Family caregivers play a crucial role in supporting older adults living with chronic illness and disability; yet, many face significant economic challenges. Caregivers of persons living with dementia experience substantial out-of-pocket expenses due to medical copayments, necessary home modifications, specialized caregiving supplies, personal care services, and home care. These costs precipitate far-reaching economic and psychological consequences, including financial strain and anxiety [1-3]. Households of individuals diagnosed with dementia have been shown to experience more than a 2-fold increase in out-of-pocket health care spending and a decline in net worth exceeding 60% within 8 years of diagnosis [2]. This kind of financial insecurity can have both immediate and long-term effects on caregivers’ ability to meet basic needs, career development, generational wealth, and overall economic well-being [4,5].

The financial burden of caregiving is acutely evident among resource-limited populations disproportionately impacted by dementia [6], with recent findings showing that out-of-pocket costs and related financial strain disproportionately affect historically marginalized groups, including racial and ethnic minority populations [4]. Latino caregivers are particularly vulnerable to these financial pressures [7,8]. This is due in part to delayed access to services, more unpaid care responsibilities, and limited availability of culturally tailored support. Despite depending heavily on informal care and choosing more affordable health care options (ie, adult day care over nursing facilities) [8], Latino families of persons living with dementia still incur higher costs than non-Latino families [7,9]: on average, caregivers spend 26% of their annual household income on caregiving, whereas Latino caregivers spend nearly twice as much (47%) [3]. One study found that Mexican American caregivers contend with caregiving burdens that are intensified by socioeconomic constraints and disrupted life opportunities, contributing to greater financial strain and worse physical and mental health outcomes [8].

Understanding values and norms central to Latino culture is crucial for addressing needs and developing financial support programs. Cultural values that influence approaches to caregiving and spending patterns include Famalismo and Marianismo [7,10-12]. Famalismo—prioritizing family welfare over individual desires—can contribute to career compromises that reduce potential earnings when a caregiver provides direct care over formal services. Marianismo—the characterization of women as family-centered and selfless—may reduce household income by Latinas’ prioritizing unpaid care roles over paid labor force participation. Within Latino families, caregiving expectations often fall disproportionately on women, which can limit their participation in the paid workforce and contribute to unequal caregiving burdens [7,8]. Caregivers under strain are more likely to consider skilled nursing facilities for their loved ones [13]. However, despite providing more intensive care, Latino caregivers historically prefer providing care in the community, possibly due to familial obligations and concerns about the quality of nursing facilities [8,11,14].

Strengthening caregivers’ financial security is a national priority in the United States, reflected in the first-ever National Strategy on Caregiving [15]. Financial education and training interventions have been found to improve money management and the overall well-being of participants [16], and several studies have shown the positive impact of psychosocial interventions in easing caregiver burden and mitigating distress [7,16-18]. Interventions tailored to meet participant needs, preferences, and values increase satisfaction and engagement [8,19,20]. Despite increasing recognition of the unequal caregiving burden felt among Latino families, most evidence-based interventions have not been adapted for their cultural needs, and few address financial strain directly [21].

The Confidently Navigating Financial Decisions and Enhancing Financial Well-Being in Dementia Caregiving (CONFIDENCE) intervention was developed to reduce financial stress and lower Latino caregivers’ out-of-pocket spending on care costs by displacing such spending with community and informal resources and facilitating help-seeking behaviors (personal communication by Dr Kylie Meyer, 2024). This study aims to test the acceptability of its pilot program using Sekhon’s theoretical framework of acceptability (TFA) as a guide [20]. Evaluating acceptability can identify factors affecting adherence, execution, and outcomes, facilitating necessary adjustments to the intervention’s design to boost its practicality and acceptance. The TFA breaks acceptability into 7 validated components: affective attitude, burden, perceived effectiveness, ethicality, intervention coherence, opportunity costs, and self-efficacy, defined further in Multimedia Appendix 1. We selected this framework to guide our study because it provides a comprehensive structure for assessing emotional, cognitive, and practical dimensions of intervention acceptability. Given the strong influence of cultural values, caregiving expectations, and financial vulnerabilities within Latino communities, it was important to use a framework that could not only capture general satisfaction with the program but also be in alignment with participants’ values and perceived burdens. The TFA’s multidimensional focus makes it well-suited to evaluate culturally tailored interventions like CONFIDENCE.

This study used qualitative and quantitative methods to examine the perspectives of Latino communities caring for persons living with dementia who participated in CONFIDENCE. Data were collected through in-depth, semistructured qualitative interviews (n=14) and a 14-item quantitative satisfaction survey (n=27). The TFA guided the study design, including the interview guide, coding, and interpretation processes [20].

We applied thematic analysis to examine interview transcripts [26]. Codes were devised to address each component of acceptability from Sekhon’s TFA, facilitating triangulation between qualitative findings and survey responses (Table 2). Four research team members (SM, RAR, DS, and KM) independently coded transcripts using NVivo (version 1.7.1; Lumivero). After initial coding, the team met with the lead coder (SM) for peer debriefing sessions. Discrepancies identified were resolved through discussion after each round, leading to iterative refinements of the codebook. As new codes were identified, like those related to culture, they were incorporated into the codebook and retrospectively applied to earlier transcripts. New codes and unresolved discrepancies were discussed with KM, who was available to adjudicate coding disagreements; however, no such adjudication was ultimately required. To assess participant satisfaction, we summarized survey responses using means and percentages.

The University of Southern California institutional review board (IRB) reviewed the study protocol and issued an exempt determination (UP-23‐00020) for the secondary analysis of deidentified data. Data collected from the primary study were approved under 2 separate protocols by the Case Western Reserve University IRB: an expedited protocol (STUDY20221010) for caregivers enrolled in the optional pre- and posttest study and an exempt protocol (STUDY20221415) for caregivers completing the CONFIDENCE program outside the pre- and posttest study. Caregivers who were eligible for the pre- and posttest study provided written consent to participate prior to enrollment. For participants not enrolled in the study who were invited to complete the satisfaction survey, consent was implied upon survey completion following a review of an information sheet. Caregivers who participated in qualitative interviews gave verbal consent after reviewing a study information sheet. All consent forms and information sheets stated that deidentified data may be retained for future use. The University of Southern California IRB did not require additional consent for the use of deidentified data shared from Case Western Reserve University. Participants in the optional pre- and posttest study received up to $25 USD in Amazon gift card value, which included compensation for completing the satisfaction survey. Caregivers who participated in a qualitative interview received a $25 USD gift card, and those not enrolled in the study but who completed a satisfaction survey were given the option to provide their email address to receive a $25 USD gift card.

In total, 14 Latino caregivers of persons living with dementia participating in CONFIDENCE between May 2022 and September 2023 consented to an interview following completion of the program (Table 3); 11 (79%) in English and 3 (21%) in Spanish. The mean age of participants was 60 (SD 7) years. Most were women (95%). Nearly two-thirds (64%) had attended at least 3 CONFIDENCE sessions; roughly half (44%) completed all sessions.

Interview findings revealed four key themes: (1) perceived need for financial intervention, (2) perceived effectiveness of the intervention, (3) positive responses to participation, and (4) recommendations to improve the intervention.

Theme 2 reflected the TFA’s categories of “perceived effectiveness” and “self-efficacy” [20]. Analyses of interview transcripts indicated that participants believed they acquired new knowledge and skills to help them manage their financial situation.

In alignment with the “ethicality” and “affective attitude” TFA domains [20], caregivers expressed a favorable opinion toward the intervention, indicating that it aligned well with their values and could benefit other caregivers.

Caregivers were asked to reflect on their experiences and provide feedback, offering insights into potential modifications and improvements to the intervention. This feedback elucidated potential “burden” and “opportunity costs” [20] associated with participation.

Following the intervention, 27 of 69 (39%) caregivers who participated in the CONFIDENCE program completed satisfaction surveys. Most were women (78%) and lived with the care recipient (70%), 74% were children or children-in-law, and 26% were spouses or partners. In total, 25 (93%) respondents identified that they had served as the primary caregiver for over 2 years. Near half (41%) provided 15 or more care hours per week; 48% were employed. Additional respondent characteristics can be found in Table 4.

Caregivers expressed high satisfaction with CONFIDENCE’s content, setting, and delivery. All respondents (27/27, 100%) agreed (ie, responding “agreed” or “strongly agreed”) that they would recommend the program to all caregivers and specifically to Latino caregivers. All respondents (27/27, 100%) agreed that the information presented was trustworthy and applied to their caregiving situation and that they felt comfortable sharing personal experiences and financial details. Nearly all caregivers (26/27, 96%) enjoyed participating in the program and found the content easy to understand. Most respondents (25/27, 93%) found CONFIDENCE easy to access via Zoom, with nearly 90% (24/27, 89%) responding that it was convenient to attend the group discussion sessions. Additionally, most respondents (25/27, 93%) agreed that take-home assignments added to their learning. A full summary of the survey results is presented in Figure 1.

This study examined the acceptability of a financial psychoeducation program, CONFIDENCE, for Latino caregivers of persons living with dementia by assessing its perceived value, effectiveness, and participants’ overall satisfaction. Feedback was gathered on the program’s structure, relevance, most beneficial aspects, and suggestions for improvement. Caregivers endorsed the program, reporting increased financial awareness and high satisfaction with its content and delivery. Quantitative survey data corroborated qualitative findings, indicating that caregivers found the intervention engaging, understandable, relevant, and trustworthy (Figure 1). The use of an underlying framework (Sekhon’s TFA) facilitated the evaluation of the overlap between qualitative and quantitative findings. Survey responses and interviews reflected comfort and willingness to discuss caregiving experiences and financial situations. In addition, participants shed light on areas of the intervention that might need modification or improvement.

Caregiver interventions seldom address financial well-being [27], despite evidence that most caregivers are unprepared for health care expenses not covered by insurance. The CONFIDENCE program targeted caregivers from the Latino community who generally experience even higher levels of financial strain than the average caregiver population [3]. Content for the CONFIDENCE financial psychoeducational intervention was developed based on interviews with Latino caregivers and iterative feedback from a community advisory board. These strategies followed best practices in culturally tailoring interventions and likely enhanced the program’s acceptability by ensuring that content was relevant to caregivers [28-30]. CONFIDENCE also incorporated proven strategies such as service systems and resource navigation, financial education, and asset-building to alleviate financial strain and enhance financial well-being [27].

Despite different content and aims, caregiver satisfaction reports align with findings from the literature, highlighting the benefits of group-based programs for interactive problem-solving regarding preparing for the future, identifying and reorganizing the support team, and self-care [31]. Findings of high satisfaction suggest the perceived value of interactive problem-solving among caregivers, resonating with results from similar interventions for caregivers [31-33]. Communication skills training is considered essential for caregivers, as it helps strengthen emotional connections with other caregivers, family, and friends [34]. Including this type of training in CONFIDENCE fostered relationships and understanding between the caregivers during group sessions—and with their network of friends and family outside of the intervention to promote help-seeking behaviors. Active participation and skill-building increase financial and self-confidence among caregivers, supporting the TFA [20].

Previous studies have established the appeal of web-based interventions for family caregivers [32,33,35]. Although previously reported challenges of web-based interventions, like time constraints and scheduling conflicts, were also found in this study, participants were satisfied with the overall design. Like other digital group-based interventions, such as TeleSavvy, CONFIDENCE prioritized mental health, which helps create a safe, positive learning environment [36]. Mirroring the advantages of such programs, the hybrid model blended web-based group interactions with the flexibility of asynchronous delivery. Our research supports findings that peer support is beneficial for managing the complexities of financial well-being among caregivers, as it encourages open discussions on financial issues, enhancing the group’s collective problem-solving capacity [31,32]. CONFIDENCE’s flexible format, which allows caregivers to engage with materials at their own pace, was well-received and well-suited to varying schedules. The design facilitated independent learning, underscoring the effectiveness and practicality of self-paced learning models.

Findings indicate that CONFIDENCE is an acceptable culturally tailored financial education program for Latino caregivers, a demographic with higher-than-average out-of-pocket care costs and a greater likelihood of limited formal financial engagement [3,37]. Latino caregivers may also face unique financial strains, often shouldering out-of-pocket expenses not covered by Medicare or Medicaid [7,11]. The US Latino population is both increasing and aging, adding to increases in dementia. Combined with lower use of formal care services and barriers to accessing care, overall expenses for Latino persons living with dementia and their caregivers are expected to increase at a faster rate than for non-Latino persons living with dementia [7,9]. There is a need for culturally targeted financial programs to address their higher levels of out-of-pocket costs [21,22,38].

Research acknowledges the importance of culturally informed support for caregivers belonging to communities where caregiving is heavily influenced by ethnic identity and cultural values [10,11,38,39]. However, many existing programs fail to meet the unique needs of diverse ethnic groups [21,40]. Preparing families to navigate available resources and financial decisions could mitigate financial risks while aligning with cultural norms about caregiving within the Latino community [7,11]. CONFIDENCE addresses the unique challenges of juggling caregiving with financial duties while acknowledging the preference for in-home care. Caregivers in this study reported that the program addressed the needs of Latino family caregivers by providing strategies to manage high costs, such as communicating with other family members and acknowledging cultural norms around caregiving financial decisions.

Despite enthusiasm for the program, lower-than-expected attendance and completion rates suggest that caregivers may experience time barriers to participation [33]. Previous research suggests that live-in caregivers with intense caregiving duties lack time for web-based interventions [31]. Shorter or fewer sessions may increase participation and commitment. Further, paralleling other web-based studies, technical difficulties, audio issues, and schedule clashes impacted user experience and potential program adoption [33]. Caregivers also encountered logistical challenges that hampered their ability to complete assignments. Helping caregivers identify strategies to complete homework could foster greater program acceptance and treatment adherence. Examining participants’ expectations before delivering the program may benefit future implementations of CONFIDENCE [41].

Despite high acceptance levels among respondents, only 39% of caregivers who completed the CONFIDENCE intervention answered satisfaction survey questions. Moreover, the investigators did not record data on the proportion of participants who accepted qualitative interview invitations. A high nonresponse rate and lack of information about the qualitative response rate hinder a comprehensive assessment of caregiver experiences, as it is unknown whether survey completers had similar experiences to noncompleters. Future studies should prioritize strategies to enhance survey completion rates for a more representative analysis of the intervention’s impact, including providing a payment incentive for satisfaction surveys. The demographic composition of our sample also presents limitations. Most participants were women, such that male caregiver perspectives may not be adequately represented.

Additionally, most sessions were delivered in English, and most caregivers chose to complete interviews in English. A deeper analysis of language preferences and cultural differences could provide valuable insights. Coding in Spanish could uncover subtleties that go unnoticed, thus capturing nuances lost in translation and enriching the depth of our findings. Finally, while web-based delivery offers the benefit of reaching caregivers across geographic regions, it imposes a constraint by requiring a certain level of technological proficiency, restricting who can participate. Our study may not capture the acceptability experiences of caregivers without internet access, whose perspectives on financial circumstances may differ.

Finally, variation in session attendance and the voluntary nature of participation in surveys and interviews may have introduced self-selection bias. Participants who completed the evaluation components may have been more motivated or held more favorable views of the intervention. Missing demographic data in some survey responses further limits the ability to fully characterize the participant population. These factors should be considered when evaluating the generalizability and transferability of findings to the broader Latino caregiver population.

Findings from this study suggest that the CONFIDENCE intervention is acceptable to Latino caregivers of persons living with dementia who seek to enhance their financial well-being and reduce out-of-pocket caregiving expenses. They also identified areas of improvement to make the program more accessible and more effective. This study contributes to the small but growing body of research on financial interventions designed to support caregivers, particularly within the Latino community. These caregivers have a higher risk of poor financial health while providing care, especially considering the rising rates of dementia among the Latino community [42]. Using culturally relevant psychoeducational interventions can enhance financial resilience and address the disproportionate costs borne by Latino caregivers.