Training and support for caregivers of people with dementia: The process of culturally adapting the World Health Organization iSupport programme to Portugal

Reading-level adjustments

Portuguese informal caregivers have low to intermediate education levels which is in line with international trends (Barbosa & Matos, 2014; OECD, 2011). According to the Eurostat classification of educational activities based on the International Standard Classification of Education (UNESCO Institute for Statistics, 2011), a low education level include “Less than primary, primary and lower secondary education”, while an intermediate education level covers “Upper secondary and post-secondary non-tertiary education” (Eurostat, 2017). Barbosa and Matos (2014) found that informal Portuguese caregivers with more than 50 years of age have an average level of schooling ranging from 2.1 for co-residential caregivers to 2.8 for extra-residential caregivers, corresponding to low and intermediate education levels, respectively.

Accordingly, the translation and adaptation work required the adjustment of words and expressions to ensure the content accessibility to the target group. To be syntonic with this group, an informal and straightforward verbal style was used in the Portuguese version. Among the translation choices (e.g. synonyms), plain words were chosen whenever possible. More complex reformulations were required in some cases as no satisfactory synonyms were available to pass on the message on a plain language (e.g. “Practice listening without negative judgement” vs. the Portuguese and reading-level equivalent “Practice listening without being hard on yourself”). Moreover, the Portuguese translation from English and content adaptation expanded the text in 10.4%. Some sentences were minimally adapted from the original version to fit in two rather than one sentence in the Portuguese version, to avoid long and complicated phrases. The appropriateness of reading-level adjustments throughout the 23 lessons was globally well appraised by the expert panel (cf. Expert panel appraisal under Results section).

Conceptual and semantic equivalence

Since words and expressions often convey a different conceptual meaning or have multiple meanings across cultures, adjustments to local standards were needed to ensure that those were correctly interpreted. For instance, the word “lesson” in the source text is defined as “a period of time in which a person is taught about a subject or how to do something” (Cambridge dictionary). While having the same meaning in the target language, its use is typically reserved to formal education contexts (“Lesson: what the professor explains or the student must learn”; Priberam Portuguese dictionary). Therefore, the semantic equivalent “session” (Portuguese = “sessão”) was adopted, taking into account the intervention context. Also, the word “compassion”, extensively used in the source text to describe a strong feeling of sympathy, is commonly interpreted in the target language as being linked with religious practices, or as feeling sorry/pity for someone. If used to refer to people with dementia, the original term can be interpreted as having a depreciative tone. For that reason, the word “understanding” was used to replace it in the target text. The word “miserable” in the source text, meaning “extremely unhappy or sad”, does not have a direct translation into the target language. Some of the closest single-word equivalents like “infeliz” (unhappy) or “desafortunado” (unfortunate) do not necessarily carry the semantic traits expressing the same degree of sadness or unhappiness. In the adapted version, this word was eliminated as it appears in a context where sadness is already expressed (source text: “makes you feel angry, sad, happy, or miserable”). In another example, the expression “wash herself before breakfast” in the source text, used to describe the process of making oneself tidy and clean, would be interpreted strictly in the target language as “washing”. Thus, an equivalent word in the target language, “grooming” (Portuguese: “arranjar-se”), was used in alternative.

In addition to words or expressions conveying different conceptual meanings in the Portuguese language, conceptual equivalence was required in situations where for the source language a single word can describe a concept while the same does not occur in the target language. That was the case, for instance, of the words (incontinence) “pad”, “blender”, or the pronoun “you”. The latter is conveyed by different words in the target language depending on the formal or informal context of use (Portuguese: “tu”, “você”, “a senhora/o senhor”). The way to address someone is of great importance given that children and grandchildren of older adults living today in Portugal traditionally treat them using the formal tone since the informal could be interpreted as disrespectful. The inverse situation, i.e. the use of a single word in the target text to describe two or more words/concepts in the source text also occurred. For example, even though “taking a bath” and “showering” are two different concepts in both the source language and the target language, in practice, a single term is commonly used in the target language (Portuguese: “banho”) to refer to this action, whether the person is washing herself using a shower or a bathtub.

Additional work on conceptual equivalence relates to the institutionalised practices and services in the target culture. For instance, if considering the source text “care at home, in the community or a care facility”, we realise that “care at home” or “in the community” are different concepts in contexts where the model of life care communities is in practice. As this model is not established in Portugal, the concepts of “caring at home” or “in the community” are conceptually equivalents in the target language. On the other hand, in the Portuguese context, the concept of “care facility” might represent either a model of care delivery by the health care system (Units for Integrated Continuous Care) or by the social support system (residential solutions/nursing homes).

Personal names

Translating and adapting personal names is challenging and requires sensitive decision-making, especially in the absence of very clear translation guidelines for these contents (Pour, 2009). For the entire programme, 96 personal names of characters used in scenarios (42 male and 54 female names) were adapted to Portuguese names. As personal names are deeply rooted in the culture of the speakers of a language (Pour, 2009), the research team knowledge about cultural references and figurative use of language was a key element in this process. As this knowledge is eminently subjective, different procedures can be and were applied in the process of translating and adapting personal names. In this paper, the procedures are named according to the work of Fernandes (2006). The application of each procedure was balanced with a judgement on how common the personal name was in the Portuguese population, as framed by generational trends, i.e. if a character was an older person, how common was the name in the country at the time she/he was born. This judgement made use of national databases (e.g. Institute of Registries and Notaries).

A first approach to the translation and adaptation of personal names was the use of the copy strategy when the names in the source language exist in the target language. In those cases, the names are reproduced without any orthographic adjustment in the target text. This strategy was employed in 11 of the 96 personal names (e.g. Maria, Manuel, Marina). When the first strategy could not be implemented, a second approach – transcription – was used, i.e. the names in the source text were transliterated or adapted morphologically, phonologically, or grammatically to match the target language system. This was the case for nine names (e.g. Martha-Marta; Esther-Ester; Olivia-Olívia; George-Jorge). A third approach was to employ the strategy of phonological replacement, i.e. names in the target text were chosen to mimic phonological features of those in the source text. This strategy was used in most cases (67 names; e.g. John-João; Rosie-Rosa; Pablo-Paulo; Anne-Ana). In cases where no other strategy was possible, a formally or semantically unrelated name was used in the target text to replace another in the source text (substitution strategy). This strategy was used mostly to replace names with origin in Eastern languages (nine names; e.g. Wei-António; Xu-Luísa; Guoliang-Alberto).

Resources

In the scope of iSupport, resources can be understood as those contents referring to or redirecting the informal caregivers to: (i) additional information sources or materials; (ii) support services and specialised professionals in the local context; and (iii) technologies, products, or solutions that might be employed to address particular issues (e.g. weight loss).

The adaptation work resulted in the replacement of 14 links, either to webpages (12) or informative manuals (2). All original links are to pages and materials of Alzheimer’s Disease International. Those were relatively straightforward to replace by links to analogous pages, i.e. pages containing roughly the same information, from the national Alzheimer Association (Associação Alzheimer Portugal). However, finding alternatives for the informative manuals was challenging, as no direct equivalent was available in the Portuguese context. For example, while the e-manual “Help for caregivers” (WHO, 2006) is available in several languages, it has not yet been translated into Portuguese. Alternatively, Portuguese e-manuals targeting informal caregivers of people with dementia were mapped and their contents compared with those in the original e-manual. As a result, the e-manual “Manual do cuidador” (Alzheimer Europe & Alzheimer Portugal, 2006) was chosen as the most suitable alternative. Both pieces of information are comparable as they cover the same thematic contents, and points of comparison were detailed for the fidelity check process. In other two cases, however, several alternatives needed to be included in the Portuguese version to cover all contents approached in the original resource as no single equivalent resource was available.

Adaptations were also required concerning the reference to health or social support services available in the local context as well as the way to access them. For example, some of the recommendations in the source text are to consult a doctor to “check if the glasses prescribed to the person with dementia remain adequate” or consult the general practitioner to “identify loose teeth, ulcers or infections” due to difficulties in using the dentures. For the first case, it is more common in the Portuguese context to consult an optometrist or optician who is usually more accessible than ophthalmologists, both in terms of costs per consultation and waiting time. In the second case, consulting a dentist would be the most probable action. For each case, both alternatives were included in the target text in the interest of suitability to the local context. In addition, adjustments to text excerpts referring to the process of accessing a service were also required. For instance, in case of suspicion that a relative or friend might have dementia, the source text recommends to “call a medical doctor office and make an appointment”. In the Portuguese context, this procedure is associated with private medical practice as access to a specialised doctor through the national healthcare system, such as a neurologist, is done by referral from the general practitioner/family doctor.

Minor adaptations were proposed when the source text referred to technologies, products, or solutions that might be used to address particular problems (e.g. incontinence). While all of those mentioned in the source text are available in the Portuguese context (which might not be the case for certain countries), subtle differences were found regarding their use in care provision according to current local practices. Accommodating those differences never required the replacement of the presented solutions, but further detail was added in the target text to describe some of them. For example, while the source text refers to “commercial stir-in thickeners”, a more common recommendation in the local context would be “flavourless commercial stir-in thickeners” as a rejection of thickeners with flavour by the people with dementia is a common problem. Another example is the reference in the source text to “incontinence pads” with no further specification, while incontinence panties are currently the most recommended type of pad in the Portuguese context. Additions to the description of these solutions were mostly derived from the expert panel appraisal.

Cultural habits, customs, and traditions

A significant part of the adaptation work concerned the cultural equivalence of the Portuguese version, i.e. in adapting the original contents to capture the experience of daily life in the local culture. The need to find equivalents for cultural experiences, such as habits, customs, and traditions, was identified for several content categories including leisure activities, food, daily routines, customary practices, customary expressions, and religious practices. Those contents were adapted on the basis of cultural knowledge of the research team, and for specific topics, empirical studies carried with the Portuguese population were also used. This was the case for selecting the most popular leisure activities in the local context to replace those proposed in the source text (Instituto Nacional de Saúde Doutor Ricardo Jorge, 2017; Martins, 2010; Perista et al., 2016). For instance, activities such as “Watch birds or animals”, “Watch the clouds or explore nature”, or “Play a musical instrument” (source text) are not typical leisure activities performed by Portuguese middle-aged or older adults. Therefore, those were replaced with popular and culturally adequate activities such as “Have friends over to visit or visit friends”, “Go out to eat”, “Watch TV”, or “Shop for yourselves or others” (target text).

As gastronomy is deeply embedded in a country’s culture, references to food were adapted when needed. For instance, “having/inviting someone to have a cup of tea” from the British culture was replaced by “having/inviting someone to have a coffee” since in the Portuguese culture inviting someone to “take a coffee” is a customary expression for meeting someone to socialise. Other examples entailed the replacement of products/foods referred in the source text originating from the oriental culture, such as “noodles”, “rice cakes”, or “soy sauce”, products hardly found in a Portuguese kitchen/pantry, especially to be consumed by older generations.

The reference to cultural habits and daily routines also required, in some cases, adaptation work: for example, in the source text, the sentence “he/she may need someone to put out ingredients” (for preparing the breakfast) does make sense in a cultural context where breakfast is cooked, but it does not apply to Portuguese habits with a common breakfast including milk, coffee or tea, and bread. Other routines mentioned in the source text, such as “having dinner around 6 pm” do not fit the local context, where a common work schedule finishes at 7 pm and as a consequence dinner time is about 1–2 hours later.

Expressions that appeared in the source text referring to the mother-in-law as “mother” or saying that someone is “in his late 70 s” are not customary in the Portuguese culture, where “mother” is usually reserved to the person’s actual mother, and rather than the previous, the next age landmark is used (e.g. someone is “almost 80 years old”).

In addition, references to religious groups, practices, or habits were also adapted (e.g. resorting to a faith community for support; saying prayers before going to sleep; pray or meditate with the people with dementia). While approximately 85% of the Portuguese population reported being Roman Catholic, more than half claim not to be active participants of the church/faith community or to pray regularly (Luijkx et al., 2017). References to religious groups or practices were not eliminated in the target text but were given less relevance by using them as examples rather than highlighting them in the text, or by including disclaiming remarks such as “if this is a person’s habit and belief”.

Qualitative and quantitative appraisal

Most of the comments and suggestions that emerged from the qualitative appraisal carried out by the panellists were immediately accepted for proposal to WHO when concerning: (a) modifications of initial translation choices, including replacement of words by synonyms or minor sentences reformulations that did not alter in any way the meaning of the text and that were related with stylistic preferences or comprehensibility improvements and (b) additions to the adaptation work of contents similar in nature to those referred in the adaptation guide (cf. Cultural adaptation section).

In addition to the qualitative appraisal, the experts performed a quantitative evaluation of each lesson, covering five criteria (cf. Methods section). Table 1 presents the median scores per criteria and lesson, and the overall median scores per lesson.

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Table 1.

Expert panel appraisal: quantitative appraisal for each lesson of iSupport European-Portuguese version, across five parameters.

	Sensitiveness Mdn	Comprehensibility Mdn	Familiarity Mdn	Precision Mdn	Cultural adequacy Mdn	Overall appraisal Mdn
M1_L1	4	4	4	4	4	4
M2_L1	3.5	3.5	4	3	4	3.5
M2_L2	4	4	4	3	3.5	4
M2_L3	3.5	3.5	4	3.5	4	3.5
M2_L4	3.5	3	4	3.5	4	3.5
M3_L1	4	4	4	4	4	4
M3_L2	4	4	4	4	4	4
M3_L3	4	4	4	3.5	4	4
M4_L1	4	4	4	4	4	4
M4_L2	4	4	4	3.5	4	4
M4_L3	3.5	3.5	3.5	4	3	3.5
M4_L4	3.5	3.5	3.5	3.5	3.5	3.5
M4_L5	4	4	4	4	4	4
M5_L1	3	3	3	2.5	4	3
M5_L2	4	4	4	3.5	4	4
M5_L3	3.5	3.5	3.5	3	4	3.5
M5_L4	4	3.5	4	3.5	4	4
M5_L5	4	4	4	3.5	4	4
M5_L6	4	3.5	3.5	3	4	3.5
M5_L7	4	4	4	4	4	4
M5_L8	4	4	4	3.5	4	4
M5_L9	4	4	4	3.5	4	4
M5_L10	4	4	4	4	4	4

Note: Scores are given from 1 (lesson completely miss the parameter) to 4 (lesson fully contains the parameter). M = Module; L = Lesson.

Overall, no scores of 1 indicating the absence of the analysed quality were given to any lesson, by any expert, in the five criteria. The cultural adaptation work carried out by the research team was well rated by the panel. The contents subjected to cultural adaptation (phase 1) were considered “adequate, no need for revision” (Mdn = 4) for most lessons (n = 20). Three lessons were considered to be “adequate, in need for minor revisions” by two (Mdn = 3.5) or more experts (Mdn = 3) (cf. Table 1). Minor revisions concerned the adaptation of solutions to the local nomenclature and practices (e.g. the word “pad” refers not only the Portuguese equivalent to multi-layered sheet pads but also to another kind of pads, such as panties). While scores for the cultural adequacy of the adapted contents can be directly attributed to the adaptation work, scores given to the remaining four criteria do not necessarily mirror that work, i.e. scoring a lesson with 2 or lower, for instance, on the comprehensibility of contents, can be either attributable to less adequate translation/adaptation choices or to issues encountered in the original text. For that reason, the scores were crossed with the qualitative appraisal, and clarifications were requested when needed to discern among cases. For the entire programme, only a couple of suggestions for revision derived from translation/adaptation choices which were influential in the appraisal of the clarity and comprehensibility criteria.

Specifically, the language “sensitivity” was rated well for most lessons (Mdn = 4; n = 16), and seven lessons were appraised as “adequate, in need for minor revisions” (Mdn = 3 to 3.5) (cf. Table 1). All comments identifying revision needs for improving sensitivity were related to expressions used in the source text, and suggestions were made to use hedged language, e.g. (he/she) “is unable to” (source text) to (he/she) “shows difficulty in” (target text); or “this is not correct!” (source text) to “this is not a suitable answer!” (target text).

Similarly, the “clarity and comprehensibility” of contents, as well as the “familiarity” of terms/expressions, were well rated by the panellists in most lessons. A median of four (Mdn = 4) was obtained for 14 lessons regarding the first criteria and 18 lessons regarding the second. It was considered that minor revisions would be needed in nine lessons regarding comprehensibility and in five lessons regarding familiarity (Mdn = 3 to 3.5) (cf. Table 1). Most of the revisions identified as needed to improve either comprehensibility or familiarity were related to expressions used in the source text. Recommendations included: (i) replacing non-specific words such as “thing(s)” (e.g. “do the things he is still able to do”) by words naming tasks/objects or other context-specific words; (ii) introducing a few linguistic amplifications (Molina & Hurtado Albir, 2004) by means of providing examples to clarify potentially unknown expressions (e.g. replace “change from open-ended questions to closed-ended questions” by “change from open-ended questions (What have you done today?) to closed-ended questions (Did you have tea with Maria?)”); (iii) rephrasing sentences to improve their consistency with the message to convey in the text (e.g. in the lesson “shared decision-making” replace the sentences “Prepare instructions” or “Make sure you plan well for the future” by “Help preparing instructions” and “Make sure you plan well for the future together with the person”, in order to stress the shared nature of the process); (iv) eliminating the use of jargon (e.g. “This is often referred to as “sundowning”); and (v) clarifying the explanation of concepts (e.g. replace “Unreal thoughts and seeing things that aren’t there (delusions and hallucinations)” by “when the person keeps fixed false ideas or beliefs about the reality (delusions) or sees, hears, smells, tastes or feels thing that aren’t there (hallucinations)”).

Finally, in what concerns the “precision” criteria, most lessons (n = 14) were considered to be in need of minor revisions (Mdn = 3 to 3.5), while no need for revision was seen for eight lessons (Mdn = 4) (cf. Table 1). The first lesson on module five was the only one obtaining a median rate below 3 (Mdn = 2.5) for the precision criteria, which relates to theoretical and interventional discussions presented below. Most comments suggesting the improvement of concept precision or scenario presentations according to cultural lenses stemmed from the source text rather than from translation/adaption choices. Examples include: (i) sentences containing two or more concepts, but not clearly distinguishing among them (e.g. “Delusions and hallucinations: things a person sees or hears that are not there”, where only hallucinations are defined); (ii) unstraightforward examples illustrating the concepts (e.g. “Challenging behaviour: Kyla cannot remember who came to visit”, where not remembering might or might not be framed as a challenging behaviour according to theoretical point of views); and (iii) scenarios elements that can be interpreted as culturally inappropriate (e.g. elements suggestive of gender imbalance). As some comments made to the precision quality required more comprehensive changes, those were further debated in a consensus and adaptation validation round.

Consensus and adaptation validation round

One round per module was conducted to solve disagreements expressed by divergent comments along the texts from the experts. The rounds also allowed to discuss the suggestions of more in-depth changes (for instance, in scenarios) or theoretical and interventional issues raised by one or more experts. The purpose of expanding the typical goal of disagreement resolution to consensus rounds was to provide insights on the extent to which experts who did not suggest more in-depth changes or did not raise theoretical and interventional concerns would consider culturally adapted scenarios and/or culturally framed theoretical approaches and intervention practices as relevant to achieve in the Portuguese version. All issues taken to further discussion were solved in one round.

Only a few cases were related to disagreements: examples include deciding whether the expression “person living with dementia/(someone) lives with dementia” or “person with dementia/(someone) has dementia” should be adopted; and whether using the term “condition” or “disease” was more appropriate. These expressions were used interchangeably in the source text, whereas the second options were adopted in the target text by agreement of all experts. Other topics taken to discussion included changes in scenario descriptions (e.g. reformulations to minimise suggestions of gender imbalance) as well as in answer options for iterative exercises (e.g. replace the wrong answer “They should say to Feng that (…) if he continues to behave in this way, he will be sent to a long-term care facility” (source text) by “They should say to Feng that (…) if he continues to behave in this way, their sons-in-law will be angry with him” (target text)). Recommendations for changes having theoretical and interventional implications included, for instance, the case of making decisions in the best interest of the person with dementia, where the sentence (consider) “any relevant statement written when he/she did not have dementia (source text) was suggested to be replaced by “any relevant statement written when he/she was still able to make decisions”. In spite of their complexity, a consensus was easily reached about these and other similar issues, as most were raised by two or three experts.

Theoretical and interventional discussions

As stressed by Card et al., 2011, core elements of evidence-based interventions should not be changed, unless there is convincing countervailing evidence from a stage of information gathering in the adaptation process. Nevertheless, it is not always straightforward to discern which elements of an intervention are core or discretionary (Card et al., 2011). For the Portuguese adaptation of iSupport, theoretical and interventional discussions that emerged from the expert panel appraisal were translated into specific adaptation recommendations, documented in the adaptation forms, and subjected to a fidelity check, where the issue of whether adaptations were core or discretionary is addressed. For illustrative purposes, some of those discussions are described below.

The first issue that was raised and that had a consequential influence on the presentation of the programme lessons, especially on module 5 – Dealing with challenging behaviours, was related to whether the expression “challenging behaviours” should be employed as an umbrella for a set of symptoms and common issues in dementia cases. In the generic version of the programme, this is the case for memory loss, aggression, depression or anxiety, difficulty sleeping, delusions and hallucinations, repetitive behaviour, wandering, and poor or decreased judgement. The underlying theoretical question relies on what can be framed as “challenging behaviour”. A challenging behaviour can be defined as broadly as a “behaviour of such an intensity, frequency or duration as to threaten the quality of life and/or the physical safety of the individual or others and is likely to lead to responses that are restrictive, aversive or result in exclusion” (Royal College of Psychiatrists, 2007). The same behaviour, however, may be considered challenging in certain contexts or cultures but not in others, and professionals/researchers can also disagree about whether a behaviour is challenging. For instance, the National Institute for Health and Care Excellence refers to challenging behaviours as those including aggressive, destructive, disruptive, self-injurious, and sexually harmful behaviour (National Institute for Clinical Excellence (NICE), 2015). The institute stresses, for example, that while sleep difficulties of the care receiver can be very challenging for caregivers, it is not the poor sleep that is challenging, but the behaviour occurring when the person would normally be asleep (NICE, 2015). The Portuguese expert panel showed to be more aligned with this strict understanding of the concept, which excludes, for example, difficulty sleeping or memory loss, this last understood as a cognitive symptom. In alternative, the expressions “behaviour change(s)” or “changed behaviour(s)” were proposed for the Portuguese version. The debate also focused on whether forgetting something is actually a behaviour (e.g. “Challenging behaviour: Kayla cannot remember who came to visit”; source text). A broader interpretation of behaviour as “an organism’s activities in response to external or internal stimuli, including objectively observable activities, introspectively observable activities, and nonconscious processes” as opposing to a strict interpretation as “any action or function that can be objectively observed or measured in response to controlled stimuli” (American Psychological Association, 2018) appears to be at stake.

An additional theoretical discussion raised by the panellists concerned the issue of advance directives covered in the programme (Module 2), in particular, the statement that relevant written declarations from “when he/she (the person with dementia) did not have dementia” (source text) should be taken into account. It was the panel’s understanding that first, establishing with enough certainty when the person developed the first symptoms of dementia is tricky as those are frequently confused with normal ageing; and second, it is also questionable to use the diagnosis of dementia as a landmark, especially when the mean duration from the onset of dementia-related symptoms until the diagnosis may range from one (Wilkinson et al., 2004) to three years (Speechly et al., 2009). Even though this is a controversial issue, the experts argued that it seemed more reasonable and aligned with the local approach to assume a perspective that advance directives should be completed while the person still has “legal capacity”, which is not conflicting with the disease having been already detected. For the Portuguese version of the program, the original statement was suggested to be replaced by (consider any relevant statements written) “when he/she was still able to make decisions”.

Further theoretical considerations concerned the definition of concepts like hallucinations as “things a person sees or hears that are not there” (source text); or wandering as “walking around a lot” (source text). On the first case, it was considered that in spite of being well known that auditory and visual hallucinations are the most common, the definition omits that hallucinations may affect any of the senses; while the second definition was considered little informative, being proposed to be replaced by “seemingly aimless ambulation” (target text).

Concerning interventional considerations, i.e. to what extent intervention practices described in the programme are aligned with common practices in the local context, the panel raised minor questions on specific recommendations made throughout the lessons. Adjustments proposed consisted mostly in adding disclaimers on the original recommendations. For instance, when a timetable is used to remind the people with dementia to drink throughout the day, add statements for discouraging drinking after 6 pm; when flexibility is recommended about mealtimes in case the people with dementia needs/wants to rest, add a statement on the need to guarantee that the person does not spend too many hours without eating; or when it is recommended that artificial dentures are cleaned when needed, prefer the alternative of doing it on a regular/daily basis, in line with local standards.

Finally, particular elements from scenarios were discussed. For instance, a couple of scenarios were viewed as suggesting gender imbalance, since they depict care responsibilities (and consequences) as relying on women who are relatives-in-law of the people with dementia (e.g. daughter-in-law), when a blood relative (son) or a spouse (husband) is present and available. While this is plausible to happen in the Portuguese culture, the message conveyed was considered undesirable and affecting the acceptability by the target group. In another scenario, trying to convey the message that a person with dementia should never be threatened, the illustrative menace is sending the person to a long-term care facility. Again, in spite of being a plausible situation in the local context, it may inadvertently support negative stereotypes linked to institutional care. For each theoretical and interventional discussion raised, concrete alternatives were proposed and later appreciated by the programme authors.