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RESEARCH ARTICLE |
College of Nursing, University of Iowa, Iowa City.
Address correspondence to Lisa Skemp Kelley, College of Nursing, University of Iowa, 488 NB, Iowa City, IA 52242. E-mail: lisa-kelley{at}uiowa.edu
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Abstract |
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Methods. Data were obtained in a four-phase, 5-year, community-based ethnographic field study that included in-depth network analysis of elder households.
Results. One hundred eighty-eight informal caregivers assisted 14 elder networks in obtaining the things they needed to live through provision of 355 care activities. Forty-five children (ages 3
to 16) provided 111 of 355 (31%) care activities. The frail elders gave adults and children community member caregivers 196 and 94 benefits, respectively.
Discussion. Minor children are integrally involved in reciprocal exchanges for elder care in this village. Although they do not provide all of the same care activities as adults, they clearly assist elders, especially with running errands. Elders emphasized different motivational mechanisms for involving minor children and adults in their care networks.
RESEARCH from social network, social support, and elder caregiving perspectives has begun to extend understanding about care of community-dwelling elders beyond a primary caregiver view and has helped to elucidate the network structures, social support activities, and care activities provided to elders. Yet, this research has focused largely on adult members of elder care networks and the activities that they provide to elders (Penning, 2002
; Rawlins, 2001; Thoits, 1995; Unger, McAvay, Bruce, Berkman, & Seeman, 1999). On the other hand, the importance of intergenerational care is increasingly recognized in the discussions of the social phenomenon of grandparents caring for minor children (Fuller-Thomson & Minkler, 2001). This literature is often limited to care given by the elder to the grandchild and not the inverse (care that is given by minor children to the elder). Documenting the involvement of minor-age children in elder social support and care networks is important for a comprehensive understanding of elder care. Much of the research on elder caregiving has been conducted in Western European cultures where formal services may mask naturally occurring elder care structures. This study was conducted in the developing country of St. Lucia where there were limited governmental or formal paid services, thereby providing not only the opportunity to observe, first hand, the values and behaviors linked to elder care but also the opportunity to examine minor children's and adults' involvement in the informal caregiving network for elder care in a community context. This article describes and compares child and adult care involvement in elder care networks in a Caribbean village community.
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LITERATURE REVIEW |
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TOPAbstractLiterature ReviewMethodsResultsDiscussionReferences |
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and Barnes (1954) as a methodologic strategy to study families, communities, complex groups, and organizations (Emirbayer & Goodwin, 1994), the social network literature describes the organization of elder care. Social networks are the web-like structures of varying size and composition that provide a set of linkages among a collection of persons of all ages to interpret social behaviors of the network members.
Elders have different networks for different purposes. For example, an elder's support network may include people that are not part of the caregiving network. Whereas elder social support networks and elder caregiving networks are conceptually different, with elder care networks, a specific type of support network (Bernard, 1998; Schensul, LeCompte, Trotter, Cromley, & Singer, 1999), they are often used interchangeably (Akiyama, Antonucci, & Campbell, 1989; Birkel & Jones, 1989; Cohen & Sokolovsky, 1979a,b; Cohen & Syme, 1985; Johnson & Barer, 1990; Taylor & Chatters, 1991; Thoits, 1995; Unger et al., 1999; Wenger, 1996). Elder support or care networks are the individuals or agencies that provide a service or commodity to elders for the purpose of support or care. The study of informal (nonpaid/nonprofessional) elder care has focused on adult network members including family/kin (including spouses, adult children, and siblings), friends, and neighbors (Adamchak, Wilson, Nyanguru, & Hampson, 1991; Connidis, 1994; Ikkink, Tilburg, & Knipscheer, 1999; Litwin, 1997; McIlvane & Reinhardt, 2001; Unger et al., 1999). While Pruchno, Burant, and Peters (1997) included children as young as 11 years in a study of elder caregiving family types and the congruence with family well-being, the involvement of younger children was not examined, with the sample having a mean age of 19 and a range of 11–31 years.
Differentiated from the network web-like structures, social support comprises the functional aspects or the emotional, financial, or social function of a relationship (Ryan & Austin, 1989) as well as an interpersonal interactive behavioral process (O'Reilly, 1988) in which some "content" is provided by one person to another. This content has been labeled in a number of ways, including attachment, social interaction, nurturance, reassurance of worth, reliable alliance with bloodline kin, and availability of guidance from an authority figure when stressed (Weiss, 1974); affect, affirmation, and aid over the life course (Kahn & Antonucci, 1980); emotional, informational, and tangible support (Schaefer et al., 1981); emotional, appraisal, informational, and instrumental assistance (House, 1981); directive guidance, nondirective support, positive social interaction, and tangible assistance (Barrera & Ainlay, 1983); and esteem-enhancing appraisals and stress-related interpersonal transactions (Heller, Swindle, & Dusenbury, 1986). Social support has been studied as "anticipated support" (Wethington & Kessler, 1986) and for its enduring nature whereby past support may be accessed and used as a form of social capital, "bank," or coffer for future support (Antonucci, 1990; Greene & Marty, 1999; Kahn & Antonucci, 1980). Insurance and investment models propose that elder care is proportional to what the elder gave in the past, with the insurance model differentiated as being triggered by elder need (Silverstein, Conroy, Wang, Giarrusso, & Bengtson, 2002). Conversely, the caregiving literature categorizes elder care behaviors as helping with activities of daily living (ADLs; e.g., dressing, using the toilet, moving about the house, bathing, transferring), instrumental ADLs (IADLs; e.g., shopping, meal preparation, light and heavy housework, using the telephone, laundry), and advanced ADLs (AADLs; e.g., yard work, medications, taking care of money, and looking after long-term personal finances) (Penning, 2002). What the labels of content have in common is provision of a service or commodity to the elder.
Altruistic norms of amity obligate kin to interact through mutual assistance, solidarity, and trust based on kinship rather than contractual obligation, affection, or resource exchanges (Fortes, 1969). Normative expectation for family members to provide care for elders, held by both elders and their offspring (Brody, Johnsen, & Fulcomer, 1984; Lee, Netzer, & Coward, 1994, 1995; Seelbach, 1977, 1984), was described as a universal phenomenon as early as 1945 (Simmons, 1945). Gouldner (1960) contends the "norm of reciprocity cannot apply with full force in relations with children [or] old people" (p. 178); however, motivations for elder care have been studied, particularly with reference to reciprocity (Becker, 1986; Gouldner, 1960), exchange (Blau, 1964/1998; Dowd, 1975, 1980), equity (Walster, Berscheid, & Walster, 1973; Walster, Walster & Berscheid, 1978), and contingency theory (Deutsch, 1975). Reciprocity is "a mutually gratifying pattern of exchanging goods and services" (Gouldner, 1960, p. 170) or, more generally, returning good for good (Becker, 1986). According to social exchange theory (Blau, 1964/1998), the ability to reciprocate is influenced by an individual's status and power within the social structure. Based on the early work of Simmons (1945), elder status assesses the position of the aged within a society. Status determines who is in relationship with whom and what is exchanged in the relationship. In his classic work, Dowd (1975) used exchange theory to expand the notion that elders withdraw from society because they are often disadvantaged and, as such, do not have the resources to maintain social status and reciprocal exchanges in their relationships with younger age groups.
The notions of social attractiveness and trust are vital for understanding motivations intrinsic to interdependencies (Deutsch, 1962), stable social relations, and social exchange (Blau, 1964/1998). According to Blau (1964/1998), intrinsic and extrinsic social attraction processes are what compel humans to not only begin to interact with another in a social exchange but continue these interactions, especially with nonkin groups. Initial attraction is often centered on extrinsic factors such as looks, charisma, supportiveness, and friendliness. Inherent in trust is the strengthening of social bonds through the expectation that others will remain obligated and trustworthy to fulfill their obligations over time (Blau, 1964/1998). Conversely, if a person does not have anything to exchange, Blau (1964/1998) identifies four alternatives:
First, he may force the other to give him help. Second, he from an early age may obtain the help he needs from another source. Third, he may find ways to get along without such help. ... If he is unable or unwilling to choose any of these alternatives, however, there is one other course of action left for him; he must subordinate himself to the other and comply with his wishes, thereby rewarding the other with power over himself. (p. 22)
As a more general theory, equity theory proposes that humans strive to maintain balance of inputs and outcomes in a relationship (Walster et al., 1973, 1978). Based on the "assumption that man is selfish" (Walster et al., 1978, p. 7), equity theory has four interrelated propositions: (a) Individuals try to maximize their outcomes; (b) social groups develop normative systems that reinforce members who treat others equitably; (c) individuals are distressed (i.e., feel angry or guilty) if they are in an inequitable relationship; and (d) to relieve distress, individuals will attempt to restore equity through "actual equity" by altering their inputs or outcomes (i.e., through compensation) or by "psychological equity." Psychological equity includes justification of the inequity by altering perceptions through mechanisms such as derogation of the victim (e.g., the elder deserves to be harmed), minimization of the victim's suffering, or denial of responsibilities. It is best to restore equity through such mechanisms as compensation or the victim minimizing his or her suffering to prevent further derogation of the victim. Contingent exchange is based on the notion of need (Deutsch, 1975). Social, equity, and contingent exchange theories inform the study of motivations for elder care.
Research on elder care network member motivations for involvement includes repayment to the elder for things given in the past (e.g., filial obligation for birth; McGrew, 1998; Parsons, 1997), the balance between giving and receiving assistance in current interactions (Becker, Beyene, Newsom, & Mayen, 2003; Boerner & Reinhardt, 2003; Liang, Krause, & Bennett, 2001), and the intent to acquire something in the future (e.g., inheritance; Caffrey, 1992). The complexity of elder care motivations is evident in the 27-year longitudinal survey Study of Generations that found investment (where offspring provide support to parents in an amount similar to what parents had earlier given to them), insurance (where, contingent on parent need, the offspring provide support in an amount similar to parents prior giving to them), and altruism and other nonreciprocal models (where offspring provide support to parents who had not provided for them in the past) were all supported as mechanisms for intergenerational elder care exchange (Silverstein et al., 2002). Although not from the perspective of minor children or elders, social exchange theory is used in work with middle-aged Caribbean women who describe taking care of grandchildren to guarantee themselves some measure of financial, nutritional, and other support (Clark, 1966; Massiah, 1986; Saint Victor, 1986; Sennot-Miller, 1989). The strength of this expectation is supported by Powell (1986), who found that young children were the second most frequently identified source of support for the middle-aged women respondents in the Women in the Caribbean Project. Although scholars agree that children have been identified as a source of support (Clark, 1966; Massiah, 1986; Powell, 1986; Pruchno et al., 1997; Saint Victor, 1986; Sennot-Miller, 1989), there is a paucity of research on minor children's participation in elder care.
Minor Children's Involvement in Care
The study of minor children's involvement in caregiving has focused on care of family members (e.g., parents, siblings) with a chronic illness. This work includes a retrospective study on adults' remembering of caregiving activities for a family member when they were a child (Lackey & Gates, 2001), provision of care for adults with cancer by children aged 10–18 (Gates & Lackey, 1998), and children's perceptions of caregiving for an ill family member (Aldridge & Becker, 1993). In a qualitative interview study, 15 minor children caregivers describe ongoing intense caregiver experiences with chronically ill family members (Aldridge & Becker, 1993). These children were identified as hidden caregivers because they were not included in informal (nonpaid, such as family, friends, and neighbors) or formal (paid) care providers' assessment of care needs or care service activities. The lack of recognition of children's involvement was highlighted in one informant's narrative about years of intense involvement in her mother's care and her memories that health professionals did not talk with her about her mother's care until after she became an adult. Care support identified by children included domestic, personal, and intimate care activities (Aldridge & Becker, 1993) as well as emotional support to the adult caregiving parent (Stommel & Kingry, 1991). Children have described feeling overwhelmed, ill informed, and ignored (Aldridge & Becker, 1993) as well as feeling that the care was "hard but gratifying" (Gates & Lackey, 1998). Adults remembered that, as children, they liked that caregiving helped them to learn responsibility and they felt like they were useful, needed, and part of the family (Lackey & Gates, 2001). All of the research located on care provided by young children has emphasized the problems (rather than benefits) children experience in providing care. As such, recommendations from research have included not only recognizing that children are involved in care support and need to be informed about care practices but also assuring that children are not consumed by caregiving but have the chance to enjoy the more carefree rights and opportunities that other children enjoy (Aldridge & Becker, 1993; Gates & Lackey, 1998; Lackey & Gates, 2001).
Whereas research has exposed difficulties perceived by children in family care situations, there is limited research on the actual observed involvement of minor children in elder care in Western or other cultures. The purpose of this research is to describe the involvement of minor children in naturally occurring elder care networks, care activities they provide, and motivations for these elder care associations in a non-Western community context where there were limited formal services. Through a comparison with adult elder care exchanges, this article extends understandings of minor children's involvement in elder care networks.
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METHODS |
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; Bernard, 1998) was conducted from May 1998 through May 2003. Through the use of formal (n = 81) and informal interviews, participant observation, genograms and care diagrams (n = 24 elder family households), focus groups, document review, and a survey of primary school children (n = 173), Phase I described the island and village context and expectations for elder care. To describe elder care needs and how elders obtained the things they need to live, the Phase II network study activities included (a) conducting a community survey for obtaining an up-to-date list of all community-dwelling "old people" or frail elders (n = 72 elders); (b) based on findings from the Phase I community context study that the presence of family members, community relations, and the control of resources (economic, spiritual, knowledge, and experience) were variables that influenced how elders' obtained the things they needed to live, selection of a core sample of 14 community-dwelling frail elder families (e.g., elders with family members present and elders without family members present); and (c) obtaining of elder ego-centered network data from the 14 elder households by conducting interviews and participant observation. Whether the researcher was present at the time of a visit with one of the elder household members or met caregivers on the road after they had visited an elder, the caregiver often spoke of receiving something from an elder for providing care. It was this observation that prompted the documentation of all exchanges for the purpose of elder care over a minimum of 1 week with each key informant. Phase III of the research was to review, validate, and extend the findings of this research through interviews on the preliminary findings of the research with key elder and village informants, island religious leaders, and members of the Ministry of Health including social service personnel, nurses, and physicians. Phase IV involved dissemination of the final research findings to key village informants and members of the Ministry of Health. This article describes the involvement of minor children and adults in the 14 elder care networks.
Setting
Hillside (a pseudonym) is a semirural village of approximately 4,000 people on St. Lucia, one of the independent English-speaking islands in the Caribbean. Most of the homes have electricity and access to phone line hook-up. Running water is available for a couple of hours each day. Some villagers have water and septic systems in their homes; others obtain their water from roadside standpipes. Sources of income include fishing, jobs located in one of the urban centers, money sent from family members who reside overseas, the local health and education systems, and temporary stands where women sell local ground produce and "anything [they] can get [their] hands on." The predominant religion in Hillside is Roman Catholicism. In addition, obeah (for protection and healing) and maji nwe' (black magic) feature significantly in the spiritual life. Maji nwe' includes a belief that some people, including elders, are gaje' or practicing witchcraft. Those that are gaje' are said to sell their soul to the devil in exchange for power to turn themselves into animals and "go about doing things to people."
The village dependency ratio is 0.76 (0–14 years old + 65+ years old)/(15–64 years old) with approximately 6% of villagers over age 65 and 37% under age 15. Community leaders and villagers describe the expectation that elders are cared for by family members (Kelley, in press). Indeed, in Hillside, most elders live with or near family members; however, they often spend their time alone in their homes. There is an expectation from community members that elders have put their time in and should "be off to the side." Anticipated sources of elders' income include remittances from family members, social welfare checks, coins given from people when they pass, and, much less frequently, pensions, money received by renting out family land, and personal savings accounts.
Children play an important role in family and community life. As members of the family and community, children are socialized at a young age to assist around the home and neighborhood. Primary school children often had chores, such as washing clothes and errands that they did before they left for school in the morning. It was not unusual for a child of 3 to begin running errands to nearby neighbors. Children are expected to be quiet, obedient, and well mannered (Barrow, 1996). Similar to other Caribbean islands (Barrow, 1996; Smith & Mosby, 2003), if they misbehave, they are threatened or inflicted with a "beating." Adults explained that beating is necessary to help the children stay on the "straight and narrow." In the Phase I community context study, overwhelmingly, children identified that they did not want to get old, that is, to become one of those people who had wrinkles, gray hair, functional disabilities, and who "would be worthless" and not be able to "go out or take part in activities" (Kelley, in press). They wrote of both loving and being afraid of old people. For example, a 9-year-old girl wrote, "There is an old lady she is very kind. She is very sick and the children is afraid of her. Every afternoon I always visit miss dapheen." Another child wrote, "An old person is usually found walking with a stick. ... Their hair turn grey. Which makes some of us children think that they are witches." On the other hand, children also wrote about activities that they did for the old people, such as combing hair, bathing, bringing them water and bread, and helping them cross the street. For example, one girl wrote: "There once was a lady who lived in a little [house]. She was very, very sick. She had a diareor [diarrhea]. I use to frow [throw] the poop, comb her hair, help her to cross the street, cook food for her and even sleep with her."
On the other hand, adolescents and young adults explained about the "old people": "They like to talk a lot and get into your business. Like see you talking to a boy they like to tell your mother that. It wasn't like that for them, in their generation, didn't have boys talking like that by the roadside. They had to come home and ask the parents but now sho-sho (hot–hot) in the corner."
Although there was an expectation that elders were revered and cared for by family members, this was not always the case (Kelley, in press). For example, while discussing adolescents and young adults, an elderly female community member explained: "Once you are old, you are like me, you are no use to them, stay in the corner, they want their freedom because they don't want to sacrifice themselves for the elderly.... The world has so much to offer, material things. I don't want to miss anything the world has to offer ME! So if I stay with you I miss those things on the outside."
Elder Sample
The Phase II elder ego-centered network study consisted of 15 elder participants who lived in 14 households (2 of the elders were married and lived together) and included 10 women and 5 men who had a mean age of 84 with a range from 65 to 104 years. Three of the women and three men lived alone. Like elders island-wide, medical diagnoses included vascular diseases such as hypertension (n = 4), decubitus ulcers (n = 4), congestive heart failure (n = 1), confusion (n = 3), diabetes (n = 2), cancer (n = 2), and arthritis (n = 2). Five had impaired vision, with three becoming blind in their later years. One elder each had leprosy, epilepsy, and prostate problems. All of the elders were essentially homebound because of difficulties with walking, blindness, confusion, or weakness. In the order of greatest frequency, elders identified need for food (n = 11), money (n = 11), supplies (n = 6), and assistance with housekeeping and laundry (n = 6). Five elders needed assistance with getting their medications and ADLs (e.g., bathing, combing hair), whereas four each identified water, food preparation, symptom management, errands, and transportation as needs. Adult informal caregivers of four of the elders identified a need for "everything." Three informal adult caregivers of confused elders identified the need for protection. Two of the four elders who had decubitus ulcers identified needing assistance with dressing changes. Two elders identified housing repairs and the need for a program of Home Help whereby the elders could pay someone to help them in the home. One elder described the need for more preventive services of blood pressure monitoring and safer roads.
Elder Network Study Analysis
To obtain a description of the elder care network and activities from the perspective of the elder and the elder's significant others, data were collected for a minimum of 1 week with each elder household. Participants were asked to identify any persons or agencies that were members of the elders' care networks and why they provided the care, and data were obtained on all people who visited the elder for the expressed purpose of elder care. Records were kept on all materials and interactions that were exchanged and the relationship of the person to the elder. Data were recorded through participant observation and journaling by the elder, family members, and neighbors. The researcher conducted participant observation for at least 6 hours during various times of the day (morning, afternoon, and early evening) at each household. Congruency of care activities and benefits was discussed through review of the lists with elders and significant others who were present at the various visits. There were no instances of disagreement. As will be discussed later, there were a few observed activities (e.g., children coming over to visit with an elder) that were not identified as part of elder care but rather done for reasons such as social interaction.
Care network members (caregivers) include adults and children who were family, friends, or neighbors. For this article, care providers were excluded if they were paid (e.g., family members who hired assistants) or the government financed care providers (e.g., nurses, community health aides, or social service persons). The count of "caregivers" in the following analyses is taken from the perspective of the elder. Consequently, at the community level, four of the caregivers were listed in more than one elder network.
In this study, care exchanges are defined as care activities and benefits. An elder "care activity" is the care provided by a caregiver to an elder on at least one occasion. An elder "caregiver benefit" is what an elder gave to the caregiver for elder care on at least one occasion. When the "care activity" or "caregiver benefit" data are each aggregated across the 14 networks, this count represents the frequency of elder care exchange in at least one dyadic transaction among Hillside elders. Consequently, each kind of exchange content observed or reported was counted only once for each elder and caregiver dyad. For example (Figure 1), if a daughter, Ms. Gilma, gave her elderly mother a bath every morning and evening for 7 days of the week, this activity was counted only one time for that elder and daughter. As Ms.Gilma also cooked food for her mother and managed her mother's money, that mother/daughter dyad was engaged in three elder care activities. In exchange, Ms. Gilma described the care benefit of fulfilling her obligation for "birth–life" and possibly inheriting her mother's home in the future. Additionally, at the community level, an elder, Mr. M., identified that Ms. Gilma was a "friend" and part of his care network. She brought him food at least once a week. This also was counted as one care activity. In exchange, when Ms. Gilma visited, Mr. M would give her whatever food he had available (mangoes, breadfruit, ripe bananas) or one care benefit of "food." Therefore, these counts are useful for knowledge of the collective caregiver members and exchange contents of these Hillside elders' networks. Because the focus is on the collective and not individual dyadic exchanges, for this analysis, these counts do not provide information regarding the exact number or intensity of individual care acts. Audio-taped interviews and field notes were transcribed within 24 hours. Content analysis techniques were used to analyze the qualitative data (Bernard, 1998). Content analysis focused on an identification of recurring ideas that then were grouped into common themes and relational patterns primarily focusing on the care of elders in the community. Comparison of different sources of data highlighted similarities and incongruities that fostered additional research questions and validation from multiple sources (informants, theory, research) for agreement and disagreement between data and emerging themes and patterns. Analysis identified what was typical (i.e., common or most prevalent) as well as what was not typical, variables (i.e., phenomena that differed from one situation to another), and comparison of these variables with what was known in the literature. These variables guided the procedures and analysis of the study. Validation of analysis techniques included review by three expert researchers: a nurse researcher expert in elder care, a nurse anthropologist expert in Caribbean research, and an anthropologist with expertise in St. Lucia. The research findings were reviewed with key elders and other village informants, island religious leaders, and members of the Ministry of Health including social service personnel, nurses, and physicians.
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RESULTS |
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and 12 years and 4 children between the ages of 13 and 16.
Elder Care Activities
As a collective, these adults and young children provided 355 elder care activities (Table 1). The most frequent care activities of adults and children included company/visit (n = 67), food (n = 56), errands (n = 25), laundry (n = 23), money (n = 22), supplies (n = 19), water (n = 18), protection (n = 15), sweep/dishes (n = 14), and "check on" (n = 9). When categorized by services or commodities, there were more services than commodities (n = 231, 65% of the 355 activities).
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Children and adults shared in similar activities such as providing company/visits. There were proportionate differences of children's greater involvement in errands (n = 22) than adults (n = 3). On the other hand, only adults were identified as providing liaison activities (n = 7). These complementary care activities expose the complexity and interconnectivity of the elder care network members. For example, Ms. Olive's adult daughter Dawn acted as a liaison coordinating her care. Although Dawn did not see her mother daily, she not only coordinated her care with different family members but sent her own children to bring food, run errands, or check on Ms. Olive.
Additionally, there were differences in care activity intimacy, with children providing assistance with emptying the chamber pot (n = 7), whereas only adults were providing the more intimate hands-on incontinence care (n = 2) for elders who had a catheter or were bedridden. Congruent with children's abilities and resources, they did not participate in the instrumental or advanced activities (IADLs or AADLs) such as acting as liaison with the health care system, financial management, protecting land, transportation, massage, or home repairs. Although both adults and children provided food and water, adults provided other costly commodities such as money, supplies, medications, clothing, and appliances.
Motivations: Network Member Care Benefits
Motivations for adult and children caregivers to assist elders emerged within the 280 caregiver benefits. Interestingly, these benefits were similar to the care activities. The most frequently identified caregiver benefits included food (n = 45), company/visits (n = 32), money (n = 30), prayers (n = 23), housing (n = 20), birth/life (n = 17), clothing/supplies (n = 17), and good deeds in the past (n = 11).
These benefits emerged and were then sorted in the temporal categories of historical, current, and future reciprocity (Table 2). Forty-one (15%) caregiver benefits were because of what the elder had given the caregiver in the past (e.g., birth/life, were raised, loved as a child) and 34 (12%) were for possible future benefits (that included inheritance and prayers for spiritual protection or salvation). There were 205 current benefits (73% of the total benefits), of which 135 (48%) were commodities and 70 (25%) were services.
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Similar to adults, children's current benefits included money (n = 24), food (n = 11), housing (n = 5), company/visit (n = 5), protection (n = 5), and information (n = 1) as well as the future benefit of prayers (n = 18). Unlike adults, children also received clothing/supplies (n = 17), stories (n = 4), and access to television (n = 2). When visiting one elder who lived near the school, it was typical to find young boys climbing her mango trees for fruit or other children showing the dollar coin she provided for the errand they had done for her.
Only adults identified the potential benefit of inheriting a house or land. Both adults and children, however, discussed the future benefit of prayers (or spiritual reciprocity). These prayers included intercessions to God as well as rituals that might cause the caregiver harm if they did not help the elder. The notion of spiritual reciprocity or the elders' ability to reciprocate through a spiritual power of obeah' or maji'nwe was discussed by both children and adults. A social service worker explained this belief:
In St. Lucia, gajes', witches, would be very secretive and not part of an organized religion because, here taboo, no status as a religion. If anyone is labeled as a gaje', then your life is going to be very miserable.... I am in no position to say there are no gajes'; in St. Lucia, probably we do because some people do the occult. I haven't studied it, but I firmly believe that a lot of the people who are labeled as gajes' are innocent people.... Most older people, they call this way.... It is very nasty what they do to the older people ... the gaje'. I don't know, but I believe if one accepts good, one must also accept that there is the other side of good. There is a constant struggle between good and evil.
This notion of power inherent in spiritual reciprocity was a mixture of beliefs and a blend of interpretations of various practices. For example, Ms. Christiana (an elderly female professed devout Catholic) explained a situation where children asked her to pray for them so they could do well in school. Yet, other neighborhood children had been taunting her because she had a cut on her leg. The day before, the children had thrown a rock at a dog and harmed its leg. These children said that this proved she was gaje' or able to turn herself into an animal and go about "doing things" to people. Ms Christiana explained this perception that others had for her ability to reciprocate through spiritual intercessions to God or the devil on their behalf:
Yes, this is true about the gaje'.... They say I am gaje', grey hair, [but] I not let them in my business.... [Every morning] I up early—light my candle and say prayers. [They] say I doing work of the devil, but I with God. It through God receives what has. ... Yes, fly at night, that is what they say [I do]. But wait, they in trouble and [they] come to ask me, light candles and pray for them!
Network Care Exchanges
This ethnographic research including in-depth network analysis allowed focused exploration of the dynamic exchanges between elders and caregivers involved in the elder care system. More care activities (n = 355) than caregiver benefits (n = 280) were identified. Care activities were proportionately more services, whereas caregiver benefits were proportionally more commodities for now or in the future. Although elders had more care activities, these activities were all to fulfill elders' current care needs. In exchange, care benefits identified were temporally different. Most (73%) were for current commodities and services; however, 15% were based on a repayment for what was given to them by the elder in the past, and 12% were for possible future benefits.
Although all elders engaged adults in their care networks, two men, Mr. Malcolm and Mr. Andrew, had the only networks that did not identify children as care network members. Mr. Malcolm, who had a very good family and community reputation, economic resources, and a daughter living with him, though friendly toward children and engaged in social activities (e.g., telling stories, giving treats to children), did not identify these children as caregivers or elicit their assistance for care. The other elder without children in his care network was Mr. Andrew, who had a poor community reputation for "drinking the rum," no resources other than a garden located outside of the village, and no family living nearby. Although he identified no children assisting him, he was taunted by young boys in the village who would run past him and call him names.
Of those 12 elder networks with children, two women, Ms. Hermine and Ms. Olive, identified the largest numbers of children. Ms. Olive had a network of 26 family members that included >18 grand- and great-grandchildren whom she identified as assisting her with care. At least 10 of these children lived near her home and were sent to play nearby and stay with Ms. Olive. Although she found caring for the babies "too much now," she provided the children with food, clothes, and "small coins" for errands and other care activities. Similarly, Ms. Hermine spoke of many children who passed on their way to school and she would "take them on—ask for things—give them what I have." These children were often hungry and thirsty. She had fruit, coins, and sweets she had "saved" to give to the children. It was not unusual to find children talking with her or up in one of her trees picking and eating the fruit. Ms. Hermine explained that when she asked the children to pick fruit for her, she would also tell them to take some for their "belly." Although Ms. Hermine, who lived alone, did not have grandchildren, she did have at least 11 neighborhood schoolchildren who were integral to her care. For example, at one visit, one primary school child hung her clothes out on the bushes to dry and turned on the water standpipe; Ms. Hermine gave her a dollar coin. Later that day, some of the other "school children" brought her clothes back into the home for her and fetched her water bucket. She told them to take some mangoes. Another preadolescent girl frequently stayed with Ms. Hermine after school and would sweep for her and do dishes. She benefited by being protected because her mother worked until late in the evening and the girl did not like being alone at her home. According to an island health official, there is a high incidence of rape (field notes, 1998). Ms. Hermine explained that some young men, especially those who are jumbees (someone who uses crack cocaine and is "no good"), would "bother" young girls.
Five of the elder women talked of neighbor children being available to help them if they called out. Ms. Dauphine was dependent on neighbor children for getting her social welfare check as well as acquiring food and water. To get her social welfare money, she sent a neighbor boy with her pink government book to pick up her check at the post office; in exchange, he received a dollar coin. Ms. Josephine, who had a poor community reputation and spent most of the day alone, depended on neighbor children to answer her calls. A boy who lived in a house behind Ms. Josephine's house ran errands for her if she could get his attention and if she had a coin to pay him. On one visit, she reported that although this boy's house was open and she had called for him since 5:30 that morning, he still hadn't come at 10 AM. Both these women addressed the problem of trust and uncertainty of care from children and, consequently, when depending primarily on children, having extended periods of nothing to eat.
Six of the elder women who depended on young children for care used the strategy of hiding and hoarding things. For example, in addition to food, Ms. Hermine had coins hidden away that she exchanged with neighbor children to persuade them to continue to visit her. She also exchanged her right to fair treatment by choosing to ignore what children stole from her, expressing, "a little now for a dollar later ... not letting right hand [giving] know what the left hand [taking] do."
Physical appearance and mannerisms influenced young children's involvement in elder care. Ms Hermine had greater continuity in her young children network members. She was known for giving things to children, her quiet manner, taking care of her appearance, and being less likely to yell at, curse, or threaten children who did not comply with her wishes. In contrast, Ms. Dauphine had less continuity of young children in her network. She was very outspoken, less concerned about her appearance, and refused to be "off to the side." It was believed that bad obeah had caused her to become ill and homebound. Furthermore, some villagers spoke of her as gaje'. It was not unusual to observe children assisting her because she had "caught their eye" and they were afraid of her ability to do them harm.
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Whereas elder care studies often restrict the care network to adult family and community members (Penning, 2002; Rawlins, 2001; Thoits, 1995; Unger et al., 1999), congruent with work conducted in the United States (Pruchno et al., 1997), this research demonstrates that not only in the home of the elder, but throughout the village community, minor children are substantial elder care network members. Unexpectedly, like adults, minor children caregivers were identified as family members or neighbors, but, unlike adults, none of these elders identified minor children caregivers as friends, thus highlighting a need for further research not only on minor children's involvement in elder care in different cultural contexts but also on differential adult and children elder caregiver relationships and expectations held for these relationships.
In Hillside, elder care activities are similar to the more intimate, daily, and ongoing care activities identified in the literature as ADLs, IADLs, and AADLs (Penning, 2002). Although sharing in many similar activities, adults provide for those that require more intimacy (i.e., incontinence care versus emptying the chamber pot) as well as more resources (e.g., money and medications) and skill. For example, although adults provide the more complex care management activity of liaison with other family members and the health care system, children act as messengers, running errands for the elder (at the request of the elder or their mothers).
In reviewing participant observation data with the activities and benefits for elder care identified by the elder, some of the same activities are used by the elder in relationship with children, but for different purposes. This is apparent with Mr. Malcolm, who identifies adult daughters, friends, and neighbors as providing for his elder care needs but does not identify any minor children as caregivers or interactions with children for the purpose of elder care. He is, however, involved with children in other activities (e.g., visiting, telling stories) for the purpose of social interaction. Consequently, although the terms "social support networks" and "elder care networks" are frequently used interchangeably in the literature, conceptually, by the nature of the relationship of the network member to the elder and the purpose of the "content" provided, this work brings into question if they may be at different levels of abstraction. In Hillside, elder care networks are specific to what the elder identifies as important for obtaining the things they need to live. Social support networks may provide activities that the elder participates in but does not identify as essential to life and consequently does not invest valuable care capital in, that is, the important "bank" or coffer they have accumulated for future elder care (Antonucci, 1990; Greene & Marty, 1999; Kahn & Antonucci, 1980). This finding calls for further research on conceptual clarity between elder care support and elder social support activities. By highlighting a difference between elder care and support activity exchanges, this research provides insight for health care providers on a possible mechanism to respect and strengthen elders' informal care networks by eliciting and supporting elders' choice of who they want involved in their care at various times across the caregiving trajectory.
The counts of care benefits provide understanding about the temporal nature of the elder care motivations for children and adults. Both children and adults were motivated by obtaining some current commodity or service from the elder. Congruent with equity theory (Walster et al., 1978) and the importance of a balance between giving and receiving assistance in elder care (Becker et al., 2003; Boerner & Reinhardt, 2003; Liang et al., 2001), children, in particular, were motivated by a current commodity such as a small coin or food. As proposed in social exchange theory (Blau, 1964/1998), social attractiveness may also influence children's desire to interact with and remain in association with elders, in that elders who were more socially attractive (quiet, dressing nice, not yelling or cursing at the children) had more continuity in young children network members. Elders chose how they acted toward children (with kindness) as well as benefits that were desirable and needed by poor (coins) and hungry (food) children to promote ongoing interactions and possibly soften distress over loss of relationships with children if they did not fulfill these obligations as they became older.
According to social exchange theory, power and status in a community are acquired through participation (Blau, 1964/1998). There were 67 visitation care activities, of which 47 were from adults and 20 from young children. Visitation emerged as a critical mechanism whereby homebound elders continue to interact and participate in a family and community context. Interestingly, 41 of the 45 identifiable minor children caregiver network members were preadolescents. Many of the preadolescent children lived near the elder, were sent by their mothers to assist the elder, or walked past elders' homes on their way to the primary school. In a village with a high degree of poverty, preadolescent children, by essence of their age and abilities, depended on adults and elder family and neighbors for sustenance and safety. On the other hand, as children become adolescents, they have increased social options and competition for their time and resources from other more powerful socializing groups (e.g., media, school, friends).
Adolescent teens are deciding with whom to participate to increase their status within their age group and their community. Elders, villagers, and young adults confirmed that typically adolescent children do not like being around the "old people" who should be "off to the side" or "in a corner." Given that trust is vital for interdependence (Deutsch, 1962) and ongoing associations (Blau, 1964/1998), this work highlighted that an elder care relationship may garner a different level of trust and intimacy in exchange activities than would a social interaction relationship. According to equity theory (Walster et al., 1978), elders may want to maximize their outcomes by not using elder care inputs in an elder care relationship with adolescents, who they recognize may not fulfill these obligations, thereby protecting themselves from becoming distressed over an inequitable relationship and possibly suffering further derogation. However, if elders have to depend on young children and adolescents for care, they may, like Ms. Hermine, use psychological equity (Walster et al., 1978) as she subordinated herself through purposefully exchanging her right to fair treatment (Blau, 1964/1998) by choosing to ignore what children stole from her, expressing, "a little now for a dollar later ... not letting right hand [giving] know what the left hand [taking] do." It was better for Ms. Hermine to maintain equity in her relationships with children than risk losing ongoing associations with them or, like Ms. Dauphine, yell at, curse, or lash out at children who did not comply with her wishes as a means to retaliate and prevent further derogation (Berscheid, Boye, & Walster, 1968).
In contrast to current reciprocity, historical reciprocity was identified by adults, but not the children, as repayment to the elder for things given in the past (McGrew, 1998; Parsons, 1997; Powell, 1986). Similar to the findings of others (Greene & Marty, 1999; Kahn & Antonucci, 1980; Silverstein et al., 2002), elders and adult caregivers recognized an accumulated bank or coffer of care capital the elders drew on both as investment (birth/life) and, because all of the elders were in need, insurance models for elder care (Silverstein et al., 2002). For adults, historical reciprocity included not only the elders' reputation for having given to their own children (birth/life) but elders' reputation in the community for deserving care. At the community level, the importance of an elder having invested in the community by giving (e.g., having been a teacher) and obtaining a positive reputation was apparent. Conversely, an elder who had poor care did not cause neighbors to feel guilty (distressed) and experienced derogatory acts by children taunting him. Rather than compensation for poor care, neighbors restored equity by not giving him assistance because he had not given to the community in the past.
Although adults identified being motivated by possible inheritance in the future (Caffrey, 1992), a new motivator of both children and adults, not previously identified in the literature, was the future benefit of prayers (e.g., spiritual rituals). In contrast to reciprocity theory, which is based on "a mutually gratifying pattern of exchanging goods and services" (Gouldner, 1960, p. 170), or returning a good deed for a good deed (Becker, 1986), these children and adults believed that spiritual reciprocity could be used by elders to not only help the caregivers but to also cause future harm (bad luck, repercussions from God, or evil) if they did not do as was expected by the elder. Although it requires further study, similar to discussions on witchcraft and sorcery in East Africa (Middleton & Winter, 1963) and with the Azande (Evans-Pritchard, 1976), the belief in gaje' or witchcraft may be one mechanism by which frail homebound elders protected themselves from harm as well as forced care support from other community members who were fearful of repercussions if they did not comply (Berscheid et al., 1968; Blau, 1964/1998).
If an observer was viewing exchanges in current time, the elder care exchanges appeared "unbalanced." Compatible with social exchange theory, however, the temporal nature of elder care exchange benefits over their lifetimes is the glue that holds these naturally occurring elder care systems together. These elders demonstrated how they used whatever resources they had in the past, now, or anticipated to have in their future to promote attachment and ongoing interactions with community members for acquiring care (Kahn & Antonucci, 1980). In comparison of young children and adults, elders were more likely to choose the more vested benefits of historical reciprocity and future commodities (e.g., the house, inheritance) for exchanges with adults (who had remained obligated and trustworthy to fulfill their obligations over time) and current small tangible benefits (not necessitating trust or ongoing obligations) with young children. Although it will require further study, the past, current, and future temporal care benefits may carry different motivational weights for fostering ongoing associations and exchanges for elder care.
Although there is a pervasive expectation that elders should withdraw from society and "make room for the young that think in new ways," this is not the experience of these frail elders. Despite having limited resources, rather than withdrawing from society (Dowd, 1975), these elders are attempting to get the things they need to live by maintaining their involvement in the community through diverse care exchange networks, tolerance for stealing (Ms. Hermine), and living with uncertainty (Ms. Dauphine, Ms. Josephine). However, elders such as Mr. Andrew and Ms. Josephine who had the least available resources, absent family, and the poorest community reputation had the most difficulty in getting the things they needed to live from both children and adults.
Through a comparison with adult elder care exchanges, this article has described and extended understanding about the involvement of minor children in naturally occurring elder care networks. Although researchers have described children's perceptions of caring for chronically ill family members centering on difficult care activities, the need for support, and the right not to become consumed by the caregiving experience but also to experience childhood (Aldridge & Becker, 1993; Gates & Lackey, 1998; Lackey & Gates, 2001; Stommel & Kingry, 1991), in this Caribbean community, the rights of childhood were inclusive of active involvement and socialization to elder care as a life activity beginning as young as 3 years of age. This may give insight into the positive perspective reported by adults who remembered that as children, caregiving helped them to learn responsibility and feel useful and needed as part of the family (Lackey & Gates, 2001).
Theoretically, this research has exposed the importance of equity and social exchange theory in understanding the complexity and temporality of the underlying structures of elder care in a community context. It could be questioned if these or similar underlying structures are also present in cultures with more formal care available. This research highlights the need for cross-cultural comparative descriptive and inductive work on elder care beyond a focus on children's difficulties but including children's (and elders') involvement and benefits for participation in elder care. Additionally, these findings may inform the design and testing of intergenerational care programs. For example, intergenerational visitation programs could evaluate the importance of social attraction and ensure that there are meaningful age and culturally appropriate commodities or services for elders to exchange with visitors of all age groups as a possible mechanism to promote ongoing, dignified (so the elder does not need to use psychological equity), and valued visitation.
Global trends include reduction of state responsibility and a call for the transfer of elder care activities from the formal (government and private pay) to the informal sector of families and other nonpaid sources of assistance (Restrepo & Rozental, 1994). This work demonstrates that rather than grounded in norms of amity (Fortes, 1969), these frail elders are attempting (through ongoing participation) to access, build, and maintain exchange system networks for obtaining elder care.
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Received for publication March 17, 2004. Accepted for publication July 28, 2004.
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