Understanding informal caregivers' motivation from the perspective of self-determination theory: an integrative review

Literature Review: Support for caregivers of children on the ketogenic diet for epilepsy and other neurologic disorders

Epilepsy affects millions of people and when medications are insufficient to maintain seizure control, individuals are diagnosed with refractory epilepsy (RE). Medical ketogenic diet therapy (KDT), a diet high in fat and low in carbohydrates and sufficient in protein, is a well-established treatment for RE. However, compliance is one of the main reasons for discontinuation of KDT and, with pediatric RE patients, the ability of informal caregivers, typically family members, to maintain diet adherence is vital for successful KDT treatment. The central role that informal caregivers play for effective KDT implementation is recognized, however, there is a need to elucidate the rationale and theoretical underpinnings of effective KDT caregiver support programs to inform best practices. Therefore, this systematic literature review aims to identify the existing fundamental understandings of KDT caregiver support to help build a foundation of theory-based knowledge to promote evidenced practice. After screening 137 publications, three studies that discussed potential underlying components of effective caregiver support were included in this review. These articles followed a similar approach as they 1) employed qualitative methods delving into caregiver needs, 2) findings highlighted the importance of support from family, friends, fellow caregivers and their child's medical team, and 3) the inclusion of caregiver support findings were a supplement to the main purpose of the manuscript. Research focused on KDT caregivers is in its infancy. There is a clear need for the systematic examination of support for KDT caregivers to build a foundation for effective support programs and to increase the access to quality support programming to foster KDT implementation, desirable patient outcomes, and caregiver well being. In this article we discuss opportunities to apply self-determination theory to the KDT caregiver support research and practice.

Intergenerational Caregiving Patterns and Cognitive Health among the Sandwich Generation Within Four-Generation Families

This study aims to investigate whether generational differences in intergenerational caregiving patterns (caring for parents only, caring for grandchildren only, and caring for parents and grandchildren simultaneously) are associated with cognitive health disparities among the sandwich generation within four-generation families, drawing upon the theories of intergenerational solidarity and intergenerational stake. Moreover, this study seeks to identify mediators that help explain these disparities. A nationally representative sample of 8,065 respondents was drawn from the 2011 and 2018 waves of the China Health and Retirement Longitudinal Study. The findings reveal that the sandwich generation caring for grandchildren only, as well as those caring for grandchildren and parents simultaneously, exhibit better cognitive health. However, caregiving for parents only is not significantly related to their cognitive health. This study identifies the inability to reduce depressive symptoms as a mediator explaining the insignificant association between caregiving for parents only and the cognitive health of the sandwich generation. The findings underscore the importance of offering support to the sandwich generation within four-generation families to enhance their cognitive health. Moreover, it is imperative to distinguish between different intergenerational caregiving patterns based on generational differences among the sandwich generation, with a specific emphasis on allocating public resources aimed at promoting cognitive health for those engaged in caring for parents.

Family carers' experiences and perceived roles in interprofessional collaborative practice in primary care: A constructivist grounded theory study

BACKGROUND

Chronic conditions can lead to physical, cognitive and social decline; thus, increasing an individual's dependence on family who assist with activities of daily living. Interprofessional collaborative practice (IPCP), involving two or more health professionals working with the patient and their family, is one model of care for the high-quality management of individuals with chronic conditions in primary care. Nevertheless, family carers have reported a disconnect between themselves and healthcare providers in previous research. This study aimed to explore the experiences and perspectives of family carers for individuals with chronic conditions, regarding their involvement in IPCP.

METHODS

Aspects of constructivist grounded theory methodology were used. Family carers of individuals with chronic conditions were invited to participate in a one-on-one, semistructured interview about their experiences with IPCP in the care of their loved one. Interview transcripts were analysed using Charmaz's four-step iterative process: (1) line-by-line coding, (2) focused coding, (3) categorisation of codes and (4) potential theme and subtheme development with memo writing to support each phase of analysis. The research team collaborated on reflexivity exercises, the conceptualisation of categories and the development of themes.

RESULTS

Constructivist data analysis of interviews (average 40 min) with 10 family carers resulted in two themes. (1) Stepping in for my loved one represents the notion that carers take on external roles on behalf of their loved ones (subthemes: working with interprofessional teams, supporting independence and learning as I go). (2) Taking on the carer role, represents the internal factors that influence the external roles described in theme 1 (subthemes: feeling obligated to be involved and changing relationship dynamics).

CONCLUSION

This study outlines the external actions and internal influences on family carer involvement in an interprofessional team. The required knowledge and support to care for their loved ones is currently learned in an ad hoc manner, and carers' resources should be better promoted by health professionals. Additionally, the relationship dynamics between a carer and their loved one change as the carer becomes more involved in IPCP and influences how and the extent health professionals involve family carers.

PATIENT OR PUBLIC CONTRIBUTION

Carers were the study population involved in this qualitative study. Patient advocates who have chronic conditions, and are informal family carers, were involved in the creation and design of this study, including a review of the research question, participant information sheet and the interview guide.

Impacts of Perceived Choice on Physical Strain, Emotional Stress and Health among Caregivers

BACKGROUND

Having no choice in becoming a caregiver has been associated with higher levels of emotional stress and physical strain. This secondary analysis examined associations between caregivers' perceived choice and health outcomes.

METHODS

This study utilized data from caregivers who answered a question about whether they felt they had a choice to take on caring for a care recipient in the Caregiving in the U.S. in 2020 survey. Variables of caregivers' and recipients' characteristics, caregiving activities, and health outcomes were extracted. Data were analyzed using descriptive statistics, t-tests, Chi-squared tests, and regression models.

RESULTS

More than half of the 1,642 caregivers (54.4%) perceived no choice in becoming a caregiver. Having no choice was associated with higher levels of physical strain and emotional stress, and greater negative impact on caregiver's health. Other predictive variables of higher physical strain included being a primary caregiver, recipients having more comorbidities, and a higher level of care intensity. Higher education level, household income, number of recipient's conditions, level of care intensity, and being a primary caregiver were associated with higher levels of emotional stress. Taking care of a spouse and non-relative compared to taking care of a grandparent or parent was associated with lower emotional stress. Recipients with more comorbidities and higher care intensity were associated with worse caregiver health.

CONCLUSIONS

There is a need to screen and identify caregivers who have no choice in caregiving and assist them in providing care for their recipient to prevent them from being invisible patients.

The impact of different care dependencies on people's willingness to provide informal care: a discrete choice experiment in Germany

BACKGROUND

Informal care provided by family members, friends, or neighbors is a major pillar in the German long-term care system. As the number of care-dependent older adults grow, ensuring their future care still relies on the willingness of family members, friends, or neighbors to assume the role of an informal caregiver. This study aimed to investigate the impact on people's willingness to provide informal care to a close relative with predominately cognitive compared to physical impairments.

METHODS

An online survey was distributed to the general population in Germany, which resulted in 260 participants. A discrete choice experiment was created to elicit and quantify people's preferences. A conditional logit model was used to investigate preferences and marginal willingness-to-accept values were estimated for one hour of informal caregiving.

RESULTS

Increased care time per day (hours) and expected duration of caregiving were negatively valued by the participants and reduced willingness to care. Descriptions of the two care dependencies had a significant impact on participants' decisions. Having to provide care to a close relative with cognitive impairments was slightly preferred over caring for a relative with physical impairments.

CONCLUSIONS

Our study results show the impact of different factors on the willingness to provide informal care to a close relative. How far the preference weights as well as the high willingness-to-accept values for an hour of caregiving can be explained by the sociodemographic structure of our cohort needs to be investigated by further research. Participants slightly preferred caring for a close relative with cognitive impairments, which might be explained by fear or discomfort with providing personal care to a relative with physical impairments or feelings of sympathy and pity towards people with dementia. Future qualitative research designs can help understand these motivations.

Motivation in Aphasia Treatment: Self-Determination Theory Applied to the FOURC Model

PURPOSE

Although the importance of motivation to successful rehabilitation is frequently acknowledged in the aphasia literature, little evidence-based guidance has been provided on how to support it. The purpose of this tutorial is to introduce a well-validated theory of motivation, self-determination theory (SDT); explain its role as the foundation for the FOURC model of collaborative goal setting and treatment planning; and explain how it may be applied during rehabilitation to support the motivation of people with aphasia.

METHOD

We provide an overview of SDT, explore the link between motivation and psychological wellness, and discuss how psychological needs are addressed in SDT and the FOURC model. Concrete examples from aphasia therapy are used to illustrate main concepts.

CONCLUSIONS

SDT offers tangible guidance for supporting motivation and wellness. SDT-based practices support positive forms of motivation, which is one of the targets of FOURC. An understanding of SDT's theoretical foundation will help clinicians maximize the impact of collaborative goal setting and aphasia therapy more generally.

[Informal caregivers in Germany: achieving work-life balance]

Informal caregivers are the main pillar of care provision in Germany. Almost a quarter of adults know a person who needs assistance or care. Caring for a person needing assistance is becoming an everyday task for more and more people. These demands must often be balanced with the requirements of work and/or care of underage children. Not only in this sandwich position informal caregivers neglect their own lives and endanger their health. The narrative review focuses on the challenges of reconciling care at home and work. In addition, the importance of informal caregiving as a relevant public health topic is discussed. A spotlight is placed on children in need of care and the particular demands of their caring parents. Current recommendations for a better reconciliation of care and work as well as for the recognition of relatives' valuable caregiving work provide an outlook on solution strategies that come from science and should be addressed by policymakers.

"Parenting my parents": Perspectives of adult children on assuming and remaining in the caregiver's role

Background

Family caregivers are essential when responding to the long-term care needs of aging societies. The complex and multifaceted caregiver's role encompasses a unique set of challenges and strains, however, it can be a rewarding experience with many benefits and positive outcomes. Moreover, there is a link between the caregiver's wellbeing, quality of care, and the quality of life of the care recipient. Thus, the current study aimed to explore why adult children are assuming and remaining in the caregiver's role despite its challenges.

Methods

Research data was collected through the use of qualitative semi-structured interviews from September 2021 to July 2022. In total 16 Lithuanian and Italian caregivers were recruited through convenience/snowball sampling. The study utilized the constructivist grounded theory for data analysis and self-determination theory for data interpretation.

Results

Adult children's caregiving experiences revealed three themes related to the motivation to assume and continue with family care: (1) believing in the inherent value of family care; (2) making sense of the changing nature of caregiving; and (3) "making the best of it". Key motivational drivers of these decisions were associated with the satisfaction of the three basic psychological needs - autonomy, competence, and relatedness. Results show that finding meaning and making sense of the caregiving role when responding to a parent's increased care needs may result in positive caregiving experiences and outcomes even at rather low levels of the care recipient's autonomy.

Conclusion

Caregivers were able to experience family care as a meaningful and rewarding experience while acknowledging its challenges and limitations. Implications for family caregiving decisions and experiences, social policy, and future research are discussed in more depth in the paper.

Burden, satisfaction caregiving, and family relations in informal caregivers of older adults

Introduction

Family caregivers of older persons devote much of their time and energy to caring for another person. This exposure may burden caregivers and compromise their health and quality of life.

Objective

To investigate the relationship between burden, sociodemographic, caregiving, and health characteristics of informal caregivers of dependent older adults.

Methods

Cross-sectional and analytical study carried out in Palmas, Tocantins, Brazil, with 52 informal caregivers of older persons who need full-time help for basic living activities. Caregivers' burden was assessed by Zarit Burden Interview (ZBI). Data were analyzed using a T-test, Pearson's correlation, and Multiple Linear Regression.

Results

The ZBI mean score of caregivers was 26.3 points (SD = 14.6; min = 0; max = 68). Burden scores were higher among caregivers who did not receive help from other people in care (p = 0.016), reported family dysfunction (p = 0.001), and had depression symptoms (p = 0.007). A correlation was found between the scores of burdens and satisfaction with care (r = 0.76; p < 0.001) and perceived material support (r = -0.30; p = 0.40). Satisfaction with care (β: 0.61; p < 0.001) and family dysfunction (β: 8.07; p = 0.033) were significantly associated with the burden score.

Conclusion

Caregivers with dysfunctional families and satisfaction with the care presented the highest-burden scores. The findings reveal the need for strategies to facilitate mediation and reduce caregiver burden by strengthening the family network support or providing professional assistance.

Caregivers' Profiles Based on the Canadian Occupational Performance Measure for the Adoption of Assistive Technologies

The COPM (Canadian Occupational Performance Measure) is a tool that is based on the identification of self-perceived performance and satisfaction problems in the performance of occupations, allowing the creation of a hierarchy in the order of the interventions to be carried out, and speeding up the identification of the necessary AT (Assistive Technologies). Given the importance of the caregiver's perception about their own performance in the design of AT, this research examines the caregiver's profile through the COPM. A sample of 40 caregivers volunteered to participate in the study. A cluster analysis was carried out on the COPM scores. Two caregiver profiles were found in relation to the COPM measure, one with low scores on performance and satisfaction and another with high scores on both of these two variables. The main predictor was found to be the self-perception of performance. The structure was replicated through a hierarchical cluster analysis, where the role of caregivers was of interest. These results are relevant on both a theoretical and practical level.

Exploring the Motivations of Family Caregivers Caring for Older Persons in Urban Poor Accra, Ghana

There is a general paucity of studies on family caregivers' motivations for providing care to older persons in the urban poor context in Ghana. This study seeks to explore family caregivers' motivations for providing care to older persons in urban poor Accra, Ghana. A qualitative descriptive design was used and in-depth interviews were conducted with thirty-one family caregivers. The QSR NVivo 10 software was used to analyze the data thematically. We found that autonomous motivation inspired family caregivers to provide care. Empathy and affection intrinsically motivated some caregivers to provide care to their care recipients, while others were extrinsically motivated by filial responsibility, reciprocity, and obligation to provide care. These findings showed that family caregivers were autonomously motivated to provide care to older persons. We recommend the need for future studies to explore changes in family caregivers' motivations to provide care over time.

Using self-determination theory in research and evaluation in primary care

BACKGROUND

Multimorbidity (the co-existence of two or more long-term conditions within an individual) is a complex management challenge, with a very limited evidence base. Theories can help in the design and operationalization of complex interventions.

OBJECTIVE

This article proposes self-determination theory (SDT) as a candidate theory for the development and evaluation of interventions in multimorbidity.

METHODS

We provide an overview of SDT, its use in research to date, and its potential utility in complex interventions for patients with multimorbidity based on the new MRC framework.

RESULTS

SDT-based interventions have mainly focused on health behaviour change in the primary prevention of disease, with limited use in primary care and chronic conditions management. However, SDT may be a useful candidate theory in informing complex intervention development and evaluation, both in randomized controlled trials and in evaluations of 'natural experiments'. We illustrate how it could be used multimorbidity interventions in primary care by drawing on the example of CARE Plus (a primary care-based complex intervention for patients with multimorbidity in deprived areas of Scotland).

CONCLUSIONS

SDT may have utility in both the design and evaluation of complex interventions for multimorbidity. Further research is required to establish its usefulness, and limitations, compared with other candidate theories.

PATIENT OR PUBLIC CONTRIBUTION

Our funded research programme, of which this paper is an early output, has a newly embedded patient and public involvement group of four members with lived experience of long-term conditions and/or of being informal carers. They read and commented on the draft manuscript and made useful suggestions on the text. They will be fully involved at all stages in the rest of the programme of research.

A systematic review of systematic reviews of needs of family caregivers of older adults with dementia

Family caregivers provide vital assistance to older adults living with dementia. An accurate assessment of the needs of caregivers supports the development and provision of appropriate solutions to address these needs. This review of systematic reviews analyzes and synthesizes the needs identified by family caregivers. We conducted a systematic review of systematic reviews using the AMSTAR guideline. Electronic databases were searched for systematic reviews on the needs of caregivers in the context of dementia using a combination of keywords and medical subject headings. Records resulting from the search were screened by two reviewers. Data on the needs of caregivers were extracted from the articles and analyzed using a narrative synthesis approach. Out of the 17 potentially eligible systematic reviews obtained initially, 6 met the inclusion criteria. In total, 20 main needs were identified in the reviews included in this study. The need for information and social support were prominent in this review. Factors such as gender, resources available to the caregiver and the care recipient's health status may influence caregivers' needs. Interventions can be tailored toward addressing the most prominent needs of caregivers such as adequate information and resources and available programs may further accommodate and offer need-tailored support to them.

Informal Caregivers’ Experiences with Performing Telemonitoring in Heart Failure Care at Home—A Qualitative Study

Informal caregivers have an important role in caring for family members at home. Supporting persons with a chronic illness such as heart failure (HF) in managing their self-care is reported to be a challenge and telemonitoring has been suggested to be of support. Aim: to explore informal caregivers’ experiences with performing non-invasive telemonitoring to support persons with HF at home for 30 days following hospital discharge in Norway and Lithuania. Methods: A qualitative explorative study of informal caregivers performing non-invasive telemonitoring using lung-impedance measurements and short message service (SMS). Data was collected using semi-structured interviews with informal caregivers of persons with HF in NYHA class III-IV in Norway and Lithuania. Results: Nine interviews were conducted with informal caregivers of persons with HF who performed non-invasive telemonitoring at home. A sequential process of three categories emerged from the data: access to support, towards routinizing, and mastering non-invasive telemonitoring. Conclusion: Informal caregivers performed non-invasive telemonitoring for the first time in this study. Their experiences were of a sequential process that included access to support from health care professionals, establishing a routine together, and access to nurses or physicians in HF care as part of mastering. This study highlights involving informal caregivers and persons with HF together in the implementation and future research of telemonitoring in HF care.

Women Caring for Husbands Living with Parkinson’s Disease: A Phenomenological Study Protocol

Parkinson’s disease (PD) is an emerging pandemic caused by aging, longevity, and industrialization. Most people diagnosed with PD initially experience mild symptoms, but over time the symptoms become debilitating. Given their intensive care requirement, most married people living with PD receive care from their spouses; most are female caregivers. Because caregiving is hard work with long hours, caregivers experience stress, fatigue, and depression, often leading to exhaustion and burnout. The purpose of this descriptive phenomenological study is to understand the lived experience of women caregivers of husbands living with PD. As part of this study protocol, women caring at home for their husbands diagnosed with PD will be purposely recruited from the Colorado Parkinson Foundation. Semi-structured interviews will be conducted by Zoom© until data saturation is achieved. Colaizzi’s seven-step process will be used to analyze the data in Atlas.ti. Strategies have been incorporated into the study protocol to maximize trustworthiness and to insure methodological rigor. The study will be reported using recommendations from the Standards for Reporting Qualitative Research and the Consolidated Criteria for Reporting Qualitative Research. Findings from this study may guide intervention development to improve the caregiving experience and to inform clinical practice guidelines for health care professionals.

Willingness and preparedness to provide care: interviews with individuals of different ages and with different caregiving experiences

Background

At present, the provision of informal care to older relatives is an essential pillar of the long-term care system in Germany. However, the impact of demographic and social changes on informal caregiving remains unclear.

Methods

Thirty-three semi-structured interviews were conducted with care consultants, informal caregivers and people without any caregiving experience to explore if people are willing to provide older adult care and how prepared these are with regard to the possibility of becoming care dependent themselves.

Results

In total, three main categories (willingness to provide care, willingness to receive care and information as preparation) with several sub-categories were identified during the content analysis. While almost all interviewees were willing to provide care for close family members, most were hesitant to receive informal care. Other factors such as the available housing space, flexible working hours and the proximity of relatives were essential indicators of a person’s preparedness to provide informal care. It is, however, unclear if care preferences change over time and generations. Six out of 12 informal caregivers and nine out of 14 care consultants also reported an information gap. Because they do not possess adequate information, informal caregivers do not seek help until it is too late and they experience high physical and mental strain. Despite the increased efforts of care consultants in recent years, trying to inform caregivers earlier was seen as almost impossible.

Conclusions

The very negative perception of caregiving as a burden was a reoccurring theme throughout all interviews and influenced people’s willingness to receive care as well as seeking timely information. Despite recent political efforts to strengthen home-based care in Germany, it remains unclear whether political efforts will be effective in changing individuals’ perceptions of informal caregiving and their willingness to be better prepared for the highly likely scenario of having to care for a close relative or becoming care dependent at a later stage in life.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02149-2.

Caring for home-dwelling parents with dementia: A qualitative study of adult-child caregivers' motivation

Aim

To explore adult children's motivation in caregiving for their home-dwelling parents with dementia.

Design

Qualitative design with a phenomenological approach.

Methods

Semi-structured individual interviews with 21 adult sons and daughters who were caregivers for a parent with dementia. Data were analysed using systematic text condensation.

Results

Inspired by self-determination theory, three categories were identified in the empirical data representing the main motivational drivers for adult-child caregivers: relatedness (to the parent with dementia, the parent's spouse, other persons), competence (in handling dementia, in the parent's need) and autonomy (freedom of choice, innate values and tasks). Caregivers report relatedness as their key motivational driver.These results imply that nurses and other health professionals should value the importance of relatedness when interacting with dementia caregivers and establish belonging support structures. Further research should generate more knowledge of the positive motivational drivers, including interventions to improve relatedness, competence and autonomy.

Blessings or burdens: an Interpretative Phenomenological Analysis (IPA) study on the motivations and their impact on end-of-life caregiving among Asian family caregivers

BACKGROUND

While the impact of family caregiving has been well-documented, many of such studies center on investigating external factors such as socioeconomic status, accessibility to resources and availability of social support as the primary causation of caregiver wellbeing outcomes. This paper explores the motivations that drive family caregivers in supporting their family members at the end-of-life, and critically examines how internal appraisal processes of such motivations can both positively and negatively impact their wellbeing.

METHODS

This study adopted an interpretative phenomenological analysis (IPA) to investigate the motivations and internal appraisal processes of Asian family caregivers in Singapore who were tending to a dying family member. Qualitative dyadic interview data (N = 20) was drawn from a larger Randomized Controlled Trial for a novel Family Dignity Intervention (FDI) for palliative care patients and their families. The sampling population consisted of participants aged 21 and above who were identified to be the primary caregivers of older palliative care patients with a prognosis of less than 12 months. Data collection was conducted in the homes of patients and family caregivers.

RESULTS

Findings revealed six themes that could either nurture or diminish caregiver wellbeing: 1) Honoring Fidelity (caregivers were motivated to commit to their caregiving roles in order to avoid regret), 2) Alleviating Suffering (caregivers were motivated to relieve their family member's pain), 3) Enduring Attachment (caregivers were motivated to spend time together with their family member), 4) Preserving Gratitude (caregivers were motivated to express their appreciation to their family member by caregiving), 5) Navigating Change (caregivers were motivated to adapt accordingly to changes in the illness trajectory) and 6) Reconciling with Mortality (caregivers were motivated to respond accordingly to their family member's prognosis). The final theme of the Wellbeing Determinant is posited as an indication of self-determination, and is conjectured to influence how caregiving motivations are appraised by the caregiver.

CONCLUSION

Fulfilling and enhancing one's sense of self-determination appears central to infusing one's caregiving motivations with positive meaning, and consequently nurturing one's wellbeing in the end-of-life caregiving journey. These findings are discussed with recommendations for healthcare professionals working with family caregivers of palliative care patients.