
  4–5 times/week 8(32)
  6–7 times/week 9(36)
  1–3 times/month 8(32)
Religious beliefs
  Nil 12(48)
  Catholic 6(24)
  Christian 7(28)
Family member with dementia in RCH—Age
  51–60 3(12)
  61–70 2(8)
  71–80 7(28)
  81–90 6(24)
  >91 7(28)
Family member with dementia in RCH—Gender
  Male 8(32)
  Female 17(68)
Table 3. Themes and subthemes of the study.
Table 3. Themes and subthemes of the study.
ThemesSubthemes
Theme 1: Virtue of respect and filial pietyAffected by Confucian beliefs
Mitigation or affliction
Theme 2: Family expectations and hopesSupport for nutritional deficits
Support for physical deficits
Support for cognitive deficits
Theme 3: From red flags to resilience and rebuilding stronger relational bondsSupport for emotional deficits
Resolving conflicts
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Yip, A.; Yip, J.; Tsui, Z.; Yip, K.M.R. Unseen Strength: Dementia, the COVID-19 Pandemic, and the Resilient Hearts That Never Stopped Caring. COVID 2025, 5, 93. https://doi.org/10.3390/covid5060093

AMA Style

Yip A, Yip J, Tsui Z, Yip KMR. Unseen Strength: Dementia, the COVID-19 Pandemic, and the Resilient Hearts That Never Stopped Caring. COVID. 2025; 5(6):93. https://doi.org/10.3390/covid5060093

Chicago/Turabian Style

Yip, Alice, Jeff Yip, Zoe Tsui, and Ka Man Rachel Yip. 2025. "Unseen Strength: Dementia, the COVID-19 Pandemic, and the Resilient Hearts That Never Stopped Caring" COVID 5, no. 6: 93. https://doi.org/10.3390/covid5060093

APA Style

Yip, A., Yip, J., Tsui, Z., & Yip, K. M. R. (2025). Unseen Strength: Dementia, the COVID-19 Pandemic, and the Resilient Hearts That Never Stopped Caring. COVID, 5(6), 93. https://doi.org/10.3390/covid5060093

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