Disadvantaged and disenfranchised in bereavement: A scoping review of social and structural inequity following expected death

Supporting the Family After the Death of a Child or Adolescent

Whether death occurs in the context of a chronic illness or as the sudden loss of a previously healthy infant, child, or adolescent, the death of a child is a highly stressful and traumatic event. Psychosocial support for families after the death of a child embodies core medical values of professional fidelity, compassion, respect for human dignity, and promotion of the best interests of a grieving family. The pediatrician has an important role in supporting the family unit after the death of a child through a family-centered, culturally humble, trauma-informed approach. This clinical report aims to provide the pediatrician with a review of the current evidence on grief, bereavement, and mourning after the loss of a child and with practical guidance to support family caregivers, siblings, and the child's community. Pediatricians have an important role in helping siblings and helping families understand sibling needs during grief. Ways for pediatricians to support family members with cultural sensitivity are suggested and other helpful resources in the community are described.

Prolonged grief during and beyond the pandemic: factors associated with levels of grief in a four time-point longitudinal survey of people bereaved in the first year of the COVID-19 pandemic

Background

The COVID-19 pandemic has been a devastating and enduring mass-bereavement event, with uniquely difficult sets of circumstances experienced by people bereaved at this time. However, little is known about the long-term consequences of these experiences, including the prevalence of Prolonged Grief Disorder (PGD) and other conditions in pandemic-bereaved populations.

Methods

A longitudinal survey of people bereaved in the UK between 16 March 2020 and 2 January 2021, with data collected at baseline (n = 711), c. 8 (n = 383), 13 (n = 295), and 25 (n = 185) months post-bereavement. Using measures of Prolonged Grief Disorder (PGD) (Traumatic Grief Inventory), grief vulnerability (Adult Attitude to Grief Scale), and social support (Inventory of Social Support), this analysis examines how participant characteristics, characteristics of the deceased and pandemic-related circumstances (e.g., restricted visiting, social isolation, social support) are associated with grief outcomes, with a focus on symptoms of PGD.

Results

At baseline, 628 (88.6%) of participants were female, with a mean age of 49.5 (SD 12.9). 311 (43.8%) deaths were from confirmed/suspected COVID-19. Sample demographics were relatively stable across time points. 34.6% of participants met the cut-off for indicated PGD at c. 13 months bereaved and 28.6% at final follow-up. Social isolation and loneliness in early bereavement and lack of social support over time strongly contributed to higher levels of prolonged grief symptoms, while feeling well supported by healthcare professionals following the death was associated with reduced levels of prolonged grief symptoms. Characteristics of the deceased most strongly associated with lower levels of prolonged grief symptoms, were a more distant relationship (e.g., death of a grandparent), an expected death and death occurring in a care-home. Participant characteristics associated with higher levels of prolonged grief symptoms included low level of formal education and existence of medical conditions.

Conclusion

Results suggest higher than expected levels of PGD compared with pre-pandemic times, with important implications for bereavement policy, provision and practice now (e.g., strengthening of social and specialist support) and in preparedness for future pandemics and mass-bereavement events (e.g., guidance on infection control measures and rapid support responses).

Engaging and supporting the public on the topic of grief and bereavement: an evaluation of Good Grief Festival

Background

Good Grief Festival was originally planned as a face-to-face festival about grief and bereavement. Due to COVID-19, it was held online over 3 days in October 2020.

Objective

To evaluate the festival's reach and impact.

Design

Pre/post evaluation.

Methods

Pre-festival online surveys assessed reasons for attending and attitudes to bereavement across four items (fear of saying the wrong thing, avoiding talking to someone bereaved, knowing what to do if someone bereaved was struggling, knowing how to help). Post-festival online surveys evaluated audience experiences and the four attitude items. Free-text responses, analysed using thematic analysis, generated suggestions for improvement and general comments.

Results

Between 5003 and 6438 people attended, with most attending two to five events. Pre-festival survey participants (n = 3785) were mostly women (91%) and White (91%). About 9% were from Black or minoritised ethnic communities. About 14% were age ⩾65 years, 16% age ⩽34 years. Around 75% were members of the public, teachers, students or 'other'; 25% academics, clinicians or bereavement counsellors. A third had been bereaved in the last year; 6% had never been bereaved. People attended to learn about grief/bereavement (77%), be inspired (52%) and feel part of a community (49%). Post-festival participants (n = 685) reported feeling part of a community (68%), learning about grief/bereavement (68%) and being inspired (66%). 89% rated the festival as excellent/very good and 75% agreed that they felt more confident talking about grief after attending. Higher ratings and confidence were associated with attending more events. Post-festival attitudes were improved across all four items (p < 0.001). Attendees appreciated the festival, particularly valuing the online format, opportunities for connection during lockdown and the diversity and quality of speakers. Suggestions included improving registration, more interactive events and less content.

Conclusion

Good Grief Festival successfully reached a large public audience, with benefit in engagement, confidence and community-building. Evaluation was critical in shaping future events. Findings suggest festivals of this nature can play a central role in increasing death- and grief-literacy within a public health approach.

Mental health among bereaved youth in the ALSPAC birth cohort: Consideration of early sociodemographic precursors, cognitive ability, and type of loss

BACKGROUND

Bereaved youth are at greater risk for adverse mental health outcomes, yet less is known about how social context shapes health for bereaved children. Ecosocial theory is employed to conceptualize bereavement in the context of sociodemographic factors.

METHOD

This longitudinal study used data from the Avon Longitudinal Study of Parents and Children. Of the 15,454 pregnancies enrolled, 5050 youth were still enrolled at age 16.5 and completed self-report questionnaires on life events and emotional/behavioral symptoms.

RESULTS

Sociodemographic precursors associated with parent, sibling, or close friend bereavement included maternal smoking, parental education levels, and financial difficulties. The significant yet small main effect of higher cognitive ability, assessed at age 8, on reduced emotional/behavioral symptoms at age 16.5 (β = -0.01, SE = 0.00, p < 0.001) did not interact with bereavement. Bereavement of a parent, sibling, or close friend was associated with a 0.19 point higher emotional/behavioral symptom log score compared to non-bereaved youth (95% CI: 0.10-0.28), across emotional, conduct, and hyperactivity subscales.

CONCLUSIONS

Descriptive findings suggest sociodemographic precursors are associated with bereavement. While there was an association between the bereavement of a parent, sibling, or close friend and elevated emotional/behavioral symptoms, cognitive ability did not moderate that effect.

Social exclusion and critical transitions in later life: Trajectories, forms and mechanisms

Unequal ageing patterns are increasingly prevalent within the life courses of heterogeneous older populations. Critical transitions in later life may contribute to these patterns and to more multifaceted deep-rooted forms of social exclusion. Yet despite significant research in this area, knowledge gaps remain regarding the subjective experiences of these transitions, the trajectories and constituent events of these transitions, and the related mechanisms that may drive exclusion. With a focus on lived experience, this article aims to investigate the role of critical life transitions in older age in constructing multidimensional social exclusion. The onset of dementia, bereavement of a significant other, and forced migration are selected as three illustrative transitions in older age. Based on 39 in-depth life-course interviews and life-path analyses, the study sets out to illuminate common features of the transitional process that increases exclusion susceptibility, and the potential commonalities regarding transition-related exclusionary mechanisms. Transition trajectories related to each of the transitions are first described identifying shared exclusionary risk features. Transition-related mechanisms that can generate multidimensional social exclusion are then presented as arising from a transition's nature and character, its structural and management aspects, and its symbolic and normative positioning. Findings are discussed with reference to the international literature and future conceptualisation of social exclusion in later life.

Employment and family income in psychological and immune outcomes during bereavement

Spousal bereavement is one of the most stressful experiences in adulthood. In a sample of 183 widow(er)s, bereaved about three months prior, we examined the intersection of employment, family income, and health outcomes (proinflammatory marker production, perceived stress, and grief symptoms). Bereaved employees had higher levels of monocyte-stimulated interleukin-6, tumor necrosis factor-α, chemokine ligands 4, and perceived stress than bereaved retirees. We also found an interaction such that family income was positively associated with perceived stress and grief symptoms for employed window(er)s, but not for retirees. These findings align with the reserve capacity model, which states that people at higher levels of socioeconomic status have more psychosocial resources to address psychosocial stressors. Employment likely served as an added psychological and inflammatory burden for all bereaved workers, except those with the highest incomes.

Bereavement affinities: A qualitative study of lived experiences of grief and loss

Attending to bereaved peoples' lived experiences offers considerable potential for better understanding how to improve support following loss. In-depth interviews (n = 36) and solicited diaries (n = 23) were conducted with bereaved adults following a death in palliative or residential aged care. A constructivist grounded theory approach guided data analysis, through which three themes were derived: making sense of the lived experience of bereavement; relationships in bereavement; and bereavement over time. The results reveal the nuances within everyday experiences of bereavement, in particular the multiplicity of affinities, present or lacking, in social support and recognition.

Factors Associated With Higher Levels of Grief and Support Needs Among People Bereaved During the Pandemic: Results from a National Online Survey

We identified factors associated with higher levels of grief and support needs among 711 people bereaved during the COVID-19 pandemic in the UK (deaths 16 March 2020-2 January 2021). An online survey assessed grief using the Adult Attitude to Grief (AAG) scale, which calculates an overall index of vulnerability (IOV) (range 0-36), and practical and emotional support needs in 13 domains. Participants' mean age was 49.5 (SD 12.9); 628 (88.6%) female. Mean age of deceased 72.2 (SD 16.1). 311 (43.8%) deaths were from confirmed/suspected COVID-19. High overall levels of grief and support needs were observed; 28.2% exhibited severe vulnerability (index of vulnerability ≥24). Grief and support needs were higher for close relationships with the deceased (vs. more distant) and reported social isolation and loneliness (p < 0.001), and lower when age of deceased was above 40-50. Other associated factors were place of death and health professional support post-death (p < 0.05).

Racial and ethnic differences in retrospective end-of-Life outcomes: A systematic review

The purpose of this systematic review was to provide a comprehensive account of racial and ethnic differences in retrospective end-of-life outcomes. Studies were searched from the following databases: Abstracts in Social Gerontology, Academic Search Premier, CINAHL Plus with Full Text, ERIC, MEDLINE, PsycINFO, PubMED, and SocIndex. Studies were included if they were published in English, included people from groups who have been minoritized, included adults aged 18 and older, used retrospective data, and examined end-of-life outcomes. Results from most of the 29 included studies showed that people from groups who have been minoritized had more aggressive/intensive care, had less hospice care, were more likely to die in a hospital, less likely to engage in advance care planning, less likely to have good quality of care, and experienced more financial burden at the end of life. Implications for practice (timely referrals), policy (health insurance access), and research (intervention studies) are provided.

"Once you open that door, it's a floodgate": Exploring work-related grief among community service workers providing care for structurally vulnerable populations at the end of life through participatory action research

BACKGROUND

At the end of life, people experiencing structural vulnerability (e.g. homelessness, poverty, stigmatization) rely on community service workers to fill gaps in access to traditional palliative services. Although high levels of burnout are reported, little is known about these workers' experiences of grief.

AIM

To explore community service workers' experiences of grief to identify ways of providing more tailored, meaningful, and equitable supports.

DESIGN

A community-based participatory action research methodology, informed by equity perspectives, was employed.

SETTING/PARTICIPANTS

In an urban center in western Canada, community service worker (primary) participants (n = 18) were engaged as members of an action team. A series of 18 action cycles took place, with secondary participants (n = 48) (e.g. palliative, social care, housing support, etc.) being recruited throughout the research process. Focus groups (n = 5) and evaluative interviews (n = 13) with participants were conducted. Structured observational field notes (n = 34) were collected during all team meetings and community interventions. Interpretive thematic analysis ensued through a collaborative and iterative process.

RESULTS

During initial meetings, action team participants described experiences of compounding distress, grief, and multiple loss. Analysis showed workers are: (1) grieving as family, not just providers; (2) experiencing complex layers of compounded grief; and (3) are fearful to open the "floodgates" to grief.

CONCLUSIONS

Findings contribute to our understanding on the inequitable distribution of grief across society. A collective and material response is needed, including witnessing, acknowledging and valuing the grief process; facilitating community wellness, collective grieving, and advocacy; and providing training and tools in a palliative approach to care.

'Sadly I think we are sort of still quite white, middle-class really' - Inequities in access to bereavement support: Findings from a mixed methods study

BACKGROUND

Voluntary and community sector bereavement services are central to bereavement support in the UK.

AIM

To determine service providers' perspectives on access to their support before and during the COVID-19 pandemic.

DESIGN

Mixed methods study using an explanatory sequential design: (1) Cross-sectional online survey of UK bereavement services; (2) Qualitative interviews with staff and volunteers at selected services.

SETTINGS/PARTICIPANTS

147 services participated in the survey; 24 interviews were conducted across 14 services.

RESULTS

67.3% of services reported there were groups with unmet needs not accessing their services before the pandemic; most frequently people from minoritised ethnic communities (49%), sexual minority groups (26.5%), deprived areas (24.5%) and men (23.8%). Compared with before the pandemic, 3.4% of services were seeing more people from minoritised ethnic groups, while 6.1% were seeing fewer. 25.2% of services did not collect ethnicity data. Qualitative findings demonstrated the disproportionate impact of the pandemic on minoritised ethnic communities, including disruption to care/mourning practices, and the need for culturally appropriate support. During the pandemic outreach activities were sometimes deprioritised; however, increased collaboration was also reported. Online provision improved access but excluded some. Positive interventions to increase equity included collecting client demographic data; improving outreach, language accessibility and staff representation; supporting other professionals to provide bereavement support; local collaboration and co-production.

CONCLUSIONS

Service providers report inequities in access to bereavement support. Attention needs to be paid to identifying, assessing and meeting unmet needs for appropriate bereavement support. Identified positive interventions can inform service provision and research.

Bureaucracy and burden: An Intersectionality-Based Policy Analysis of social welfare policy with consequences for carers of people with life-limiting illness

BACKGROUND

For informal carers of people with life-limiting illness, social welfare policy related to income support and housing has been associated with varied psychosocial issues, yet remains relatively under-explored. An intersectional approach offers potential to illuminate diverse experiences and implications.

AIM

To explore the way in which caring in the context of life-limiting illness is framed within welfare policy, to articulate inequities encountered by carers, and to identify policy and practice recommendations.

DESIGN

The Intersectionality-Based Policy Analysis (IBPA) Framework was used to situate findings of a broader qualitative study.

SETTING/PARTICIPANTS

Data were collected via semi-structured interviews with participants who were bereaved carers (n = 12), welfare workers (n = 14) and palliative care workers (n = 7), between November 2018 and April 2020, in an Australian region associated with socioeconomic disadvantage. Five elements of IBPA were applied to the products of analysis of this data.

RESULTS

Use of the IBPA Framework revealed that representations of carers and causes of their welfare needs in policy were underpinned by several assumptions; including that caring and grieving periods are temporary or brief, and that carers have adequate capacity to navigate complex systems. Policy and processes had differentiated consequences for carers, with those occupying certain social locations prone to accumulating disadvantage.

CONCLUSIONS

This intersectional analysis establishes critical exploration of the framing and consequences of welfare policy for carers of people with life-limiting illness, presented in a novel conceptual model. Implications relate to intersectoral development of structural competency, responsiveness to structurally vulnerable carers in clinical practice, and needed policy changes.

Acknowledging bereavement, strengthening communities: Introducing an online compassionate community initiative for the recognition of pandemic grief

Despite public health measures and collective efforts, millions of individuals have unfortunately died from COVID-19 complications worldwide, leaving several million family members at risk of developing bereavement complications. In the Canadian province of Quebec, where substantial deaths were associated with COVID-19, we established an online support community for bereaved caregivers who lost a loved one during the pandemic. We explain how we created a community that recognized pandemic grief and advocated for its wider acknowledgment. We discuss "compassionate communities," the theoretical underpinning of our initiative, as a means to foster solidarity, normalize finitude, create and maintain a safe social space through group sharing, and challenging capitalist principles. We then describe the eight areas of activities inspired by the Charter of Pallium Canada: education and training, hospices and nursing homes, media and social media, commemoration, celebrations, artistic practices and storytelling, marginalized populations, and review and evaluate. We propose that online communities constitute a powerful space for community members to gather and advocate for greater awareness of the inequities found in end-of-life care and bereavement services, to denounce abusive situations experienced by many individuals who died from COVID-19 complications, and to fight against the lack of recognition experienced by numerous caregivers.

Emotional geographies of loss in later life: An intimate account of rural older peoples' last move

Providing a rural example of the interconnection between aging, emotion, time and place, this paper explores the intimate experiences of loss as older adults move into long-term care settings. Drawing on findings from a qualitative case study of transitions in care in rural Canada, we demonstrate the spatial and temporal dimensions of the experiences of older adults and their carers. In so doing, we highlight the benefits of embracing emotional geographies of care as a new lens in transitions in care research and outline emergent questions for research, policy and practice that will enhance knowledge in the field.

Caring and Grieving in the Context of Social and Structural Inequity: Experiences of Australian Carers With Social Welfare Needs

Caring for and bereavement following the death of someone with a life-limiting illness may precipitate social welfare needs related to income support and housing. Nevertheless, carer experiences of welfare policy and institutions have not received significant attention. This qualitative study explored experiences of carers who navigated social welfare policy while caring for someone with a life-limiting illness, and in bereavement. In-depth interviews were conducted with 12 bereaved carers in an area associated with socioeconomic disadvantage. Carers differentially encountered precariousness, with some experiencing structural vulnerability. These positionalities appeared to be shaped by policy and process-related burdens, perceptions of the welfare state, and degrees of legitimisation or disenfranchisement of forms of capital and coping orientations. Recommendations that may improve carer experience were identified. Implications relate to the need for an expanded conceptualisation of vulnerability in health and welfare practice, policy that authentically validates caring and grieving, and upstream strategies that address inequity.

How does housing affect end-of-life care and bereavement in low-income communities? A qualitative study of the experiences of bereaved individuals and service providers in the United Kingdom

Background:

Access to affordable, appropriate housing is one of the key social determinants of health, affecting well-being across the lifecourse. However, beyond a recognition that housing quality is linked to place of death, little is known about the ways in which housing status impacts social, emotional, and practical aspects of dying and bereavement.

Method:

The Checking Out project is a qualitative study aiming to explore the ways in which socio-economic status impacts people’s experiences of, and attitudes towards, death, dying, and bereavement in the United Kingdom. Qualitative interviews were carried out with 14 bereaved individuals with experience of poverty at end of life or in bereavement, and 15 professionals supporting individuals in low-income communities. Interviews were conducted via phone/video call, and data include experiences of end of life and bereavement both before and during the pandemic. Transcripts were examined using thematic analysis.

Results:

Housing emerged as an important factor affecting people’s experiences, with 7 of the 14 bereaved individuals and all except 1 of the professionals discussing housing-related issues. Participants described ways in which unsuitable housing and housing insecurity impacted practical aspects of dying but also emotional and social well-being at end of life. Housing-related issues affected both patients and their families, though families found it difficult to air these concerns when their relative was dying.

Conclusion:

The paper demonstrates how trusted professionals are able to advocate or address the issues faced by bereaved individuals and suggests implications for policy and practice. A greater awareness of the potential impact of housing status across public services, including healthcare practitioners, welfare support, and housing providers, could better support patients and practitioners to address these issues proactively. Housing providers and policy-makers should be included as key partners in collaborative public health approaches to palliative care.

"Still Caring for the Family": Condolence Expression Training for Pediatric Residents

CONTEXT

Insufficient communication from the medical team following a child's death may compound parental grief. Pediatric residents care for children who die, yet the landscape of condolence expression education within residency programs has not been studied.

OBJECTIVES

The objective of this study was to evaluate pediatric residents' levels of experience and comfort with condolence expression and to assess their needs and desires for training in condolence expression.

METHODS

A cross-sectional, mixed-methods survey was developed by palliative care clinicians in collaboration with bereaved parents. In 2020, following pilot testing, an electronic survey measuring resident experience with, comfort with, and training on condolence expression was distributed to 202 third-year pediatric residents across 17 Accreditation Council for Graduate Medical Education-accredited programs representing varying sizes and geographic regions.

RESULTS

Ten percent of pediatric residents surveyed reported having training on condolence expression. Almost all residents considered condolence expression to be beneficial for bereaved families and most for clinicians, too, yet very very few had formally expressed condolences in their roles as physicians: 83.1% had never written a condolence letter; 85% had never made a condolence phone call; and 90.5% had never attended a memorial event. Commonly reported barriers to condolence expression included lack of experience and training, as well as concern about upsetting families.

CONCLUSIONS

Pediatric residents lack comfort with and training in condolence expression and desire education to address these gaps. These findings should inform development and investigation of educational resources and training opportunities for residents to learn and practice compassionate provision of condolences to grieving families.

The impact of poverty and deprivation at the end of life: a critical review

This critical review interrogates what we know about how poverty and deprivation impact people at the end of life and what more we need to uncover. While we know that people in economically resource-rich countries who experience poverty and deprivation over the life course are likely to die younger, with increased co-morbidities, palliative care researchers are beginning to establish a full picture of the disproportionate impact of poverty on how, when and where we die. This is something the Covid-19 pandemic has further illustrated. Our article uses a critical social science lens to investigate an eclectic range of literature addressing health inequities and is focused on poverty and deprivation at the end of life. Our aim was to see if we could shed new light on the myriad ways in which experiences of poverty shape the end of people's lives. We start by exploring the definitions and language of poverty while acknowledging the multiple intersecting identities that produce privilege. We then discuss poverty and deprivation as a context for the nature of palliative care need and overall end-of-life circumstances. In particular, we explore: total pain; choice at the end of life; access to palliative care; and family caregiving. Overall, we argue that in addressing the effects of poverty and deprivation on end-of-life experiences, there is a need to recognise not just socio-economic injustice but also cultural and symbolic injustice. Too often, a deficit-based approach is adopted which both 'Others' those living with poverty and renders invisible the strategies and resilience they develop to support themselves, their families and communities. We conclude with some recommendations for future research, highlighting in particular the need to amplify the voices of people with lived experience of poverty regarding palliative and end-of-life care.

Family caregiver grief and post-loss adjustment: A longitudinal cohort study

OBJECTIVE

In order to better understand the different grieving trajectories of the family caregivers (FCs), this study aims to examine the evolution of prolonged grief disorder (PGD) symptoms and the predictive role of the caregiving-related factors in the FCs' grieving trajectory from pre- to post-death.

METHOD

A prospective cohort study was carried out with advanced cancer FCs evaluated before death (T1) and 6-12 months post-loss (T2).

RESULTS

Participants in T1 (n = 156) were mostly female, adult child, or spouse of the care recipient, with a mean age of 51.78 (SD = 13.29). At T2, 87 FCs participated in the survey. PGD prevalence was higher pre-death (38.6%) than in bereavement (33.7%). Of those who met the PGD criteria before death, most also met these criteria after death (n = 26, 61.9%). Psychological distress and caregiver burden were highly correlated with pre-death grief, which in turn played a critical role in mediating the link between psychological distress and bereavement outcome. Great emotional closeness in the relationship was predictive of PGD symptoms persistence. In contrast, the long-term consequences of caregiver burden were not confirmed.

SIGNIFICANCE OF RESULTS

This study provides evidence for the diversity of individual FC responses and the complex pattern of interactions between caregiving-related factors, relationship quality, and PGD symptoms evolution from pre- to post-death.

Personal and Political: Post-Traumatic Stress Through the Lens of Social Identity, Power, and Politics

Post-traumatic stress disorder (PTSD) has always been controversial and highly politicized. Here, using a social identity approach, we review evidence that trauma and its aftermath are fundamentally linked to social position, sociopolitical capital, and power. We begin this contribution by demonstrating how a person's group memberships (and the social identities they derive from these memberships) are inherently linked to the experience of adversity. We then go on to consider how it is through group memberships that individuals are defined by their trauma risk and trauma histories-that is, a person's group memberships and their trauma are often inherently linked. Considering the importance of group memberships for understanding trauma, we argue that it is important to see these, and group processes more generally, as more than just "demographic" risk factors. Instead, we argue that when groups are defined by their trauma history or risk, their members will often derive some sense of self from this trauma. For this reason, attributes of group memberships are important in developing an understanding of adjustment and adaptation to trauma. In particular, groups' status, their recourse to justice, and the level of trust and solidarity within the group are all central to the impact of traumatic events on individual-level psychological resilience. We review evidence that supports this analysis by focusing on the exacerbating effects of stigma and social mistrust on post-traumatic stress, and the value of solidarity and strong identities for resilience. We conclude that because of these group-related processes, trauma interweaves the personal with the political and that post-traumatic stress is fundamentally about power, positionality, and politics.

Social welfare needs of bereaved Australian carers: Implications of insights from palliative care and welfare workers

An individual and psychological emphasis has influenced practice and research on bereavement following informal care provision in the context of life-limiting illness. Consideration of the potential for bereavement to be shaped by intersecting social and structural inequities is needed; and should include an understanding of interactions with government institutions and social policy. This qualitative study employed interpretive description to explore the way in which palliative care workers and welfare sector workers perceive and approach experiences and needs of bereaved carers receiving government income support or housing assistance in Western Sydney, an area associated with recognised socioeconomic disadvantage. A total of 21 palliative care workers within a public health service and welfare workers from two government social welfare services participated in in-depth interviews. Data were analysed using framework analysis. Participants highlighted social welfare policy and related interactions that may impact bereavement, potentially related to financial, housing and employment precariousness. Personal, interpersonal and structural factors perceived to shape the navigation of welfare needs were explored, alongside needed professional and structural changes envisioned by workers. With limited forms of capital, vulnerably positioned carers may encounter difficulties that heighten their precariousness in bereavement. Transactional organisational cultures alongside health and welfare agencies that function in a siloed manner appear to contribute to structural burden for carers, following death due to life-limiting illness. Palliative care and welfare workers also associated elements of their work with bereaved carers with their own experiences of helplessness, frustration and distress. Findings point to a need for the development of interagency strategies in addition to policy underpinned by more nuanced understandings of vulnerability in bereavement, post-caring.

Caring precariously: An interpretive description of palliative care and welfare worker perspectives on end of life carers navigating social welfare

BACKGROUND

Caring at end-of-life is associated with financial burden, economic disadvantage, and psychosocial sequelae. Health and social welfare systems play a significant role in coordinating practical resources and support in this context. However, little is known about social policy and interactions with public institutions that shape experiences of informal carers with social welfare needs at end-of-life.

AIM

To explore ways in which palliative care and welfare sector workers perceive and approach experiences and needs of the carers of people with life-limiting illnesses who receive government income support or housing assistance, in an area of recognised socioeconomic disadvantage.

DESIGN

An interpretive descriptive study employed in-depth, qualitative interviews to explore participants' reflections on working with carers of someone with a life-limiting illness. Data were analysed using the framework approach.

SETTING/PARTICIPANTS

Twenty-one workers employed within three public services in Western Sydney were recruited.

RESULTS

Workers articulated understandings of welfare policy and its consequences for carers at end-of-life, including precariousness in relation to financial and housing circumstances. Identified resources and barriers to the navigation of social welfare needs by carers were categorised as personal, interpersonal and structural.

CONCLUSIONS

Caring at end-of-life while navigating welfare needs was seen to be associated with precariousness by participants, particularly for carers positioned in vulnerable social locations. Findings highlighted experiences of burdensome system navigation, inconsistent processes and inequity. Further exploration of structural determinants of experience is needed, including aspects of palliative care and welfare practice and investment in inter-agency infrastructure for supporting carers at end-of-life.

Operationalizing intersectionality as a framework in qualitative grief research

The field of thanatology emphasizes understanding grief as situated within social contexts. Yet, existing research largely examines individual experiences, neglecting to critically examine the role that sociocultural systems and forms of oppression play in how people grieve. In this manuscript, we use the social constructionist model of grief as an epistemological stepping stone to operationalize intersectionality as a framework to engage in this critical qualitative research. We provide an overview of the research process implementing an intersectional framework, including examples of research questions and procedures throughout, and discuss implications for helping praxis and education and future scholarship.