Exploring positive experiences of primary and secondary caregivers of older persons in resource-limited urban settings in Accra, Ghana.

Family caregivers experience both negative and positive outcomes. However, most studies have mainly focused on the negative outcomes. In addition, few studies have focused on both primary and secondary caregivers. This study explored the positive experiences of primary and secondary caregivers of older persons in resource-limited urban settings in Accra, Ghana. This study used phenomenological design, and thirty-one family caregivers were interviewed in James Town and Ussher Town. The interviews were audio-recorded, transcribed verbatim, and analysed thematically using NVivo 10. The findings show that the primary and secondary caregivers derived tangible and intangible rewards from providing care to older persons. The tangible rewards included gifts, while the intangible include blessings, skills acquisition, enhanced personal attributes, family cohesion, and health consciousness. Positive caregiving experiences can mitigate caregivers' burden and burnout. Therefore, policymakers and social workers should design interventions that will enhance the positive experiences of family caregivers. They should also consider the gender and age of caregivers in designing these interventions.

Introduction

Globally, there has been an increase in the proportion of older persons (aged 65 years and older). Between 1990 and 2021, the proportion of the population of older people to the total global population increased from 6 percent to 10 percent, and it is estimated to reach 16 percent in 2050 [1, 2]. In Ghana, the proportion has increased from 3 percent in 1960 to 4 percent in 2021 [2, 3]. By 2050, it is estimated that about 9 percent of Ghanaians will be aged 65 years and older. The increase in the proportion of older persons can be attributed to increasing longevity and declining fertility [4].

Older persons, especially those aged 75 years and over, may need some assistance due to their functional limitations. In Ghana and other sub-Saharan African countries, the family is the main provider of care and support to older persons [3, 5, 6]. The provision of unpaid care to a relative, partner, friend, or neighbour who needs care is referred to as family caregiving [7]. Family caregiving roles are often performed by women [8-10]. In addition, women often provide personal care (such as bathing, cooking, laundry, and dressing). In contract, men provide financial care (such as giving money for food and paying medical and other types of bills) [9, 11].

In Ghana, modernisation processes (such as urbanisation) have influenced the role of the family in providing care to older persons due to financial constraints and increased involvement of women in the paid labour market [12-14]. For instance, the increased participation of women in the labour market affects the availability of women to provide personal care to older persons [15]. In addition, research has established that financial constraints limit the financial care provided to parents [16]. Also, poverty in coastal urban areas (including the study area, Ga Mashie) has worsened over time [17], and this has repercussions for financial care to older persons.

Previous studies have established that family caregivers experience both negative and positive outcomes from performing their roles and responsibilities [18-21]. For instance, researchers have shown that family caregiving enhances caregiver-recipient relationship [20-22] and caregivers’ confidence [21]. Also, caregivers learn to handle difficult situations [21, 22] and derive satisfaction from their caregiving responsibilities [21, 23]. However, most studies on family caregiving to older persons have mainly focused on the negative outcomes to the neglect of the positive outcomes [21, 23, 24]. In this regard, previous studies have established that family caregivers of older persons experience financial constraints, poor physical and mental health, and weight loss [9, 13, 25, 26].

In addition, family caregivers often share their roles and responsibilities with others [27, 28]. In every caregiving situation, there is always someone who provides the most care. This person is referred to as the primary caregiver, while others who support this main person are known as secondary caregivers. However, most studies on family caregiving to older persons have mainly focused on primary caregivers [29-33], with limited studies on both primary and secondary caregivers [13, 26, 34]. The main focus on primary caregivers is partly because they provide most care and may experience a greater brunt of the negative outcomes of family caregiving. Nevertheless, family caregiving is dynamic, and caregiving roles change over time [21].

The available literature does not indicate that any study has explored the positive experiences of both primary and secondary caregivers of older persons in Ghana and sub-Saharan Africa in general. The paucity of studies on the positive experiences of primary and secondary caregivers in Ghana and sub-Saharan Africa limits researchers’ and policymakers’ understanding of the nuances of family caregiving experiences which would enable them to design appropriate interventions to address the associated challenges. Accordingly, this study explored the positive experiences of primary and secondary caregivers in urban resource-limited communities in Accra, the capital city of Ghana. It specifically explored the rewards that primary and secondary caregivers derived from providing care to older persons.

Conceptual framework

This study was guided by Kramer’s model of caregiver adaptation [35]. She highlights that well-being outcomes (whether positive or negative) are influenced by the background and context of caregiving, and intervening processes. According to Kramer [35], the background and context of caregiving component consist of caregiver characteristics (namely age, gender, duration of caregiving activities, and employment status), care recipient characteristics (that is, the type of illness, the severity of illness, care recipient needs), and caregiver attitudinal variables and efforts (such as motivations for providing care). In addition, resources (such as social support and coping strategies) and appraisal of role gain and strain in the form of caregiving satisfaction and burden were identified as factors that enhance and reduce positive and negative outcomes of caregivers, respectively.

Although Kramer’s model of caregiver adaptation discusses both positive and negative outcomes, this study focused on the positive outcomes of caregivers. Therefore, it adopted and modified Kramer’s model of caregiver adaptation (Fig 1). Positive outcomes were conceptualised as the rewards caregivers derive from providing care to their care recipients.

Fig 1

Conceptual framework for positive experiences of primary and secondary caregivers.

This manuscript is derived from a broader thesis that collected data on characteristics of family caregivers and their care recipients, and caregivers’ motivations for providing care to their care recipients (Kyei-Arthur [Unpublished]). In addition, data were collected on family caregivers’ social support and coping strategies. Previous studies have documented that background and context of caregiving, and intervening processes influence caregiver well-being outcomes [36-38]. Therefore, we also conceptualised that the background and context of caregiving can directly influence positive outcomes.

This manuscript does not seek to assess the pathways to positive caregiving, but it seeks to describe positive outcomes among family caregivers in a context that has rarely been studied.

Methods

Design and study setting

This study used phenomenology to explore the positive caregiving experiences of primary and secondary caregivers. Phenomenology describes people’s lived experiences and how they interpret their experiences [39, 40]. Phenomenology was selected because it assists investigators to explain the meaning people assign to their experiences [41, 42].

This study was conducted in James Town and Ussher Town, which are neighbouring communities in the city of Accra, commonly referred to as Ga Mashie. Ga Mashie is one of the six indigenous Ga localities and one of the oldest localities in Accra, the capital city of Ghana [43]. They are located on the Gulf of Guinea and recognised as resource-limited urban localities in Accra [44]. They are densely populated, and residents lack access to basic social amenities such as potable water and waste disposal. Fishing and fishing-related activities are the main economic activities of residents. Residents in James Town and Ussher Town dwell in multigenerational households.

Data collection

The data collection for this study followed a two-stage procedure. In the first stage, the first author obtained the list and identifiers (e.g., structure, household and individual identifiers) of family caregivers who participated in the third wave of the Regional Institute for Population Studies’ (RIPS) Survey dubbed “Urban Health and Poverty Survey” from the Principal Investigators. The first author was a research assistant during the third wave of the RIPS Survey, while the second and third authors were co-investigators on the RIPS Survey. The Urban Health and Poverty Survey took place in September 2013. It is a longitudinal survey that examines the health, poverty, and development nexus in Agbogbloshie, James Town, and Ussher Town. Overall, 57 family caregivers were involved in the third wave of the Urban Health and Poverty Survey.

In the second stage, the first author and trained research assistants contacted family caregivers involved in the RIPS Survey and they helped the research team (first author and trained research assistants) reach out to their care recipients. In total, the first author and trained research assistants were able to contact 30 out of the 57 family caregivers using the structure and household identifiers (e.g., enumeration area number, structure number of household, name of the head of household, and contact of the head of household) and family caregiver identifiers (e.g., name, and contact numbers). In addition, care recipients assisted the research team in reaching out to all persons who provided care to them since the study was interested in primary and secondary caregivers.

Generally, a family caregiver refers to a relative and non-relative (including friends) who provide unpaid care to persons in need of care. In this study, a primary caregiver refers to a family caregiver who performs most caregiving activities for their care recipient. In contrast, a secondary caregiver is a family caregiver who supports a primary caregiver to provide care to their care recipient. Secondary caregivers complement the care provided by primary caregivers.

Family caregivers who met the following criteria were interviewed: they must be 18 years and over; a relative or non-relative of the care recipient; currently providing the unpaid care to an older person; and should have provided unpaid care for at least six months prior to the data collection. Also, family caregivers who met the following criteria were excluded from the study: care recipients had died more than six months preceding the data collection; family caregivers being less than 18 years old; providing care to an older person less than six months preceding the data collection; and not willing to share their caregiving experiences.

The data collection for the study was conducted in November 2016. In total, thirty-one family caregivers were interviewed. The in-depth interviews were conducted in the Ga language by trained research assistants. The interviews ranged between 30 and 55 minutes. Ethical clearance for the study was received by the Ethics Committee for the Humanities (ECH) of the University of Ghana (ECH 009/16-17). Participation in the study was voluntary, and informed consent of caregivers was sought before they were interviewed.

Data analysis

All the interviews were audio-taped and transcribed verbatim from the Ga language into English. The interview transcripts were quality checked and analysed using the thematic analysis approach [45]. All the transcripts were read several times to ensure a comprehensive understanding of the data. Codes were then assigned to important text in the form of categories and subcategories using NVivo 10 software. These categories and subcategories were then aggregated to develop themes of positive caregiving experiences.

Trustworthiness of findings is essential in qualitative research. To achieve trustworthiness in qualitative studies, numerous strategies have been recommended, including thick description, peer review/debriefing, development of a coding system, and member checking [46]. To achieve trustworthiness in the study, the researchers worked collaboratively and closely. Also, they consulted peers during the entire data analysis process to ensure that data were analysed from the perspectives of family caregivers. Their feedback on quotes and/or themes were addressed by re-analysing/re-examining those quotes and/or themes. Also, the study’s findings after data analysis were shared with family caregivers to confirm if the analysis reflected their experiences or provide additional information. Eight family caregivers accepted to go through the analysis and confirmed the analysis reflected their experiences. They, however, did not provide any additional information.

Results

Socio-demographic characteristics of the family caregivers and their care recipients

Table 1 presents the socio-demographic characteristics of family caregivers. Family caregivers were aged between 21 and 76 years. Out of the 31 family caregivers, 15 were primary caregivers, while the remaining 16 were secondary caregivers. Most primary and secondary caregivers were females (73.3%) and Ga-Dangme (86.7%). The majority of the secondary caregivers (100%) had formal education than primary caregivers (93.3%). Most primary and secondary caregivers (77.4%) were employed, and more than half (75%) worked at home or close to home. In addition, 27 of the respondents were Christians, and 20 had ever married.

Table 1

Characteristics of family caregivers.

	Primary caregivers (n = 15)		Secondary caregivers (n = 16)
	Frequency	Percent	Frequency	Percent
Age
Range (years)	25–76		21–70
Mean (years)	44.9		45.9
Standard deviation	16.5		17.4
Sex
Male	4	26.7	1	6.3
Female	11	73.3	15	93.7
Ethnicity
Ga-Dangme	13	86.7	11	68.7
Akan	2	13.3	2	12.5
Other	0	0.0	3	18.8
Education
No education	1	6.7	0	0.0
Formal education	14	93.3	16	100.0
Employment
Unemployed	3	20.0	4	25.0
Employed	12	80.0	12	75.0
Place of Work *
At home	2	16.7	4	33.3
Away from home, nearby	6	50.0	6	50.0
Away from home, far away	4	33.3	2	16.7
Religion
Christian	14	93.3	13	81.2
Muslim	1	6.7	3	18.8
Marital Status
Never married	4	26.7	7	43.8
Currently married	7	46.6	2	12.4
Formerly married	4	26.7	7	43.8
Locality
James Town	11	73.3	11	68.7
Ussher Town	4	26.7	5	31.3
Relationship with care recipient
Spouse	1	6.7	0	0.0
Son/daughter	9	60.0	6	37.5
Other relative	5	33.3	8	50.0
Friend	0	0.0	2	12.5
Number of years providing care
Range (years)	1–15		1–16
Mean (years)	5.93		5.50
Standard deviation	5.3		4.3
Average time spent per day providing care to care recipients
Range (hours)	1–6		1–4
Mean (hours)	3.60		2.13
Standard deviation	1.8		1.2

* Total of place of work = 12 caregivers.

Furthermore, most of the caregivers (71%) lived in James Town. Nine of the primary caregivers and eight (8) of the secondary caregivers were sons/daughters and other relatives of the care recipients, respectively.

In terms of caregiving experience, primary caregivers have provided care over a longer period (5.93 years) than secondary caregivers (5.50 years). On average, primary caregivers spent more time per day (3.6 hours) providing care to their care recipients than secondary caregivers (2.13 hours). In addition, both primary and secondary caregivers provided personal, financial, emotional and health-related care to their care recipients (Table 2).

Table 2

Types of care provided by family caregivers.

Types of care	Caregiving activities performed for care recipients
Personal care	Cooking, fetching water for bathing, warming water for bathing, accompanying care recipient to social gatherings, laundering, running errands for care recipient, shopping for groceries, dressing care recipient
Financial care	Provision of funds for feeding, payment of hospital bills and medication
Emotional care	Chatting with care recipient
Health-related care	Accompanying care recipient to the hospital, administering and supervising medication

Regarding care recipients, their mean age was 77.5 years (Table 3). Most care recipients were females (85%) and had formal education (55%). Also, most care recipients were unemployed (65%), belonged to the Ga-Dangme (90%), Christians (90%), and widowed (65%).

Table 3

Characteristics of care recipients.

Background characteristics	Elderly care recipients (N = 20)
	Frequency	Percentage
Age
Range (years)	64–95
Mean (years)	77.5
Standard deviation	10.29
Sex
Male	3	15.0
Female	17	85.0
Education
No education	9	45.0
Formal education	11	55.0
Employment
Unemployed	13	65.0
Employed	7	35.0
Ethnicity
Ga-Dangme	18	90.0
Ewe	1	5.0
Hausa	1	5.0
Religion
Christian	18	90.0
Islam	2	10.0
Marital status
Never married	3	15.0
Living together	0	0.0
Married	4	20.0
Divorced/Separated	0	0.0
Widowed	13	65.0
Number of children
Range (number of children)	1–10
Mean (number of children)	3.75
Standard deviation	2.17
Locality
James Town	15	75.0
Ussher Town	5	25.0
Health conditions
Communicable diseases (e.g., malaria, fever)	4
Non-communicable diseases (e.g., arthritis, stroke, hypertension, and diabetes)	1	5.0
Sources of income per month*
Remittances from children	20	100.0
Remittances from other relatives	10	50.0
Pension income	2	10.0
Rental of properties (e.g., land/house)	1	5.0
Income from business venture	7	35.0
Social protection programmes (e.g., Livelihood Empowerment Against Poverty)	1	5.0
Donations from friends	11	55.0

*Proportion of care recipients who received a source of income.

The mean number of children of care recipients was 3.75, and most care recipients were from James Town (75%). In terms of health conditions, most care recipients were living with non-communicable diseases such as hypertension, diabetes, and arthritis. In addition, care recipients receive income each month from their significant others. Remittances from children (100%) and other relatives (50%) and donations from friends (55%) were the primary sources of income for care recipients.

Positive experiences of the primary and secondary caregivers

Several types of rewards were received by the primary and secondary caregivers, and they are described in the succeeding sections. Primary and secondary caregivers received tangible and intangible rewards. Table 4 shows the themes, categories and subcategories.

Table 4

Themes, categories and subcategories.

Themes	Categories	Sub-categories
Tangible rewards derived from providing care to their care recipients	Gifts received from care recipients, relatives, friends, and church	Cash gifts received from care recipients, relatives and church
		In-kind gifts received from care recipients, relatives, and friends
		Real estate received from care recipient
Intangible rewards derived from providing care to their care recipients	Blessings from God due to providing care
	Skills acquisition from providing care	Skills in providing care to older persons
		Learnt to perform household chores
	Enhanced personal attributes of family caregiver	Appreciation of caregiving efforts
		Feeling valued due to privileges caregiving has bestowed on family caregiver
		Learnt humility and patience due to providing care
		Learnt to be compassionate due to providing care
	Family cohesion among family due to providing care
	Health consciousness of conditions affecting care recipient

Tangible rewards

Gifts. Gifts emerged as a tangible reward for caregiving to older persons. A total of 21 primary and secondary caregivers received gifts as rewards for the provision of care to their care recipients. They received three types of gifts namely: (1) cash; (2) in-kind; and (3) real estate.

Care recipients sometimes financially supported their caregivers when they were financially constrained. Some of them assisted their caregivers to pay their children’s school fees. Relatives of the care recipients and churches of both care recipients and caregivers also provided cash to family caregivers to motivate them to continue their care provision. A total of 16 caregivers who received financial gifts were females. The ensuing quotes highlight these financial gifts caregivers received.

“Due to the care I provide to my mum, the church we attend sometimes gives me money to motivate me to continue to provide care to her.” (R11)

“Sometimes when I am ‘broke’, my mum supports me financially.” (R31)

In addition, the care recipients, relatives, and friends gave other tangible gifts, including bread, biscuits, cooking oil, and rice, to family caregivers. Family caregivers who received in-kind gifts were females. Some primary and secondary caregivers explained that:

“I come [to the care recipient] for milk, provisions, bread, and other supplies. When she has food, she gives me.” (R29)

“I sometimes get some provisions due to the care I provide for my mum.” (R11)

Family caregivers also received land and free room/accommodation as a reward for caregiving. One primary caregiver mentioned that he received a piece of land from his father in appreciation for his caregiving roles and responsibilities. He narrated that:

“He [care recipient] has given me a piece of land in Kokrobite to build a house. He has been pressuring me to build on it but the challenge is money.” (R18)

In addition, a male primary caregiver noted that the care he provided to his grandmother enabled him to get free room/accommodation in their family house, which would have been impossible due to his young age. He explained that:

“I have a room [in our family house] and it is because of the care I provide to her.” (R9)

Intangible rewards

Five emerging themes from intangible rewards were stated: (1) blessings; (2) skills acquisition; (3) enhanced personal attributes; (4) family cohesion; and (5) health consciousness.

Blessings. Seven caregivers (2 males and 5 females) stated that they received blessings from God due to the care they provide to their care recipients and it has consequently opened up opportunities for them. A female primary caregiver explained that:

“Since I started providing care for my mum, I have never lacked anything. The Good Lord blesses me and sees to it that we never lack anything that we need.” (R5)

The blessings received from their caregiving manifested in various forms. A secondary caregiver explained that he was saved from an accident due to the financial care he provided his care recipients. He narrated the following:

“All the time, I am being delivered. Like the other time, a tragedy occurred, a serious one. The shop that you see over there [participant pointed to a shop], I hope you have seen the violet shop? We just rebuilt it. It collapsed and I was inside it. Two vehicles crushed and entered it. It even hit me but by the Grace of God, nothing happened to me. So you see, the good things that I do, the good that I use to do to people, you see that the blessing is following me”. (R4)

Skills acquisition. The primary and secondary caregivers described their skill acquisition in two areas: (1) skills in providing care; and (2) learnt to perform household chores.

Skills in providing care. Four caregivers who provided physical care (such as dressing up the care recipient, fetching water for bathing, cooking, and cleaning care recipients when they soil themselves) reported that they had acquired skills in caring for older persons. These caregivers narrated they had no prior experience in providing care to older persons before they took on their current caregiving roles and responsibilities. All the caregivers who acquired skills in caring for older persons were females. A female primary caregiver who cooks and dresses her grandmother stated the following:

“It has helped me to know how to take care of older persons because at first, I didn’t know how to do it.” (R12)

Learnt to perform household chores. Two family caregivers (1 primary and 1 secondary) narrated that the provision of care to their care recipients has helped them to learn how to perform household chores such as cooking. A secondary caregiver said:

“It has taught me how to cook and do household chores.” (R3)

Enhanced personal attributes. The primary and secondary caregivers were of the view that caregiving to older persons enhanced their attributes. They expressed enhanced personal attributes in four ways: (1) appreciation; (2) feeling valued; (3) learnt humility and patience; and (4) learnt to be compassionate.

Appreciation. Four family caregivers (3 primary and 1 secondary) explained that they felt appreciated as relatives and non-relatives recognised their caregiving efforts that had improved the general well-being of their care recipients. All the caregivers who felt appreciated were females. A primary caregiver commented that:

“People even tell me that I have done well by taking care good care of my mum. During the Easter celebration, we went to church and when people saw her, they gave me a handshake that I have done well by taking good care of my mum. When they do that, I feel appreciated.” (R5)

Feeling valued. Family caregivers sometimes accompany their care recipients to family meetings. In Ga Mashie and other parts of Ghana, attending and participating in family meetings are often reserve for older persons. However, two female caregivers had the privilege to attend family meetings with their care recipients and this made them feel valued.

“… I feel I am important because I get to sit at places where I would not sit if I was alone. I get to sit at the high table when I accompany her to family meetings. If it was not because of her, I will not be sitting there because my age doesn’t qualify me.” (R6)

“Because of the care I provide to my care recipient, I can attend family meetings. If not for her, my age would have disqualified me from attending such meetings.” (R24)

Learnt humility and patience. Three caregivers (2 primary and 1 secondary) stated that providing care to older persons helped them to cultivate humility and patience. All these caregivers were females. One secondary caregiver narrated that:

“It has taught me to be humble and patient in whatever I do.” (R17)

Learnt to be compassionate. According to a female secondary caregiver, providing care to her father has helped her to cultivate compassion towards the needy and assisting them when the means are available. She reported that:

“The help I give to him has helped me learn a lot of things. Some of the things that I have learned are that if someone is in need and you are capable you should help him or her.” (R2)

Family cohesion. One female primary caregiver explained that before assuming her caregiving roles and responsibilities, there used to be quarrels within her family, however, provision of care to her mother has bonded the family.

“There used to be some quarrels in the family but since I started providing care to my mum it has brought the family together.” (R5)

Health consciousness. The caregivers who provided health-related care often accompanied their care recipients to hospitals/clinics for health checkups, and this provided them with the opportunity to be educated on health conditions affecting their care recipients. One primary caregiver who cared for her mother diagnosed with hypertension and diabetes explained that access to health education on these conditions made her cautious of her diet and took the necessary precautionary measures to reduce her risk of developing hypertension and diabetes. She noted:

“Health-wise, I have learned a lot of things that affect the family that can equally affect me so I am taking precautions now and then to make sure I don’t fall a victim. So I check my diet.” (R26)

Discussion

This study explored the positive experiences of primary and secondary caregivers in resource-limited urban settings in Accra, the capital of Ghana. It sought to contribute to researchers’ and policymakers’ understanding of the nuances of caregiving experiences and why caregivers continue to provide care to older persons despite their negative experiences, which are often reported in the family caregiving literature. Although caregivers may experience some negative outcomes from caregiving, they derive benefits (both tangible and intangible) which motivate them to continue their challenging caregiving roles and responsibilities.

The findings from the study showed that caregivers received gifts from their care recipients, relatives, non-relatives, and religious institutions (such as the church) as a token of appreciation for their caregiving roles and responsibilities. In the Ghanaian setting, the older persons are often given food items, especially bread, when they are visited by their relatives and non-relatives. Caregivers of older persons tend to benefit from these food items. In addition, some older persons occasionally support their caregivers financially. This finding corroborates previous studies in the United States, which indicated that caregivers received financial support from their care recipients [47, 48].

This study found that the family caregivers also received real estate as a reward for the care they provide to their care recipients, namely: land and free room/accommodation. This finding is significant because it is absent in the family caregiving literature, especially in Ghana and the rest of sub-Saharan Africa.

The caregivers believed that providing care to older persons brought blessings to their lives. This belief may be linked to their religiosity and/or spirituality. Previous studies in the United States also found that caregivers perceived caregiving roles and responsibilities as a blessing [49, 50].

In addition, the findings showed that caregiving to older persons provided family caregivers with the opportunity to learn skills such as performing household chores (for example, cooking and cleaning) and caring for older persons. All the caregivers who reported that they learnt skills through caregiving had no prior caregiving experience. This finding corroborates Fruhauf et al.’s [48] study in the United States which found that family caregiving helped caregivers to acquire the requisite skills to provide care to their care recipients.

Also, the study found that a caregiver became health conscious due to her caregiving roles and responsibilities. Through her interaction with health professionals, she became knowledgeable about hereditary conditions and consequently, became mindful of her diet and thereby reduced her risk of developing those conditions. This finding corroborates Thornton and Hopp’s [20] study in the United States, which indicated that daughters became knowledgeable about their parents’ health conditions which could help prevent or reduce their risk of developing those conditions.

The findings further showed that caregivers felt appreciated and valued while cultivating humility and patience, and compassion towards the impoverished. The efforts of caregivers to improve the general well-being of their care recipients were recognised by others, and this made the caregivers feel appreciated and proud in their caregiving roles. This result supports previous studies in Hong Kong, Portugal, and the United States, where family caregivers reported that they appreciated the recognition of their caregiving efforts by their care recipients and others [20, 51–53]. Also, previous studies in Hong Kong, Singapore, and the United States found that providing care to care recipients helped family caregivers to develop patience or become more patient [48, 52, 54–56].

Family caregivers also reported that caregiving to their care recipients had strengthened their family bond, especially among siblings Since family members shared their caregiving roles and responsibilities among themselves, they collaborated to enhance their care recipient’s well-being, which strengthened the bond among them. This finding supports previous studies that found that family caregiving enhanced relationships among caregivers, care recipients, and other relatives [20, 55–59].

Concerning Kramer’s model of caregiver adaptation adopted for this study, the findings showed that caregiver characteristics (such as age and gender) are linked to some positive outcomes (gifts and skills acquisition). With respect to gifts, the findings showed some gender dimensions. For example, only female caregivers received gifts in cash and in-kind, while only male caregivers received gifts in the form of land and access to room/accommodation. Male caregivers often provide financial care [60-62], and which explain why only female caregivers received gifts in cash and in-kind. This finding suggests that interventions to promote positive caregiving outcomes should consider the gender dimensions of family caregiving and the associated rewards.

Regarding age, all family caregivers who learned skills through family caregiving were young and middle-aged adults (25–45 years). This finding suggests that skills acquisition during caregiving may vary by age. Therefore, it is important that specific interventions to promote positive outcomes of caregiving focus on the age of caregivers.

In addition, care recipient characteristics (sources of income per month) influenced some positive outcomes. For instance, the income care recipients received each month from their significant others enabled them to assist their caregivers financially.

The findings of this study have some implications. First, this study found that family caregivers derived tangible and intangible rewards when caring for their care recipients. Such rewards could reduce the burden and burnout of the caregivers. Studies have linked positive caregiving experiences with a lower caregiving burden [63, 64]. Therefore, policymakers and social workers should consider family caregivers’ positive caregiving experiences when designing appropriate interventions to mitigate caregivers’ burden and burnout. Second, this study found that younger family caregivers acquired skills in providing care and learnt to perform household chores by providing care to their care recipients. This insight could be incorporated in advocacy for family caregiving to older persons to encourage younger persons to assume family caregiving roles and responsibilities.

Limitation

This study has two main limitations. First, researchers are using phenomenological design are expected to suspend their views and ideas about the phenomenon they are studying. However, it is impossible to wholly suspend one’s views and ideas about a phenomenon of interest. Second, phenomenological design focuses on describing the experiences of individuals than an explanation of those experiences. Despite these limitations, this study has provided comprehensive information on the positive experiences of primary and secondary caregivers and thus contributes to the literature on this neglected aspect of caregiving in Ghana and the rest of sub-Saharan Africa.

Conclusions

This study demonstrated that family caregivers derive positive experiences from providing care to older persons in their communities. For example, family caregivers received gifts, blessings, acquired skills, and became health conscious. In addition, caregiving enhanced family bonds and personal traits of caregivers. Positive caregiving experiences can mitigate caregivers’ burden and burnout. Therefore, policymakers and social workers should design interventions (such as counselling and emotional support) that will enhance the positive experiences of family caregivers. Also, this study found that tangible rewards varied by gender and age. Hence, policymakers and social workers should consider family caregivers’ gender and age dynamics in designing interventions to enhance the positive experiences of family caregivers.

Interview guide for qualitative study.

(DOCX)

Click here for additional data file.

Themes and their sample quotes for rewards family caregiver derived from providing care to their care recipients.

(DOCX)

Click here for additional data file.

24 Feb 2022

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Vijayaprasad Gopichandran

Academic Editor

PLOS ONE

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2. We note that you have referenced (Kyei-Arthur F. Family caregiving: Experiences of caregivers and their elderly care recipeints in urban poor communities in Accra, Ghana [Unpublished doctoral thesis]: University of Ghana; 2017.) which has currently not yet been accepted for publication. Please remove this from your References and amend this to state in the body of your manuscript: (ie “Bewick et al. [Unpublished]”) as detailed online in our guide for authors

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Partly

Reviewer #3: Partly

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: N/A

Reviewer #3: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: Yes

Reviewer #3: Yes

**********

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PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: Yes

Reviewer #3: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: This is an interesting topic of research and the purpose is clearly stated and important. Overall, the manuscript is prepared logically and the data collection seem detailed. There are a few issues the authors need to address. One is the type of this study this falls into. The manuscript is presented in light of qualitative study but no description of that is provided. Authors need to provide that clearly and what type of qualitative study. Secondly, the authors repeatedly used the terms primary and secondary caregivers but have not provided any operational definitions of those terms rather than mentioned them in passing. The tables in the manuscript need to be formatted in a better way like APA style table. The entire paper needs to be edited and formatted too. A couple of minor grammatical errors were made and the authors can correct that using grammerly.

The conclusions need to clearly presented

Reviewer #3: Thanks to the authors for submitting this manuscript which explored positive experiences of caregiving in resource-poor urban settings in Accra, Ghana. There are some major methodological issues that need to be addressed, and the implications of the findings need to be clearly stated to demonstrate the usefulness of this piece of work.

Abstract

• State the research methodology used

• Review the conclusion and make it applicable to the findings of the study. The findings demonstrated that there were intangible and tangible rewards. What is/are the implication(s) of the findings of the study?

Introduction

Page 3, lines 60-64. This section needs to be developed further. The authors made reference to processes influencing the role of the family. Provide information on the nature of influences.

Page 4 – While the author has noted that positive experiences have been reported in the literature, they should be described in the introduction section, rather than just including citations. The majority of readers will not readily go to the reference list and try to search for the articles to identify the positive experiences.

Conceptual Framework

Page 5 – refer to the author by name, instead using the terms she/her.

Materials and Methods

What qualitative method was used in this study?

Page 6 – “family caregivers were purposely selected” – what criteria was used for this selection? This should be stated.

Page 7

The recruitment strategy is unclear

• Line 133 – “The first author and research assistants were able to track 30 out of the 57 family caregivers” – how was this done? The details need to be provided

• Line 136 – Why were care recipients interviewed, if the researcher had ‘tracked’ the caregivers?

The exclusion criteria should be explicitly stated.

What was the aim of the component of the study related to care recipients?

What information was obtained from the care recipients (reference made to 20 in-depth interviews that were done)?

The interview guide captured questions on motivation for providing care, caregiving experiences, coping strategies, perception and other issues. The aim of the study was to capture positive experiences. Some of the information from the interview guide is relevant and appropriate. If the authors indicate in the methods section that coping strategies, for example, was explored, then the finding related to this should also be presented.

Correct the sentence “ethical clearance for the study was approved…” to “ethical clearance for the study was received…”

Did the care recipients provide informed consent?

Did the conceptual framework guide the development of the interview guide?

Review the section on data analysis and remove duplicated information.

When was the qualitative aspect of the study conducted? Was it also done in 2016 when the third wave of the UPHS was conducted? It is not clear.

Operationally define the following:

• Family caregiver

• Primary caregiver

• Secondary caregiver

Results

It may be more meaningful to report the percentages in the narrative rather than the numbers (n).

Review the numbers presented to ensure that they match up to what is in the table. For example, it was indicated that the majority of primary caregivers (n=15) had formal education. In the table, only 14 persons had formal education. Please also noted that formal education is not a term used in the table. Accordingly, the terms in the table should appropriately match what is in the narrative aspect of the results.

Table 1:

• Please report the standard deviation for the mean age

• Add the unit of measurement for age range

• The “n=12” in the row with label “place of work” needs to be reconsidered – why was this done? Were data elements missing?

Adding the label n=12 is confusing. My assumption is that subsequent variables in the table are related to that label (n=12). This is not the case, as the variable ‘religion’, for example, n=15 and n=16 for primary and secondary caregivers respectively would not apply to that label. You could consider using footnotes to reduce confusion.

• Why is the source of the socio-demographic characteristics from the Informal Caregiving Study, 2016? Again, when was the qualitative aspect conducted. Would the characteristics have changed if the qualitative aspect of the study conducted at a later date?

No results have been provided for the care recipient. Please provide an explanation for this, since in-depth interviews were conducted.

Please add details about caregiving experiences of the caregiver, to provide some context to the positive experiences that were reported (for example, information on the number of years providing care, number of hours worked, and the type of care provided).

The legend for Table 2 should be expanded to say what the themes, subthemes and sub-categories relate to.

Discussion

Line 333 – What evidence do you have to conclusively say that the knowledge gap has been filled by your study?

In general, the discussion highlights the findings of the study and predominantly compares the findings with other studies. While this is appropriate and useful, the implications of the findings are not discussed. It therefore begs the question about the usefulness of the study. There is need to strengthen this aspect of the paper.

The conceptual framework is not adequately/appropriately used to discuss the finding of the study. This needs to be addressed.

Limitations

The limitations should be reviewed. The research was not cross-sectional. This should be corrected. It is also well established that the intent of qualitative studies is not to generalize findings. The authors should examine the methodology and identify the limitations of the study.

Conclusion

The conclusion needs to be specific to the findings of the study. What are the implications of the positive experiences identified?

**********

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Reviewer #2: No

Reviewer #3: No

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While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Submitted filename: EXPLORING POSITIVE EXPERIENCES-2.docx

Click here for additional data file.

16 Mar 2022

Responses to academic editor and reviewers’ comments

Academic Editor

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming.

Response: We thank the academic editor for the comment and suggestion. We have revised the entire manuscript to ensure it meets PLOS ONE requirements.

2. We note that you have referenced (Kyei-Arthur F. Family caregiving: Experiences of caregivers and their elderly care recipeints in urban poor communities in Accra, Ghana [Unpublished doctoral thesis]: University of Ghana; 2017.) which has currently not yet been accepted for publication. Please remove this from your References and amend this to state in the body of your manuscript: (ie “Bewick et al. [Unpublished]”) as detailed online in our guide for authors

Response: We have removed the unpublished manuscript from the references and we have replaced the in-text reference with (Kyei-Arthur [Unpublished]) in the revised manuscript. See page 5-6, lines 112-114.

“This manuscript is derived from a broader thesis that collected data on characteristics of family caregivers and their care recipients, and caregivers’ motivations for providing care to their care recipients (Kyei-Arthur [Unpublished]).”

3. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly.

Response: We have included a caption for our Supporting Information at the end of our manuscript. See page 34, lines 632-636.

Reviewer 2

1. One is the type of this study this falls into. The manuscript is presented in light of qualitative study but no description of that is provided. Authors need to provide that clearly and what type of qualitative study.

Response: We have specified that the study used a phenomenological design in the revised manuscript. See page 2, lines 29-30 and page 6, lines 126-129.

2. The authors repeatedly used the terms primary and secondary caregivers but have not provided any operational definitions of those terms rather than mentioned them in passing.

Response: We thank the reviewer for the comment. We have defined who primary and secondary caregivers are in the data collection section in the manuscript. Also, we defined who family caregivers are. See page 8, lines 159-163.

3. The tables in the manuscript need to be formatted in a better way like APA style table.

Response: We thank the reviewer for the suggestion. Unfortunately, PLOS ONE does not used APA style for its table formatting. We have formatted all tables in the revised manuscript to meet the table format of PLOS ONE.

4. The entire paper needs to be edited and formatted too.

Response: We have edited and formatted the revised manuscript.

5. A couple of minor grammatical errors were made and the authors can correct that using grammerly.

Response: We have edited the revised manuscript to address the grammatical errors.

6. The conclusions need to clearly presented.

Response: We have made the conclusion section specific in the revised manuscript. See page 24-25, lines 454-462.

Reviewer 3

1. Abstract - State the research methodology used.

Response: We have specified that the study used phenomenology design in the revised manuscript. See page 2, line 29-30.

2. Abstract - Review the conclusion and make it applicable to the findings of the study. The findings demonstrated that there were intangible and tangible rewards. What is/are the implication(s) of the findings of the study?

Response: We have included the implications of the findings of the study in the abstract in the revised manuscript. See page 2, lines 35-38.

3. Introduction - Page 3, lines 60-64. This section needs to be developed further. The authors made reference to processes influencing the role of the family. Provide information on the nature of influences.

Response: We have provided details on how modernisation processes influence care for older persons in the revised manuscript. See page 3, lines 64-67.

“For instance, the increased participation of women in the labour market affects the availability of women to provide personal care to older persons [15]. In addition, research has established that financial constraints limit the financial care provided to parents [16].”

4. Introduction - Page 4 – While the author has noted that positive experiences have been reported in the literature, they should be described in the introduction section, rather than just including citations. The majority of readers will not readily go to the reference list and try to search for the articles to identify the positive experiences.

Response: We thank the reviewer for the comment. We have indicated some of the positive experiences of family caregivers in the introduction section of the revised manuscript. See page 4, lines 71-74.

5. Revise the sentence “Between 1990 and 2021, their proportion of the total global population increased from 6 percent to 10 percent, and it is estimated to reach 16 percent in 2050 [1, 2].” to “Between 1990 and 2021, the proportion of the population of older people to total global population increased from 6 percent to 10 percent, and it is estimated to reach 16 percent in 2050 [1, 2]”.

Response: I have revised the sentence in the revised manuscript. See page 3, lines 48-50.

6. Replace “their” with “the” in the sentence “In Ghana, their proportion has increased from 3 percent in 1960 to 4 percent in 2021 [2, 3]”.

Response: We have replaced “their” with “the” in the sentence in the revised manuscript. Please see page 3, line 50.

7. Conceptual Framework - Page 5 – refer to the author by name, instead using the terms she/her.

Response: We have used the name of the author “Kramer” to replace “her” in the revised manuscript. Please see page 5, line 100.

8. Replace “article” with “manuscript” in the manuscript.

Response: We have replaced “article” with “manuscript” in the revised manuscript. Please see page 5, line 112 and page 6, line 119.

9. Materials and Methods - What qualitative method was used in this study?

Response: We have specified that the study used phenomenology design in the revised manuscript. See page 6, lines 126-129.

In addition, we have revised the heading “Study setting” to “Design and study setting” in the revised manuscript. See page 6, line 125.

10. Revise the heading “Materials and Methods” to “Methods”.

Response: We have revised the heading “Materials and Methods” to “Methods” in the revised manuscript. Please see page 6, line 124.

11. I think using communities will be more appropriate than towns.

Response: We have replaced “towns” with “communities” in the revised manuscript. Please see page 6, line 131.

12. Replace “poor” with “limited” in the manuscript.

Response: We have replaced “poor” with “limited” in the revised manuscript. See page 1, line 5; page 2, line 29 and 39; page 5, line 93; page 6, line 133; and page 20, line 367.

13. Page 6 – “family caregivers were purposely selected” – what criteria was used for this selection? This should be stated.

Response: In the first stage of the data collection, family caregivers were not purposely selected. We apologise for the misinformation. We have revised the entire data collection section in the revised manuscript to make it clearer. See page 7-8, lines 140-176.

14. Page 7

The recruitment strategy is unclear

• Line 133 – “The first author and research assistants were able to track 30 out of the 57 family caregivers” – how was this done? The details need to be provided

Response: We have provided more details on how the research team was able to contact the 30 family caregivers in the revised manuscript. See page 7, lines 152-158.

“In total, the first author and trained research assistants were able to contact 30 out of the 57 family caregivers using the structure and household identifiers (e.g., enumeration area number, structure number of household, name of the head of household, and contact of the head of household) and family caregiver identifiers (e.g., name, and contact numbers). In addition, care recipients assisted the research team in reaching out to all persons who provided care to them since the study was interested in primary and secondary caregivers.”

15. • Line 136 – Why were care recipients interviewed, if the researcher had ‘tracked’ the caregivers?

Response: We thank the reviewer for the comment. Care recipients were interviewed because we wanted to identify all persons (primary and secondary caregivers) provided care to them. Although interviewing family caregivers we tracked could helped us to identify primary and secondary caregivers, we were of the opinion that interviewing the care recipients first and interviewing primary and secondary caregivers they identified was the best way to go about it since caregiving roles and responsibilities changes over time. It is the caregiving roles and responsibilities which are used to determine who is the primary or secondary caregiver.

16. The exclusion criteria should be explicitly stated.

Response: We have explicitly reported the exclusion criteria in the revised manuscript. See page 8, lines 167-170.

17. What was the aim of the component of the study related to care recipients?

Response: The aim of the study related to care recipient was to explore the perspectives of care recipients on the care they received from their caregivers. This was part of the larger project. However, it is not focus of this manuscript. This manuscript focused on the positive experiences of family caregivers. In the methods section of the revised manuscript, we have deleted most of the details about care recipients since it is not the focus of this manuscript. It is worth noting that we described the characteristics of care recipients in the revised manuscript. See page 10, lines 215-223, and Table 3 on page 12-13, line 231-232.

In addition, we have revised the subheading “socio-demographic characteristics of family caregivers” to “socio-demographic characteristics of family caregivers and their care recipients” in the revised manuscript. See page 9, lines 198-199.

18. What information was obtained from the care recipients (reference made to 20 in-depth interviews that were done)?

Response: Care recipients were asked their perspectives on the care they received from their caregivers. We have described the characteristics of care recipients in the revised manuscript. See page 10, lines 215-223, and Table 3 on page 12-13, line 231-232.

19. The interview guide captured questions on motivation for providing care, caregiving experiences, coping strategies, perception and other issues. The aim of the study was to capture positive experiences. Some of the information from the interview guide is relevant and appropriate. If the authors indicate in the methods section that coping strategies, for example, was explored, then the finding related to this should also be presented.

Response: We thank the reviewer for the observation. Although information on coping strategies was collected using the interview guide, we have already published an earlier manuscript which focused on family caregivers’ challenges and their coping strategies. Consequently, we decided not to present such data since it has already been published elsewhere and focused on family caregivers’ positive caregiving experiences which has not been published.

20. Correct the sentence “ethical clearance for the study was approved…” to “ethical clearance for the study was received…”

Response: We have corrected the sentence “ethical clearance for the study was approved…” to “ethical clearance for the study was received…” in the revised manuscript. See page 8, lines 170-171.

21. Did the care recipients provide informed consent?

Response: Care recipients gave their informed consent as well as family caregivers. All care recipients had no cognitive impairment so they were able to provide informed consent before they were interviewed.

22. Did the conceptual framework guide the development of the interview guide?

Response: The conceptual framework partly guided the development of the interview guide. The review of literature and pilot of the interview guide also influenced the development of the interview guide.

23. This data was collected over five years ago. Don’t you think the findings being reported here may be obsolete? Or don’t you think things may have changed significantly between 2016 and 2022?

Response: We appreciate the concern of the reviewer. We agree that there could be significant changes in the experiences of caregivers between 2016 and 2022. Despite the potential changes in caregivers’ experiences, it is worth sharing their experiences as of 2016 since their experiences could help in the design of interventions to enhance family caregivers’ positive caregiving experiences in Ghana.

24. Review the section on data analysis and remove duplicated information.

Response: We have revised the data analysis section in the revised manuscript. See page 8-9, lines 179-195.

25. You need to remove yourself from the data and allow it to assume neutrality of how it was handled.

Response: We thank the reviewer for the suggestion. We have removed ourselves from the data analysis and revised the data analysis section in the revised manuscript. See page 8-9, lines 179-195.

26. When was the qualitative aspect of the study conducted? Was it also done in 2016 when the third wave of the UPHS was conducted? It is not clear.

Response: The Urban Health and Poverty Survey was conducted in September 2013 and the qualitative study was conducted in November 2016. We have revised the data collection section in the revised manuscript to make things clearer. See pages 7-8, lines 140-176.

27. Operationally define the following:

• Family caregiver

• Primary caregiver

• Secondary caregiver

Response: We have defined family caregiver, primary caregiver and secondary caregiver in the data collection section in the revised manuscript. See pages 8, lines 159-163.

28. It is important that the authors provide definitions of primary and secondary caregivers for this research. I know you mentioned above who they are but it will help to clearly answer that question before readers out ask it when you are not there to explain. Provide a paragraph under methods to explain who primary and secondary caregivers are for the sake of your study.

Response: We have defined primary caregiver and secondary caregiver in the data collection section in the revised manuscript. We also defined family caregiver in the revised manuscript. See pages 8, lines 159-163.

29. Results - It may be more meaningful to report the percentages in the narrative rather than the numbers (n).

Response: We have used percentages in the narratives as suggested by the reviewer in the revised manuscript. See page 9-10, lines 200-223.

30. Review the numbers presented to ensure that they match up to what is in the table. For example, it was indicated that the majority of primary caregivers (n=15) had formal education. In the table, only 14 persons had formal education. Please also noted that formal education is not a term used in the table. Accordingly, the terms in the table should appropriately match what is in the narrative aspect of the results.

Response: We thank the reviewer for the observation. We have reconciled the figures and terms used in the Tables and narrative in the revised manuscript. See page 9-13, lines 200-232.

31. Table 1 - Please report the standard deviation for the mean age

Response: We have added the standard deviation of the mean age to Table 1 in the revised manuscript. See page 11, line 225.

32. Table 1 - Add the unit of measurement for age range

Response: Age range was measured in years. We have indicated years as the unit of measurement in the revised manuscript. See page 11, line 225.

33. The majority of the primary caregivers (n = 15) had formal education, while all 16 secondary caregivers had formal education. Please, read this phrase and correct accordingly. Which group had formal education?

Response: We have revised the sentence “The majority of the primary caregivers (n = 15) had formal education, while all 16 secondary caregivers had formal education.” To “The majority of the secondary caregivers (100%) had formal education compared to primary caregivers (93.3%).” in the revised manuscript. Please see page 10, line 203-204.

34. Table 1 - The “n=12” in the row with label “place of work” needs to be reconsidered – why was this done? Were data elements missing?

Response: We apologise for using “n=12” in the manuscript. It was used to show that the total for “place of work” is less than the total of the other items/indicators/variables in the table. We have deleted the “n=12” in the revised manuscript and used asterisks on the “place of work” and explained below the Table that the sum/total of the “place of work” is 12 caregivers. See page 11-12, line 225-226.

35. Adding the label n=12 is confusing. My assumption is that subsequent variables in the table are related to that label (n=12). This is not the case, as the variable ‘religion’, for example, n=15 and n=16 for primary and secondary caregivers respectively would not apply to that label. You could consider using footnotes to reduce confusion.

Response: We thank the reviewer for the suggestion. We have deleted the “n=12” in the revised manuscript and used asterisks on the “place of work” and explained below the Table that the sum/total of the “place of work” is 12 caregivers. See page 11-12, line 225-226.

36. Why is the source of the socio-demographic characteristics from the Informal Caregiving Study, 2016?

Response: We are sorry for the misinformation. The “Informal Caregiving Study, 2016” was a name the first author gave to the qualitative study that was conducted. We have deleted the source of data as “Informal Caregiving Study, 2016” in the revised manuscript to avoid any confusion.

37. Again, when was the qualitative aspect conducted. Would the characteristics have changed if the qualitative aspect of the study conducted at a later date?

Response: The qualitative data was conducted in November 2016. Some characteristics of family caregivers will change if it was conducted at a later date, especially in 2017 and beyond.

38. No results have been provided for the care recipient. Please provide an explanation for this, since in-depth interviews were conducted.

Response: We have provided information on the characteristics of care recipients in the revised manuscript. However, it is worth noting that this study focused on family caregivers. See page 10, lines 215-223 and Table 3 in pages 12-13, line 231-232.

39. Please add details about caregiving experiences of the caregiver, to provide some context to the positive experiences that were reported (for example, information on the number of years providing care, number of hours worked, and the type of care provided).

Response: We have provided details on the number of years providing care, average time spent providing care to care recipients, and the type of care provided in the revised manuscript in Table 1 and Table 2. See page 10, lines 210-214; Table 1 in pages 11-12, lines 225-226; and Table 2 in page 12, lines 228-229.

40. The legend for Table 2 should be expanded to say what the themes, subthemes and sub-categories relate to.

Response: We have revised the themes, categories and sub-categories in Table 3 and supporting information (S2 Appendix) to make it easier for readers to understand the themes, categories, and sub-categories. See page 14, line 242.

41. Communicating with older persons - You need more than just narrative here to prove the case

Response: The theme on communicating with older persons had only one quote so we have deleted it from results and discussion sections in the revised manuscript.

42. Discussion - Line 333 – What evidence do you have to conclusively say that the knowledge gap has been filled by your study?

Response: We thank the reviewer for the comment. We cannot conclusively prove that our study has filled the knowledge gap. Consequently, we have deleted the sentence “The examination of this aspect of caregiving has been limited or even absent in the literature on caregiving in Ghana and the rest of sub-Saharan Africa. This knowledge gap in Ghana is filled by this study.” in the revised manuscript.

43. “The examination of this aspect of caregiving has been limited or even absent in the literature on caregiving in Ghana and the rest of sub-Saharan Africa. This knowledge gap in Ghana is filled by this study.” This has already stated in the introduction.

Response: We have deleted the two sentences in the revised manuscript.

44. Replace “interviews with family caregivers” and “they” with “study” and “caregivers” respectively on line 334.

Response: We have replaced “interviews with family caregivers” and “they” with “study” and “caregivers” respectively in the revised manuscript. See page 21, line 373.

45. In general, the discussion highlights the findings of the study and predominantly compares the findings with other studies. While this is appropriate and useful, the implications of the findings are not discussed. It therefore begs the question about the usefulness of the study. There is need to strengthen this aspect of the paper.

Response: We have included information on implications of the findings in the discussion section of the revised manuscript. See page 23-24, lines 432-441.

46. The conceptual framework is not adequately/appropriately used to discuss the finding of the study. This needs to be addressed.

Response: We thank the reviewer for the comment. The conceptual framework was used in the larger project but this study focuses on some aspects of the framework (i.e. positive caregiving experiences). We used the conceptual framework to describe the positive experiences of family caregivers rather the pathways to positive caregiving. We demonstrated that some caregivers characteristics (age and sex) influence positive caregiving in the manuscript. We have also described how care recipients’ characteristics, specifically their sources of income per month, influence family caregiver positive caregiving experiences in the revised manuscript. See page 23, lines 429-431.

In addition, we have revised the conceptual framework adopted (Fig. 1) for this study to make it clearer. It is worth noting that caregiver attitudinal variables and efforts, and resources in the conceptual framework were not the focus of this study.

47. Limitations - The limitations should be reviewed. The research was not cross-sectional. This should be corrected. It is also well established that the intent of qualitative studies is not to generalize findings. The authors should examine the methodology and identify the limitations of the study.

Response: We have revised the limitation section in the revised manuscript. See page 24, lines 444-451.

48. Conclusion - The conclusion needs to be specific to the findings of the study. What are the implications of the positive experiences identified?

Response: We have revised conclusion section in the revised manuscript. See page 24-25, lines 454-462.

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

18 Mar 2022

Exploring positive experiences of primary and secondary caregivers of older persons in resource-limited urban settings in Accra, Ghana

PONE-D-21-29801R1

Dear Dr. Kyei-Arthur,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Vijayaprasad Gopichandran

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

24 Mar 2022

PONE-D-21-29801R1

Exploring positive experiences of primary and secondary caregivers of older persons in resource-limited urban settings in Accra, Ghana

Dear Dr. Kyei-Arthur:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

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Thank you for submitting your work to PLOS ONE and supporting open access.

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on behalf of

Dr. Vijayaprasad Gopichandran

Academic Editor

PLOS ONE