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van Gorkom RNFG, Meulenbroek AL, de Vries J, Frost DM, van der Laan L. A fluctuating intensity of care: A qualitative study on the experiences of informal caregivers of patients with critical limb-threatening ischemia. PLoS One 2024; 19:e0298959. [PMID: 38739667 PMCID: PMC11090309 DOI: 10.1371/journal.pone.0298959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 02/01/2024] [Indexed: 05/16/2024] Open
Abstract
Informal caregivers play a significant role in providing care for older, often vulnerable, patients, and supporting them as they live with chronic diseases. Due to the rising prevalence of older vascular patients and their use of healthcare, the role of their informal caregivers will become more important. However, little is known about the experiences of informal caregivers of patients with critical limb-threatening ischemia and the impact of informal care on different aspects of these caregivers' lives. In addition, literature does not describe the burden this role brings with it, or lack thereof. Therefore a qualitative study using a phenomenological approach, specifically interpretive phenomenological analysis, was used to gain insight into the experiences of the primary informal caregivers of patients with chronic limb-threatening ischemia. Data were collected via semi-structured interviews and focus groups discussions. Fifteen primary informal caregivers of patients with critical limb-threatening ischemia under the care of the vascular surgeon at a tertiary teaching hospital in the Netherlands were included. Data analysis yielded three themes: the perceived identity of this group of caregivers; the varying intensity of informal care; and the collaboration between informal carers, their care recipients and the professional care provider within the vascular surgery department. In contrast to carers of other chronic diseases, the shifting intensity of care that informal caregivers of critical limb-threatening ischemia patients experience seems to prevent long-term overload. Adapting to that fluctuating situation requires flexibility from healthcare providers within the vascular surgery department. In addition, professionals need to involve informal caregivers in the patient's decision-making process and recognize their role in that process.
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Affiliation(s)
| | | | - Jolanda de Vries
- Admiraal de Ruyter Hospital, Goes, The Netherlands
- Department of Medical and Clinical Psychology, Tilburg University, Tilburg, The Netherlands
| | - Donna M. Frost
- School of People & Health Studies, Fontys University of Applied Sciences, Tilburg, The Netherlands
| | - Lijckle van der Laan
- Department of Surgery, Amphia Hospital, Breda, The Netherlands
- Department of Cardiovascular Science, University Hospitals Leuven, Leuven, Belgium
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Zarzycki M, Vilchinsky N, Bei E, Ferraris G, Seddon D, Morrison V. Cross-country variations in the caregiver role: evidence from the ENTWINE-iCohort study. BMC Public Health 2024; 24:898. [PMID: 38532418 DOI: 10.1186/s12889-024-18302-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 03/07/2024] [Indexed: 03/28/2024] Open
Abstract
BACKGROUND Globally, economically developed countries face similar ageing demographics and the challenge of a 'care gap', yet they vary due to different care and formal support systems, and different cultural and societal norms around illness and care. The aim of this exploratory study was to examine cross-country variations in caregiver motivations, willingness, values, meaning in life, illness beliefs, and experiences of wellbeing, gain, health-related quality of life, burden and depression, across 6 European countries and Israel. Cross-country differences in the above-mentioned informal caregiver experiences are rarely described. METHODS An online survey (ENTWINE-iCohort) was conducted using validated measures wherever possible. This paper utilises data from 879 caregivers and seven countries (Greece, Italy, the Netherlands, Poland, Sweden, the UK, and Israel). RESULTS No consistent finding supporting the concurrent relationship between caregiver support policies/country culture and caregiver motivations/willingness was found. Caregivers in countries typically characterised by individualist cultures reported lower familism, higher self-enhancement values, and greater perceived illness threat compared to more collectivist countries. Search for meaning was higher in poorer countries than in wealthier countries. Higher negative caregiver experiences (e.g., burden) and lower positive experiences (e.g., wellbeing) were generally observed in countries with underdeveloped caregiver support as compared to countries with more developed formal support systems. CONCLUSIONS Cross-country variations can be explained to varying degrees by national policies around care (or their absence) and country cultural contexts. The results emphasise the importance of formal support services for achieving positive caregiver experiences, and help inform the development of policies and measures to support caregivers in Europe and Israel.
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Affiliation(s)
- Mikołaj Zarzycki
- Department of Psychology, Liverpool Hope University, Liverpool, United Kingdom.
- School of Psychology and Sports Sciences, Bangor University, Bangor, Wales, United Kingdom.
| | - Noa Vilchinsky
- Department of Psychology, Faculty of Social Sciences, Bar-Ilan University, Ramat Gan, Israel
| | - Eva Bei
- Department of Psychology, Faculty of Social Sciences, Bar-Ilan University, Ramat Gan, Israel
- Department of Political and Social Sciences, University of Bologna, Bologna, Italy
| | - Giulia Ferraris
- Department of Health Psychology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Diane Seddon
- School of Medical and Health Sciences, Bangor University, Bangor, Wales, United Kingdom
| | - Val Morrison
- School of Psychology and Sports Sciences, Bangor University, Bangor, Wales, United Kingdom
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Ferraris G, Gérain P, Zarzycki M, Elayan S, Morrison V, Sanderman R, Hagedoorn M. The associations of dyadic coping strategies with caregiver's willingness to care and burden: A weekly diary study. J Health Psychol 2024:13591053231223838. [PMID: 38197315 DOI: 10.1177/13591053231223838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2024] Open
Abstract
This weekly diary study investigated associations of weekly dyadic coping strategies with caregivers' willingness to care and burden. Multilevel modelling was applied to assess between- and within-person associations for 24 consecutive weeks in 955 caregivers. Greater willingness to care was reported in weeks when caregivers used more collaborative (b = 0.26, p < 0.001) and supportive (b = 0.30, p < 0.001) strategies, whereas uninvolved coping was associated with lower willingness to care (b = -0.44, p < 0.001). Using collaborative coping strategies was associated with lower weekly burden (b = -0.13, p < 0.001). A greater burden was reported in weeks when caregivers used more uninvolved (b = 0.19, p < 0.001) and controlling (b = 0.13, p < 0.001) coping strategies. A full understanding of whether caregivers' willingness to care and burden may be improved owing to weekly dyadic coping is essential for developing timely support for caregivers.
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Affiliation(s)
- Giulia Ferraris
- University Medical Center Groningen, University of Groningen, The Netherlands
| | | | | | - Saif Elayan
- University Medical Center Groningen, University of Groningen, The Netherlands
| | | | - Robbert Sanderman
- University Medical Center Groningen, University of Groningen, The Netherlands
| | - Mariët Hagedoorn
- University Medical Center Groningen, University of Groningen, The Netherlands
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Søvde BE, Sandvoll AM, Natvik E, Drageset J. Caregiving for frail home-dwelling older people: A qualitative study of family caregivers' experiences. Int J Older People Nurs 2024; 19:e12586. [PMID: 38009411 DOI: 10.1111/opn.12586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 09/22/2023] [Accepted: 10/21/2023] [Indexed: 11/28/2023]
Abstract
BACKGROUND The increasing frailty of home-dwelling older people can lead to rising expectations from their family caregivers due to various demographic developments and political guidelines. European data show that 60% of home-dwelling older people receive informal care. Frailty among older people is a state of vulnerability, increasing the risk of adverse health outcomes, declining daily activities and needing long-term care. AIM To explore family caregivers' lived experiences with caring for frail, home-dwelling older people. METHODS We conducted a phenomenological study to obtain in-depth descriptions of the phenomenon. We interviewed nine family caregivers, five men and four women between 52 and 90 years old, in-depth in their homes. We used a hermeneutical phenomenological approach described by van Manen and followed the COREQ checklist. RESULTS The phenomenon's essential meaning is described as striving to adapt throughout the caring relationship. The interrelated themes describe different caring relationships, caring for a family member and letting go of the primary caring responsibility. CONCLUSIONS Family caregivers describe care as meaningful yet demanding. In our study, the varying condition of frailty was an additional challenge in care. By addressing these challenges, healthcare providers can better support and help family caregivers to withstand their caring relationships. The Norwegian Centre for Research Data approved the study (Ref.61202).
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Affiliation(s)
- Bente Egge Søvde
- Department of Health and Caring Sciences, Western Norway University of Applied Sciences, Førde, Norway
- Department of Global Public Health and Primary Care, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Anne Marie Sandvoll
- Department of Global Public Health and Primary Care, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Eli Natvik
- Department of Global Public Health and Primary Care, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Jorunn Drageset
- Department of Health and Caring Sciences, Western Norway University of Applied Sciences, Førde, Norway
- Department of Global Public Health and Primary Care, Faculty of Medicine, University of Bergen, Bergen, Norway
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Welsh A, Hanson S, Pfeiffer K, Khoury R, Clark A, Ashford PA, Hopewell S, Logan P, Crotty M, Costa M, Lamb S, Smith T, Hip Helper Study C. Perspectives of informal caregivers who support people following hip fracture surgery: a qualitative study embedded within the HIP HELPER feasibility trial. BMJ Open 2023; 13:e074095. [PMID: 37977867 PMCID: PMC10660837 DOI: 10.1136/bmjopen-2023-074095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 09/28/2023] [Indexed: 11/19/2023] Open
Abstract
OBJECTIVES This study aims to illuminate the perspectives of informal caregivers who support people following hip fracture surgery. DESIGN A qualitative study embedded within a now completed multicentre, feasibility randomised controlled trial (HIP HELPER). SETTING Five English National Health Service hospitals. PARTICIPANTS We interviewed 20 participants (10 informal caregivers and 10 people with hip fracture), following hip fracture surgery. This included one male and nine females who experienced a hip fracture; and seven male and three female informal caregivers. The median age was 72.5 years (range: 65-96 years), 71.0 years (range: 43-81 years) for people with hip fracture and informal caregivers, respectively. METHODS Semistructured, virtual interviews were undertaken between November 2021 and March 2022, with caregiver dyads (person with hip fracture and their informal caregiver). Data were analysed thematically. FINDINGS We identified two main themes: expectations of the informal caregiver role and reality of being an informal caregiver; and subthemes: expectations of care and services; responsibility and advocacy; profile of people with hip fracture; decision to be a caregiver; transition from hospital to home. CONCLUSION Findings suggest informal caregivers do not feel empowered to advocate for a person's recovery or navigate the care system, leading to increased and unnecessary stress, anxiety and frustration when supporting the person with hip fracture. We suggest that a tailored information giving on the recovery pathway, which is responsive to the caregiving population (ie, considering the needs of male, younger and more active informal caregivers and people with hip fracture) would smooth the transition from hospital to home. TRIAL REGISTRATION NUMBER ISRCTN13270387.Cite Now.
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Affiliation(s)
- Allie Welsh
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - Sarah Hanson
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - Klaus Pfeiffer
- Department of Clinical Gerontology and Geriatric Rehabilitation, Robert Bosch Hospital, Stuttgart, Germany
| | - Reema Khoury
- Norwich Clinical Trials Unit, University of East Anglia, Norwich, UK
| | - Allan Clark
- Norwich Medical School, University of East Anglia, Norwich, UK
| | | | - Sally Hopewell
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Pip Logan
- Community Health Sciences, University of Nottingham, Nottingham, UK
| | - Maria Crotty
- Rehabilitation, Aged and Extended Care, Flinders University, Adelaide, South Australia, Australia
| | - Matthew Costa
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Sallie Lamb
- College of Medicine and Health, University of Exeter, Exeter, UK
| | - Toby Smith
- School of Health Sciences, University of East Anglia, Norwich, UK
- University of Warwick, Coventry, UK
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Ferraris G, Zarzycki M, Gérain P, Elayan S, Morrison V, Sanderman R, Hagedoorn M. Does willingness to care fluctuate over time? A weekly diary study among informal caregivers. Psychol Health 2023:1-19. [PMID: 37608731 DOI: 10.1080/08870446.2023.2249538] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 07/21/2023] [Accepted: 08/12/2023] [Indexed: 08/24/2023]
Abstract
OBJECTIVE Informal caregivers are expected to be willing to care for relatives with care needs. Little is known about whether and how willingness to care changes over time. Using a weekly diary study, we examined changes in the willingness of 955 caregivers from nine countries. Caregivers provided information on their caregiving context, relationship type, and relationship satisfaction with the care recipient. METHODS AND MEASURES For 24 consecutive weeks, caregivers evaluated willingness to care as it was 'right now'. RESULTS Willingness differs from one caregiver to another (68% between-level variability) but also fluctuates in the same caregiver from week to week (32% within-level variability), with a decrease over 6 months (intercept = 8.55; slope = -0.93; p < .001). Regardless of individual differences in average willingness to care based on caregiving context and relationship satisfaction, caregivers reported decreases in willingness. Caregivers who presented one or more health conditions themselves reported higher weekly fluctuations in willingness than caregivers with no health conditions. CONCLUSION Willingness is not a stable attitude because it decreases and caregivers experience fluctuations from week to week. A clearer understanding of weekly processes is optimal for monitoring the caregivers' well-being and tailoring interventions in line with weekly individual variations.
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Affiliation(s)
- Giulia Ferraris
- Department of Health Psychology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Mikołaj Zarzycki
- Department of Psychology, Liverpool Hope University, Liverpool, UK
| | - Pierre Gérain
- Faculty of Psychology and Educational Sciences, Vrije Universiteit Brussel, Brussels, Belgium
| | - Saif Elayan
- Department of Economics, Econometrics and Finance, Faculty of Economics and Business, University of Groningen, Groningen, Netherlands
| | - Val Morrison
- School of Human and Behavioural Science, Bangor University, Bangor, UK
| | - Robbert Sanderman
- Department of Health Psychology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Mariët Hagedoorn
- Department of Health Psychology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
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Tornu E, Dzansi G, Wilson DM, Richter S, Aziato L. Mothers' perspectives of physical and psychological issues associated with caring for Ghanaian children living with tuberculosis: A qualitative study. Nurs Open 2023; 10:2439-2448. [PMID: 36479915 PMCID: PMC10006641 DOI: 10.1002/nop2.1499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 05/25/2022] [Accepted: 11/15/2022] [Indexed: 12/13/2022] Open
Abstract
AIM The aim of the study was to explore and describe the mothers' perspectives on issues associated with caring for Ghanaian children aged 0-14 years living with tuberculosis. DESIGN Exploratory descriptive qualitative design. METHODS Semi-structured individual interviews were conducted face to face with 15 purposively sampled mothers from two health facilities in the Greater Accra area. Transcribed data were analysed using computer-enhanced thematic analysis. RESULTS Findings were grouped into (1) physical burden on the mothers and (2) psychological burden on mothers. The eight subthemes indicate that mothers of children living with tuberculosis experienced tiredness, sleeplessness, body pains, weight loss and sicknesses as they cared for their children. In addition to worrying, mothers experienced stigma and negative emotions such as sadness, guilt, fear and loneliness. CONCLUSION Mothers of children diagnosed with tuberculosis in Ghana experience physical and psychological health problems related to their caregiving roles. Nurses and other healthcare providers should identify specific problems and offer broad-based emotional and other support for these women.
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Affiliation(s)
- Eric Tornu
- Department of Adult Health, School of Nursing and Midwifery, College of Health Sciences, University of Ghana, Accra, Ghana
| | - Gladys Dzansi
- Department of Adult Health, School of Nursing and Midwifery, College of Health Sciences, University of Ghana, Accra, Ghana
| | - Donna M Wilson
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | - Solina Richter
- College of Nursing, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Lydia Aziato
- Department of Adult Health, School of Nursing and Midwifery, College of Health Sciences, University of Ghana, Accra, Ghana
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Smith T, Mansfield M, Hanson S, Welsh A, Khoury R, Clark A, Dures E, Adams J. Caregiving for older people living with chronic pain: analysis of the English longitudinal study of ageing and health survey for England. Br J Pain 2022; 17:166-181. [PMID: 37057251 PMCID: PMC10088417 DOI: 10.1177/20494637221144250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background Chronic pain is a disabling condition. Many people with chronic pain seek informal support for everyday activities of daily living (ADL). However, there remains uncertainty on the type of people with chronic pain who access this support, what types of support they need and who provides such support. The purpose of this analysis was to answer these uncertainties. Methods Data from the Health Survey for England (HSE) and English Longitudinal Study of Ageing (ELSA) were accessed. People who reported chronic pain (moderate or above for minimum of 12 months) were identified. From these cohorts, we determined if individuals self-reported receiving informal care. Data on caregiver profiles and caregiving activities were reported through descriptive statistics. Logistic regression analyses were performed to compare health status outcomes between people with pain who received and who did not receive informal care. Results 2178 people with chronic pain from the ELSA cohort and 571 from the HSE cohort were analysed. People who received care were frequently female, older aged with several medical morbidities including musculoskeletal diseases such as arthritis. People with chronic pain received informal care for several diverse tasks. Most frequently these related to instrumental activities of daily living (IADL) such as shopping and housework. They were most frequently provided by partners or their children. Although they reported greater disability and symptoms ( p < 0.001), people who received care did not report differences in health status, loneliness or wellbeing ( p = 0.27; p = 0.46). Conclusions Whilst it may be possible to characterise people living in chronic pain who receive informal care, there is some uncertainty on the impact of informal caregiving on their health and wellbeing. Consideration should now be made on how best to support both care recipients and informal caregivers, to ensure their health and quality of life is promoted whilst living with chronic pain.
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Affiliation(s)
- Toby Smith
- Warwick Medical School, University of Warwick, Coventry, UK
- Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - Michael Mansfield
- Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
| | - Sarah Hanson
- Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - Allie Welsh
- School of Education, University of East Anglia, Norwich, UK
| | - Reema Khoury
- Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - Allan Clark
- Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - Emma Dures
- Faculty of Health and Life Sciences, University of the West of England, Bristol, UK
- Academic Rheumatology, Bristol Royal Infirmary, Bristol, UK
- School of Health and Social Wellbeing, University of the West of England, Bristol, UK
| | - Jo Adams
- Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
- School of Health Sciences, University of Southampton, Southampton, UK
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Zarzycki M, Seddon D, Morrison V. Informal caregiver motivations, values, challenges and gains: A photovoice and interpretative phenomenological analysis of interrelationships. J Health Psychol 2022; 28:568-582. [PMID: 36300898 PMCID: PMC10119898 DOI: 10.1177/13591053221124647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The adoption of a caregiving role in the context of illness and disability is often taken for granted. This study explores caregivers’ motivations to provide care and how these relate to values, and to the challenges and gains of caregiving. Eight semi-structured interviews were conducted with caregivers and photographs were taken by caregivers to exemplify their caregiving experiences. This photo-elicitation method complemented the use of Interpretative Phenomenological Analysis when applied to verbatim transcripts. Superordinate themes included: caregiver’s life story; significance of family; caregiving obligations; caring relationship; challenges and gains associated with caregiver motivations. Intrinsic and extrinsic motivations were less distinct in caregivers’ lived experiences than previously suggested, and were influenced by family values and specific challenges and gains of caregiving. The coexistence of different motivations and the nature of single complex motivations is discussed. The importance of caregiver assessment and support planning, and regular breaks from caregiving are highlighted.
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Zarzycki M, Seddon D, Bei E, Dekel R, Morrison V. How Culture Shapes Informal Caregiver Motivations: A Meta-Ethnographic Review. QUALITATIVE HEALTH RESEARCH 2022; 32:1574-1589. [PMID: 35737473 PMCID: PMC9411702 DOI: 10.1177/10497323221110356] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
The provision of informal care presents a significant global challenge. To better understand how cultural factors underpin and shape motivations and willingness to provide informal care for adults, an in-depth qualitative synthesis was conducted. Six electronic databases and a wide range of additional sources were searched. Following meta-ethnographic guidelines, 37 qualitative studies were synthesised. Six main concepts were identified: cultural self-identity, which appeared as an overarching explanatory concept; cultural duty and obligations; cultural values; love and emotional attachments; repayment and reciprocity; and competing demands and roles. These concepts informed a model of cultural caregiving motivations, offering an inductive-based exploration of key cultural motivators and highlighting implications for theory development, future research, policy and practice. The model holds implications for the actual exchange of care. Caregiver motivations should not be taken for granted by healthcare or social care professionals involved in assessment and support planning, educational endeavours at a population level may support caregiving, and support should be sensitive to cultural caregiving motivations.
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Affiliation(s)
- Mikołaj Zarzycki
- School of Human and Behavioural Sciences, College of Human Sciences, Bangor University, Bangor, UK
| | - Diane Seddon
- School of Medical and Health Sciences, Bangor University, Bangor, UK
| | - Eva Bei
- Department of Psychology, Bar-Ilan University, Ramat Gan, Israel
| | - Rachel Dekel
- School of Social Work, Bar-Ilan University, Ramat Gan, Israel
| | - Val Morrison
- School of Human and Behavioural Sciences, College of Human Sciences, Bangor University, Bangor, UK
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