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

First published: 17 July 2019, Wiley Online Library
 

Heidi Dombestein
Faculty of Health Sciences, University of Stavanger
heidi.dombestein@uis.no

Anne Norheim
Faculty of Health Sciences, University of Stavanger

Anne Marie Lunde Husebø
Faculty of Health Sciences, University of Stavanger


Abstract


Background

A long-term illness is stressful both for the person with the diagnosis and for his or her informal caregivers. Many people willingly assume the caregiving role, so it is important to understand why they stay in this role and how their motivation affects their health. Self-determination theory (SDT) is a theory of human motivation that has been successfully applied in human research domains. To our knowledge, there is no literature review on the application of SDT in a caregiver context. A systematic review of the literature could improve the understanding of motivation in caregiver work and contribute to the utility of SDT.


Aim

To describe and explore empirical studies of caregivers' motivation from the perspective of self-determination theory.


Methods

An integrative literature review according to Whittemore and Knafl was conducted with systematic repetitive searches in the MEDLINE, Scopus, PsychInfo, PsycNET, Chinal, Cochrane Library and EMBASE databases. The searches were performed from May through December 2018. The PRISMA diagram was used for study selection, and papers were assessed for quality based on the Mixed Methods Appraisal Tool. Data analysis consisted of a four-stage narrative analysis method.


Result

Of 159 articles, 10 were eligible for inclusion. All studies considered satisfaction of the three basic psychological needs for competence, autonomy and relatedness as essential in predicting the quality of caregivers' motivation and thereby their well-being. In this review, autonomous motivation was the most important determinant of caregivers' well-being.


Conclusions

Findings showed that SDT can be applied to identify, categorise, explain, predict, promote and support motivation among caregivers. This lends interesting support for SDT and promotes further study and application of the theory as a psychological approach to caregivers' health and health promotion.


Introduction

Long-term serious illness such as dementia, Parkinson's, multiple sclerosis, and cancer are demanding and often debilitating conditions that affect both the care recipients themselves and their informal caregivers on several levels1, 2. As the illness progresses, the need for care and assistance increases for the person living with a long-term condition. Family members or other informal caregivers, either instead of or in addition to professional caregivers 3, 4 attend to the person with a patient's needs. Informal caregiving consists of the ongoing activities and experiences involved in offering unpaid help to relatives or friends who are unable to take care of themselves5, 6. In Norway, informal caregivers provide approximately 50% of all care7. Across the EU, family carers account for more than 80% of all care4, 8. Informal caregiving will continue to be essential in the light of the future demographic makeup of the population and the cost pressure on long-term care systems. Supporting and maintaining the supply of family care appears to benefit the care recipient, the caregiver and the public system3, 4. Accordingly, the research literature recommends tailored interventions1 and support services9, to caregivers who are struggling to remain motivated10.

Motivation for long-term caregiving is crucial for the way in which the informal carers experience caregiving10. The perceived burden on the caregiver, the caregiver's approach to caring and his or her coping strategies depend on the type of illness or condition2; family relations11; volition in caregiving12; and caregiver's resources13. The present understanding of caregiving, still based on a stress-coping paradigm to reduce the burden on caregivers has become the main goal in the health services6, 14. The promotion of the positive aspects of caregiving, such as the sense of satisfaction, autonomy and expertise among caregivers as specific and legitimate goals5, 6, 14, 15 deserves greater attention. Many people offer informal caregiving so it is important to understand their motivation for assuming and remaining in this role10 and these topics are not fully understood5. Motivational processes energise behaviour, initiate, generate and increase task engagement and direct actions towards certain goals. Support for healthy motivation by important others influences a person's motivational orientations over time and shape his or her sense of well-being, psychological growth and resilience over the long-term16. Studying motivation within a theoretical framework can illuminate the ways in which different motivations can positively or negatively influence caregivers' well-being10.

Self-determination theory (SDT) is a broad framework that conceptualises the empirical study of human motivation17, 18. SDT identifies three innate psychological needs as a key drivers of motivation that influence well-being and thriving: autonomy, competence and relatedness. The need for autonomy refers not to independence but rather to volition – the sense that one's actions are endorsed by oneself, that one has a feeling of choice and ownership of his or her actions. The need for competence relates to the mastery and to the perception of performing a task with confidence; the need for relatedness is a feeling of mutual belonging and of supporting and being supported by others17-19. Fulfilment of these basic needs promotes autonomous motivation and intrinsic aspirations, reflecting innate psychological nutriments essential for functioning, psychological health and well-being17, 18, 20. SDT is particularly concerned with how social contextual factors support or thwart people's ability to thrive through the satisfaction of their basic psychological needs18, 19, 21. According to SDT, motivation is not characterised by frequency or amount, like little or much motivation, but rather by a continuum from amotivation or controlled motivation to high-quality motivation distinguished by autonomous regulated behaviour18, 22. From the perspective of SDT, a high quality of motivation predicts beneficial health outcomes like well-being, thriving and psychological growth22.

No literature review to date on the application of SDT in a caregiver context has been identified in scientific databases or as protocols for literature reviews in Cochrane Library or Prospero, International Prospective Register of Systematic Reviews. A systematic review of literature could aid the understanding of motivation in caregiver work and might contribute to the utility of SDT. The theory has been applied in many research domains, such as education, work, sport, religion, psychotherapy, health care and behaviour change20, 23. Within these contexts, the theory has been used to identify, understand, explain, predict, promote and support individual motivation19-21. According to the theory developers, the SDT perspective may predict the motivation of family caregivers for becoming caregivers, influencing the effect of the role on them. Preliminary evidence shows that autonomous versus controlled motivation for giving care to ill family members tends to affect the well-being and health outcomes of caregivers18. Thus, further exploration of the role of SDT in understanding caregiving motivation is recommended.


Aim

To describe and explore empirical studies of caregivers' motivation from the perspective of self-determination theory.


Method

This integrative review was conducted as outlined by Whittemore and Knafl24. An integrative review incorporates evidence from studies conducted using a wide variety of research methodologies25. This approach is especially useful when the research topic may lend itself to theoretical, quantitative and qualitative methods of investigation24. An integrative literature review is suitable when the topic has not been extensively researched26. A preliminary literature search revealed a limited research area that consisted of diverse methodologies. Therefore, the integrative review method by Whittemore and Knafl24 was considered as the most efficient approach. This allowed the inclusion of both qualitative and quantitative studies in order to more fully understand the research topic of caregivers motivation, and provide more solid evidence base with the potential for contributing to SDT theory development24.


Research question and eligibility criteria

Having identified the research area of interest, the research question that guided the review process was formulated as follows:
 
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Table 1 shows the priori inclusion and exclusion criteria.

Table 1. Inclusion and exclusion criteria
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Literature search

Eligible studies were identified from database searches, a manual search of reference lists, and consultation with experts. The literature search in databases used combinations of the following search terms: ‘caregiver’, ‘family care’, ‘next of kin’, ‘informal care’ and ‘self-determination theory’. Relevant MeSH and thesaurus terms were applied when possible. The search strategy began with the union (‘OR’) of terms to capture articles related to the main concept ‘caregiver’, and then the intersection (‘AND’) of the term ‘self-determination theory’ to identify the full range of articles that combined the two main concepts. In databases that allowed limitations, peer reviewed articles were preferred, and no limitations were placed on publication year or language. The searches were done under the supervision of a specialised librarian at the University of Stavanger.

An initial systematic literature search of bibliographic databases MEDLINE, Scopus, PsychInfo, PsycNET, Chinal and Cochrane Library was conducted in May 2018, resulting in 105 titles. An updated and extended search was performed in December 2018, including the search terms ‘spouse’, ‘filial’ and ‘relatives’, and by adding the EMBASE database. The updated search identified 54 new titles, and entries for two new eligible papers were added to the annotated bibliography. The new papers tended to confirm or extend, rather than challenge, the initial synthesis. See Table 2 for an example of search strings form the database MEDLINE.

Table 2. Example of systematic literature search in MEDLINE, conducted December 2018
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Study selection

A total of 159 titles were identified. After removal of duplicate items (N = 100), none of the remaining records (N = 59) were excluded after scanning of titles. Guided by the eligibility criteria (Table 1), the remaining abstracts were independently evaluated by the authors. Reasons for exclusion abstracts were mostly studies not reporting from a health context (N = 15), and studies reporting patient outcomes only (N = 19). Of the reviewed abstracts, 14 articles were selected for a full-text read. After screening the full-text records identified in the database search, eight articles were included in the review. Manual searches were performed in the reference lists of included studies and two additional studies were included. Figure 1 details and describes the identification and selection process using the PRISMA flow diagram27.
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Figure 1
Paper selection strategy flow chart. PRISMA workflow of the identification, screening, eligibility and inclusion of the studies in the integrative review27


Data evaluation

Data evaluation is crucial to enhance the rigour of an integrative review24. The Mixed Methods Appraisal Tool (MMAT), version 201828, was used to evaluate the methodological quality of the included articles. The MMAT29 is designed for methodological quality appraisal when performing complex systematic reviews, and assesses the quality of qualitative, quantitative and/or mixed methods studies28. For this review, checklists for qualitative, randomised and descriptive quantitative research studies were used. Rating and reporting a total score for each article is not recommended, but is rather used to give a description of study quality30. Data evaluation was performed by all authors who independently rated the articles, followed by a discussion to achieve consensus. The quality of the included studies was above moderate, with MMAT remarks on four of them. See Table 3, spreadsheet on the MMAT for more information. No papers were excluded based on the quality assessment.

Table 3. Quality appraisal of the selected studies (N = 10) spreadsheet on the Mixed Methods Appraisal Tool (MMAT)28
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Data analysis

The included articles are presented in Table 4, comprising information on first author, publication year, origin, study aim, study design, sample description and short summary of main findings relevant to our research question. The data analysis comprised four stages, (1) data reduction, (2) data display, (3) data comparison and (4) conclusion drawing and verification24. The synthesis of evidence was performed as a narrative analysis allowing for a movement from descriptions of patterns and relationships to higher levels of abstraction from the particular to the general24, 26.

Table 4. Characteristics of the included studies

The data analysis was carried out during two analysis workshops in which all authors participated. In the first stage, relevant data from each article were extracted and compiled into a matrix (Table 4) (data reduction). In the second stage, extracted data were converted into a display to visualise patterns and relationships among the primary sources (data display). The tabulation of quantitative and qualitative findings within a single matrix supported the synthesis of both statistical and narrative data, facilitating a systematic comparison of the primary data sources24. The third stage involved coding of text by the first author and a read-through by the authors to identify new themes or data suggesting variance or dissonance within or between articles (data comparison). In the fourth stage, an interpretive approach was used to describe how caregivers' motivation could be understood from an SDT perspective. The data synthesis was then verified by the findings from the included articles for confirmability and accuracy (conclusion drawing and verification).


Results

Three themes emerged from the narrative analysis. The first theme address descriptions of caregivers' motivation. The second theme contains information on the connection between caregivers' motivation and their well-being; the third theme describes how caregivers' motivation can be supported.


Description of caregivers' motivation

All studies included here lent insight to the situational demands that influenced adult caregivers' motivation for providing care to a friend or relative with a long-term illness. Most of the studies had investigated caregivers' quality of motivation and classified it according to different constructs in SDT such as intrinsic motivation, identified motivation, introjected motivation, external motivation31-38 and amotivation35. In these studies, SDT terminology has been used to identify, measure, classify, categorise or describe caregivers' quality of motivation. In several of the studies, SDT constructs were presented as categories of autonomous motivation like intrinsic motivation (i.e. helping because you enjoy/value this behaviour and experience volition and choice), or controlled motivation, understood as extrinsic motivation (i.e. helping because you believe you should)31-37, 39. One qualitative study reported that in real life, the constructs and categories of motivation are more ambiguous than, and not as easy to identify as, in the theory37.

Two studies did not assess quality of motivation in particular, but were concerned with how caregivers could fulfil their need for autonomy, competence and relatedness40 or the importance of internalisation where caregivers have integrated the duties and responsibilities resulting from their friend's or relative's illness38. Pierce et al.38 found that maintenance of motivation over time requires caregivers to internalise values and skills for caregiving and to experience self-determination. This could lead to greater identification with caregiving and could foster enthusiasm and well-being among caregivers. Several studies found that caregivers' feelings of caregiving as voluntary and that the need for autonomy was fulfilled, was especially important for high quality of motivation31, 32, 34, 36, 38, 39.

The majority of studies presented evidence for caregivers' helping motivation and the contribution to changes in their daily outcomes through the improvement of their need satisfaction and a decrease in their need frustration. Two studies explicitly concluded that the autonomous helping motivation was positively associated with the satisfaction of basic psychological needs32, 34, while most of the other studies merely implied it. Several studies found that autonomously motivated help compared with controlled motivated help, had beneficial effects on caregivers31-37, 39.


Caregivers' motivation and well-being

Most of the studies reported on outcomes for caregivers' well-being31-38. In addition, equivalent terms like psychological well-being32, mental health33, 37 physical health33, life satisfaction32, quality of life33 and long-term health37 were presented. All studies except Strekalova's40 found that caregivers' different reasons for engaging in helping behaviour indicated why some caregivers experienced more stress and worse well-being than others. In five studies, variations in reasons for providing care were discussed as important elements in understanding caregivers' psychological well-being 32-34, 37, 38. Two studies explicitly presented satisfaction of the basic psychological needs for autonomy, competence and relatedness as mediators for predicting the quality of motivation and thereby psychological health and well-being among caregivers32, 34.

Common among the studies was the examination of the relationship between caregivers' controlled versus autonomous motivation to help, and the consequences for their well-being32-37. These studies found that controlled (extrinsic) motivated reasons for providing care as feeling forced or obligated to take care, led to diminished well-being among caregivers. Kindt and colleagues35 found that controlled-motivated caregivers gained little well-being from helping a partner with chronic pain and experienced increased exhaustion and stress. In other studies, caregivers reported more internal relational conflicts34, negative affect36 tensions in their relationship34, and less control over their caregiver situation37. Extrinsic motives for caregiving predicted greater depressive symptoms36, less life satisfaction32, more stress36 and increased caregiver burden33.

Six studies found that caregivers who were autonomously motivated to help experienced less stress and exhaustion than did those who viewed caregiving as an obligation32-37. In Kindt et al.34 partners who did not experience external or internal pressure, but who were committed to helping and derived enjoyment from it reported better well-being34. Caregiving motivation was characterised as autonomous when caregivers' psychological needs for relatedness, autonomy and competence were met within the caregiving context34-36. Satisfaction of these needs was associated with life satisfaction, subjective vitality and positive affect among spousal caregivers32-36. Caregivers who perceived gratitude from the patient36 or who were enthusiastic about caregiving38, were more willing to provide help. Autonomous motivated caregivers reported fewer depressive symptoms32, greater spirituality and better mental health33, greater personal growth and saw benefits in caregiving32. Autonomous motivation led to increased happiness, positive affect, a sense of well-being, greater satisfaction with life36, 38 and better personal functioning and less exhaustion as a result of helping someone with a long-term illness34-36.


Support of caregivers' motivation

All studies presented implications for further research and recommended finding better ways to support caregivers. Most of the studies argued for the value of mapping variation in the reasons for providing care and for considering the underlying motives of helping behaviour32, 34, 36-38. Some studies pointed out that considering the reasons for providing informal care is important to identify caregivers who experience diminished well-being32, 38 and who might benefit from support services or counselling34, 38. Caregivers' helping motivation predicted32-36, 38, described37 or supported31, 39 their health outcomes. Strekalova40 addressed the psychological needs for competence (i.e. information and understanding the diagnosis), autonomy (i.e. making choices and planning for the future) and relatedness (i.e. contact and support from other families in a similar situation). She found that early identification of caregivers' needs may lead to better psychological coping and improved health outcomes40. To increase caregivers' self-determination, Pierce et al.38 suggested that healthcare professionals support caregivers by helping them see the options available to them and allowing them greater freedom of choice with respect to caregiving tasks. Findings from Kim et al.33 suggest that caregivers may benefit from interventions that facilitate their ability to be autonomously motivated.

Several studies concluded that the development and testing of SDT-based support services and interventions in a caregiver context might be useful for development of effective motivational support to caregivers31-39. Only two studies had developed, tested and evaluated interventions to support motivation in caregivers. Badr et al.31 tested an SDT intervention to improve quality of life for patients with advanced lung cancer and their family caregivers. The intervention consisted of standardised, tailored manuals on self-care, stress and coping, symptom management, communication skills, problem solving, and maintaining and enhancing relationships. In addition, dyads of patient and caregiver participated in weekly telephone counselling sessions. The intervention group reported improvements in depression and anxiety, a significant decrease in caregiver burden, and caregivers' increased autonomous motivation31. Cossette and colleagues39 tested an SDT-based intervention on dyads of heart failure patients and their caregivers. While the patient was hospitalised, the dyads were offered two face-to-face meetings with a project nurse; after the patient was discharged, they were offered three telephone-based meetings. The caregivers reported that they were less amotivated in their caregiver work and felt they provided better support to the patient39. Results from the two intervention studies reported that the caregivers were generally satisfied with the interventions and found them helpful, relevant and convenient31, 39. Ng and colleagues37 suggested that models of supporting caregiver wellness and intervention work ought to focus not just on reducing anxiety and depression, but also consider meaning and motivation as foundations for caregivers' long-term health and well-being.


Discussion

To our knowledge, this is the first review of the research literature that explores and discusses caregiving motivation from the SDT perspective. In sum, the analysis of the included articles has found that all studies considered satisfaction of the three basic psychological needs for autonomy, competence and relatedness as essential for predicting caregivers' quality of motivation and thus their well-being. The review holds the potential to form an important foundation for future research, and for the development of interventions that will increase caregivers' sense of self-determination.


Caregivers' motivation and well-being in a long-term illness context

The most significant finding was that fulfilment of caregivers' psychological needs and autonomous motivation was strongly associated with their greater well-being. Our findings are consistent with Milyavskaya and Koestner23 who found that need satisfaction is universally linked to motivation and well-being across important life domains. Other researchers have come to the same conclusion in workplace studies19, 22, among patient populations in health care, and in health promotion contexts20. Moreover, Weinstein and Ryan21 found that intrinsic motivation for helping yielded benefits for the helper through greater need satisfaction. Perception of choice in entering the caregiver role is positively associated with well-being among caregivers, and internalised values about the importance of caregiving are essential12. This is consistent with our findings, where the maintenance of motivation over time requires that caregiver's internalise certain values, duties, responsibilities and skills. Moreover, this review suggests that the feelings of caregiving as voluntary and fulfilment of the need for autonomy is especially important for high-quality motivation. Also, caregivers' perception of support for their autonomy from family and friends, from their workplace and from health professionals may be associated with less depression and increased well-being and life satisfaction. In line with this, high-quality motivation is a central marker of well-being and associated with high performance22 and personal growth20, 21. In extension of this, we see the need for health professionals supporting the caregivers' volunteering behaviour and offering guidance towards caregiving solutions to support sense of autonomy.

Our findings support the theoretical proposition that fulfilment of the basic needs for autonomy, competence and relatedness is a primary form of psychological nurturance that facilitates well-being17, 18 in caregivers. Intrinsic motivation is distinguished by autonomous motivation and self-determined behaviour where the person acts out of interest, engagement and enjoy the activity18, 20. The review show that fulfilment of the three basic psychological needs for autonomy, competence and relatedness are important determinants of caregivers' well-being, protecting them from high levels of psychological distress associated with ill-being and caregiver burden. In a job satisfaction context, amotivation, where the motivational quality is lowest and the employee finds no value or interest in acting, is associated with poor well-being and performance19, 22. The employee appears to have no self-determination and the motivation for acting is controlled, resulting in poorer well-being17. Our narrative analyses confirmed this by showing that caregivers who reported feeling forced or obligated to offer care were extrinsically motivated or amotivated, which predicted more depressive symptoms, less life satisfaction, and greater stress and caregiver burden.


Targeting caregivers' autonomous motivation

We found that a motivational perspective on helping, as provided by SDT, is useful in explaining variations in personal and relational well-being and distress among caregivers. Early identification of caregivers who are struggling or at risk of struggling is crucial4. It is important to identify this subgroup of caregivers so that they can receive evidence-based services6. SDT constructs can identity, clarify and explain why caregivers in apparently similar situations differ in terms of well-being and in their desire to continue offering care. According to Roth et al.6 it is important to target evidence-based services to the subgroup of caregivers who are under stress or at risk in other ways6. In line with this, we found that by identifying caregivers who were intrinsically motivated or amotivated and suffering from the caregiver experience, health professionals might better understand why certain caregivers experience worse well-being than others, and how these caregivers will benefit from receiving support services or counselling.

Our results highlight the need for improved ways of supporting caregivers' motivation. Moreover, it is crucial for health professionals to understand when the provision of caregiver support is considered helpful and beneficial for the caregivers' well-being. According to previous caregiver research, health services ought to see informal carers as no less important than the patient2, 4, 11. Different kinds of caregivers need different kinds of support and interventions based on, that is, types or severity of the relatives' long-term illness1, 9. Support and services to caregivers are indispensable to caregivers' psychological well-being by preventing burnout4, 8. This is consistent with our findings that well-being is facilitated by perceived support, especially support for autonomy from health professionals, the patient and from others. Given the critical role of autonomous helping motivation, health professionals can meet caregivers' needs by being autonomous supportive. Promising result from the two pilot interventions in the fields of cancer and heart failure encourage further development and testing of interventions that support caregivers. The interventions recommend that health professionals reinforce caregivers' autonomous motivation by offering choices rather than restrictions, showing the range of options available to them, avoiding criticism and giving encouragement31, 39. Accordingly, health providers should view caregivers as partners5, and take into account caregivers' resources13. Here, a more balanced image of the caregiver as a resilient and capable ally is useful6. Health professionals could work more effectively and systematically with patients to identify, inform and collaborate with their informal caregivers6. According to Quinn et al.10 efficacious interventions should be developed and implemented to support caregivers' motivation and thus their well-being.


Future directions for SDT in the caregiver context

Our findings suggest that models of understanding caregiver well-being ought to focus not just on the absence of stress and caregiver burden, but also consider motivation as the foundation for caregivers' long-term health and well-being. These findings meet previous research calls for promotion of benefits of caregiving, such as sense of satisfaction, autonomy and expertise among caregivers that may act as specific and legitimate goals for motivational support5, 6, 14, 15. The existing dominance of a stress-coping approach pathologies caregiving6, 14. In contrast, SDT represents greater attention to health promotion20 and offers a promising theoretical framework for future research, by shifting the focus from health threat to health resources in the caregiving context.

All of the included articles described how SDT was applied in their respective studies, depicting SDT as an effective framework for understanding caregivers' motivation. In this context, it would be valuable to know more about the application of SDT in research on caregiving, and in particular, qualitative research is warranted to identify the SDT constructs' application in real life. Moreover, all of the reviewed articles included both male and female caregivers, while only two studied SDT constructs with respect to gender32, 33. The gender issue in current SDT research has provided inconsistent findings41 representing a knowledge gap in the SDT research on caregiver motivation.

Most of the studies included in this review used SDT measurements and questionnaires validated in or adapted from other contexts. Accordingly, the development, testing and validation of SDT-based instruments and questionnaires in different languages adapted to a caregiver context are warranted. Further development of qualitative research approaches to identify methods of promoting caregivers' autonomous motivation is recommended. This could add value to a field of SDT research that is already dominated by quantitative methods. Future SDT research on caregivers should endorse reporting and reflecting on the application of SDT.


Methodological considerations

It can be methodologically challenging to include mixed evidence within one literature review. The integrative review method has been successfully adapted to allow diverse primary sources and multiple perspectives to be combined, to gain in-depth understanding of complex phenomena26. Whittemore and Knafl's integrative review method24 provided a stringent approach to the current review study, represented by its rigorous and systematic review procedure.

Our search strategy was comprehensive, comprising two searches (initial and follow-up) in seven multidisciplinary bibliographical databases. This allowed for an updated and interprofessional approach to the literature search. Even though no limitations on year or language were added to the literature search, only 159 articles were found, most of them published since 2015 and published in English. This indicates a circumscribed research area, but at the same time the combination of caregiving and SDT seems new and upcoming in both research and practice. Despite a comprehensive literature search, the inclusion of grey literature might have given expanded access to the research area. To enhance the rigor of our review, a priori and well-defined selection criteria were used. All authors participated in study selection, ensuring that the identified documents were eligible for inclusion. Choosing a single motivational theory (SDT) as a theoretical perspective might be considered a strength of this review, but may have narrowed the knowledge base. The inclusion of other motivational theories might have contributed to a broader view on caregiving motivation.


Conclusions

This integrative literature review found that SDT can be applied to identify, categorise, explain, predict, promote and support motivation among caregivers. The findings are an initial demonstration of the differential effects of caregivers' autonomous versus controlled motivation for helping a friend of relative with a long-term illness. Autonomous motivation is demonstrated as an important determinant of caregivers' well-being and may protect them from feeling overstressed and overworked. When caregivers voluntarily offer their help, they experience a greater sense of autonomy, relatedness and competence; and need satisfactions that in turn appear to enhance caregivers' sense of well-being. This review gives important support for SDT and promotes further study and application of the theory as a psychological approach to health and health promotion in the caregiver context. The further development and implementation of autonomy-supportive interventions and services to caregivers as the target group are endorsed. For future SDT research in the caregiver context, more reporting and reflection on the application of SDT are recommended. Furthermore, contributing a fresh theoretical perspective to a familiar field is a strong argument for applying SDT to the caregiver context in future research and practice.


Acknowledgements

The authors would like to thank Grete Mortensen, Specialized Librarian, University of Stavanger, for assistance with data collection for this study and Professor Chris Niemiec, University of Rochester, United States, for contributing to the development of the idea to this article.


Conflicts of interest

The authors state explicitly that there are no conflicts of interest in connection with this article.
 

Author contribution

HD is the main author and takes responsibility for the content of this article. Data collection and analysis were guided by AN and AMLH. All authors critically revised the manuscript. This study is a part of a PhD thesis for which AN is a supervisor.


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