Introduction The Kawa model was developed by a Japanese occupational therapist Iwama (2006) in order to address the collectivist

This poster was designed to analyse a case study of Rani*using the Kawa model. Rani was diagnosed with Alzheimer’s disease culture of Japan. However, it has been successfully used with other collectivist and individualist cultures since. The model,
which is the most common condition under the dementia umbrella term, causing decline in the brain function. The condition translating as a “river” from Japanese, uses the metaphor of the river to represent one’s life journey, starting from the
manifests itself in significant difficulties with speech, cognition, memory and physical function. It is a progressive disease with mountains at birth and ending in the ocean (De Jonge and Turpin, 2019).
symptoms becoming more severe with time, causing considerable changes in the lives of the person with dementia and their The Kawa model Five Kawa model elements
family (Alzheimer’s Society, 2020).
*Pseudonym has been used The river flow is shaped by various o River flow and water - represent the life
surroundings as it flows through, just as a journey and priorities.
person’s life journey is shaped by o Riverbanks and walls – represent contexts
Case study: and environments.
Rani is a 75-year-old woman who has been referred to a memory clinic to see an occupational therapist. Rani was diagnosed different contexts and environments.
Using this model a river is drawn, while o Rocks - represent obstacles and challenges.
with Alzheimer’s disease a year ago. Her family have requested for an occupational therapist to assess Rani at home and to o Driftwood – represents influencing factors
discuss what can be done to help Rani and her family as they have been finding it increasingly difficult to care for her. Originally illustrating various elements that provide
a better understanding of the person and (material and immaterial) such as values,
from North India, Rani moved to the UK with her husband fifty years ago. They live in a two-bedroom council-owned flat in beliefs, family and wealth.
London. Their two children work full-time; however, they are very much involved in their mother’s health needs and try to help their life journey. The main focus of the
model is to promote the spaces between Adapted from: o Spaces between rocks - represent
as much as they can. They children have been concerned about the well-being of their father and the difficulties he has been https://www.pinterest.co.uk/pin/ opportunities for enhancing the flow
experiencing with looking after Rani, especially with washing, being woken up through the night, difficult behaviour and obstructions that impede on the life flow, 612278511820368569/

anxiety. There have been a few incidents of Rani wandering off and leaving the flat when the husband was in the kitchen. The thus providing opportunities to restore It is said that in order to depict the client’s true aspirations or barriers, the
children would like to discuss options that are available in the future as they feel their dad is experiencing a carer burnout and and increase the client’s life energy. An river needs to be drawn by the client themselves (De Jonge and Turpin,
may not be able to care for Rani soon. A home visit has been booked for an occupational therapist to meet with Rani and her occupational therapist can use this 2019). However, the client may not always be able to draw or provide a
family. model to enhance occupational narrative due to the cognitive or physical barriers experienced, in which case
performance by learning of the strengths the therapist may need to complete the drawing through the relative’s or the
and difficulties the client is experiencing significant other’s description, which may not truly capture the client’s
in their daily life (Teoh and Iwama, 2015). challenges and aspirations. Constructing a narrative through the use of the
Social context
Rani lives with her husband and has two adult children who v People with dementia may often experience feelings of Kawa model may prove to be time-consuming due to the detail required.
are very involved in her care and visit frequently. She has been loneliness and depression and maintaining social connections
attending and volunteering at the Hindu temple for a number through a number of activities and social engagements can
of years which allowed Rani to develop friendships and build a increase their well-being and bring a sense of belonging and a
close support network. The husband had also admitted that feeling of “connectedness” (Van Vliet et al., 2017).
ever since the diagnosis, they do not go out as much. v Due to relationships often being consumed by the carer role,
Kawa model carers participating in activities together with dementia
• Social context - Riverbanks and walls patients can improve the quality of the relationship and
• Rani’s supportive family - Driftwood provide an opportunity to connect with individual interests
• Enjoyment from helping in the community - Driftwood and to maintain a sense of “self” (Conway et al., 2018).
• Abstaining from social activities recently - Rocks v An occupational therapist could advise and provide
How to create spaces? information to Rani and her husband of activities they could
v An occupational therapist may want to discuss how Rani’s do together, such as cooking classes, art and music therapy,
children can further support their dad to care for Rani by reminiscence therapy, attending local places of worship,
taking her out for walks and bringing cooked meals. exercise classes, meeting friends and going for walks (Social Adapted from: https://www.sutori.com/story/kawa-model-origins--AJdjR9yD75FyoPxjgZdipay5
Care Institute for Excellence, 2015).
v The traditional role of Indian women in the family has meant that women have taken lesser hierarchical roles to husbands,
Cultural Context: placing greater importance on the needs of others (Chadda et al., 2013).
• Originally from North India, Rani immigrated to the UK with her husband 50 years ago. v There is a strong cultural focus for children to care for their elderly parents (Cipriani and Borin, 2015). However, Rani’s children
• She maintained a very close connection with her religion and the local Hindu community. were born in the UK and having full-time jobs believe that the specialist dementia care facilities will be best in the future.
• When children left home, Rani volunteered at the Hindu temple once a week preparing and serving meals. v Evidence shows that there is a limited awareness of dementia in India with the belief of it being a “normal” aging process but with
• Rani has been a housemaker throughout her life, taking pride and enjoying looking after her husband and children a tendency for carers to keep the diagnosis “hidden” from the community (Cipriani and Borin, 2015).
The Kawa model v It would be necessary for an occupational therapist to explore the extent of stigma attached to this diagnosis in Indian community
• Rani’s culture including religion - Riverbanks; • Possible lack of awareness and stigma of dementia - Rocks and further discuss with the family of ways to increase Rani’s life flow by creating opportunities for her to enjoy activities and to
How to create spaces? access the right services (Social Care Institute for Excellence, 2015). This would include attending temples, finding ways to
v Understanding the cultural elements can create an opportunity for an occupational therapist to find continue helping and contributing to the community and meeting with friends and family.
motivating factors and gain insight into what Rani and her family consider meaningful and valuable. v It would also be helpful to consider the effect Rani’s condition has had on her husband too. Notably, the change of roles in
v Hinduism is a predominant religion in India and participating in religious events and helping others within the community connection to the cultural “norms” and ways to alleviate the carer burden through help from the family and social care. This will
is considered a large part of Indian culture (Cipriani and Borin, 2015). be further discussed in the section below.

Physical context:
Political and economic contexts
• The couple share a two-bedroom council-owned flat on a second floor, with external stairs and no lift access.
Kawa model:
• Rani spends most of her day in the living room with her husband watching TV, listening to music and eating. • Children seeking for mum to be moved to a
• Political and economic context - Riverbanks and walls
• Her husband assists Rani with most of her daily tasks but finds washing particularly difficult. dementia care home in the future - Rocks
• Council property design not suitable for an ageing/person
• Rani has a shower daily in a step over bath, during which she has to hold on to her husband’s hand.
• Rani’s husband is also complaining of a backache and exhaustion as Rani frequently wakes up through the night. with dementia - Rocks
How to create spaces?
• Although the flat is quite spacious, the kitchen is small and is separated from the rest of the flat. Rani often gets
agitated when her husband is cooking and is out of sight. v It is estimated that just under 1 million people are living with v Rani’s husband and family will be able to request an
• Rani had wandered off on a few occasions when the husband was cooking. Dementia in the UK (Alzheimer’s Society, 2014), with women assessment for social care at home and a separate carer
making up two-thirds of the dementia population due to assessment, which may offer additional support such as
Kawa Mode longer life expectancy and gender-specific social respite care, day centre, dementia carer support groups
determinants, such as a low-paid employment and poor and counselling (Alzheimer’s Society, 2020).
• Physical environment - River banks and walls • External stairs and absence of lift - Rocks education (UCL Institute of Health Equity, 2016). v The Mental Capacity Act 2005 was designed to support
• The bathroom and kitchen - Narrowing of the river • Living room where couple spend most of their day v Dementia is said to cost the UK £26 billion per year. people with dementia to ensure they have every
• Closed off kitchen design (wall) and a bath tub - Rocs together, watching TV, eating and listening to music - v Approximately two-thirds of people with dementia are living opportunity to make their own decision about their
• One-level living with a spare bedroom - Driftwood The wide part of the river at home with one in three people are said to care for care. However, if Rani is assessed lacking capacity on a
• Rani’s condition including anxiety, difficult behaviour, • Living in London with access to multiple amenities- someone with dementia in their lifetime (Department of particular aspect of her care, the family may decide to
wandering off and waking up at night - Rocks Driftwood Health, 2015). apply for a decision to be made “in her best interest”.
v The Prime Minister's Challenge on Dementia 2020 (2015) v While in the early stages of dementia, Rani may also
How to create spaces? states that by 2020 there will be an increased focus on choose to appoint a person she trusts to have a Lasting
people living in their own home, and more dementia- Power of Attorney who will be able to make all decisions
v An occupational therapist would need to consider parts of the home that promote occupational participation as well friendly communities will be created. about her care in the future (Social Care Institute for
as those that the family find challenging in their daily life. v In support of independent living and where home Excellence, 2017).
v Modifications in the bathroom such as grab rails of contrasting colours (Alzheimer’s Society, 2017), a bath board and a adaptations are insufficient or financially not feasible, Rani’s v The Race Equality Foundation Briefing Paper (2013)
non-slip mat to enable Rani to wash safely and ensure maximum independence can be recommended. Other family could apply for sheltered or extra care housing (Social states that despite the increasing evidence of higher
adaptations such as a bath lift or a walk-in shower would need to be considered by an occupational therapist in the Care Institute for Excellence, 2019). prevalence of dementia in Black and Asian UK
future as the condition progresses, but would be a question of affordability and assessment with the social services v The Care Act 2014 was introduced stating new duties on local population, very little research has been done on this
(Mandelstam, 2016). authorities with regards to eligibility to social care, payments, topic. The evidence suggests that understanding of
v Due to people with dementia experiencing the environment differently, changes at home may become crucial in considering the well-being of carers and the opportunity to dementia is limited and highly stigmatised in many black
helping Rani to lessen the anxiety and confusion and make her home more dementia-friendly; request a direct payment for social care needs. and ethnic minority communities. Thus, a culturally
v This may include using colour contrast for walls, floor, furniture and doors, improve lighting, assesses for shadows, v Depression and social isolations are two most common issues appropriate approach from the awareness to the end-of-
patterns and remove unnecessary mirrors as these may cause further confusion and anxiety (SCIE, 2015). that affect the carers of dementia patients, and can in turn life care support to reach these communities is needed
v In contrast, the effect of home modifications would also need to be considered in relation to the husband. Studies cause carers mental health disorders (UCL Institute of and can prevent residential care admissions and
show that carers who cohabit with a person with dementia are more likely to suffer from depression, with the home Health and Equity, 2016). be more cost effective in the long run.
design playing a significant role in the well-being of the carer (Pierce et al., 2015).
v A qualitative study by Kallitsis et al. (2018) found that live-in carers often found the meaning of their home changing Creating spaces through the virtual context
since becoming carers and needed their own space within the home. This finding could be useful in order to discuss
creating a separate space for the husband. The same study also found that an open-space dining allowed for more v Using technology to be creative through the use of online applications. Rani could use online applications to draw, create
accessible care, especially with the condition progressing. Universal design is said to be the most sustainable housing music lists, photobooks or use online reminiscence therapy (SCIE, 2017). A systematic review of touchscreen interventions
option; however due to profitability concerns overarching any social benefits, such properties are often limited conducted by Tyack and Camic (2017) found that such interventions have multiple benefits on the well-being of a person
(Soilemezi et al. 2017). with dementia, including contributing to feelings of accomplishment and pride. However, inclusion criteria meant that
v Behavioural symptoms in people with dementia can sometimes occur due to unsatisfying interaction and a lack of there was no clear differentiation on the participants’ stages of the disease. Therefore, it would be hard to conclude on
sensory stimulation (Jacob and Collier, 2017). Considerations could be made to provide a multisensory stimulation for how appropriate this intervention is once Rani has progressed into the middle and later stages of the condition.
Rani through daily activities and within the home environment. This could include activities such as kneading the v Online support groups and forums for Rani’s husband. Caring for someone with dementia can be challenging and
dough or involving Rani in prepping an easy dish in the living room. Displaying photos or creating a reminiscence book demanding with often little time left for carers to access community for support due to the carer demand. A systematic
that will encourage her long-term memory and prompt discussions can be helpful (SCIE, 2017). review for online support has been conducted by Hopwood et al. (2018) on 40 studies. The study showed that online
vAssistive technology such as automatic lights, alarm systems (telecare), wander guards, reminders and tracking devices support groups had multiple advantages such as peer support and provision of information; however, due to the multiple
can also promote safety and autonomy for Rani and give reassurance to her family (Alzheimer’s Society, 2017). components of interventions it was challenging to demonstrate which intervention was most successful.

Alzheimer’s Society (2014) Dementia UK: Update, 2nd ed, London: Alzheimer’s Society.
Alzheimer’s Society (2017) Making your home dementia friendly. Available at: www.alzheimers.org.uk/dementiafriendlyhome (Accessed: 17 April 2020).
Alzheimer’s Society (2020) Alzheimer’s disease. Available at: https://www.alzheimers.org.uk/about-dementia/types-dementia/alzheimers-disease (Accessed: 10 April 2020).
Alzheimer’s Society (2020) Types of equipment. Available at: https://www.alzheimers.org.uk/get-support/staying-independent/types-equipment (Accessed: 19 April 2020).
Chadda, R. et al. (2013) “Indian family systems, collectivist society and psychotherapy”, Indian Journal of Psychiatry, 55 (2), pp. 299-309. DOI:10.4103/0019-5545.105555 (Accessed: 15 April 2020).
Cipriani, D. and Borin, G. (2015) “Understanding dementia in sociocultural context: a review”, International Journal of Social Psychiatry, 61(2), pp.198-204. DOI:10.1177/0020764014560357 (Accessed: 20 April 2020).
Conway, E. et al. (2018) “Is it all bleak? A systematic review of factors contributing to relationship change in dementia”, International Psychogeriatrics, 30(11), pp.1619-1637. DOI: https://doi.org/10.1017/S1041610218000303 (Accessed: 23 April 2020).
Department of Health (2015) Prime Minister’s challenge on dementia 2020. Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/414344/pm-dementia2020.pdf (Accessed: 17 April 2020).
Harrison, M. (2020) Mental health occupational therapy. Available at: https://www.pinterest.co.uk/pin/612278511820368569/ (Accessed: 17 April 2020).
Hopwood, J. et al. (2018) “Internet-based interventions aimed at supporting family caregivers of people with dementia: systematic review”, Journal of Medical Internet Research, 20(6), DOI: 10.2196/jmir.9548 (Accessed: 23 April 2020).
Iwama, M. (2006) The Kawa Model; Culturally Relevant Occupational Therapy. Edinburgh: Churchill Livingstone-Elsevier Press.
Jakob, A. and Collier, L. (2017) “Sensory enrichment for people living with dementia: increasing the benefits of multisensory environments in dementia care through design”, Design for Health, 1(1), pp. 115-133, DOI: 10.1080/24735132.2017.1296274.
Kallitsis, P. et al. (2018) “Disabling Spaces and Special Strategies: Feminist Approaches to the Home Environment of Family Caregivers of People with Dementia”, Home Cultures, 15(3), pp.265-287, DOI: 10.1080/17406315.2018.1690293.
Mandelstam, M. (2016) Home adaptations: The Care Act 2014 and related provision across the United Kingdom, London: College of Occupational Therapists.
Murthi, K. (n.d.) Kawa Model: Origins. Available at: https://www.sutori.com/story/kawa-model-origins--AJdjR9yD75FyoPxjgZdipay5 (Accessed: 10 April 2020).
Pierce, M. et al. (2015) Research for Dementia and Home Design in Ireland Looking at New Build and Retro-Fit Homes from a Universal Design Approach: Key Findings and Recommendations Report”, Dublin: Centre for Excellence in Universal Design.
Race Equality Foundation (2013) Black, Asian and Minority Ethnic Communities and Dementia – where are we now? Available at:https://www.better-health.org.uk/wp-content/uploads/2018/03/health-30.pdf (Accessed: 27 April 2020).
Social Care Institute for Excellence (2015) Dementia-friendly environments. Available at: https://www.scie.org.uk/dementia/supporting-people-with-dementia/dementia-friendly-environments/ (Accessed: 18 April 2020).
Social Care Institute for Excellence (2015) Living with Dementia. Available at: https://www.scie.org.uk/dementia/living-with-dementia/ (Accessed: 23 April 2020).
Social Care Institute for Excellence (2019) Dementia and decision-making. Available at: https://www.scie.org.uk/dementia/supporting-people-with-dementia/decisions/ (Accessed: 23 April 2020).
Social Care Institute for Excellence (2019) Dementia and Housing. Available at: https://www.scie.org.uk/dementia/support/housing (Accessed: 20 April 2020).
Soilemezi, D. et al. (2017) “Exploring the Meaning of Home for Family Caregivers of People with Dementia”, Journal of Environmental Psychology, 51, pp. 70–81. DOI: 10.1016/j.jenvp.2017.03.007 (Accessed: 17 April 2020).
The Care Act 2014, c.23. Available at: http://www.legislation.gov.uk/ukpga/2014/23/contents/enacted (Accessed: 22 April 2020).
The Mental Capacity Act 2005, c.9. Available at: http://www.legislation.gov.uk/ukpga/2005/9/contents (Accessed: 23 April 2020).
Tyack, C. and Camic, C. (2017) “Touchscreen interventions and the well-being of people with dementia and the caregiver: a systematic review”, International Psychogeriatrics, 29(8), pp. 1261-1280. Doi:10.1017/S1041610217000667
(Accessed: 23 April 2020).
UCL Institute of Health Equity (2016) Inequalities in Mental Health, Cognitive Impairment and Dementia Among Older People. Available at: http://www.instituteofhealthequity.org/resources-reports/inequalities-in-mental-health-cognitive-impairment-and-dementia-
among-older-people/inequalities-in-mental-health-cognitive-impairement-and-dementia-among-older-people.pdf (Accessed: 20 April 2020).
Van Vliet, D. et al. (2017) “Felling useful and engaged in daily life: exploring the experiences of people with young-onset dementia”, International Psychogeriatrics, 29(11), pp. 1889-1898. DOI: https://doi.org/10.1017/S1041610217001314
(Accessed: 17 April 2020).