Table 4 Study findings

Albinsson & Strang (2003) [30]

Motivations included obligation & feelings of guilt, being faithful, reciprocity, responsibility & having always taken care of others.

This study underlines the importance of not only identifying carer physical & psychosocial features but also existential ones. Staff need to be more aware of these issues in order to support families also in existential crisis.

Cahill (2000) [31]

Husbands’ motivations included love, marriage & duty or a combination of all three. They also reported reciprocity & commitment to their marriage vows & religious obligation was also important.

Men reported wanting to ‘do the right thing’ & continue caring for their wives at home. Men & women are similar in their motivations to care.

Chang et al. (2011) [32]

Placing relatives in a care home was seen as a violation of filial piety. Some worried that doing so could be seen as ‘un-filial’ by family members. Placement decisions were influenced by filial piety, limited financial resources & information, older adults’ preferences, family disagreement, distrust of nursing home care quality & limited availability.

Carers chose to continue caring due to distrust of nursing home quality & the perception that nursing homes are where people go to die.

Nursing home placement continues to contradict the Chinese value of filial piety causing decisional conflict for many carers. To understand this process among Chinese carers, filial piety & collectivism, traditional & changing family carer roles & nursing home quality & care quality all need to be considered.

Eriksson et al. (2013) [33]

Motivations & commitment to caring were based on the carers female identity – they had always cared for their families & this is an extension of this.

Caring experiences relate to society’s expectations about women’s roles. Women view their caring role & responsibilities as paramount. Other duties, including caring for themselves, are deemed less important. The intense commitment & responsibilities experienced by female carers must be acknowledged.

Gurayah (2015) [34]

Duty to provide care for family members was seen as part of African culture, with both a sense of obligation & responsibility.

Caring for parents & family is implicit in African culture & is embodied in the concept of Ubuntu. Individuals are part of the community & need to fulfil their obligations to the collective. Caring is seen as character-building.

Harris (1998) [35]

Sons reported a sense of duty, responsibility, love & filial obligation. Being a dutiful son was a driving force.

Sons were motivated by a sense of love & or obligation. This did not depend on whether there was a sister to provide care.

Harris & Long (1999) [36]

Sons: Japanese sons reported an obligation to care for their parents based on filial piety. It was most often considered the eldest son’s responsibility to care for a parent. For American sons, birth order played little part, instead they reported caring out of love, commitment & duty.

Husbands: Japanese husbands reported caring out of commitment, love & reciprocity. It was thought natural for them to take on the caring role. American husbands also reported caring out of reciprocity & love but in addition talked about upholding marriage vows.

The same traditional values were also motivators for providing care as opposed to placing relatives in nursing homes.

Culture shapes caring experiences. Japanese sons spoke frequently about filial responsibility. The Japanese multigenerational structure influences obligation to provide care, with children taking on caring responsibilities & parents assuming their children will care for them. American husbands talked about wedding vows & believed their children have their own lives & do not expect them to provide care.

Ho et al. (2003) [37]

Traditional Chinese cultural values instilled an obligation & responsibility to provide care for family members. Due to filial obligation, many carers expected to be carers at some point. Participants compared themselves positively to Western attitudes to care.

Providing care is part of Chinese culture. Many seemed distressed by the apparent inconsistency between traditional ways & the reality of caring. Although they accessed outside support & were considering care home placements, this was discussed as part of becoming assimilated into Western culture.

Kim (2009) [38]

Motivations included the continuation of marital relationship, love, making the cared for comfortable & filial piety derived from cultural norms. Caring was seen as a ‘family affair’.

Caring was described as a continuation of marriage. Love helps them to continue caring.

Caring is determined by multiple motives: filial piety, the availability of carers, the history of communal relationships & attachment to elderly parents. Obligation seemed insufficient motivation for caring for an older person with dementia.

Lin et al. (2011) [39]

Spouses described caring out of emotional commitment, happiness derived from caring, love, responsibility & duty (moral & societal obligations) & reciprocity. Four categories emerged: my life changed, commitment, responsibility, duty & support. My life changed represented the beginning of the caring journey. Learning from experience offered new perspectives on carers’ experiences.

Responsibility and duty increased over time but the support from formal & informal sources fluctuated. All carers experienced changes in the caring journey.

Moral & societal obligations are linked to a sense of duty, with deciding to provide care influenced more by societal expectations than innate desire to care.

McDonnell & Ryan (2014) [40]

Sons cared for their parents out of a sense of love, devotion, loyalty & respect. They reported a strong sense of duty & satisfaction. Reciprocity was also highlighted.

Devotion & willingness to care for parents were highlighted. However, the study took place in rural Ireland & farm succession plans may have played a role.

Meyer et al. (2015) [41]

Underlying all themes was the idea that cultural beliefs, values & expectations impacted on caring experiences. Caring was motivated by filial piety. Placing the care recipient in a care home went against Vietnamese culture. Some cared out of love & affection & some out of guilt. Carers highlighted reciprocity for sacrifices their parents made, especially related to the Vietnam war.

An overarching theme was that cultural beliefs, values & expectations impacted on caring experience. Differing levels of acculturation sometimes led to family conflict as younger family members did not always see it as their duty.

Morgan & Laing (1991) [42]

Carers fitted into either ‘grief’ & ‘role strain’ groups. In the ‘grief’ group, spouses cared out of love & wanting to provide a sense of normalcy & continuity. Many of them also suggested that reciprocity was a motivation. In the ‘role strain’ group responsibility & duty were the main motivations.

Health care professionals need to be aware of how past relationships can influence their attitude towards caring.

Murray et al. (1999) [43]

Motivations included reciprocity for past care (12%), the desire for continued companionship (16%), ‘job satisfaction’ (16%) & the fulfilment of duty (39%).

Continued companionship & the satisfaction of providing care were motivations for continuing to care.

Spousal carers in the 14 countries described the difficulties & rewards of caring in similar terms. This suggests commonality of experience, in spite of diversity in informal & statutory provision of care for older people between different countries.

Pang & Lee (2017) [44]

Spouses believed caring was part of their marital obligation. Spiritual & religious beliefs were also described, with some describing caring as their destiny & that everything in life was already planned out for them. Their religion also motivated them to continue their caring role. Both husbands & wives described repaying the care or support they had received from their spouses in the past as a motivation for caring.

Providing good quality care led to a sense of satisfaction for the carers which motivated them to continue caring.

In Chinese culture, couples are bound to a martial philosophy which asserts a lifelong commitment to mutual care. Carers were resigned to their caring role as they believed everything in life is pre-determined. Carers focused more on the positives & meaningful side of caring, not on losses. They felt satisfied & were more motivated to continue caring.

Peacock et al. (2010) [45]

All carers described positive aspects of caring. In particular, it provided them with the opportunity to for reciprocity to the family member out of love & wanting to make them as comfortable as possible. Spouses talked about caring being part of marriage, however husbands discussed repaying wives for past care whilst wives saw it as a continuation of the relationship. Many reported doing all they can so the person with dementia can stay at home as long as possible.

Caring for a family member is full of opportunities, e.g., being able to ‘give back’, to discover personal strengths & become closer to the person with dementia. Spouses viewed caring as an opportunity to continue in their marital relationship despite numerous challenges.

Qadir et al. (2013) [46]

Caring was viewed as an obligation & part of their duty. It was influenced by their religious (Islam) obligation to care for relatives & ‘worthy of divine reward’. Reciprocity was also important & was expected to be rewarded by prosperity & success.

In Islamic society, displaying respect towards parents is part of worship of God & is an obligation highlighted in the Quran. Reverence towards parents & closeness to family are emphasised in early childhood & continues to be important throughout life.

Quinn et al. (2015) [47]

Carers’ relationship with their relative was the primary reason for taking on caring. Reciprocity & appreciation of their help gave caring meaning. Caring was seen as ‘something you just get on with’ & a natural continuation of relationships. Some also felt they had no choice, that it was their ‘job’, & no one else could do it. They would feel guilty if they were to place the cared for in an institution.

Carers often had no choice but to continue providing care as no one else could do it & they saw it as their ‘job’.

Carers need to find meaning from providing care & derived this from believing it was their responsibility to provide care & they were reciprocating past help from relatives. The relationship with the relative was the primary motivation for taking on the caring role.

Russell (2001) [48]

Husbands reported caring out of commitment, devotion & responsibility. Many husbands felt their commitment to providing care prevented their wives from needing care home placements. Some talked about reciprocity for the previous care their wives had given them.

While men may experience isolation & feelings of being an ‘invisible’ carer, they exhibit powerful feelings of commitment as well as adaptability & resilience.

Santos et al. (2013) [49]

Motivations included duty, responsibility, feelings of gratitude, reciprocity, familism (family caring is regarded as natural even if the pre-morbid relationship was not good) & religiosity.

Motivations to provide care are determined by both cultural & individual aspects & may influence disease awareness. Family caring may be motivated by affection, altruism, social norms of responsibility & also egotistic motivation.

Siriopoulos et al. (1999) [50]

Motivations included feeling obliged to reciprocate care provided by their wives, love & belief in their marriage vows. Husbands were devoted to caring for their wives.

The quality of the relationship was important for husbands in deciding to care. Husbands felt a sense of reciprocity due to the love & dedication of their wives throughout their marriage. Spouses’ demographic characteristics appeared to have no effect on their attitudes to caring.

Sterritt & Pokorny (1998) [51]

Caring was seen as a ‘traditional family value’, was the right thing to do & was something they could feel good about. They also cared out of love & found it rewarding. Caring was seen as a female role & men were not expected to provide care.

More cultural awareness of reasons for providing care needs to be incorporated into training nurses & physicians. These efforts may strengthen & enhance the existing use of support networks & provide culturally congruent care.

van Wezel et al. (2016) [52]

Caring for a family member was described as superior to professional care & was imposed by religion & culture. Reciprocity was important but many younger carers also viewed it as an obligation. Others said caring was a test from God or Allah or that providing care was seen as a duty & a role for women.

Carers continue caring because they view family care as superior to professional care, e.g. more loving & better meets the care recipients’ cultural & religious needs.

Carers see caring as something that should be performed with respect & love. Caring is the act of a ‘good religious person’. They derive great satisfaction from caring. This fulfilment largely outweighs the burden of care.

Vellone et al. (2002) [53]

Family duty was described as an important.

Italians see it as their duty to care. Caring for people with Alzheimer’s disease at home is consistent with their culture.

Wallhagen & Yamamoto-Mitani (2006) [54]

There were many commonalities between the Japanese & American carers. Both referred to reciprocity, moral obligation & responsibility. The word obligation was not used by Japanese carers who described it as a ‘matter of course’. More Japanese carers discussed moral obligation to care & their culture. Japanese carers said their family position meant they had to adopt the role - it was an expected ‘career’. This was not so for American carers.

The finding that reciprocity & attachment as motivations to provide care are supported by previous research. Japanese culture recognises & praises caring activities, with Japanese carers deriving a strong sense of fulfilment, pride & self-worth. American carers, by contrast viewed caring as an unexpected career & without the same level of societal praise.

Yamamoto & Wallhagen (1997) [55]

Three societal norms influence filial piety in Japan: filial responsibility, beliefs regarding women’s role which attributes high value to caring & family position (daughters in-law of first born sons expect to take on this role). Caring was motivated by reciprocity for past parental care & was also felt by daughters in-law on behalf of her husband. Emotional bonds between the carer & care recipient, the carer’s sense of achievement & gratitude from care recipients were also important.

Daughters continue to care in order to live free of regret when caring ends, remain committed to decisions made & because of religious beliefs. Rewards are also financial (e.g. avoiding nursing home costs).

Societal norms have a strong conforming power in Japanese society & the norm of filial responsibility influenced daughter & daughter in-law carers. Rather than saying they become carers because there is nobody else to take on the role, most Japanese carers felt they were expected to provide care, due to the norms in Japan which honour caring as part of women’s roles.