Copyright Claudia Knapman, 1996. One copy of this paper can be made for the purpose of personal, non-commercial use, subject to proper attribution to the author.



OLDER PEOPLE IN RURAL COMMUNITIES: RETHINKING THE MEANING OF FAMILY-BASED CARE


Dr Claudia Knapman
Department of Psycholgy & Sociology
James Cook University of North Queensland

ABSTRACT

The current restructuring of aged care, which emphasises reduced institutionalisation and the development of community support services, is predicated on the value position that the vast majority of care should and will be provided by the family. While research on metropolitan areas suggests that such assumptions may be problematic, there is a general belief that in rural communities family ties are stronger and there is more stability in family life. On the other hand, in rural communities concern is often expressed about the urban pull on younger people breaking up families..This paper examines the views of various family members about caregiving and living arrangements of older people in a predominantly canegrowing area of North Queensland. What do older people think are the best options when they need help with daily living? Do those who are closest to them share their views? What plans have been made for their care, should help become necessary? Does previous experience of providing support and care influence older people's attitudes and expectations?


The research findings discussed here are part of a larger study of changing patterns of family care for older people in two rural areas in Far North Queensland. This paper reports on the views older people and their families living in the Johnstone Shire expressed about the options available for living arrangements in older age, and the decisions which have been made as the need for assistance arose. In this sample of 20 families, the older person who was the key to each family was of Anglo-Celtic background. At least one member of the family, or the individual's close contacts, was interviewed as well as the older person.

The older people consisted of 9 men and 11 women, aged 77 to 95 years, who needed some assistance with the normal activities of daily life. None of the men lived on their own, but nearly half of the women did. All had lived in the Johnstone Shire for most of their adult lives. The majority had been involved consistently, or for most of their working lives, in the sugar cane industry. Some supplemented this with fruit growing and cattle. Many men had undertaken a wide range of farm, sugar mill or labouring activities before and after mechanisation in the sugar industry, and a few had worked in the timber industry with bullock teams, a pioneering occupation which lasted into World War II in this region. Some combined rural occupations with urban ones such as a profession or business or hotel work, mainly in Innisfail, the Shire's centre. Prior to marriage the women had undertaken nursing, clerical, hotel and domestic work. The women on farms had been integrally involved in the farm management and labour - including heavy physical labour in some cases - throughout their working age years, with one exception. Many farm and other women had contributed to or run their husbands' businesses. Only one single woman had engaged in fulltime, formal employment as a mature adult, and only one married woman had routinely relied on domestic help to carry out traditional household duties.

The biographical approach taken in this study is based on a theoretical framework which holds lifecourse choices to be a result of personal, cultural and structural factors which impinge over time on the individual's particular situation and environment. Thus, in examining living arrangements for older people in a rural community, an historical perspective has been taken to developing an understanding of the way decisions about living arrangements and care are shaped by:

It is clear that the effort to describe the decision making process about living arrangements as being predictable from a limited set of variables, related to illness events or social support networks, may severely distort the subjective reality (Wallace, 1994:152). As Keith points out, misleading generalizations about old people derive from lack of information about meaning: '[f]or research related to service delivery or policy analysis, data about the assumptions, values, and wishes of intended recipients are essential.'(1994: 105) But the literature provides little insight into the experience of decision making, or the subjective perceptions, reasoning and understandings of older people and their families, as Wallace indicates in his study of family decision-making about nursing home entry (1994:148). In one case he reports, the couple started the story of when the decision-making process began with reference to the institutionalisation of the wife's mother 30 years before (Wallace, 1994: 150), reinforcing the importance of an historical perspective.

In their study of family responsibilities in Greater Manchester, Finch and Mason argued that in practice 'people have to work out what type of responsibilities they are going to acknowledge to particular relatives. Family responsibilities thus become a matter for negotiation between individuals and not just a matter of following normative rules...' (Finch and Mason,1993:12, their emphasis). In order to study processes within families they relied on qualitative research methods, principally semi-structured interviewing: '[w]e believed that there would be great benefit in interviewing several members of the same family, since we were focussing on processes of negotiation and therefore we needed to know how these were experienced by different parties to them' (Finch and Mason 1993:13). They were anxious to avoid the criticisms of much previous work, where one person's account stands for a whole family group. This is the approach taken in the present study. It is summed up as follows: specific decisions emerge as part of longstanding relationships between the parties which have a past as well as a present, and anticipate a future. The past and the future are at least as important as the present in understanding how people come to accept particular decisions (adapted from Finch and Mason, 1993:25).

The salience of these perspectives was confirmed by the findings of this study. It is not possible to understand why older people or their kin and friends held particular views without an understanding of their personal experience in a particular social context. One example that makes this clear concerns many older people's negative views about institutional care. It became clear that this was often linked to ideas and patterns of behaviour connected to the past. It is too simple, and incorrect, to explain this in terms of an apparent golden past where families cared for older people, or by an alleged 'fact' that older people did not go into homes in the past. In a number of cases, part of the negative association had to do with the fact that older men did go into homes in the past, mainly in Charters Towers or Brisbane. It transpired that these older men were alcoholic, unable to look after themselves, or were considered too 'difficult' to manage with or without family support. Sometimes they were fathers or fathers-in-law of the older people in the sample, sometimes older men who had worked on their farms or were well known in their town or district. Although not explicitly stated, one way or another their problems and situations were seen to be tied to a failure to survive a pioneering lifestyle in a way which guaranteed a secure and loved old age. So, for some women, the idea of an old people's home was 'unthinkable' on gender grounds, and for some men, to consider this would have been seen as a sign of personal failure.


What do older people think are the best options when help is needed with daily living?

Most older people thought 'to be carried out' (I4.0 female, 79) of their own home without having to make a decision precipitated by increasing dependence, was the best option. For some of them, that decision had already been made or was in the process of being made. There was a certain reluctance to express their views about the most desirable living arrangements, as if in some way this might be pushing their luck or might make explicit the disjuncture between what they really thought and their present or likely future situation.

The views expressed differed for men and women. The men who were living with spouses were sure that their wives could manage, even if the women were in fact under pressure already. Being at home, looked after by your wife, was undoubtedly the best option. Moving to a unit with a wife was considered acceptable by some, even though this did not necessarily address their identified needs. The men were prepared to accept help from a daughter, but drew the line at personal care being managed by a daughter. No men thought that living on their own was an option at all, and no men in the sample did live on their own. (One man's wife was in hospital at the time.) If they did not have a wife or daughter able to help them in their own home, they lived in residential accommodation. However, while this was not considered desirable prior to entering such accommodation, once in an institutional setting it did not mean they were dissatisfied or unhappy with life. As nothing was expected of them in terms of domestic tasks, they indicated that they were well looked after, which appeared to be the main concern.

The women's views were more varied and also reflected the range of actual living arrangements from living next door to a daughter, so she could do the personal care like bathing, to being in a hostel environment where 'it's very nice' (I7.0 female, 90). Many of the women lived on their own but next door to a daughter, or even between the houses of daughters and sons. This was especially the case where several houses had been built on a family cane farm as the children grew to adulthood, where a farm had been sold but allotments retained for the family's own homes, or several houses had been bought in a small town close to the main family farm. This was considered a very good arrangement by the older women concerned. The next preferred step was to move in with one or other of these children and their families. Women were more likely than men to be prepared to discuss what they thought were the best options, several explicitly saying they would hate to go into a hostel or nursing home: 'it is no life, is it?' (I9.0 female, 77). Although one woman of 80, living with her 93 year old husband in their own home, felt that it was better to go 'into a place than have words with your children' (I23.0).

While some had services - Meals on Wheels, home help or the Blue Nurses - this was not seen as a desirable option, only a necessary one. Some men absolutely refused to have anyone but their wives do things for them, which led to hospitalisation or institutionalisation. Women were more prepared to consider using services, but this was certainly not seen as a desirable option. The perception that community help 'is only for the practically useless' (I9.0 female, 77) indicates that service usage was as much about personal identity and self-esteem as about access or need.


What do the younger generation who are closest to them think are the best options?

In general, family members shared the perception of nursing homes and hostels as being 'a horrible life' (I7.1 daughter-in-law) and it is ' better if they can stay in their own home and the family visit them there' (I17.1 son). Experience suggests to family members that the best option of being supported by family in their own home is not necessarily viable in practice, for a number of reasons discussed below. In this sample, however, there was only one family in which the best option was actually working well according to both parties.

While older people appeared to be satisfied with family support while living in their own homes, the families were not so sure that the arrangement was working in practice. In some cases, the frailty of the older person was becoming problematic to the younger generation, as more was expected of them in order to keep Mum at home. Worry over safety escalated, especially vulnerability to falls and not eating properly. The social isolation and loneliness of her mother was the main concern of one daughter who asked 'Are they really happier at home? Would that social part [in residential accommodation] be better than the family part we have? ...it should be a happy time' for the mother and in the daughter's view it wasn't (I6.1).

The second most common preference of living with a family member was even more contentious in practice: 'it's not always the perfect, satisfactory solution...Mum was a bit spoilt...could be hard to live with' (I13.1). While an older woman claimed living next door to her daughter was 'a very good arrangement' (I22.0), the daughter found 'sometimes it's not really easy living here...we have some good rows...I'd never recommend it to anybody' (I22.1). Such family members see that the best option does not work very well in their particular situation, but often assume that it does work well in others. When the history of family relationships and circumstances is investigated, it becomes clear that there are good reasons which have developed over time to make the so-called best option difficult.

For instance, two women in their 40s, one divorced and one widowed, and each of whom had several young adult children, felt that they had had no life of their own. One commented 'I really haven't got a choice...well, I really would love to be somewhere other than here' (I22.1). The other was looking for an answer to a range of issues in her personal situation, in which she felt that she could do no more, was too young to be 'doing this' and that what she did was inadequate anyway. Sometimes women who have already done a lot of caring over many years could not face much more, especially where there was a history of resentment and even dislike: 'He was a very, very hard, mean man...I tried' (I9.1 daughter-in-law). Despite the reservations and problems which can occur, family members rarely saw these as a reason to force a change of circumstances, even when they were struggling to manage: 'I wouldn't think of saying to him 'Go into Warrina' or anything like that. I couldn't' (I15.1 daughter); 'Mum will stay here...if she behaves herself [laughter]' (I21.1 daughter).

In cases where the older person was resident in a nursing home or hostel already, family members saw this as an inevitable outcome of the particular family situation: 'She couldn't live with any of us. No, she knew that' (I31.1 daughter); 'It was his decision. He just decided that was what would happen [after his wife died] because he had never looked after himself' (I20.1 daughter).


What plans have been made for the future living arrangements of the older people?

While this question is usually directed towards those who are not in residential accommodation, it is clear that being in a particular institutional setting is not necessarily seen as a final solution. For instance, one woman who was currently accommodated in a dementia unit, had moved there from hostel accommodation when her husband, who had watched her wandering, died. Her closest contact, a niece of the husband, felt that the aunt should not be there and was looking for alternatives: 'She's a real lady from the old times and the others, the men...it's not suitable. Men use their toilets, wee in the rubbish bins...I'd hate it myself'' (I21.1). The niece was also concerned about the safety aspect, where the residents were locked in without supervision and, at one stage, her aunt was the only woman in the unit. In another instance, a woman was in a nursing home after a fall and hip operation. The doctor recommended she stay, but her son asserted that 'If she wants to go to her own home she should be given the opportunity...she's going to stay in the house as long as she can' (I17.1).

Very few of the older people living in their own homes had concrete plans for the future. For couples, the general approach was usually expressed by the wives who, often with problems of their own, were principal carers for their husbands: 'I think we are capable of looking after ourselves at the moment' (I3.1 female 76) and 'I can do it' (I12.1female, 80).

There was considerable reluctance to plan: 'just talk at the moment' (I3.0 male, 78); 'I don't want to live to 100. I'm ready to go anytime...some days I feel I can't go on. It's a bit difficult' (I17.0 female, 90); 'we just don't think about that' (I18.1 female, 85). Such comments often concealed worry, which was especially common among the older women caring for a spouse or older father: 'I don't know' (I15.1 female, 73); 'Like everybody, you worry about what you're going to do, you know' (I23.1 female, 80).
Some older people assumed they would live with a daughter or other family member. In only one case had this been discussed and worked through by all of the family concerned, with financial matters organised and building begun on extending the daughter's house so that appropriate accommodation would be ready when needed. In other cases, the family members were not so sure that moving in was desirable; 'It's a predicament and we don't know what to do' (I16.1 daughter).

In practice, a crisis usually forced a decision because it was no longer possible for the older person or couple to continue as they were. For men, the move to residential accommodation was often precipitated by the death or illness of a wife.


Does previous experience of providing support and care influence older people's attitudes and expectations?

The family histories show that care of older parents by the present older person was unusual. Individuals and families moved around all over the North, and sometimes to Brisbane or New South Wales. This mobility was not one sided: pioneers of Geraldton (early Innisfail) in the nineteenth century, sometimes moved South in retirement to join a son or daughter who had moved, leaving their other children (one of whom was an older person in this sample) without close contact with them in their later years. Or, the older person of this sample may have come from 'down South' (perhaps Lismore or Maryborough, Queensland), to make their own way in the world in the expanding North, still with its pioneering settlements and industries well into the middle of the twentieth century. Many of the older people in this sample had lived in quite different places from those where their parents and in-laws lived.

Where families were in the same area, it was still unusual for the older person to have provided major support: 'both Mother and Father died quickly at home' (I7.0 female, 90); 'Mother looked after Father' (I12.0 male, 85); 'Mother was a very old age and went into the hospital' (I18.0 male, 88). The result was that most of the older people had not cared for their own parents or parents-in-law at all. Only a few had cared for the older generation 'decades ago', or within the last 10 or 15 years in the case of women in their 70s now, who had a parent who had lived into his or her 90s. It was more common for an older woman to have cared for her husband in recent years, than to have cared for a parent when younger.

No older person explicitly linked their past experience of looking after an older relative to their present ideas and expectations. It is possible that not having cared made the thought of living with children more acceptable, since experience had not demonstrated the kinds of problems which might emerge. In one case, a Mother had lived with each of her three children in turn during her 80s and early 90s. Her son (an older person in this sample), had given little thought to his future, as his wife 'can manage' (I3.0 male, 78). One older man had thrown his own father out of his home in the 1940s, because he was difficult and bad-tempered and had accused his grandchildren of stealing. This was one of the cases of institutionalisation in Charters Towers mentioned above. Some older people were aware that their own parents and parents-in-law had been emphatic about not wanting to go into a home and, as discussed above, shared this view now.


Conclusion

In general, there is a prevailing feeling that the current solutions to living arrangements for older people and their families are inadequate. In part this reflects the limited choices available in terms of service options and residential facilities in the region, and the fact that rural people expect little from outside sources and are used to having to deal with all manner of problems themselves. This accounts for the often expressed view that 'I don't think there's a solution to all these things. I just think it's part of life. You can't solve every problem' (I24.1 female neighbour). Or, as one 85 year old woman put it, she used to feel sorry for babies being so helpless, 'but I'm telling you old age is worse' (I24.0).

It is very clear from the study that old age is not just a concern of the old, however. It was seen primarily as a normal life circumstance which integrally involved older people and their families, or particular members of families. In the few cases where there were no close family members, nieces, neighbours and friends took the place of family, involving themselves in the lives of the older person. Relationships and family support, even where they seemed to be strong, were not necessarily satisfying to the parties concerned, nor necessarily 'good'. However, they were intimate and complex. This challenges the view that the mobility of the younger generation leaves older people in rural communities isolated.

The findings also point to the history of an area shaping family patterns, so that we should be cautious about making generalisations, especially about the supposed stability of rural life and extended families in the past, and the disruption of family life in the present. It is striking that it was much more common for the younger person, that is the family member or friend, to have had previous experience of serious caregiving for a parent, in-law or aunt, than the older person in the study. One woman in the sample who was giving support to an older person who was not a spouse, was herself 73 and gave assistance to her own mother as well as a number of other older people. Some of the younger family members helping a parent or in-law and who still had children at home, had cared for or were looking after others needing assistance, as well as the older person of this sample. The experience of having provided care for older family members was not a strong feature of the past. In this study the reverse was the case.

Nor was there a direct link between the experience of having cared and present views. Those who had provided care for a family member in the past, were not necessarily of the view that they did not want to impose such a 'burden' on their own children, nor of the opposite view that therefore the same should be done for them. Older people's views, and those of their families, were developed in a much more complex way. The example of how an older family member had lived out their old age in the previous generation, and not wanting to be like that, seemed to be a more salient factor than previous caregiving experience.

The negative views expressed about nursing homes were not in any way connected to the failure of family members to take responsibility. Rather, the family members saw themselves as doing their job as best they could within their particular situations. The one exception was a Brisbane-based son who others said, due to his personal success, should have taken his mother out of a nursing home so far away from him and her grandchildren. Nursing homes were seen by most as a last resort, even as terrible, life-destroying places.

It is clear that much more work needs to be done on the ways in which structural constraints and options, individual preferences and expectations, and the social relationships within which individuals live their daily lives, shape people's hopes and expectations about older age. Ageing and aged care policies need to be understood within a broader framework than 'old age', using sets of indicators purportedly measuring independence and support. It is essential that a sociology of the family in sociohistorical context informs our understanding, if we are to avoid a future in which older people see no alternatives - 'where else would there be for me to go?' (I23.0 male, 93) - and their family members find their feelings conflict with reality: 'actually he's not that much bother to me here. I can cope. I really can. It's just that sometimes I think 'Oh, if only I could be on my own', I do. Well, you can imagine that, can't you?' (I15.1 female).


References

Finch, Janet & Mason, Jennifer (1993) Negotiating family responsibilities. London & N.Y.: Tavistock/Routledge

Keith, Jennie (1994) 'Consequences for Research Procedure', Chapter 7 in Gubrium, Jaber and Sankar, Andrea (eds) Qualitative Methods in Aging Research. Thousand Oaks, CA.: Sage, pp.105-119

Wallace, J.Brandon (1994) 'Life Stories', Chapter 9 in Gubrium, Jaber and Sankar, Andrea (eds) Qualitative Methods in Aging Research. Thousand Oaks, CA.: Sage, pp. 137-154


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