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RESEARCH ARTICLE |
Department of Sociology, Case Western Reserve University, Cleveland, Ohio.
Address correspondence to Eleanor Stoller, Department of Sociology, Case Western Reserve University, Mather Memorial Building, 10900 Euclid Avenue, Cleveland, OH 44106-7124. E-mail: eps3{at}po.cwru.edu
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Abstract |
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Methods. We gathered data through structured personal interviews with 578 retired migrants identified through screening from telephone listings, supplemented with snowball sampling techniques.
Results. Lifetime migration patterns and current ethnic involvement are significant predictors of mentioning nursing home placement as a strategy for possible long-term care needs.
Discussion. We interpret these results within the framework of Rowles's emphasis on the permeability of community–nursing home boundaries.
THE importance of family members as caregivers of frail elders raises questions concerning long-term care plans of elderly people who migrate to Sunbelt retirement communities. Retired migrants who encounter health problems, widowhood, or financial difficulties sometimes consider a second move, either a return to their community of origin or to an adult child's current location (Litwak & Longino, 1987
). Others, however, plan to age in place in their new location (Stoller & Longino, 2001). In this article, we give special attention to the impact of migration patterns, ethnic involvement, and informal networks on anticipated long-term care plans, including possible nursing home placement, of retired Sunbelt migrants who plan to remain in the retirement location.
Nursing Homes: A World Apart or a Permeable Boundary?
A move to a nursing home usually means severing ties with people, familiar places, and treasured possessions, threatening the continuity that enhances both function and quality of life among elderly people (Gubrium, 1973/1997). Challenging the image of the nursing home as a "world apart," Rowles, Concotelli, and High (1996) described a rural nursing home where residents preserved "their ongoing involvement in the larger community, retaining their self-identity and continuity with their pasts" (p. 189). The authors attributed this greater involvement to the permeability of the boundary between the nursing home and the community, a situation in which the exchange of people, resources, and communication blurs the social and psychological divide between the nursing home and its environment. Kinship and friendships generated personal relationships among residents and staff, whose lives were intertwined through shared histories sometimes lasting a lifetime. A sense of community ownership was further enhanced by use of the facility for community meetings and social functions (Rowles, 1996).
Rowles and colleagues studied a rural nursing home, but they hypothesized that community integration and continuity can also occur in urban settings, most likely in nursing homes that serve a particular neighborhood or subpopulation. In this article, we explore the hypothesis that migration patterns and ethnic homogeneity among potential nursing home residents can generate the blurred boundaries described by Rowles and colleagues, increasing the likelihood that retired Sunbelt migrants will consider nursing home placement in their new location.
Migration Patterns, Informal Networks, and Nursing Home Preference
Migration patterns can influence anticipated nursing home preference among Sunbelt migrants in two ways. The first involves chain migration, the process through which earlier migrants attract new migrants from the same community of origin (Gober & Zonn, 1983). When friends recruit friends, social ties and homogeneity within friendship networks at the community of origin are transferred to the destination community. Applied to nursing home admissions, the process creates client populations with preexisting social ties that facilitate adjustment to an institutional setting (Bondevik & Skogstad, 1996; Groger, 1994) and generate the "lifelong conversations [that] can be a valuable resource in the context of nursing home living" (Gubrium 1993, p. 132). Chain migration creates clusters of migrants linked together by long-term relationships (Cuba, 1989). When these migrants encounter poor health, a move to the same nursing home provides an opportunity to continue these long-term friendships.
Individual migration histories can also influence anticipated moves to a nursing home. Elderly people with a history of geographic mobility are less likely to have developed a strong attachment to place. Memories are less likely to be invested in a particular house or locale. The experience of frequent geographic mobility has also taught them how to make transitions to new environments. Gubrium (1993) coined the term "travelers" for elders for whom a nursing home is just "one more place on the road" (p. 115) within the context of a lifetime of migration.
Ethnicity, Informal Networks, and Anticipated Nursing Home Preference
Friendships can be enriched by shared ethnic background (Stoller, Miller, & Guo, 2001). Shared ethnicity implies a shared history and similar culture; often it implies organizational ties, religious preference, and language patterns. In their studies of second- and third-generation European Americans, Alba (1990) and Waters (1990) found a sense of affinity among people of similar ethnic background, which they described as a feeling of communality or even kinship.
Living within an area of ethnic residential concentration increases the likelihood that social contacts will place older people in contact with persons of similar ethnicity. Residential concentration can support an ethnic infrastructure and intensify ethnic cultural experiences, a phenomenon Alba (1990) described as the "supply side of ethnicity." By highlighting the visibility of an ethnic group, supply-side features of ethnic communities enhance the attraction of an ethnic identity and foster a sense of loyalty and attachment to the group, generating trust between individuals who are otherwise strangers to each other (Litwak & Silverstein, 1991).
A number of researchers argue that ethnic attachment intensifies in late life (Climo, 1990; Gelfand & Barresi, 1987) and that nursing homes attached to an ethnic culture are attractive to older adults who identify with their ethnic background (Sasson, 2001). Observing ethnic traditions, eating ethnic foods, and attending ethnic programs provide continuity and a social context for sharing memories with other residents. Shared ethnic background can also foster closer relationships between residents and staff (Olson, 2001). For example, one of Rempusheski's (1988) Polish American respondents said she would "be elated" if a Polish American nurse were taking care of her; another said she would consider the nurse "like family." Yeo (1993) reported that nursing homes built on American Indian reservations by tribal entities "are defined as extensions of family care" (p. 167).
These results suggest that nursing homes serving ethnic communities can demonstrate the permeable boundaries that Rowles and colleagues found in rural settings. Even when coethnics are no longer concentrated within ethnic neighborhoods, they are likely to find that friendship ties, organizational links, and overlapping biographies create a context for discovering shared memories. The proximity of elderly migrants from the same ethnic background facilitates the emergence of friendships in which members discover overlapping threads in their personal narratives. In such contexts, the decision to move to a nursing home is but one more stop on a familiar road, in which "biographical continuity with a personal past ... finds expression in the behavior and personality of residents within the nursing home" (Gubrium, 1993, p. 198).
A Model for Anticipatory Nursing Home Placement
We begin by identifying characteristics of individuals that are positively associated with the likelihood of nursing home placement, including old age, female gender, and widowhood (Belgrave, Wykle, & Choi, 1993; Wolinksy & Johnson, 1992). However, previous research has also identified circumstances that hinder or facilitate nursing home utilization, including social networks and financial resources. Among elders aging in place, people with more extensive family networks are less likely to be institutionalized than people with more limited networks (Tennstedt, Crawford, & McKinlay 1993). Retired Sunbelt migrants, however, are often geographically distant from family, particularly adult children, who most often provide informal assistance. Therefore, in assessing the impact of social resources on preference for being placed in a nursing home among a migrant sample, it is important to assess the proximity of kin. The impact of financial resources on institutional placement is inconsistent, with some researchers showing a positive association, others a negative association, and yet others no relationship at all (Keysor, Desai, & Mutran, 1999).
In addition to these covariates, we hypothesize that chain migration and shared ethnic background will be associated with mentioning nursing home placement among long-term care plans. Chain migration and shared ethnic background can generate networks of migrants with long-term friendships and overlapping biographies. Although not testable directly with our data, these hypothesized relationships are consistent with the notion of blurred boundaries between ethnic retirement communities and nursing homes serving those communities. We also hypothesize that a lifetime of migration experiences can generate skills that facilitate adaptation to new environments, including nursing homes.
To examine these hypotheses, we undertook a case study of European Americans who migrated to a metropolitan region in southeast Florida when they retired. This amenity migration represents the first stage of the Life Course Model of Retirement Migration given by Litwak and Longino (1987). Some proportion of these migrants subsequently move back to their preretirement locations, a move prompted by diminished resources and need for assistance. Anticipated probabilities of this second move among these respondents have been reported elsewhere (Stoller & Longino, 2001). In this article, we examine long-term care plans of retired amenity migrants who do not anticipate this second move. Therefore, we limit our attention to elderly people who indicate that they plan to remain in the Florida community.
Retirees in this sample are in relatively good health. Fewer than 5% needed help with activities of daily living. Therefore, descriptions of long-term care plans represent strategies for managing a possible future need for assistance. Without a follow-up study to determine actual behavior, the link between current preferences and future long-term care decisions remains an empirical question. However, we expect that elderly people's current health status will influence anticipated long-term care plans, with poor health undermining people's confidence in their ability to live independently in community settings.
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).
Geographic Setting
The study was conducted in a metropolitan area on the East Coast of Florida. We selected this area because it is both a destination of elderly Sunbelt retirees and the location of a Finnish American retirement community. This geographic setting provided the opportunity to conduct a case study of the impact of both chain migration and ethnic attachment, including the presence of an ethnic infrastructure that Alba (1990) characterized as the supply side of ethnicity.
The Finnish American community area is not a planned retirement settlement. Members are scattered residentially but linked through informal networks and ethnic organizations. This community represents a case study, and our selection of this community does not imply that Finnish Americans are unique. Future research, focused on other European American ethnic groups, will be necessary to determine the generalizability of our findings.
Florida is not a site of traditional Finnish American settlement (Copeland, 1981), and our sampling strategies (described in the paragraphs that follow) did not identify any elderly Finnish Americans in the area who had aged in place. The community began in the 1940s, when retired Finnish immigrants moved south from New England and the upper Midwest. Today, the region attracts both second-generation Finnish Americans and Finland-born Finns who lived in the United States before retiring. Most of this latter group immigrated after World War II. Local chapters of national ethnic organizations provide entry points for new retirees, and two "Halls" sponsor active cultural and social programs. Two local churches conduct services in Finnish, and a Finnish-language newspaper is published in the area.
The nonprofit Finnish American Rest Home (FARH), which includes a 150-resident assisted living facility and a 60-bed skilled nursing facility, was established in 1970 by 11 Finnish American organizations with the goal of serving elders of Finnish heritage. Although it draws its clientele primarily from retired migrants in the area, the FARH advertises nationally in ethnic publications. At the time of data collection, the majority of the staff was fluent in the Finnish language. The FARH sponsors an active calendar of events, including informational programs, musical performances, and holiday celebrations attended by residents and by members of the local Finnish American community. The FARH also provides a location for social functions, cultural programs, and receptions for visiting Finnish dignitaries.
Sampling Design
We define retired Sunbelt migrants as people aged 60 years and older who moved to Florida after retiring from jobs (or after their spouses retired from jobs) in the northern United States and who spend at least 6 months of the year in Florida. Ancestry was assessed by using the following questions: The U.S. Census asks people to identify their ancestry. How would you answer this question? When people ask you what your ethnic background is, what do you answer? From what countries or parts of the world did your ancestors come?
The sample was selected in two parts. First, 205 Sunbelt migrants who claimed European American ethnicity were identified through telephone screening, using a systematic sample with a random start of listings from local telephone directories. In households with more than one respondent, a selection grid modified from a technique developed by Groves and Kahn (1979) was used to identify the potential respondent.
We interviewed an additional 394 migrants who claimed Finnish American ethnicity. Several techniques were used to devise a sampling frame for the Finnish American sample, following techniques recommended by Kalton and Anderson (1989) for sampling rare populations. First, three people familiar with the structure of Finnish names independently reviewed the same telephone directories, producing a listing of 1,599 households. The reliability of surnames as ethnic markers is undermined by name changes and intermarriage (Waters, 1990). Given high rates of endogamy among first-generation Finns (Stoller & Karni, 1994), intermarriage will not result in significant underidentification of men, first-generation women, or never married second-generation women. Telephone listings will, however, underidentify second-generation women who married men of other ethnic backgrounds. To minimize these sources of bias, we incorporated multiple frames (membership lists of ethnic organizations; subscription lists for Finnish newspapers and magazines; and registration lists for ethnic festivals) and supplemented available frames with snowball sampling designed to identify eligible Finnish Americans with non-Finnish names. This strategy added 47 households to the frame. Finnish American households identified during the telephone screening for the European American sample were also included. We verified eligibility through telephone screening, producing a final sampling frame of 1,646 eligible households. The Finnish American sample was selected from this frame, using systematic sampling with a random start.
Because of our interest in long-term care plans within the retirement destination, we excluded respondents who had already moved to assisted living environments. Many of these respondents resided in multilevel facilities, and the move to assisted living indicates that they have already begun to implement long-term care strategies. Consistent with our interest in elders who plan to age in place in the new retirement location, we also excluded respondents who said they would not stay in Florida if they needed long-term care. Our multivariate analysis was based on data provided by 545 respondents, that is, 349 Finnish Americans and 196 other European Americans. The response rate was 78.3%.
Measures
In this section, we describe measurement strategies. Statistics describing predictors for Finnish Americans and for other European Americans are summarized in Table 1.
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Resource factors include both social network and financial resources. Measures of social support were limited to geographically proximate family and friends, with proximity defined as "within an hour's drive from here." Fifty-three percent were married and living with a spouse. Twenty percent reported at least one geographically proximate adult child; the number of children ranged from zero to four with a mean of 0.3 and a standard deviation of.6. Twenty percent reported at least one geographically proximate sibling; the number of siblings ranged from zero to three, with a mean of 0.3 and a standard deviation of.6. Twenty-three percent reported at least one geographically proximate other relative; the number of other relatives ranged from zero to four, with a mean of 0.4 and a standard deviation of.9. Given the limited variation in these indicators, we combined them into a composite of the number of geographically proximate family members. Fifty percent reported at least one geographically proximate family member; the number ranged from zero to six, with a mean of 0.9 and a standard deviation of 1.3. Finnish Americans reported a significantly lower prevalence of geographically proximate kin than did other European Americans. Eighty percent of the entire sample identified at least one close friend living in the Florida area; the number of geographically proximate close friends ranged from zero to 10, with a mean of 3.7 and a standard deviation of 3.0.
Migration patterns
Two of the migration measures tap individual migration history: the number of lifetime moves (prior to the postretirement move to the Florida community) and the number of years living in the Florida community. The number of lifetime moves was determined from lifetime migration histories. Only moves involving a change in Standard Metropolitan Statistical Area or, in the case of nonmetropolitan residence, a move across county lines, were counted. Respondents reported a mean of 2.8 lifetime moves, with a standard deviation of 2.1 and a range of 0 to 9. Finnish Americans reported a significantly higher number of lifetime moves than did other European Americans. The mean number of years living in the Florida community was 16.1 years with a standard deviation of 9.0 years. Finnish Americans had a significantly longer tenure in the retirement location than did other European Americans.
The indicator of chain migration is based on network information provided by the elderly respondents. Respondents were asked to report the first name and last initial of people on whom they most often rely or with whom they most frequently engage in three types of activities: social activities, emotional support, and instrumental assistance. A description of the items used for eliciting involvement in these relationships is reported elsewhere (Stoller, 1998). Questions about migration status (postretirement migrant vs. prior Florida resident) and prior residence ("back home" location) were asked about each network member. We summed the number of network members who shared the same back home location as the elderly respondent. Fifty-one percent reported at least one network member who had moved to Florida from the same back home community. The mean number of back home matches within networks was 1.4, with a standard deviation of 1.9 and a range of 0 to 8.
Ethnic attachment
We conceptualize ethnic attachment as a multidimensional variable, encompassing the importance of ethnic heritage in one's self-concept, involvement in an ethnic infrastructure, and the prevalence of coethnics within informal networks (Conzen, Gerber, Morawska, Pozzetta, & Vecoli, 1990; Nagel, 1994). We developed two indices to tap individual-level dimensions of ethnicity. Twenty-five items tapping various dimensions of ethnic attachment were formulated from reviews of the literature on European American ethnicity and from an analysis of transcripts of semistructured interviews with a theoretical sample of Finnish Americans (Stoller, 1996). Respondents rated each item by using a five-category Likert-type format. A factor analysis of these items yielded two measures (see Table 2). The first, composed of 10 items, includes items tapping ethnic identity (
=.89, M = 26.5, SD = 8.1, and range = 7–26.). The second, composed of 5 items, assesses involvement in an ethnic infrastructure ( =.79, M = 11.3, SD = 4.3, and range = 10–40). Finnish Americans scored significantly higher than European Americans on both indicators.
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We included a dummy variable indicating whether a respondent reported Finnish or another European ethnicity. We also constructed interaction terms between this variable and indicators of network resources, migration patterns, and ethnic attachment.
Dependent variable: Nursing home placement as a possible long-term care plan
Respondents were asked what they would do if they (and their spouse or partner) "became ill and needed constant care." Interviewers encouraged multiple responses by asking, "Is there anything else you think you might do if this should happen?" Responses were classified by using a precoded checklist; other responses were recorded verbatim and coded by project staff.
Eighty-one percent of the respondents described at least one strategy for coping with long-term care needs. Perhaps not surprisingly given their postretirement geographic move, respondents reported strategies involving formal services more frequently than reliance on informal assistance (Stoller, 1998). The most frequent response, mentioned by 41.8%, was nursing home placement. Almost one third (32.4%) planned to move to an assisted living facility. Twenty-nine percent said they would rely on home-care services from agency personnel, and 33.8% said they would hire private sector assistance. In contrast, only 19.3% planned to rely on help from family members and friends. Only 3.4% said they would move in with their children, and only 0.7% said they would move in with other relatives, a result consistent with the limited availability of geographically proximate kin.
Most of these respondents mentioned multiple strategies for handling a possible future need for long-term care; the number of strategies mentioned range from zero to six, with a mean of 1.6 strategies and a standard deviation of 1.4. Among respondents mentioning nursing home care in their description of long-term care plans, slightly under half (47.2%) mentioned nursing home care as an option after they had exhausted formal and informal sources of assistance; the remaining 52.8% mentioned nursing home care as their only long-term care plan.
In this article, we are interested in whether or not respondents mentioned nursing home placement as a strategy for managing a possible future need for long-term care. We created a dichotomous dependent variable, which is coded as "1" if a respondent mentioned nursing home placement, either initially or in response to the probe; otherwise, the variable is coded as "0."
Analytic Strategy
We use hierarchical multiple regression to examine three models. Model 1 includes only the sociodemographic and resource covariates. Model 2 adds indicators of migration patterns, and Model 3 incorporates indicators of ethnic attachment. We also tested interaction terms between ethnic category (Finnish American vs. Other European American) and indicators of network resources, migration, and ethnic attachment. Given the relatively even distribution of anticipated nursing home placement (42% mentioned nursing homes as a possible response to a future need for long-term care in comparison with 58% who did not), we estimated our models using OLS regression and logistic regression, with parallel results. Results of the OLS hierarchical regression analyses are reported in Table 3.
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Model 2: Incorporating Migration Patterns
As predicted, elderly migrants who report a larger number of friends from their back home community are more likely to anticipate moving to a nursing home if they encounter a need for long-term care. In addition, the longer a respondent has lived in the Florida retirement setting, the more likely he or she is to mention nursing homes as a long-term care plan. Consistent with Gubrium's concept of "travelers," respondents with a larger number of lifetime moves are more likely to mention nursing home care than elders who have experienced limited geographic mobility. As in Model 1, education (but not income) is negatively related to mentioning nursing home care. Elders in good health and elders with geographically proximate family members are less likely to mention nursing homes as a long-term care strategy. Model 2 explains 13.8% of the variance in preference for nursing home care. The addition of the migration variables adds 3.7% to the variance explained by Model 1, a change that is significant at the.0001 level.
Model 3: Incorporating Ethnicity Indicators
Model 3 incorporates measures of ethnic attachment. The larger the number of coethnic friends in the network, the more likely a respondent is to mention nursing home care. It is important to note that this model controls for the number of geographically proximate friends. Elders who report greater involvement in an ethnic infrastructure are also more likely to mention nursing homes as a long-term care strategy. However, the subjective importance of ethnicity is unrelated to nursing home consideration. (Because Finnish American respondents exhibit higher levels of ethnic attachment, we also estimated the model without the sample dichotomy and the results remained the same: involvement in ethnic infrastructure but not subjective importance of ethnic identity was significant.) Finally, Finnish American respondents were more likely to mention nursing homes than were the other European Americans.
None of the three migration indicators remains significant when the ethnicity variables are added to the equation. Collinearity between ethnicity and back home location within the networks of these retired migrants precluded an adequate test of our hypothesis regarding chain migration (Stoller et al., 2001). In addition, Finnish American respondents have lived in Florida significantly longer and reported significantly more lifetime moves than the other European Americans (see Table 1).
Of the variables in Model 1, only the geographic proximity of kin remained significant in the full model. Elders with geographically proximate kin were less likely to mention nursing home care than elders separated from family members. Model 3 explains 26.0% of the variance in mentioning nursing home placement as a strategy for managing a hypothetical need for long-term care. The addition of the ethnicity variables adds 12.6% to the variance explained by Model 2, a difference that is significant at the.0001 level.
Interaction Terms
We also entered interaction terms between Finnish Americans versus other European Americans and each of the indicators of network resources, migration indicators, and ethnic attachment. None of the network resource interactions were significant. Among the migration interactions, only the back home friends in network interaction was significant. Among the ethnicity interactions, only the ethnic matches in network interaction was significant. The signs of these two interaction terms indicate that having geographically proximate friends from the same back home location and with the same ethnic background is more important for members of the Finnish American sample than for members of the other European American sample.
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DISCUSSION |
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Our results are also consistent with the hypothesized impact of migration experience and ethnic attachment. Elders with a larger number of previous geographic moves were more likely to mention nursing home placement than elderly migrants with more limited migration experience. This result reinforces Gubrium's (1993) argument that a lifetime of migration experience can generate skills that facilitate adaptation to new environments. Years in the Florida retirement location was also positively related to the likelihood of mentioning nursing home care (when age was controlled for).
The number of proximate friends from the same back home location was also positively related to mentioning nursing home care in Model 2. In some cases, these back home matches were tapping long-term friendships that preceded retirement. However, common geographic origins provide another source of shared experience that can transform strangers into neighbors, even if they were not acquainted in the previous location (Gans, 1979). The coefficient for back home ties was no longer significant when the ethnic attachment indicators were added in Model 3, a result reflecting collinearity between ethnic ties and back home location in this sample. Many of these elderly migrants moved to the Florida location from Northern communities with a high concentration of coethnics. Although conceptually distinct, chain migration may contribute to the salience of shared ethnicity within the informal networks of these respondents. Understanding the relative contributions of shared ethnicity and chain migration would require a sample with greater diversity in and less collinearity between ethnic and geographic origins.
Our most intriguing results center on the impact of ethnicity indicators. Level of involvement in an ethnic infrastructure and the number of ethnic matches in friendship networks were positively related to mentioning nursing home placement as a long-term care strategy, but the subjective importance of ethnic identity was not. This result suggests that it is "doing ethnicity" rather than "feeling ethnic" that influences anticipated long-term care plans among these retired migrants. We found no evidence that these Sunbelt migrants mention nursing homes as a possible long-term strategy because they are searching for environments that reinforce their ethnic identity. Rather, what seems to matter are the relationships that people develop through participation in ethnically oriented activities and ethnically homogeneous friendship networks.
But what is it about participation in ethnic networks that increases the likelihood of anticipated nursing home placement? We do not know how many Finnish American respondents plan to move to the FARH. It is likely that the geographic target area contains nursing homes other than the FARH whose client populations share similar ethnic or religious backgrounds, but we do not know if our respondents are anticipating placement in those nursing homes. We also do not know if these respondents have friends who are already residents of area nursing homes or if they are planning to move in tandem with friends who share their ethnic background or back home locations. To answer the question posed at the beginning of this paragraph, we draw on previous literature and offer potential directions to be explored by future researchers.
One possible explanation builds upon the notion of Rowles and colleagues (1996) of the permeable boundaries between nursing homes and the communities they serve. To the extent that our respondents participate in ethnic communities that encompass a particular nursing home, they may not see institutional placement as entering a "world apart." Rather, the exchange of people, resources, communication, and activities may blur the social and psychological boundary between the nursing home and its environment. Attending social events and cultural programs and firsthand knowledge of the lived experience of current residents can also diminish negative stereotypes associated with institutional placement, at least of particular nursing homes. Finally, perhaps ethnic nursing homes are viewed as settings in which people can continue ethnic activities and ethnically based friendships that provide meaning and continuity to their lives (Luborsky & Rubinstein, 1987). A nursing home environment that emphasizes ethnic activities or in which one shares social space with people of the same ethnic background provides a setting for sharing memories and constructing coherent life stories. Although our results are consistent with this interpretation, several alternative interpretations are also possible. Perhaps retirees who plan to remain in the Florida location become involved in the ethnic community as a strategy for ensuring future support. Alternatively, facilities designed to support members of an ethnic or religious community may be seen as providing better care than for-profit facilities affiliated with large chains concerned with "the bottom line."
Our results demonstrate that migration history and ethnic involvement are significant predictors of mentioning nursing home placement as a long-term care plan among these respondents who plan to remain in their Sunbelt retirement location. Although these associations are consistent with our conceptual framework of blurred boundaries between retired Sunbelt migrant communities and the nursing homes on which residents rely, we are not able to describe the processes through which people craft either anticipated long-term care strategies or the actual solutions they will use should they encounter needs for institutional care. Neither do we know the meanings these elderly retirees attach to particular nursing home environments. Insights into these processes and meanings require qualitative analyses of the narratives through which elderly people incorporate illness and disability into their ongoing biographies (Bury, 1997). We hope to answer these questions in a follow-up study that will explore both actual long-term care strategies of these retired migrants and the factors that influenced their eventual decisions.
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Received for publication September 10, 2002. Accepted for publication March 24, 2003.
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