The concept of social care and the analysis of contemporary welfare states

How do nurses advocate for the remaining time of nursing home residents? A critical discourse analysis

INTRODUCTION

Due to the global aging trend, the number of older people who will spend the last years of their lives in nursing homes is increasing. However, nursing homes have long confronted negative social and public discourses, including stigmas on dementia and life in such facilities. Nevertheless, the remaining time of residents with dementia holds significance, for them and their families, as they seek respect and the ability to make meaningful end-of-life decisions.

OBJECTIVE

To explore how nursing home nurses advocate for the remaining lifetimes of residents with dementia.

DESIGN

A qualitative research design.

SETTING(S)

Four nursing homes in Korea from January 2023 to February 2023.

PARTICIPANTS

Twenty nurses who provide direct caregiving for residents with dementia and have a minimum of two years' experience in nursing homes were recruited.

METHODS

This study employed a critical discourse analysis. Twenty interviews conducted with nursing home nurses were examined to explore the connections between the grammatical and lexical aspects of the language used by the nurses to construct their identities as advocates for residents with dementia and the broader sociocultural context.

FINDINGS

Four discourses regarding nursing home nurses advocating for the value of life of residents with dementia were identified: (1) Bridging perspectives: I am a negotiator between medical treatment and residents' families with differing views; (2) Embracing a shared humanity: Residents are no different from me; they just need professional help; (3) Affirming belongingness: Residents still belong to their families, even when care has been delegated; and (4) Empowering voices for change: We are struggling to provide better care in a challenging reality.

CONCLUSIONS

This paper highlights the importance of nursing advocacy in safeguarding the remaining time and dignity of individuals with dementia, challenging the stigma surrounding dementia and nursing homes and calling for greater societal and political recognition of the efforts nurses make to preserve the personhood and well-being of these older adults.

Working Conditions Affecting Home Care Workers' Stress and Turnover Intention

This study explored how working conditions influence the psychological outcomes of paid family and non-family home care workers, focusing on the interaction between institutional and recipient effects. Using data from the 2019 Korean Long-Term Care Survey (N = 998), we performed regression analyses on home care workers' stress and turnover intention. For both types of home care-workers, inadequate working conditions and high occupational hazards influenced stress, while good working conditions and low occupational hazards influenced turnover intention. Overall, the findings suggest that wages, working hours, and work intensity must be reformed in a home care-worker-friendly manner; the wages for home care workers must be raised to a level appropriate to their care work; the services provided by home care workers should be explicitly stipulated; and, to eliminate occupational hazards, environments for fostering cordial relationships between recipients and home care workers must be developed.

The association between financial support of adult children to their parents and informal care provision in China and its differences in household registration, residence arrangement and community-based care services: 2008 ~ 2018

BACKGROUND

The changes in demographic and family structures have weakened the traditional norms of filial piety and intergenerational relationships dramatically. This study aims to examine the dynamic association between financial support of adult children to their parents and informal care provision in China and its differences in household registration, residence arrangement and community-based care services.

METHODS

Data was derived from the 2008-2018 Chinese Longitudinal Healthy Longevity Survey (CLHLS), which is a longitudinal survey of a nationally representative sample of individuals aged 60 and over. Random effects model was used to assess the association between financial support and informal care provision of adult children to their parents.

RESULTS

It was found that financial support showed an upward trend while informal care provision showed a download trend from 2008 to 2018. The result indicated a significant and negative association between financial support and informal care provision of adult children to their parents (B = -0.500, 95% confidence interval (CI) = -0.761 to -0.239). And the association was significant among elderly people who were from urban areas (B = -0.628, 95% CI = -0.970 to -0.287), co-resided with adult children (B = -0.596, 95% CI = -0.939 to -0.253), and had community-based services (B = -0.659, 95% CI = -1.004 to -0.315).

CONCLUSION

Financial support was negatively associated with informal care provision of adult children to their parents in China, and the association has differences in household registration, residence arrangement and community-based care services. It is suggested that policymakers should prioritize planning interventions for elderly care services and establish a family caregiver support system.

Gendering of care and care inequalities in couple therapy

Reciprocal partner or spousal caregiving in romantic relationships has been identified as a key determinant of the quality of couple relationships. In this article, we interrogate this premise concerning the presumed reciprocity of caregiving in romantic relationships, focusing on cisgender heterosexual relationships and offering implications for relationships of all genders and sexualities. Looking beyond the conventional focus on individual or dyadic processes, we theorize imbalances in care as gendered. Feminists have repeatedly critiqued gender ideology that devalues caring labor and allocates it to women. Gendered power dynamics can lead to imbalances in care-seeking and care provision. We discuss how the gendering of care and care inequalities can manifest in couple therapy, illustrating with examples from recorded interactions. Implications for therapy practice are discussed.

Community-based social care models for indigenous people with disability: A scoping review of scholarly and policy literature

Disability is experienced and understood by Indigenous people internationally in distinct ways from other populations, requiring different approaches in disability services. Furthermore, Indigenous populations access disability services at low rates. In response, policymakers, service providers and Indigenous organisations have developed specific models of care for Indigenous people with disability. Social care services, comprising personal care, transport and social activities, can support Indigenous people with disability to live with their families and in their communities. However, little is known about the range of social care models for Indigenous people with disability. To inform policy and practice, we conducted a scoping review of community-based models of social care designed to meet the needs of Indigenous peoples in Australia, Aotearoa New Zealand, Canada and the United States. Our methods were informed by best practice scoping review principles and a collaborative approach that centred Indigenous voices within research appraisal and project governance processes. Literature searches (conducted March-April 2021) yielded 25 results reporting on 10 models of care. We identified two over-arching themes (funding and governance arrangements; service delivery design) that encompass nine key characteristics of the included models. Our analysis shows promising practice in contextually relevant place-based social activity programs, support and remuneration for family carers and workforce strategies that integrate Indigenous staff roles with kinship relationships and social roles. While more research and evaluation are needed, disability funding bodies and service systems that facilitate these areas of promising practice may improve the accessibility of social care for Indigenous peoples.

Trabajo doméstico en tiempos de coronavirus: la precariedad de las empleadas de hogar migrantes en España

Resumen: La precariedad que caracteriza al empleo doméstico en España no es nueva, sin embargo, la emergencia sanitaria provocada por el covid-19 la ha agudizado. La situación migratoria de gran parte de las empleadas, así como la informalidad que prevalece en este nicho laboral, se han distinguido como elementos de mayor vulnerabilidad para este colectivo en el contexto de la pandemia. En este texto analizamos el impacto del covid-19 sobre el empleo de hogar y los cuidados en el contexto español, en concreto recuperamos la experiencia de trabajadoras domésticas de la ciudad de Zaragoza (España), resaltando sus dificultades laborales, sociales y sanitarias, así como las estrategias empleadas para enfrentar las consecuencias de la pandemia.

Migration, Domestic Care Work and Public Policies on Long-Term Care in Spain

Abstract: This article explores the impact of the Covid-19 pandemic on the labour conditions of migrant workers who provide care to elderly and dependent persons in Spain. Using data from the Active Population Survey, we analyse the effects of the health crisis on the precariousness of this labour sector (measured through unemployment, underemployment and temporary employment). The figures shed light on the degradation of working conditions during the health crisis, the situation of social vulnerability experienced by female workers and the absence of effective policy responses to reverse this inequality during the pandemic. This situation of subordination is structured around the connection between the demand for care workers in private homes and the philosophy behind the public welfare system. Special emphasis is given to the effect of cash transfer programs in the process of the commodification of care.

Advance care planning in dementia care: Wants, beliefs, and insight

BACKGROUND

Advance care planning gives patients and their family members the possibility to consider and make decisions regarding future care and medical procedures.

AIM

To explore the view of people in the early stage of dementia on planning for future care.

RESEARCH DESIGN

The study is a qualitative interview study with a semistructured interview guide. The data were analyzed according to the Qualitative Analysis Guide of Leuven.

PARTICIPANTS AND RESEARCH CONTEXT

Dementia nurses assisted in the recruiting of people with dementia for participation in the study. Study information was mailed to 95 people with early stage dementia. Ten people with dementia and eight caregiver spouses participated in the study.

ETHICAL CONSIDERATIONS

People with dementia belong to a vulnerable patient group, and care was taken in the areas of informed consent and accessible information.

FINDINGS

The views of people with dementia are characterized by a complex storyline involving tensions and movement within the themes of wants, beliefs, and levels of insight. Participants wanted to think about the future but also wanted to live in the here and now.

DISCUSSION

High demands are placed on the advance care planning process for people with dementia and their family caregivers. A dignity-enhancing approach in dementia care emphasizes the dignity of and respect for this vulnerable and care-dependent patient group.

CONCLUSION

The process of advance care planning in dementia care needs to go beyond person-centered care to a relationship-centered process. The illness trajectory and the impact on autonomy need to be taken into consideration.

New Vulnerabilities for Migrants and Refugees in State Responses to the Global Pandemic, COVID-19

This article examines the global pandemic, COVID-19, through the lens of responses to vulnerable migrants, asking what state responses mean for the future of human rights values and for humanitarian interventions. The responses of the Australian state are developed as a case study of actions and policies directed at refugees and temporary migrant workers through the COVID-19 pandemic. The theoretical framing of the article draws on racial capitalism to argue that the developments manifest during the ‘crisis times’ of COVID-19 are in large part a continuity of the exclusionary politics of bordering practices at the heart of neoliberal capitalism. The article proposes that a rethinking of foundational theoretical and methodological approaches in the social sciences are needed to reflect contemporary changes in justice claims, claims that increasingly recognize the multi-species nature of existential threats to all life.

What encourages care workers to continue working in intellectual disability services in England? Interview findings

The article reports research aimed at identifying factors relating to retention in English intellectual disability services, drawing on a study of the social care workforce. The research involved two rounds of interviews with social care managers and staff between 2009 and 2014. The study uses social exchange theory, particularly the idea of 'reciprocity' and the mechanism of 'hope', as a conceptual framework to aid interpretation of the themes relating to retention identified in the interview analysis: 'pay', 'support', 'morale', and 'training' (related to reciprocity) and 'improving quality of life' and 'supporting personal development' (related to hope). Both groups of themes are identified as being particularly appropriate to intellectual disability services. The study concludes that reciprocity and hope seem to interact in factors related to staff retention, although the study suggests that reciprocity rather than hope is directly connected with retention.

COVID-19 and care homes in England: What happened and why?

In the context of very high mortality and infection rates, this article examines the policy response to COVID-19 in care homes for older people in the UK, with particular focus on England in the first 10 weeks of the pandemic. The timing and content of the policy response as well as different possible explanations for what happened are considered. Undertaking a forensic analysis of policy in regard to the overall plan, monitoring and protection as well as funding and resources, the first part lays bare the slow, late and inadequate response to the risk and reality of COVID-19 in care homes as against that in the National Health Service (NHS). A two-pronged, multidimensional explanation is offered: structural, sectoral specificities; political and socio-cultural factors. Amongst the relevant structural factors are the institutionalised separation from the health system, the complex system of provision and policy for adult social care, widespread market dependence. There is also the fact that logistical difficulties were exacerbated by years of austerity and resource cutting and a weak regulatory tradition of the care home sector. The effects of a series of political and cultural factors are also highlighted. As well as little mobilisation of the sector and low public commitment to and knowledge of social care, there is a pattern of Conservative government trying to divest the state of responsibilities in social care. This would support an interpretation in terms of policy avoidance as well as a possible political calculation by government that its policies towards the care sector and care homes would be less important and politically damaging than those for the NHS.

Racism, racialization, and health equity in Canadian residential long term care: A case study in Toronto

To date, most of the interdisciplinary scholarly literature pertaining to care work and labor studies of marginalized groups, such as women, visible minorities, and immigrants, has focused on emotional labor as well as concerns about high stress and high turnover. However, few mention racism and racialization. Using a single-case study research design of a long term care ("LTC") home in Toronto, Ontario, Canada, this paper contributes to our understanding of racism and racialization by analyzing participants' experiences of work. It documents how particular social determinants of health ("SDoH"), such as race and racialization, can manifest themselves in the lives of workers. Drawing on critical race theory and feminist political economy, this study examines the ways in which the participants discuss their experiences of care work, with closer attention to racism and racialization.

Social Care Insurance: A Review of Psychological Influences on Uptake

There is not currently a developed market for long-term social care insurance in England. Policymakers are interested in what behavioral influences should be considered in the design of insurance products for long-term social care to increase uptake. This review describes the behavioral factors that might be barriers or facilitators of uptake and could be considered in future policy solutions. Behavioral factors include psychological capabilities (knowledge and understanding), which are important given that public knowledge on this topic is poor. Psychological motivations (reflective or automatic biases) may also influence consumers' decision-making. Cultural factors such as language barriers and family norms for caring are considered. Overall, the authors demonstrate processes by which the uptake of long-term social care insurance can be encouraged, pertinent to policymakers.

Social care for older people - a blind spot in the Norwegian care system

A growing number of older people in Norway receive care services at home. Public policy aims at promoting social safety, preventing social problems and providing recipients of care with the means to live an active and meaningful everyday life together with others. However, health-related services have long been prioritized at the expense of other care services. Our aims are to investigate how professional caregivers in Norwegian home care for older people relate their professional mandate to social care to assess what different professional positions regarding social care imply for realizing the ideal of integrated and person-centered care. Interviews with 16 professional caregivers are analyzed within the framework of positioning theory. A variety of discursive positions relating the own professional mandate to social care are identified. Findings suggest that the absence of common standards leaves it up to the individual caregiver if social care needs are met or not. Common standards for social care delivery and a more suitable skill mix among health and social care professionals are proposed.

A Study of Care Workers' Wages and Relevant Factors in South Korea

The purpose of this study is to analyze the wages of South Korea's care workers as reported by the Korean national health insurance services database. We also try to identify the factors determining the wages of these 1,221,085 care workers. According to the results of the analysis, first, the wage level of care workers is fundamentally low compared to other jobs; second, the labor conditions of home care facilities (compared to those in residential care facilities) are poor, because these depend on wages, which in turn depend on the external environment, such as care institutes' management; and third, it was verified that the locations of care institutes affect the wages of care workers. As the South Korean population continues to age, the supply of high-quality care workers has important clinical implications for improving the quality of care received by the elderly. Throughout this study, it is argued that the establishment of a social service corporation has become desirable in terms of strengthening public care institutes in Korea.

Living arrangements and fire-related mortality amongst older people in Europe

In Europe, a demographic transition has occurred meaning that countries have larger older adult populations who are increasingly living alone and receiving homecare rather than institutional care. Given that living alone is the greatest individual risk factor for fire mortality amongst older adults and that large differences exist in terms of both fire mortality risk and living arrangements between countries, this study investigates the association between co-living rates and fire mortality rates among older adults in Europe. Freely available datasets with aggregated European data on fire mortality, living arrangements among older adults, population statistics and GDP were analyzed using Poisson regression models. The results show that fire-related mortality rates amongst older adults in Europe is correlated with living arrangements after adjusting for GDP. Specifically, in Europe, when the share of older adults living alone increases by one percentage point, fire mortality rates increase by roughly 4 percent for both sexes.

Experiences of oldest-old caregivers whose partner is approaching end-of-life: A mixed-method systematic review and narrative synthesis

Population ageing has rapidly increased the number of people requiring end-of-life care across the globe. Governments have responded by promoting end-of-life in the community. Partly as a consequence, older spouses are frequently providing for their partner's end-of-life care at home, despite potentially facing their own health issues. While there is an emerging literature on young-old caregivers, less is known about spouse carers over 75 who are likely to face specific challenges associated with their advanced age and relationship status. The aim of this review, therefore, is to identify and synthesise the literature concerning the experiences of caregiver's aged 75 and over whose partner is approaching end-of-life. We conducted a mixed-method systematic review and narrative synthesis of the empirical literature published between 1985 and May 2019, identified from six databases: Medline, PsychINFO, Cumulative Index to Nursing and Allied Health Literature, Embase, Sociological Abstracts and Social Service Abstracts. Hand searching and reference checking were also conducted. Gough's Weight of Evidence and Morgan's Feminist Quality Appraisal tool used to determine the quality of papers. From the initial 7819 titles, 10 qualitative studies and 9 quantitative studies were included. We identified three themes: 1) "Embodied impact of care" whereby caring was found to negatively impact carers physical and psychological health, with adverse effects continuing into bereavement; 2) "Caregiving spouse's conceptualisation of their role" in which caregiver's navigated their self and marriage identities in relation to their partner's condition and expectations about gender and place; 3) "Learning to care" which involved learning new skills and ways of coping to remain able to provide care. We identified a recent up-surge in published papers about very old spousal caregivers, which now comprise a small, medium-quality evidence base. This review outlines a range of potential lines of inquiry for future research including further clarification of the impact of caregiving on the likelihood of mortality, the incidence of men and women providing end-of-life care amongst this age group, and the role of anticipatory grief in shaping their perceptions of their relationship and their own longevity.

Migrant Caregivers of Older People in Spain: Qualitative Insights into Relatives' Experiences

The traditional structure of families is undergoing profound changes, causing the so-called “crisis of family care.” This study describes the experiences and emotions of the family member who hires migrant caregivers for the older people. This is a qualitative study using a phenomenological design with nine women participants between 53 and 72 years of age. The data collection was carried out through two in-depth interviews and a focus group. There were three major topics: (1) the women in this study recognized that they were not able to take care of the family member directly, due to their responsibilities as female workers and mothers. The fact that migrant caregivers were chosen was conjunctural, where economic reasons were more important. (2) The family members supported the caregivers by teaching them about care and also resolving conflicts produced by culture shock. (3) Trusting the caregiver was a gradual process; the family members felt a complex set of emotions (insecurity, gratitude for the help, moral obligation). In conclusion, they wanted a caregiver who would provide the elder dependent with the love and compassion that they, as daughters, would provide if they had time to do so. The family became the caregiver’s managers and assumed the responsibility of training and helping them.

El cuidadómetro fronterizo: Sobrecarga femenina y estrategias de movilidad en la Triple Frontera del Paraná

Resumen El artículo aborda la relación entre las sobrecargas de los cuidados y las estrategias de movilidad transfronteriza femeninas en la Triple Frontera del Paraná. Se muestra cómo las asimetrías estatales entre los tres países colindantes (Argentina, Brasil y Paraguay) generan diferencias de acceso a derechos básicos, particularmente, a la atención sanitaria. Partiré contextualizando la Triple Frontera, ofreciendo una síntesis de las experiencias/problemáticas femeninas en estos territorios. Luego, revisaré los debates teóricos sobre cuidados, fronteras y género en territorios transfronterizos. Los apartados cuatro, cinco y seis recuperan mis diálogos con tres mujeres, conduciendo a reflexiones sobre cómo ellas elaboran un “cuidadómetro”: basando sus estrategias de movilidad transfronterizas en las mediciones de las potencialidades del cuidado recibido y entregado en cada lado de las fronteras.

Re-conceptualising the relationship between de-familialisation and familialisation and the implications for gender equality – the case of long-term care policies for older people

This article explores how far the concepts of de-familialisation/familialisation are adequate to the classification of long-term care (LTC) policies for older people. In the theoretical debate over LTC policies, de-familialising and familialising policies are often treated as opposites. We propose re-conceptualising the relation between de-familialisation and familialisation, arguing that they represent substantially different types of policy that, in theory, can vary relatively autonomously. In order to evaluate this theoretical assumption, this article investigates the relation between the generosity level of LTC policies on extra-familial care, and the generosity level of LTC policies on paid family care, introducing a new multi-dimensional approach to measuring the generosity of LTC policy for older persons. It also explores the consequences of this for gender equality. The empirical study is based on a cross-national comparison of LTC policies in five European welfare states which show significant differences in their welfare state tradition. Data used are from document analysis of care policy law, the Mutual Information System on Social Protection, the European Quality of Life Survey and the Organisation for Economic Co-operation and Development. The findings support the argument that de-familialising and familialising LTC policies can vary relatively independently of each other in theory. It turns out that we get a better understanding of the relationship between LTC policy and gender equality if we analyse the role of different combinations of extra-familial and familial LTC policies for gender equality. The paper brings new insights into the ways welfare states act in regard to their LTC policies. It helps to clarify how the concept of de-familialisation/familialisation can be understood, and what this means for the relationship between LTC policies and gender equality.

Gendering the Politics of Migration

Although every aspect of the migration process is shaped by political factors and migration presents many political challenges on the domestic and international levels, the attention of political scientists in the United States and Europe has been limited to relatively few topics, including control over entry and exit, and issues of incorporation and citizenship. Work that considers the political aspects of migration from a gender perspective constitutes an even smaller body of work. In considering the contribution that political science might make to our understanding of gendered migration, this essay points both to some pioneering studies of gendered patterns of migration and incorporation, and also to the growing concern with gender among international organizations and policy makers. Interestingly, the essay shows that it is scholars in neighboring disciplines who have more often have taken up questions of governance and the development of gender-fair policy towards migrants. The essay raises questions about the relationship between disciplinary boundaries and topical areas and also about the ways in which regional contexts shape the nature of scholarly inquiry by contrasting work on Asia with that in Europe and the United States.

Expériences croisées face à l’épreuve de la maladie d’Alzheimer. Quand personnes malades et proches dessinent des trajectoires d’accompagnement contrastées

Cadre de recherche : La littérature consacrée aux familles des personnes malades d’Alzheimer met en lumière la charge que peut représenter l’accompagnement d’une personne malade, mais aussi la diversité des expériences vécues par les proches. Malgré l’abondance de littérature, deux limites sont constatées : ces travaux se fondent strictement sur le discours des proches et ils appréhendent l’expérience de l’accompagnement sur la base d’une approche synchronique.

Objectifs : Cet article a l’ambition de dépasser ces deux limites en mettant en dialogue, dans la durée, les témoignages des personnes malades d’Alzheimer et de leurs proches. Nous proposons d’analyser ce qui se joue dans les dynamiques relationnelles qui se construisent au fil du temps entre les malades et leurs proches aidants.

Méthodologie : Deux vagues d’entretiens, espacés de 18 à 24 mois, auprès de 21 personnes malades d’Alzheimer et de leurs proches (24 personnes) ont été réalisés.

Résultats : Nous proposons une typologie des expériences qui met en regard le vécu subjectif des personnes malades et de leurs proches et dessine des trajectoires d’accompagnement.

Conclusions : Nous distinguons, d’une part, trois types de trajectoires dynamiques (abandon, délitement des liens et amélioration des relations) et, d’autre part, trois types de trajectoires stables (deux types de trajectoires vécues positivement, dans le « faire ensemble » ou dans l’autonomie, et un type de trajectoire sous tension, voire douloureuse). Nous tentons d’appréhender ces types de trajectoires en analysant ce qui les façonne (lien entre la personne malade et le proche, cohabitation ou non, histoire des relations entre les deux).

Contribution : Cet article permet d’analyser les relations de care comme des ensembles d’interactions dans lesquelles les personnes malades sont des partenaires à parts égales et pas uniquement les destinataires de l’aide.

The effectiveness of the Older prisoner Health and Social Care Assessment and Plan (OHSCAP): a randomised controlled trial

Background

Older people are the fastest-growing group in prisons in England and Wales and have complex health and social care needs that often remain unmet.

Objectives

(1) Evaluate the efficacy of the Older prisoner Health and Social Care Assessment and Plan (OHSCAP) in improving (i) the ability to meet older male prisoners’ health and social care needs, (ii) health-related quality of life (HRQoL), (iii) depressive symptoms and (iv) functional health and well-being and activities of daily living; (2) assess the quality of care plans produced; (3) explore the experiences of older prisoners receiving, and staff conducting, the OHSCAP; and (4) evaluate the cost-effectiveness of the OHSCAP compared with treatment as usual (TAU).

Design

Multicentre, parallel-group randomised controlled trial (RCT) with follow-up at 3 months, with a nested qualitative study and quality audit of care plans (n = 150, 68%).

Setting

Ten English prisons.

Participants

Four hundred and ninety-seven newly arrived male prisoners aged ≥ 50 years with a discharge date at least 3 months from recruitment. A total of 14 prisoners and 11 staff participated in qualitative interviews.

Intervention

Randomisation to OHSCAP or TAU. The OHSCAP group had health and social needs assessed by a trained health-care worker or prison officer. Care plans were devised and subsequent actions included professional support and appropriate referrals.

Main outcome measures

Primary outcome measure – mean number of unmet health and social care needs as measured by the Camberwell Assessment of Need – Short Forensic Version. Secondary outcome measures – measures of functional health and well-being, depressive symptoms and HRQoL. A health economic evaluation was undertaken using service contact between baseline and follow-up and appropriate unit cost information.

Results

A total of 497 prisoners were recruited (248 to OHSCAP and 249 to TAU). The 404 completed follow-ups were split evenly between the trial arms. No significant differences were observed between the intervention and TAU groups in relation to the primary outcome measure. The OHSCAP did not demonstrate convincing benefits in HRQoL over TAU, and there were no significant differences in relation to costs. Audit and qualitative data suggest that the intervention was not implemented as planned.

Limitations

As a result of the limited follow-up period, potential long-term gains of the intervention were not measured. Some of the standardised tools had limited applicability in prison settings. Cost-effectiveness data were limited by unavailability of relevant unit cost data.

Conclusions

The OHSCAP failed in its primary objective but, fundamentally, was not implemented as planned. This appears to have been attributable, in some part, to wider difficulties currently affecting the prison landscape, including reduced levels of staffing, the loss of specialist support roles for such initiatives and increased prevalence of regime disruption.

Future work

Partnership working and information sharing across disciplines within prison settings require improvement. Research should explore the potential involvement of other prisoners and third-sector organisations in identifying and addressing older prisoners’ health and social care needs to better match community provision. Further examination should be undertaken of how the prison regime and system affects the well-being of older prisoners. Future prison-based RCTs should carefully balance the fidelity of initiatives being evaluated and testing in a ‘real-life’ setting.

Trial registration

Current Controlled Trials ISRCTN11841493.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 5, No. 31. See the NIHR Journals Library website for further project information.

Precarious Situations of Care Workers in Home-Based Elder Care in Slovenia

Based on policy analysis and individual interviews, the author analyzes the care workers' precarious situations in home-based elder care in Slovenia, a post-socialist, European Union country characterized by a rapidly aging population and delays in adapting a long-term care system to this new social risk. Employment and quasi-employment positions which coexist in home-based care can be sorted along two continuums: between public and market service; between formal and informal work. The author argues that working conditions in home-based care differ according to the position of the care worker on these two continuums, that is, being employed in public services, being self-employed, working in informal care markets, holding a status of family assistant, or being an informal family caregiver. Although the working conditions in public services are deteriorating, the analysis shows that precarity is more severe in market and informal care, while formalization and socialization of care bring about less precarious conditions.

Gender inequality in self-reported health among the elderly in contemporary welfare countries: A cross-country analysis of time use activities, socioeconomic positions and family characteristics

Background

Paradoxically, despite their longer life expectancy, women report poorer health than men. Time devoted to differing social roles could be an explanation for the observed gender differences in health among the elderly. The objective of this study was to explain gender differences in self-reported health among the elderly by taking time use activities, socio-economic positions, family characteristics and cross-national differences into account.

Methods

Data from the Multinational Time Use Study (MTUS) on 13,223 men and 18,192 women from Germany, Italy, Spain, UK and the US were analyzed. Multiple binary logistic regression models were used to examine the association between social factors and health for men and women separately. We further identified the relative contribution of different factors to total gender inequality in health using the Blinder-Oaxaca decomposition method.

Results

Whereas time allocated to paid work, housework and active leisure activities were positively associated with health, time devoted to passive leisure and personal activities were negatively associated with health among both men and women, but the magnitude of the association varied by gender and country. We found significant gender differences in health in Germany, Italy and Spain, but not in the other countries. The decomposition showed that differences in the time allocated to active leisure and level of educational attainment accounted for the largest health gap.

Conclusions

Our study represents a first step in understanding cross-national differences in the association between health status and time devoted to role-related activities among elderly men and women. The results, therefore, demonstrate the need of using an integrated framework of social factors in analyzing and explaining the gender and cross-national differences in the health of the elderly population.

Caring for Blind Parents: Cost to the Education and Well-Being of Children in Tamale, Ghana

In this study we explored the experiences of the guide children (children who guide adults with visual impairment to beg for a living on the streets) in Tamale, Ghana, to unearth the impact of the guiding role on their educational participation and well-being. Data were gathered from 104 children and 57 adults using a set of questionnaires and interviews. The results showed that adults chose many of the children to take on the guide role and many of the children did not attend school. The implications for the children's well-being are discussed in relation to needs and rights.

Does Gender Matter?

When facing dependency, the majority of elderly men receive care from spouses whereas elderly women more often rely on relatives or public elder care. This Swedish population-based study of persons between ages 81 and 100 concerns public elder care and informal support in relation to having a coresiding caregiver. Findings indicate that men had higher odds of receiving care when coresident and/or extraresident and/or public home help services were included, compared to women, after controlling for functional and cognitive impairment as well as self-reported need of assistance with instrumental activities of daily living. After controlling also for coresiding, the gender differences disappeared. The main distinction was found between persons living alone and persons coresiding, not between men and women. Thus, when studying use of public elder care and support from relatives or friends, it is vital to include household composition, and thereby the possibility of receiving care from a coresiding caregiver, in the analyses.

How To Build an Integrated Neighborhood Approach to Support Community-Dwelling Older People?

BACKGROUND

Although the need for integrated neighborhood approaches (INAs) is widely recognized, we lack insight into strategies like INA. We describe diverse Dutch INA partners' experiences to provide integrated person- and population-centered support to community-dwelling older people using an adapted version of Valentijn and colleagues' integrated care model. Our main objective was to explore the experiences with INA participation. We sought to increase our understanding of the challenges facing these partners and identify factors facilitating and inhibiting integration within and among multiple levels.

METHODS

Twenty-one interviews with INA partners (including local health and social care organizations, older people, municipal officers, and a health insurer) were conducted and subjected to latent content analysis.

RESULTS

This study showed that integrated care and support provision through an INA is a complex, dynamic process requiring multilevel alignment of activities. The INA achieved integration at the personal, service, and professional levels only occasionally. Micro-level bottom-up initiatives were not aligned with top-down incentives, forcing community workers to establish integration despite rather than because of meso- and macro-level contexts.

CONCLUSIONS

Top-down incentives should be better aligned with bottom-up initiatives. This study further demonstrated the importance of community-level engagement in integrated care and support provision.

Interrogating concepts of care in the HIV care continuum: ethnographic insights from the implementation of a "Universal Test and Treat" approach in South Africa

South Africa currently sustains the largest antiretroviral treatment (ART) programme in the world. The number of people on ART is set to grow even more in the coming years as incidence remains stable, people on ART stay healthy, and guidelines for initiation become increasingly inclusive. The South African public health sector has increasingly relied on community- and home-based lay and professional "carers" to carry out the everyday tasks of rolling out the ART programme. Drawing on ethnographic research in one locality in the Western Cape, the paper explores the care practices of two such groups of carers implementing a 'Universal Test and Treat' (UTT) approach. The UTT approach being evlauated in this place is based on one model of the HIV treatment cascade, or care continuum, which focuses on the steps necessary to identify and link HIV-positive individuals to care and retain them in lifelong HIV treatment. In this context, community-based care workers are responsible for carrying out several discrete steps in the HIV care continuum, including testing people for HIV, linking HIV-positive individuals to care, and supporting adherence. In order to retain clients within the continuum, however, carers also perform other forms of labour that stretch their care work beyond more bounded notions of a stepwise progression of care. These broader forms of care, which can be material, emotional, social or physical in nature, appear alongside the more structured technical and biomedical tasks formally expected of carers. We argue that understanding the dynamics of these more distributed and relational forms of care is essential for the effective implementation of the care continuum, and of the UTT approach, in diverse contexts.

O cuidado paliativo e domiciliar em países da América Latina

O artigo analisa a assistência domiciliar em saúde dos três países da América Latina com maior gasto público social per capita no ano de 2013: Brasil, Argentina e Uruguai. Trata-se de estudo documental e bibliográfico sobre o cuidado paliativo em saúde na modalidade de internação domiciliar, tendo em conta as mudanças nas famílias latinas. A análise está estruturada em dois eixos: o contexto socioeconômico das famílias latinas e as características das políticas de desospitalização. Os resultados mostram pequena disponibilidade da mulher latina para o trabalho de cuidado na família e o reforço dessa modalidade de atenção às iniquidades em saúde.

Good-quality social care for people with Parkinson's disease: a qualitative study

OBJECTIVES

The study examines the meaning of good-quality social care for people with Parkinson's disease and their carers. It identifies, from their perspective, the impact of good-quality social care on health and well-being.

DESIGN

Qualitative case study methodology, interview and framework analysis techniques were used.

SETTING

community locations in the north and midlands of England.

PARTICIPANTS

Data were collected from 43 participants including individual interviews with people with Parkinson's disease (n=4), formal and informal social care providers (n=13), 2 focus groups, 1 with people with Parkinson's disease and their carers (n=17), and 1 with professionals (n=8), plus a telephone interview with a former commissioner.

FINDINGS

Good-quality social care, delivered in a timely fashion, was reported to have a positive impact on health. Furthermore, there is an indication that good-quality social care can prevent untoward events, such as infections, symptom deterioration and deterioration in mental health. The concept of the 'Impact Gap' developed from the findings, illustrates how the costs of care may be reduced by delivering good-quality social care. Control, choice and maintaining independence emerged as indicators of good-quality social care, irrespective of clinical condition. Participants identified characteristics indicative of good-quality social care specific to Parkinson's disease, including understanding Parkinson's disease, appropriate administration of medication, timing of care and reassessment. 'Parkinson's aware' social care was seen to generate psychological, physical and social benefits that were inter-related.

CONCLUSIONS

The findings indicate how maximising quality in social care delivery for people with Parkinson's disease can impact on health and well-being. Long-term or short-term benefits may result in prevented events and reductions in health and social care resource. Health professionals can be instrumental in early detection of and signposting to social care.

Care as social organization: Creating, maintaining and dissolving significant relations

Although increasingly debated in public, scholarly discourses on care remain frag- mented. This is not only due to the scientific division of labor, but also to different national research traditions as well as to categories that link predefined relations to specific practices. In this article I set out to establish care practices as vital elements of social organization in order to overcome commonplace dichotomies such as private-public, good–bad, modern–traditional, and micro–macro. In order to facilitate making care a central element of anthropological theory, I revisit diverse theoretical frameworks from Marxism and feminism to disability, social security and humanitarianism studies. With the decline of Marxist anthropology, the awareness it once raised regarding `public' aspects of care has virtually vanished. Today practices of care are mostly discussed in kinship debates, with the result that the importance of care for other social relations is underestimated. Finally, I propose a processual conceptualization of care with a focus on practices that can enhance our understanding of the links and overlaps between relationships that are usually analysed within distinct spheres of social life, such as economics and politics.

Long-term care for elder women in Spain: advances and limitations

In Spain, elder women are the largest group in need of long-term care. Significant improvements in this issue took place between 2007 and 2011, thanks to the Dependency Law (2006). But severe limitations showed the difficulty of overcoming the historical backwardness of Spanish social policy. This article describes the situation of Spanish people with dependency in activities of daily living. It analyzes changes driven by this law, especially in their impacts on elder women. It assesses the extent to which those changes can alter the traditional model of care. There are three major findings: First, measures promoted by the law have improved the previous situation but are incapable of developing a new model. Care for elders still relies on family, with lack of professionalism, little socialization, and expanding commodification. Second, the current care model is fundamentally detrimental to older women and women caregivers. Third, this kind of model hinders the overcoming of gender inequalities in intrafamily, generational, and social relations.

A framework to assess welfare mix and service provision models in health care and social welfare: case studies of two prominent Italian regions

Background

The mechanisms through which the relationships among public institutions, private providers and families affect care and service provision systems are puzzling. How can we understand the mechanisms in these contexts? Which elements should we explore to capture the complexity of care provision? The aim of our study is to provide a framework that can help read and reframe these puzzling care provision mechanisms in a welfare mix context.

Methods

First, we develop a theoretical framework for understanding how service provision occurs in care systems that are characterised by a variety of relationships between multiple actors, using an evidence-based approach that looks at both public and private expenditures and the number of users relative to the level of needs coverage and compared with declared values and political rhetoric. Second, we test this framework in two case studies built on data from two prominent Italian regions, Lombardy and Emilia-Romagna. We argue that service provision models depend on the interplay among six conceptual elements: policy values, governance rules, resources, nature of the providers, service standards and eligibility criteria.

Results

Our empirical study shows that beneath the relevant differences in values and political rhetoric between the case studies of the two Italian regions, there is a surprising isomorphism in service standards and the levels of covering the population’s needs.

Conclusion

The suggested framework appears to be effective and feasible; it fosters interdisciplinary approaches and supports policy-making discussions. This study may contribute to deepening knowledge about public care service provision and institutional arrangements, which can be used to promote more effective reforms and may advance future research. Although the framework was tested on the Italian welfare system, it can be used to assess many different systems.

Parenthood and employment: the impact of policies and culture on gender inequality in Switzerland

Purpose

– The purpose of this paper is to analyse the effect of cantonal social policies and cultural settings (in Switzerland) on women’s and men’s employment behaviour. Special consideration is given to the transition to parenthood.

Design/methodology/approach

– Based on data from the Swiss Labour Force Survey (SLFS) this paper conducts multilevel analyses to test individual and cantonal effects on the probability of employment and on working hours. To analyse the effect of parenthood, models for women and men with children under three are contrasted with models for women and men without children or with older children.

Findings

– The paper documents the persistence of gender inequality in employment linked to parenthood. How the reconciliation of work and family life can be realised for women and men strongly depends on a set of policies and cultural conditions. Moreover, individual characteristics such as education or marriage are important predictors.

Research limitations/implications

– A shortcoming of this study is the focus on the individual employment use and not on household-level division of labour. This disadvantage is due to the design of the SLFS, which is (at present) the only available survey to allow regionalisation at the cantonal level. However, the paper adds important results to the debate about gender inequality and parenthood in Switzerland as previous research has focused only little on cantonal diversity.

Originality/value

– The paper connects to previous cantonal comparative studies of female employment but extends their analyses in three important ways. By analysing cantonal differences in policies and culture this paper takes the diversity of framework conditions in Switzerland into account. Furthermore it simultaneously analyses male and female employment behaviour to get a better understanding of gender inequality and parenthood.

Disease Management: The Need for a Focus on Broader Self-Management Abilities and Quality of Life

The study objective was to investigate long-term effects of disease management programs (DMPs) on (1) health behaviors (smoking, physical exercise); (2) self-management abilities (self-efficacy, investment behavior, initiative taking); and (3) physical and mental quality of life among chronically ill patients. The study also examined whether (changes in) health behaviors and self-management abilities predicted quality of life. Questionnaires were sent to all 5076 patients participating in 18 Dutch DMPs in 2010 (T0; 2676 [53%] respondents). Two years later (T1), questionnaires were sent to 4350 patients still participating in DMPs (1722 [40%] respondents). Structured interviews were held with the 18 DMP project leaders. DMP implementation improved patients' health behavior and physical quality of life, but mental quality of life and self-management abilities declined over time. Changes in patients' investment behavior predicted physical quality of life at T1 (P<.001); physical activity, investment behavior (both P<.05), and self-efficacy (P<.01) at T0, and changes in self-efficacy and investment behavior (both P<.001) predicted patients' mental quality of life at T1. The long-term benefits of these DMPs include successful improvement of chronically ill patients' health behaviors and physical quality of life. However, these programs were not able to improve or maintain broader self-management abilities or mental quality of life, highlighting the need to focus on these abilities and overall quality of life. As coproducers of care, patients should be stimulated and enabled to manage their health and quality of life.

Knowledge generation about care-giving in the UK: a critical review of research paradigms

While discourse about care and caring is well developed in the UK, the nature of knowledge generation about care and the research paradigms that underpin it have been subjected to limited critical reflection and analysis. An overarching synthesis of evidence - intended to promote debate and facilitate new understandings - identifies two largely separate bodies of carer-related research. The first body of work - referred to as Gathering and Evaluating - provides evidence of the extent of care-giving, who provides care to whom and with what impact; it also focuses on evaluating policy and service efficacy. This type of research tends to dominate public perception about caring, influences the type and extent of policy and support for carers and attracts funding from policy and health-related sources. However, it also tends to be conceptually and theoretically narrow, has limited engagement with carers' perspectives and adopts an atomistic purview on the care-giving landscape. The second body of work - Conceptualising and Theorising - explores the conceptual and experiential nature of care and aims to extend thinking and theory about caring. It is concerned with promoting understanding of care as an integral part of human relationships, embedded in the life course, and a product of interdependence and reciprocity. This work conceptualises care as both an activity and a disposition and foregrounds the development of an 'ethic of care', thereby providing a perspective within which to recognise both the challenges care-giving may present and the significance of care as a normative activity. It tends to be funded from social science sources and, while strong in capturing carers' experiences, has limited policy and service-related purchase. Much could be gained for citizens, carers and families, and the generation of knowledge advanced, if the two bodies of research were integrated to a greater degree.

“When Nothing Matters, Things Just Happen”: Young Parenting Women's Reflections on Caring, Health, and Justice

The field of public health frequently issues calls for social justice, but it is not clear that everyone agrees on what this means or how to achieve it. To assess lay citizens' views on the relationship between justice and health, we conducted individual interviews with 19 young parenting women to hear and discuss their thoughts about the causes of health disparities, ways to reduce them, and the nature of the just society. A salient theme to emerge in these interviews was the topic of “caring.” This article reports on four categories identified under the theme of caring: 1) observations of apathy and indifference; 2) the effects of not caring; 3) models of caring; and 4) the pull of caring. Based on these results, the article outlines a grounded theory on the role of caring in conceptualizing health motivation.