Health care,social care or both? A qualitative explorative study of different focuses in long-term care of older people in France,Portugal and Sweden

Challenges with an ageing population are increasingly becoming a reality in the Western world. Since cognitive impairment increases with age, we can expect an increasing number of older people in need of care. The aim of this article is to describe, analyse and compare different focuses on care of older people with dementia, using examples from France, Portugal and Sweden. The questions are principally focused on the participants’ view about their tasks, the organisation of work, the professional role and cooperation with other professions. Everyday care was studied through observations and participant observations and the staff's opinion was explored by means of interviews. Twenty-two care settings for older people were included. The findings showed that France provided mainly ‘health care’, Sweden ‘social care’ and Portugal an integrated ‘health care and social care’. In a comparative perspective the Portuguese general care of older people, which focuses on integration of health care, social care and social work, also seems to provide care for older people suffering from dementia which best corresponds to the previously developed group living model.     

Negotiating a moral identity in the context of later life care

Strategies to maintain independence for older people have received considerable attention as a social policy solution to the financial and social impact of the ageing population. Critical scholars in gerontology have also highlighted the negative consequences of promoting independence in this way. Understandings of independence have profound implications for caring relationships as people age. To investigate the ways that older people talk about caring we interviewed 48 people aged 55-70years. A discourse analysis of these data showed that a dominant discourse of 'independence' was drawn upon to value self-sufficiency and construct dependence on others as burdensome. This construction of care provides a comfortable position for those who can afford to purchase professional care; however, those without resources are unable to accept unpaid help without also accepting a position of dependency. An alternative discourse of 'being there' constructs having others to provide personal care as a virtue and obligations to provide such care as based on family duty and affection. This discourse emphasises connections between people and a moral obligation to care which also creates difficulties for those with fewer material resources. The position for a dependent older subject in these two discourses may seem incompatible but can be reconciled by reframing independence as autonomy. Autonomy for those requiring care alongside a wider recognition of caring as the responsibility of all members of the community rather than with individual family members would support a flexible approach to later life care arrangements.     

Disability Discourses for Online Identities

Beneficial effects of the online medium have been reported for disabled people in terms of providing a 'levelling ground' where they can be treated on their merits as a person, rather than as a disabled person. If this occurs because impairment is invisible online, how then are disabled people managing disability disclosure within this social context? This paper addresses this issue discursively. Participants were recruited from various disability organisations in New Zealand and were invited to take part in an online interview. A 'choice to disclose' repertoire was identified and was organised around three key resources: relevance, anonymity and normality. Embedded within each resource is the idea that the presence or absence of impairment is constructed as a feature controlled by the individual. Positioning identity within a subjectivity removed from impairment was made possible through these resources and was valued by participants. Political implications associated with the absence of impairment are discussed.     

Care for place: The contributions older people make to their communities

Older people are often positioned as passive recipients of care and dependent on resources or as overly productive and active. In this paper, we seek a more nuanced, middle ground between such stereotypes, by exploring the question: what contributions do older people make to the places they live in? Drawing on qualitative research from Aotearoa New Zealand, involving focus groups and interviews, we examine the varied and active ways many older people are involved in and contribute to their neighbourhoods and communities, or what we term ‘care for place’. In particular, we identify the different forms of older people's care for place, including volunteering, activism, advocacy, and nurturing, and consider how these efforts positively impact on older people and the communities in which they live. Whilst we caution against assumptions that all older people should be productively involved, we argue that greater understanding of older people's care for place is central to challenging stereotypes of older people as either passive and dependent, or highly active.     

Equal or individual treatment: contesting storylines in needs assessment conversations within Swedish eldercare

This article examines the role of care managers and their work in putting policy into practice in micro-interactions with older people in Swedish eldercare. The care managers assess the individual needs of older people, and decide what type of social care and services will be given. Dilemmas in care management are often related to the gap between needs and resources. The aim was to study the positioning of care managers within different storylines advanced in needs assessment conversations. Positioning theory was applied to study discursive practices and discursive strategies within Swedish eldercare. Audio-recorded needs assessment conversations among care managers, older people and their relatives at care planning meetings in connection with hospital discharge were analyzed. Two overall positions were identified for care managers—as ‘professional experts’ and as ‘organizational representatives’—allowing the care managers to maneuver within two contesting storylines: ‘distribution of scarce eldercare resources based on the principles of eligibility and equal treatment’ and ‘older people entitled to eldercare according to their own perceived individual needs’. For social work, the results showed the importance of discussing how care managers might move towards exercising greater professional autonomy, becoming less dependent on their position in the organization.     

How volunteerism inhibits mobilization: a case study of shelter animal advocates

This paper presents an analysis of how volunteerism can neutralize impulses for mobilization. An ethnographic case study of shelter animal advocates, or individuals promoting shelter reform to ensure that companion animals impounded at animal shelters receive proper medical and behavioral care and are given opportunity for adoption, illuminates a specific set of mechanisms that explain why they have not engaged in collective action such as protest. The findings speak to the complex debate about the relationship between volunteerism, political engagement, and social change by identifying five processes that undercut shelter animal advocates’ capacity to act collectively in protest of how the shelter is run: (1) periods of grievance interruption; (2) exposure to the target’s institutional narratives; (3) relational ties to the target; (4) conflict avoidance; and (5) maintenance of identity as volunteers.     

The politics of care for elderly people in Scandinavia

Most of the European countries struggle with a lack of public resources for the care of elderly people. Several comparative studies have shown that the ‘social democratic’ welfare regime of Scandinavia offers more public services to older people than any other regime. This is true both for institutional care and home care. The national averages, however, hide some serious problems. The responsibility for the care of elderly people has been transferred to the municipalities. This is threatening one of the cornerstones of the Scandinavian welfare state, equality. Access to care is increasingly becoming a question of which municipality you happen to grow old in. While inequality seems to be the problem when comparing elderly living in different municipalities, too egalitarian a policy seems to be a problem within the municipalities. In a situation where every old person is entitled to get help, the number of old people is growing and the economic resources are restricted, the cheapest form of care, ‘thinly spread’, often seems to be the only solution. It is argued that this leads to unnecessary institutionalisation. Whether there are other solutions, and what consequences they have, is also discussed. Empirical findings from a study of the care of older people in five municipalities in Denmark, Finland, Iceland, Norway and Sweden from 1991 to 1995, will be used as examples.     

Caring at a distance: Learning and practice issues

Emphasis on support for informal carers focuses on those who provide, in the words of the Carers (Recognition and Services) Act 1995, 'substantial' and 'regular' care. Following research and policy, professional education has also developed interest in those who live with the people they support, such as co-resident spouses and children of all ages. This article considers those who probably do not define themselves as carers and are usually referred to as 'relatives' or 'family', living at a distance from an older relative. It explores their possible need for support as well as the form and level of their involvement in relation to care managed services. It describes key areas or events to draw out practice issues and concludes with a discussion of the extent to which care management can work with such relatives. In many ways caring at a distance forces an examination of what is meant by 'care' and who can legitimately claim this as an emotion or status. The rationale for such interest is therefore three-fold. If social workers and social work educators restrict the meaning and their definitions of carers to those who provide 'hands on' services, as part of the care package, they risk alienating relatives from the learning experience of students. In doing so they may neglect these highly valued supports of older people and may leave relatives distressed and disempowered by anxiety over their contract with social work agencies.     

Homes of Choice

Abstract

State policymakers increasingly recognize that housing is not only an important shelter resource for older persons, but also a key element of community-based care. Over the last two decades, significant state and local activity has led to an increase in service-enriched housing for older persons. Service-enriched housing refers to living arrangements that include health and/or social services in an accessible, supportive environment. Emerging forces are leading to increased pressure for the expansion of service-enriched housing. These forces include: a growing and diverse population of older renters; older adults' preferences to age in place; the increasing frailty of subsidized housing residents; the development of assisted living (AL); the enactment of Medicaid waivers; and implementation of the Olmstead decision. Although studies have not included cost-analysis, available research demonstrates that service-enriched housing promotes resident satisfaction, successfully provides services to frail populations, and supports aging in place.

Given both limited resources and research, this article addresses how states can adequately respond to and capitalize on these forces in order to best meet the long-term needs of older adults.     

Staff responses to age‐related health changes in people with an intellectual disability in group homes

The purpose of this study was to explore how supervisors in group homes caring for people with intellectual disability responded to the development of age‐related health changes in their residents. Ten group home supervisors working in the disability sector were interviewed once. Data were analysed using Dimensional Analysis. The study identified several factors related to whether a resident could stay ‘at home’ or would need to be moved to residential aged care (nursing home) including: nature and extent of group home resources, group home staff comfort with residents’ health changes, staff skill at navigating the intersection between the disability and ageing sectors, and the supervisor’s philosophy of care. The ability of older people with an intellectual disability to ‘age in place’ is affected by staff knowledge about and comfort with age‐related illnesses, staff skills at navigating formal services, staffing flexibility, and the philosophy of group home supervisors. Despite the growing international concern for the rights of people with disability, particularly in relation to decision making, questions about the older person’s choice of residence and participation in decision making about what was best for them, were almost nonexistent. Rather, decisions were made based on what was considered to be in ‘the best interest’.     

Designing ‘older’ rather than denying ageing: Problematizing anti-ageing discourse in relation to cosmetic surgery undertaken by older people

This paper problematizes anti-ageing discourse and interpretations that cosmetic surgery is an ageist practice and older people who undergo cosmetic surgery are denying ageing. It argues that conceptions of cosmetic surgery as anti-ageing are premised on an essentialist conception of the ‘naturally ageing body’. Interview data and media texts are used to demonstrate how, through the notion of “re” suggested by terms such as rejuvenation, reversal and renewal, anti-ageing discourses inscribe ‘ageing’ in the practice of cosmetic surgery by older people. The oppressive interpretation that older people who undergo cosmetic surgery are ‘denying ageing,’ and associated subjection to moral critique, are effects of this discourse. To counter interpretations of cosmetic surgery as ‘anti-ageing’, the paper takes up the idea that cosmetic surgery is undertaken to look better not younger. To advance this argument, the paper suggests that the forms of rationality associated with cosmetic surgery constitute a contemporary regimen of ‘care of the self’ which enable ethical agency and creative self-stylisation. Through this framework cosmetic surgery can be re-imagined as a practice for designing ‘older’ rather than denying ageing.     

Working with Older People with Alcohol Problems: Insight from Specialist Substance Misuse Professionals and their Service Users

Significant numbers of older people worldwide have a drinking level or pattern which places them at risk of harm. In England, older people are more likely to be admitted to hospital for an alcohol-related condition than younger people and levels of alcohol-related harm are increasing fastest in this population. Whilst alcohol problems in older people are highly treatable, they frequently go undetected or ignored. The aim of this study was to develop guidelines for health and social care workers on what intervention strategies are likely to work best with older drinkers. Insight from alcohol practitioners who specialise in working with older people and the perspectives of older people receiving alcohol treatment were gained through focus groups and individual interviews. This paper reports some of the key findings including a perception that health and social care workers often did not intervene when alcohol misuse was suspected because of ageist attitudes and false beliefs about older people's drinking. Participants however acknowledged that social workers faced difficult choices in relation to the ‘right’ of older people with alcohol problems to continue to drink and the ‘risk’ associated with them doing so. The implications for social work education and training are discussed.     

The indelible ink of the special stamp: an insider’s research essay on imprints and erasures

The medical profession ascribes otherness to people with disabilities through diagnosis and expertism, which sets in motion discursive powers that oversee their exclusion through schooling and beyond. In this paper, I present a narrative pieced together from personal experiences of ducking and weaving the deficit discourse in ‘inclusive’ education, when seeking employment and in day-to-day family interaction as a person with severely impaired vision. This work builds on previous qualitative research I conducted in Queensland, Australia with a group of young people with impaired vision who attended an inclusive secondary school. I frame this discussion using Foucault’s conception of normalising judgement against the hegemony of normalcy, and consider that inclusion for people with disabilities is reminiscent of a haunting. Through this analysis, I demonstrate how my ideology is formed, and how it in turn shapes a research agenda geared toward seeking greater inclusion for young people with disabilities in schools.     

Strangers are friends I haven't met yet: a positive approach to young people's use of social media

This article reports on a recent research project undertaken in the UK that investigated young people's use of a range of prominent social media tools for socialising and relationship building. The research was conducted by a way of online survey. The findings suggest that this sample of British young people's socialising and relationship-building practices via the range of prominent social media tools reflect similar behavioural categories used offline. The use of these social media tools provides young people with an opportunity to manage, simultaneously, different categories of relationships in a multiplicity of ‘spaces’ created by these tools. The findings challenge the widely held belief that young people expose themselves to risk on social media as they indiscriminately befriend strangers. There is an absence of evidence of ‘unjustified’ intent to harm others. Indeed the findings indicate a strong desire to primarily support and protect those with whom relationships have been carefully established. The research suggests in fact that online engagement through social media can be positive and constructive for young people. It appears to provide them with a challenging ‘space’ to practice identity and relationship management strategies.     

Bridging the Gap: ‘Doing Gender’, ‘Hegemonic Masculinity’, and the Educational Troubles of Boys

This article reviews popular and social scientific perspectives on the academic gender gap in education, specifically the finding that boys underperform compared to girls. The article highlights the utility of sociology in analyzing the gender gap and in guiding how educators respond to students’ gender. It suggests that contemporary gender theories ‘doing gender’ and ‘hegemonic masculinity’ offer the best lenses through which to view academic gender differences. These perspectives can frame boys’ academic troubles as an important social problem, but one that is rooted in the social construction of masculinity rather than institutional discrimination against boys.     

Beyond words: Older people with dementia using and interpreting nonverbal behaviour

This article addresses a gap in research on nonverbal communication and dementia. It presents findings from a study that explored ways in which older people with dementia used and interpreted nonverbal behaviour within the context of social interactions. Two researchers, using an ethnographic approach, jointly observed nonverbal communicative behaviours occurring in a day-care centre. The findings show that older people with dementia used nonverbal behaviour in meaningful ways for others to interpret, and as a way of self-communication; and that they actively interpreted others' nonverbal behaviour. In specific situations, these people acted in the context of shared meanings, possessed a ‘self’, and took on the ‘role’ of others. This approach has implications for understanding the social experience of dementia and for the ways that care is organised. The role of nonverbal behaviour offers potential for carers to preserve older people's self-identity and improve their quality of life and care.     

Variations in subjective well-being when ‘aging in place’ — A matter of acceptance,predictability and control

The aim of the present study is to explore how older home-help recipients regard their life situation in terms of subjective well-being. The background is that there seem to be two counteracting forces affecting the achievement of subjective well-being among home-help recipients: on one hand, both diminished everyday competence and dependence on others' help are supposed to reduce subjective well-being, and on the other hand, living in one's own home is supposed to affect subjective well-being positively. The analysis is based on qualitative interviews with 21 home-help recipients between the ages of 78 and 93. The findings indicate that the informants' expressions of subjective well-being fall into four main categories: ‘well-being’, ‘well-being despite it all’, ‘well-being so far’, and ‘lack of well-being’. Three comprehensive core themes were identified as relevant to a deeper understanding of the informants' various expressions of well-being. These core themes are acceptance, predictability, and control. The findings point to the possibility of experiencing subjective well-being despite diminished everyday competence and dependence on help and support from others. They suggest, in short, that subjective well-being among older people who receive help and support in their everyday lives is not only related to socio-contextual factors – such as physical and mental capability, activities and/or engagement in the outside world, the spatial and social consequences of physical limitations, social and emotional relations, as well as the social support they receive – but also to how they regard and handle these matters in terms of acceptance, predictability and control.     

Social and Health Factors Affecting Community Service Use by Vulnerable Older People

Abstract

This article reports on Outcomes for older people with complex or chronic care needs, a study undertaken by the Brotherhood of St Laurence and La Trobe University, examining older Victorians’ use of community services following Aged Care Assessment Service (ACAS) recommendations that they remain living at home. The paper reports on interviews with older people and carers undertaken at three-monthly intervals, over 12 months. This paper contributes to understanding the factors that impede or facilitate uptake of community aged care services that are critical to meeting the needs of older people and their carers. The study found that among other factors social isolation, high carer burden, and the older person reporting low mood were important barriers to service uptake. Cost, waiting lists, and service satisfaction were also identified in qualitative data as influencing factors. The study concludes there is a need for better means of identifying and supporting older people and carers at risk to improve community service uptake.     

Social assistance in Austria: regulating the poor as in-between

Not only the concept of social inclusion is widely recognized as an important basis today for making social policy, but it also provides a platform for the policing of the poor. Thinking uncritically about social inclusion prevents us from seeing how it operates to re-inscribe subordination even as we help the poor overcome their marginalization. With an awareness of the paradox of inclusion, it is possible to examine how welfare policy today operates to discipline the poor as people who must accept their plight at the bottom of the socioeconomic order. While formal policy may not make this paradox apparent, the disciplinary effects of an inclusionary social assistance policy are starkly visible when we examine its implementation, where we can see how the excluded become included in ways that perpetuate their subordination. Social assistance recipients obtain a benefit, but the way they are treated does not correspond with full social rights, which is reminiscent of Georg Simmel's discussion of the poor. As exemplified by research at one local social assistance office in Austria, welfare recipients are ultimately neither included nor excluded. Welfare, as administered today, upholds the system of social stratification by perpetuating an ‘in-between’ status for the claimants of social assistance benefits at the frontline.     

‘Su guagua no escucha nada’: Ecuadorian families confronting the deafness of a child

In accordance with the social model of disability, this study proceeded from the assumption that parents’ experiences of a child’s hearing impairment reflect the circumstances of their lives rather than anything innate in the impairment itself. Few studies have explored the influence both of culture and social structure and of families’ economic and social resources. We studied families’ experiences of the diagnosis of hearing loss in Ecuador, a multicultural country in which family ties are strong but where pronounced social and economic inequalities persist and where many people have no access to health care. The study shows how inequality – and in particular the experience of poverty – shapes families’ experiences of acquiring a diagnosis and of trying to accommodate a child with special needs.