Residential preferences and eldercare views of Hispanic elders

A cross-sectional, qualitative study was undertaken with a group(n = 10) of elderly Mexican-American men and women in an innercity congregate meal site of a large Midwestern city. The purpose of thestudy was to explicate: the older adults‘
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   Journal of Cross-Cultural Gerontology  12:  91–107, 1997.  91 c    1997  Kluwer Academic Publishers. Printed in the Netherlands. Residential preferences and eldercare views of Hispanic elders REBECCA A. JOHNSON 1 , VALERIE L. SCHWIEBERT 2 ,PATRICIA ALVARADO-ROSENMANN 3 , GLENDA PECKA 1 &NORMAN SHIRK 4 1 School of Nursing, Northern Illinois University;  2  Department of Human Services, WesternCarolina University;  3 Family Counseling Service, Aurora, Illinois;  4 Swedish American Hospital, Rockford, Illinois, USA Abstract. Across-sectional, qualitative study wasundertaken witha group (n =   10) of elderlyMexican-AmericanmenandwomeninaninnercitycongregatemealsiteofalargeMidwesterncity. The purpose of the study was to explicate: the older adults’ residential preferences shouldthey become unable to live in their own homes, and their beliefs about eldercare. Themesarising from the semi-structured interviews include: nursing homes as places of last resort, thedesire not to be a burden to children, intergenerational differences in lifestyle, and extendedfamily involvement in eldercare. Implications of the findings for helping professionals arediscussed as are areas needing further investigation. Key words:  Cross-sectional study, Eldercare views, Hispanic elders, Mexican Americans,Residential preferences Introduction Demographicchangesaffecting the Americansocietyare strongly influencedby the fact that by the year 2010, there will be approximately 6.8 millionpersonsoverage85,equaling2.4%ofthetotalpopulation(USAdministrationon Aging 1989). Demographic projections show that the population of olderAmericans will also increase in diversity as it increases in size.The population of Hispanic elders are expected to increase swiftly in com-ing decades. It is projected that the number of Hispanic elders will increasefrom 4% of the total elderly population in 1990 to 16% of the total elderlypopulation in the year 2050 (US Bureau of the Census 1992). Additionally,if recent mortality and immigration rates continue, the elderly Hispanic pop-ulation will grow 3.9% a year from 1990 to 2050. This rate is faster than theannual rate of change over the same period for the total Hispanic population(US Bureau of the Census 1992).The Hispanic population is comprised of various subgroups which differwith respect to country of srcin, number of generations born in the USA,  92  REBECCA A. JOHNSON ET AL. cultural beliefs and practices. Of the Hispanic elderly population in 1990,49% were of Mexican srcin, 15% were of Cuban srcin, 12% were of Puerto Rican srcin, and 25% reported they were of other Hispanic srcin(US Bureau of the Census 1992). The growing subpopulation of Hispanicelders presents special challenges to healthcare practitioners who are oftenfront-line contacts for elders attempting to remain as independentas they canfor as long as possible. In addition to stressors related to the normal agingprocess, Hispanic older persons may face psychological,physical, and socialstressors associated with aging that are culture-specific (McKenna 1989).For example Hispanic elders may consider themselves ‘old’ much earlierthan older persons of other cultures (Newton 1980). Additionally, Hispanicelders may be more impaired at the time of admission to nursing homes thannon-Hispanic elders (Espino, Neufeld, Mulvihill & Libow 1988). This maybe due to a strong sense of filial obligation that may exist within Hispanicfamilies. That is, impaired Hispanic elders are most often cared for by theiradult children, an obligation which may be expected in Hispanic families.Therefore, Hispanic elders may live with their adult children even when theyare experiencing severe levels of impairment. Nursing home placement is alast resort and formal services are only used when an intolerable degree of disability is reached by the elder (Espino et al. 1988).This strong sense of filial obligation may be the reason that nursing homesand other formal support services are underutilized by Hispanic elders andtheir caregivers (Greene & Ondrich 1990). Other factors which may com-poundthe difficultiesHispaniceldersexperienceinclude:agreaterlikelihoodof experiencing functional disabilities than elders of other minority groups(Markides & Mindel 1987), a high rate of illiteracy (Greene & Monahan1984), inadequate financial resources, language barriers, difficulties withcitizenship (Torres-Gil 1986), and acculturation issues (Zsembik 1993). Insummary, Hispanic elders may experience multiple chronic health problems,poorer mental health, lower life satisfaction than members of other minor-ity groups, and are generally cared for by adult children (Ailinger 1989;Ailinger & Causey 1995; Johnson, Foxall, Kelleher, Kentopp, Mannlein &Cook 1988).When family caregivers are solely responsible for providing or coordinat-ing care of elder relatives, one of the major challenges they face is the needto identify the most appropriate place for the elder to reside to obtain thelevel of care needed. Literature related to family caregiving and ethics docu-mentstheimportanceoftheolderpersons’involvementindecisionsaffectingtheirlives(Hooyman&Lustbader1986),particularly with respecttoresiden-tial preferences. In spite of this importance however, older adults may not beinvolvedwiththedecisiontorelocatetoanursinghome(Johnson,Schwiebert  RESIDENTIAL PREFERENCES AND ELDERCARE VIEWS  93& Rosenmann 1994). However, there is a paucity of research related to thefactors that affect how decisions are made in the lives of Hispanic elderswho are dependent on family caregivers, residential preferences of Hispaniceldersandtheirviewsrelatedtocaregiving(Pratt,Jones,Shin&Walker1989;Schwiebert,Johnson&Alvarado-Rosenmann,inpress).Inaddition,althoughliterature exists suggesting that different cultural and ethnic groups providecaregivingin different ways, knowledgeof the impact of thesedifferences onresidential preferences is lacking (Chatters, Taylor & Jackson 1985). There-fore, the current study was undertaken to explore the residential preferencesand views related to elder care of elderly Hispanic men and women. Literature review  Elder support preferences Hispanic elders have been found to prefer familial support and assistance toformal support services (Cox & Monk 1990). Hispanic elders, particularlythose persons who have not been acculturated to US values, were foundto share a deeply held belief in family coresidence (Zsembik 1993) andreciprocal caregiving (Valle & Martinez 1981). Thus lack of intent (Yeatts,Crow & Folts 1992), and not just lack of knowledge and/or access (Starrett,Todd, Decker & Walters 1989) was found to explain the underutilization of formal supports by Hispanic elderly.Hispaniccaregiverswerefoundtosharethispreference,reportingthattheirsense of obligation to the elder superseded their own needs, and desires of other family members (Lockery 1991). This expectation of filial support wasfoundtobesostrongthatthedeteriorationoftheelder,whichmaycommonlybeatriggerfor institutionalization(Retsinas1991),wassometimesunnoticedor disregarded. The Hispanic elder’s tendency to positively assess his or herown health without regard for his or her ability to perform the usual activitiesof daily living reinforced this dilemma (Ailinger 1989).  Elder support sources The family was identified as the most frequently used support source amongHispanic elders (Cox & Monk 1990). Adult children were cited as the mainproviders of support. Cox & Monk (1990) found that Hispanic parentsexpressed a strong expectation that the children should remain geographi-callycloseto providethisassistance.Associalandeconomicconditionshavechanged,resultinginincreasedparticipationinthelaborforceandgeographicmobilityfor adultchildren,thesechildrenmaynothavecontinuedtobeavail-able to provide the expected parent care. However, a strong and consistent  94  REBECCA A. JOHNSON ET AL. network of other relatives was found to help meet elder needs (Cox & Monk 1990).While the extended family has been found to be the most predominantsource of assistance to Hispanic elderly, formal support sources have alsobeenutilized,toamuchlesserextent.Starrettetal.(1990)determinedthatuseof formal support services by Hispanic elderly was dependent on the numberof mental health problems suffered, the severity of the illness, and on churchattendance. The supportive services used by Hispanic elders include clergy,home attendants, and nursing home placement (Cox & Monk 1990; Starrettet al. 1990). Nursing home placement was seen by both Hispanic elder andcaregiver as a last resort. McCoy & Edwards (1981) found that whites weretwice as likely to be institutionalized as nonwhites, and that fewer Hispanicsentered nursing homes. However, Montgomery and Kosloski (1994) foundthat the cumulative effect of the demands of caregiving pressured the familytoward nursing home placement.The purpose of the qualitative study reported here was to explore andidentify the residential preferences of a group of elderly Hispanic individuals(n =   10),andto elicit their viewsrelatedto eldercare.Thefollowing researchquestions guided the study:1. Where do the elderly Hispanics in the study currently reside?2. What are their residential preferences?3. What housing alternatives do they consider acceptable for older Hispan-ics?4. What are their general feelings about long term care as a housingoption?5. Whataretheperceiveddifferentialbenefitsoflivingwithfamilymembersor in elder’s own homes  versus  long term care facilities?6. What are the subjects’ beliefs about where & from whom elders shouldreceive care? Methodology Across-sectional,qualitativedescriptivedesignwasusedtoconductthestudyinalarge,Midwesterninner-cityseniorcitizencongregatemealsite.Potentialparticipants met three selection criteria: age over 60 years, self-identified asHispanic, and cognitively intact as determined by the researchersat the onsetof the informed consent process. Prospective participants were informed bythemealsitedirectorof theoverallpurposeandprocedureof thestudy.Thosepersonswhoindicatedaninterestinparticipatingwereindividuallycontactedby members of the research team. Informed consent was obtained from eachindividual, and participants received a small remuneration for their time.  RESIDENTIAL PREFERENCES AND ELDERCARE VIEWS  95 Table 1 . Sample interview questions1. Where do you live?2. Do you live with someone or alone?3. Would you ever consider living somewhere else?4. Where else would you consider living?5. What would cause you to consider living somewhere else?6. Where do you think older people should live when they can no longer liveby themselves?7. From where should older people get help when they can no longer take careof themselves?8. Would you ever consider living in a nursing home?9. Why or why not?10. What would cause you to consider living in a nursing home? Participants (n =   10) were elderly Mexican-Americans (6 males and 4females) who regularly attended the congregate meal site for a noon meal.Participants also engaged in recreational activities at the meal site such assinging,dancing,playingbingo,andmakingcraftitems.In addition,themealsite served as a source of information regardinghealth issues and communityresources.Allparticipantscompletedabriefdemographicquestionnairewhichinclud-ed questions about age, gender, number of children, current residence type,and length of time in current residence. Semi-structured, tape recorded inter-viewslastingapproximatelyonehourwereconductedusingopen-endedques-tions (Table 1) which included topics related to residential preferences andeldercare,aspreviouslyidentifiedthroughaliteraturereview.Interviewswereconducted in Spanish with non-English speaking participants by a bilingualresearchassistant.Participantsvolunteeredinformationregardingtheirbeliefsabout care of older adults, nursing homes, and residential preferences.Data were transcribed verbatim from interview tape recordings and trans-lated to English by a bilingual research assistant. Two levels of data analysiswere undertaken.First, researchersidentified explicitly stated themes in eachtranscript.Clustersweredevelopedfromthesethemesanddescriptionofeachcluster were formulated after reexamining the data to insure that the contextof the themes remained intact. Implied themes were identified relative to thecontextofstatementsmade.Clusterswereadjustedtoreflectbothexplicitandimplied themes. Next, descriptions of the clusters were refined. Data wereanalyzed separately by all five members of the research team. The researchteam met and discussed how clusters were formed (what subject statementsconstituted each cluster and why). Through this process, consensus among
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