MSU RETURNING MATERIALS: PIace in book drop to umuuuss remove this checkout from ‘— your record. FINES wm be charged if book is returned after the date stamped below. THE PERCEIVED HEALTH NEEDS, HEALTH ASSISTANCE, AND PROVIDERS OF HEALTH ASSISTANCE CONCERNING AGED PARENTS AS REPORTED BY THEIR ADULT CHILDREN BY Barbara Jepson-Taylor A THESIS Submitted to Michigan State University in partial fulfillment of the requirements for the degree of MASTER OF SCIENCE IN NURSING College of Nursing 1984 Copyright by Barbara Jepson-Taylor @1984 ii ABSTRACT THE PERCEIVED HEALTH NEEDS, HEALTH ASSISTANCE, AND PROVIDERS OF HEALTH ASSISTANCE CONCERNING AGED PARENTS AS REPORTED BY THEIR ADULT CHILDREN BY Barbara Jepson-Taylor A descriptive, eXploratory study was conducted to gain an understanding about the perceptions of adult children regarding their parents' health needs, whether or not health assistance was expected, and who would be likely to provide health assistance as their parents grow older. Although there is much evidence to substantiate health needs of aged persons, how their families perceive the health needs of older members has received minimal attention in the litera- ture. Martha Rogers' conceptual system was used as the theoretiCal basis from which nursing implications were derived for the understanding of study variables. Descriptive data were collected by means of a self- administered questionnaire mailed to 47 adult children (2 age = 43 years) with parents who were non-institutionalized, over age 65, and retired. Barbara Jepson-Taylor Nearly 85% of the respondents expected their parents to experience physical and psychological health needs and nearly 50% were neutral about their parents' socioeconomic health needs. No help/no helper needed was mentioned for nearly half their parents' health needs; for the remaining health needs, providers of health assistance within primary and secondary groups were expected to help. Males tended to have higher scores on six out of eight scales. The profes- sional nurse was expected to help with few health needs; physical health needs were mentioned most frequently. In conclusion, study findings suggest that adult children perceive a traditional role for the nurse as a provider of health assistance to their parents. Nurses must focus on directing helping behaviors that maximize health of both adult children and their parents. To my husband, Bob, and to our sons, Scott and Andrew iii ACKNOWLEDGMENTS I would like to thank my Committee members, Barbara Given, Barbara Ames, Brigid Warren, Rita Gallin, and JoAnn Westrick, for their contributions to this study. I am grateful for their eXpertise, support, and guidance. I am grateful to my nursing peers and friends for taking time out of their busy lives to help me with data collec- tion. Special thanks to Sue Haviland and Carol Garling- house for their support and to Carol for the use of her instrument. The assistance of Bryan Coyle and Robb Hymes in analyzing the data was much appreciated. I am grateful to Peri-Anne Warstler whose typing skills enabled me to meet my deadlines. Very special thanks to my husband, Bob, who provided love and encouragement throughout my graduate studies. Thanks to my children, Scott and Andrew, for their help and understanding during my many absences. I would also acknowledge the presence and guidance of God's Holy Spirit in my life (Proverbs 3:6) and especially throughout the writing of this manuscript (Phillipians 4:13, I Corinthians 10:31). iv Chapter TABLE OF CONTENTS LIST OF TABLES I O O C O O C O O O O O O 0 LIST OF FIGURES . . . . . . . . . . . . . I 0 THE PROBLEM . O O C O C I O O O O O 0 Introduction. . . . . . . . . . . . . Purpose . . . . . . . . . . . . . . . Statement of Research Questions . . . Conceptual Definitions. . . . . . . . Adult Children. . . . . . . . . . Aged Parent(s). . . . . . . . . . Extended Family System. . . . . . Perceived Health Needs of Aged Parent(s) . . . . . . . . . . . . Perceived EXpectations of Health Assistance. . . . . . . . . . . . Perceived Providers of Health Assistance. . . . . . . . . . . . Assumptions . . . . . . . . . . . . . Limitations of the Study. . . . . . . Overview of the Chapters. . . . . . . II. CONCEPTUAL FRAMEWORK . . . . . . . . Introduction. . . . . . . . . . . . . Unitary Man . . . . . . . . . . . . . Application of Rogers' Conceptual System to the Study Variables . . . . III. LITERATURE REVIEW . . . . . . . . . Introduction. . . . . . . . . . . . . Perceived Health Needs of Aged Parents . . . . . . . . . . . . . . . Page xi xiv w #4 IA 10 11 ll 12 14 15 l6 l7 19 21 21 22 27 34 34 34 Chapter Page IV. "Health" as a variable modifying intergenerational relationships . . . . . . 34 Health needs of aged parents. . . . . . . . 38 Physical health needs . . . . . . . . . . . 41 Psychological health needs. . . . . . . . . 42 Socioeconomic health needs. . . . . . . . . 44 Perceived Health Assistance for Aged Parents. . . . . . . . . . . . . . . . . . 46 The filial relationship . . . . . . . . . . 46 Additional characteristics of assistance . . . . . . . . . . . . . . . 53 Perceived Providers of Health Assistance. . . . . . . . . . . . . . . . . . . 55 Summary . . . . . . . . . . . . . . . . . . . . 63 METHODOLOGY. . . . . . . . . . . . . . . . . . 65 Overview. . . . . . . . . . . . . . . . . . . . 65 Sample. . . . . . . . . . . . . . . . . . . . . 66 Data Collection Procedure . . . . . . . . . . . 67 Methodology . . . . . . . . . . . . . . . . . . 68 Instrumentation . . . . . . . . . . . . . . . . 7l Deve10pment of the instrument . . . . . . . 71 Pretest of the study instrument . . . . . . 76 Reliability and validity. . . . . . . . . . 77 Operationalization of Study Variables . . . . . . . . . . . . . . . . . . . 78 Perceived health needs (total) . . . . . . . . . . . . . . . . . . 78 Perceived health assistance (total) . . . . . . . . . . . . . . . . . . 81 Perceived providers of health aSSistance. O O O O O O O O O O O O O O O O 82 Descriptive variables concerning the adult child and aged parents. . . . . . 84 Procedures for Data Analysis. . . . . . . . . . 84 Protection of Human Rights. . . . . . . . . . . 87 Summary . . . . . . . . . . . . . . . . . . . . 87 vi Chapter V. DATA PRESENTATION AND ANALYSIS. . . . . . overVieWO C C . C C C C O C O O O O O O 0 Descriptive Findings of the Study Sample. Variables concerning the adult child participant . . . . . . . Demographic variables . . . . Other descriptive variables . Variables concerning the aged parent(s) of the adult child participant . . . . . . . . . . Demographic variables . . . . Other descriptive variables . Additional Findings Regarding J the Study Sample. . . . . . . . . . . Summary . . . . . . . . . . . . . . . Data Presentation for Research Questions . . . . . . . . . . . . . Statistical technique for analyzing data. . . . . . . . . . Research Sub-question Research Sub-question WM!“ 0 Research Sub-question Statistical technique for analyzing perceived providers of health assistance. . . . . . . Results of perceived providers of health assistance . . . . . . . . Perceived providers of health assistance for physical health needs . . . . . . . . . . . . Perceived providers of health assistance for psychological health needs. . . . . . . . . Perceived providers of health assistance for socioeconomic health needs. . . . . . . . . Perceived providers of health assistance for total health needs vii Page 89 89 9O 9O 9O 94 97 97 100 103 110 111 111 112 119 126 126 136 136 139 141 144 Chapter Additional findings: written comments from adult child partiCipants. O O O O O O O 0 Major research question . . . . Reliability of the Questionnaire. . Summary . . . . . . . . . . . . . . VI. SUMMARY AND IMPLICATIONS . . . . overView. O C O O O O O O O O O O Descriptors of the Study Sample . . Age. Sex of the participant. Marital status. Number of offspring . . . . . . . . . . . Race or ethnic background . . . Education. Occupation. Income level 0 O O O O O O O O O O O O Sibling rank in family of origin. Health of adult child participant and their household members . . Number of living parents. Age of parents. . . . . . . . . . . Geographic distance from parents . . . . . . . . . . . . Usual type and frequency of contact . . . . . . . . . . . . Difficulty of parents living on their present income. . . . . Parents' health . . . . . . . . Additional Findings Regarding the Study Sample. . . . . . . . . . . . Age . . . . . . . . . . . . . . Sex . . . . . . . . . . . . . . Education . . . . . . . . . . . Income level .. . . . . . . . . Geographic distance from parents. Summary of additional findings regarding the study sample. . . viii Page 145 146 149 151 157 157 157 157 159 159 160 161 163 165 166 167 168 169 170 172 173 174 175 177 Chapter Research Questions. . . . . . . . . Research Sub-Question l . . . . . . Perceived physical health needs . . . . . . . . . . . . . Perceived psychological health needs. . . . . . . . . . Perceived socioeconomic health needs. . . . . . . . . . Perceived health needs (total) . . . . . . . . . . . . Research Sub-question 2 . . . . . . Perceived health assistance for physical health needs . . Perceived health assistance for psychological health needs . . . . . . . . . . . . . Perceived health assistance for socioeconomic health needs . . . . . . . . . . . . Perceived health assistance (total) . . . . . . . . . . Research Sub-question 3 . . . . . Perceived providers of health assistance for physical health needs . . . . . . . . . . . . . Perceived providers of health assistance for psychological health needs. . . . . . . . . . Perceived providers for socio- economic health needs . . . . . Perceived providers of health assistance for total health needs . . . . . . . . . . . . . Additional Findings: Summary of Written Comments. . . . Reliability and Validity of the Scales. . . . . . .-. . Major Research Question . Additional Limitations of the Study . . ix Page 178 178 178 181 183 185 186 186 187 189 191 193 193 194 199 202 205 206 215 217 Chapter Implications for Principle of Principle of Principle of Implications for Implications for Summary . . . . . APPENDICES APPENDIX A . . Nursing Practice Resonancy. Helicy . . Complementarity. 0 Nursing Education. Nursing Research . Letter of Explanation . APPENDIX B . . . Co-Signed Letter of Explanation to Study Participants . APPENDIX C. . . . Letter of Explanation . Consent Form. Study Questionnaire . . REFERENCES. . . . . . Page 218 219 222 226 231 235 238 239 240 242 243 244 245 246 247 262 Table LIST OF TABLES Page Items Pertaining to Physical, Psychological, and Socioeconomic Health Needs and the Manner Adapted from the Scales Used by Garlinghouse (1982). . . . . . . . . . . . . . . . . . 72 Sociodemographic and Other Descriptive Variables Used to Describe Adult Children and Their Parents. . . . . . . . 85 Demographic Variables Concerning the Adult Child ReSpondent (age, sex, marital status, racial or ethnic background, education, occupation, in- come level)(N=47) . . . . . . . . . . . . 91 Descriptive Variables Concerning thw Adult Child Respondent (difficulty living on present income, sibling rank in family of origin) (N=47). . . . . 95 Descriptive Variables Concerning the Health of the Adult Child Respondents (N=47) and Household Members (description of health, presence of chronic health problems, and health problems experienced). . . . . 96 Demographic Variables Concerning the Parents of Adult Children (Né47) (number of living parents, age of xi Table Page 6 parents, estimated number of miles from parents) . . . . . . . . . . . . . . . 99 7 Descriptive Variables Concerning the Parents (N=74) of Adult Children (parents' difficulty living on income, usual type and frequency of contact with parents) . . . . . . . . . . . . . . . 101 8 Descriptive Variables Concerning Health of Parents (N=74) of Adult Children (description of health, pres- ence of chronic health problems, and health problems experienced by parents). . . . . . . . . . . . . . . . . . 102 9 Correlation Matrix: Relationship Between Selected Sociodemographic Variables Concerning the Adult Child Respondent and Each Scale Utilized in the Present Study . . . . . . . . . . . . . 105 10 Summary of Statistically Significant Correlations Between Selected Socio- demographic Variables Concerning the Adult Child ReSpondent and Bach Scale Utilized in the Present Study . . . . . . . 106 11 Percent and Number of Adult Children Who Identified Physical, Psychological, and Socioeconomic Health Needs of Their Parents (in descending order) (N=47). . . . 113 12 Sample Means and Standard Deviations for Scales Used to Measure Perceived Health Needs of Aged Parents (5:47) . . . . 118 xii Table Page 13 Percent and Number of Adult Children Who Identified Health Assistance for Physical, Psychological, and Socioeconomic Health Needs of Their Parents (in descending order) (N=47). . . . 120 14 Sample Means and Standard Deviation for Scales Used to Measure Perceived Health Assistance for Physical, Psycho- logical, and Socioeconomic Health Needs of Aged Parents by Their Adult Children (N=47). . . . . . . . . . . . . . . . . . . 125 15 Percent and Number of Adult Children Who Indicated a Category of Provider of Health Assistance for Health Needs of Their Parents (N=47) . . . . . . . . . . 128 16 Mean Proportion (Percent) of Perceived Providers of Health Assistance Men- tioned by Adult Children Within Each Health Need Scale . . . . . . . . . . . . . 135 17 Summary of Reliabilities of Each Scale Using Coefficient Alpha . . . . . . . 150 18 Correlation Matrix: Intercorrela- tions of Scales Utilized in the Present Study . . . . . . . . . . . . . . . 152 19 Factor Matrix of Health Need Items Within Each Scale . . . . . . . . . . . . . 153 20 Intercorrelation Matrix of Factors Within Each Scale Utilized in Present Study . . . . . . . . . . . . . . . . . . . 208 21 Coefficient Alphas of Factors Within Each Scale Utilized in the Present Study. . 208 xiii Figure LIST OF FIGURES Page Application of Roger's Conceptual System to Health Issues of Aged Parents . . . . . . . . . . . . . . . . . 28 Nursing Assessment of the Adult Child/Environment . . . . . . . . . . . . 227 xiv CHAPTER I THE PROBLEM Introduction Adulthood has existed as a separate developmental stage, apart from infancy, since the beginning of human life. Only after the Industrial Revolution, however, were addi- tional stages of human adult life to include adolescence, young adulthood, middle adulthood, and late adulthood. Un- til recently, "middle age" has been regarded as a somewhat uneventful plateau in life (Davis, 1981). Nevertheless, research on "middle age" as a stage in human development is growing due to increased longevity and a decreasing pro- portion of adult time being spent in active parenthood (Borland, 1978). Data from longitudinal studies suggest that specific events are associated with middle adulthood (Levinson, 1978; Medinger, 1981; Palmore, 1979; Rossi, 1980). The middle- aged adult is involved with implementing earlier choices of life style, occupational mode and family life which are evident by a variety of roles (Stevenson, 1977). Over thirty years ago, Havighurst (1954) noted that the last 5-4 developmental task of "middle age" is adjusting to aged parents. Recent historical changes in this century are placing new demands on families who care for their older members (Rosenmayer, 1977; Streib, 1976; Treas, 1979; Ward, 1978). Both middle-aged adult children and their aged parent(s) are caught in a "demographic bind:" more aging parents and fewer offspring to share the care of the parent(s) as the parent(s) grow older. The contemporary middle-aged adult is probably a member of a four-generation family, although the number of five-generation families is increasing (Neugarten, 1979; Shanas, 1980). Earlier in this century four-generation families were uncommon; today half of all persons over age 65 in the United States with living children are members of four—generation families (Shanas, 1980). Thus, it is con- ceivable that the middle-aged adult assumes interlocking roles (Shanas, 1980; Stevenson, 1977; Treas, 1977) within a particular family unit. These roles may include that of parent, grandparent, and possibly ”adult child" to aging parent(s). These roles give rise to new questions: Who is the elder of the family? Who is the adult child? Who cares for whom? For how long? Under what circumstances? What care is needed? Transformations in the social and economic organiza- tion of our society, however, have decreased aging parent(s)' power to insure their support by adult children (Dowd, 1980). V. 2,.“ u r i» .3 57. AL 2.. .nu ‘ an; a C». c. With the advent of social security, aged persons are more financially independent from their adult children than pre- vious cohorts of older persons. Changes in women's social roles, particularly the rise in work outside the home, have fostered competing obligations toward care of aged persons (Brody, 1981). Due to better educational oppor- tunities and improved economic status, middle-aged persons are less financially dependent on their parents. Hess and Waring (1978), after a review of demographic trends and research literature on intergenerational relations, con- clude that the relationship between adult child and aging parent is in transition from one based on obligation due to economic interdependence to one that is voluntarily assumed and based on emotional ties. Eighty percent of aged persons have living children, and of these adult children 75% live either in the same household or within thirty minutes distance from their parents (Olsen, 1980). The number of surviving adult children does not reveal the quality of the relationship between adult child and aged parent(s), however (Neugarten, 1979; Shanas, 1980). Though separate living arrangements generally are the rule, continuing contacts and exchange of mutual services within families with older members have been documented (Jonas, 1980; Seelbach, 1978; Shanas, 1979; Spark and Brody, 1965; Sussman, 1974). Silverman et a1. (1977) point out that the multigenerational family is maintained not by spatial proximity but through dependence and psychological ties. Troll (1980) suggests that families tend to react to the aging of their members in terms of their shared family theme or value system. Families in general behave responsibly in helping elderly persons (Kent, 1972; Neugarten, 1979; Shanas, 1979; Spark and Brody, 1965). The parents of middle-aged adults may be independent throughout most of their children's middle years. There may be minimal evidence of change in the relationship between the two generations. According to Stevenson (1977), more often there is a gradual transi- tion in the relationship, with the middle adult showing more concern for the welfare of the older parent. Most aged persons want to be independent but when they can no longer manage, they expect their children, who are usually in their middle years, to come to their aid (Brody, 1981; Lopata, 1978; Neugarten, 1979). This expectation is notably apparent in times of illness of the parent (Brody, 1978; Sussman, 1974). Often an event such as re- tirement, death of a parent, or the onset of chronic ill- ness, signals to the adult child that his parent(s) are growing older (Peterson, 1979; Shanas, 1980). The middle adult begins to think about the future and responsibilities that may be upcoming toward the older family member. Blenkner (1965) coined the term "filial maturity" to indi- cate the adult child's capacity to be "depended on" by his/ her elderly parent(s). ..m« AO c In “Us A» ‘ih From an ecological perspective, "perception of aged parents" is a function of the adult child's interaction with his/her environment or extended family system. Interaction indicates a relationship of reciprocal influence between a person and his/her environment. Environment, specifically the extended family system including aging parent(s), has a subjective reality to the extent and manner the adult child perceives it (Bubolz et a1., 1979). Interaction patterns and organizational levels of families with older members are key factors explaining which families with older members recover from major problems such as illness and which families do not (Streib, 1976). Considerable evidence suggests that health of the parent is a significant factor in the affective quality of the adult child/aged parent relationship (Johnson and Bursk, 1977). Thus, within the context of an extended family system adult children can act to enhance successful aging of the parent(s) (Shanas, 1977) or they can act to accelerate the process (Johnson and Bursk, 1977; Sussman, 1974), depending on the adult child's perceptions of the aging process of the parent(s). Although "adjusting to aged parents" is presumed to be an expected task of the middle-aged adult, care of aged parent(s) is complicated by the lack of societal modes or cultural norms that guide the adult child filial responsibilities (Johnson and Bursk, 1977; Roscow, 1976; Seelbach, 1978; Treas, 1977). The dependencies of older family members tend to be continuing, progressive in some cases, and at times Sporadic or untimely (Litman, 1974; Streib, 1976). Needs of elderly persons may arise as emotional chain—reactions from the loss of certain abilities and social positions (Rosenmayer, 1977; Simos, 1973). What is "special" about needs of older persons is often the intensity of the need coupled with limitations imposed by the aging process (Silverstone, 1979). Families with older members frequently enter a health care setting after the older member has become acutely and/ or chronically ill (Egerman, 1966). In the investigator's professional nursing practice, it has been observed that middle-aged adult children often provide various ongoing help— ing activities for the benefit of their parent(s) health and sincerely desire to continue to do so. Too often, how- ever, they express ambivalent feelings toward their par- ent(s), i.e., a sense of love or duty to "help" vs. frustra- tion and anxiety about their parent(s) response to their "help." In addition, present reimbursement mechanisms for health care limit services available to families with older mem- bers who are basically in good health but in need of inter- mittent help to remain functionally independent (Brody et al., 1978; Sussman et al., 1979). Brody et a1. (1978) note that the bulk of home health services for the elderly and chronically ill are provided by family members. Their data confirm that the presence/absence of a family caring unit is an important predictor in delaying, if not preventing, institutionalization of elderly persons. The health care system offers little guidance or preparation to families who desire to care for their older members except for intermittent home care for medical problems and expensive institutionalization. In addition, the "true costs" of maintaining elderly persons in their homes have been largely hidden because the greatest portion of such costs represent the services provided by family and friends rather than those provided at public eXpense (Pegals, 1980). Health care professionals may not be aware of the role (Archbold, 1982) that the adult child plays in the helping network (Streib, 1972) of the older persons whom they see on an irregular basis or one-time-only visit (Johnson, 1978). Often "unrealistic help" is eXpected from the adult child regarding the amount, type, and duration of care to the aged parent(s) (Hess and Waring, 1978; Robinson and Thurnher, 1979; Ward, 1978). Silverstone (1982) points out often sons or daughters of older persons may overestimate their own roles in their parents' lives. Typically, the middle-aged adult is confronted with a complex set of problems: little preparation for changing family rela- tionships resulting from untimely needs of their parent(s) as they grow older (Johnson and Catalano, 1981; Silverstone, 1979; Smith, 1979), a desire to exercise filial responsibility (Seelbach, 1978; Simos, 1973), and a lack of resources, skill, or support to provide care especially over a period of years (Streib, 1972). Brody (1973) warns that if current disease-oriented approaches continue as the single approach to health, then the needs of the elderly will be unmet. From a nursing perspective the family as a unit of health care has been introduced within nursing frameworks. Nursing practice is rooted in a fundamental concept of wholeness of life (Rogers, 1970) and is therefore concerned with helping networks available to older persons. Inte- gration of the family with older members, including the adult child/aged parent(s) relationship, into the practical component of nursing depends on accurate assessment and interventions based on an understanding of the adult child's perception of filial responsibilities if he/she is to continue to provide care to his/her aged parent(s). PUIEOSG Although there is much evidence to substantiate health needs of aged persons, how their families perceive the health needs of older members has received minimal attention in the literature (Olsen, 1980). Since adult children are likely to be caregivers to their aged parents, there is a need for a descriptive study to examine perceptions of adult children regarding health issues concerning their parents . flu p? . ahu a: F». :5. ‘A as their parents grow older. This research study is a des- criptive, exploratory study of one member of the extended family system, the adult child. The purpose of this study is to collect data about the perceptions of adult children regarding their parents' health needs, whether or not health assistance will be expected, and who would be likely to provide health assistance to their parents as their parents grow older. Increased understanding of the perceptions of adult children will assist health care professionals to make knowledgeable assessments and plan apprOpriate inter- ventions for adult children who desire to care for their parents as their parents grow older. Statement of the Research Questions The goal of this study is to measure perceived health needs, perceived health assistance, and perceived providers of health assistance in a group of adult children. The results will be analyzed to answer the major research question: How do adult children perceive health issues concerning their parents as their parents grow older? The sub-questions asked about health issues are: 1. What are the physical, psychological, and socio- economic health needs of aged parents as perceived by their adult children? 2. What are the expectations of health assistance for aged parents as perceived by their adult children? '11 10 3. Who is likely to provide health assistance to aged parents as perceived by their adult children? Conceptual Definitions Adult Children The term "adult children" generally is referred to in a structural sense as the "middle persons" in studies of intergenerational relationships and/or lineage studies (Bengston, 1979) and in studies of support networks to older persons. DevelOpmentally, adult children are usually in the "middle years" of the human life cycle. Stevenson (1977) refers to middlescence or middle years as the stage in the human life cycle when the adult life-style, the occu— pational mode, and the family life pattern have been chosen and individuals are involved in settling down to implement- ing their earlier choices. The forty year period, spanning approximately age thirty to age seventy, is further divided into two segments: Middlescence I, called the core or the middle years (30 to 50 years) and Middlescence II referred to as the new middle years (50 to 70 years). For purposes of this study, adult children are conceptually defined as persons in middlescence. Since the notion of Middles- cence I and II is not generally recognized by society and since society generally considers retirement to reflect the onset of "being old" (Shanas, 1980), adult children re a C I I Q d ‘ n qnv a a» \ ¢ t a. .3 at C. 2. .».. e .r. n . ». ~ 3 E C. u». at a: C . p .. .Q C ‘ tn .5 a t C l 3. 0 z. n. nu. 1’01"; 11 are defined in this study as persons 30 to 64 years of age who have one or more aged parent(s). Aged Parent(s) According to Stevenson (1977) the years between 70 and death have been chosen as late adulthood. The chronologic age-span is arbitrary because the length of human life has typically shifted upward. Since our society generally ac- cepts retirement and/or age 65 as "entry" into old age (Shanas, 1980), aged parent(s) are defined as parent(s) of adult children where: one or both parent(s) are living, one or both parent(s) are age 65 years or older, one or both parent(s) are retired, and one or both parent(s) live in a noninstitutional setting and apart from the adult child participant in this study. Extended Family System Duvall (1971) defines the final stage of family develop- ment as the "Aging Family," a stage that spans the period from retirement to death of one or both spouses. Shanas (1980) distinguishes between family and household. For most older peOple, the "family" is defined as that group of individuals to whom they are related by blood, marriage or adOption; in contrast to the term "household" meaning those persons living under the same roof. Troll (1980) fi .324 50A 1‘. « Du QC ...3. Q c V1 Q; Q» L I. .Y\ .. 3 an... .«IM R Us av. 34 12 prefers the term "families in later life" to connote family status where there are post-childbearing parents. Steven- son (1977) suggests that the final stage of the family life cycle is the "actualizing family" and it is marked by 40 to 60 or more years of cohabitation. Stevenson's approach to the stages of the family life cycle focuses on the accomplishment of developmental tasks of both children and parents as a somewhat joint process. In this way, familial relationships can be enhanced through the growth process (vs. isolation and deterioration of the family). For purposes of this study, an extended family system is conceptualized to be an "actualizing family" and includes, but is not limited to, the adult child and aged parent(s) as previously defined. The extended family system is considered to be the context within which health needs of aged parent(s), expectations of health assistance, and providers of health assistance for aged parent(s) are perceived by adult children. Perceived Health Needs of Aged Parent(s) Health is defined as dynamic life eXperiences of a human being and implies continuous adjustment to stressors in the internal and external environment through optimum use of one's resources to achieve maximum potential for daily living (King, 1981). Perception may be conceptually defined as an individual's representation or image of ate. lfiln "j .. o§ s AV H t «uJ 4. Eat} Pk. \I a .. a» «q 5‘ .h,“ .s.\ a» a.» 13 reality, awareness of objects, persons, and events (King, 1981). According to King (1981) human beings have three fundamental health needs: (1) useable health information at a time when they require it and are able to use it, (2) preventive care, and (3) care when they cannot help them— selves (p. 8). Johnson (1982) and other researchers point out that the needs of older persons often vary with the in- tensity of the need coupled with limitations imposed by the aging process. The aging process itself is a concept that is somewhat ambiguous, since its rate and the experiences associated with it vary with individuals (Barrowclough and Pinel, 1981). For purposes of this study, perceived health needs of aged parent(s) are defined as those health needs per- ceived by the adult child as specific requirements that may be experienced by their parent(s) as aging progresses and must be met if the parent(s) are to function at their maximum physical, psychological, and socioeconomic potential- Health needs are those which occur at some time in the future and are not intended to reflect the present health status of older parent(s). 1. Perceived physical health needs are defined as future changes in locomotion, nutrition, aeration, elimination, circulation, sensation, and rest that the adult child ex- pects his/her parent(s) to experience as they grow older. eYF A ‘I-d n.~ ‘ ¥ l4 2. Perceived_psychologica1 health needs are defined as future changes in individual roles, intimacy, family relationships, self-esteem, memory, desire to reminisce, ability to learn, and problem-solving ability that the adult child expects his/her parent(s) to experience as they grow older. 3. Perceived socioeconomic health needs are defined as future changes in ability to afford food, housing, cloth- ing, utilities, health care, social activities, and social roles that the adult child expects his/her parent(s) to experience as they grow older. Perceived Expectations of Health Assistance Aged persons may require health assistance not only for their fundamental health needs (King, 1981), but for those needs imposed on them by limitations due to the aging process. Garlinghouse (1982) defines health assistance as performing, guiding, supporting, providing a developmental environment, and teaching self-care activities necessary for an individual to attain and maintain maximum physical, psychological, and socioeconomic function. For purposes of this study, expected health assistance refers to the extent to which the adult child perceives his/her parent(s) will need help with a specific health need as the parent(s) grow older. €35: c H U AL y CC 3.. Cd ix .. 4 Cu .5 C . up... A v a» u g “U4 QC \l ‘ Th f,\ I ~ 5 K e E ¢L 3 e . .. r; e. r u v a . .. ‘3 x: r . J n, v u U. u u. 15 Perceived Providers of Health Assistance Providers of health assistance refer to persons gen- erally considered to be part of the helping networks of older persons (Litman, 1974; LOpata, 1978; Weeks, 1981) and may be members of either primary or secondary groups. In general, primary groups are defined as small groups charac- terized by face-to-face contacts with some degree of perman- ence such as family and friendship groups. Secondary groups are characterized by relations that are somewhat impersonal, as opposed to the personal relations of primary groups. The distinguishing feature of secondary relations is that inter- action tends to be stereotyped, involving only specialized segments of the individual (Society Today, 1971). For pur- poses of this study, providers of health assistance are defined as those persons perceived by the adult child likely to help the aged parent(s) with a specific health need. Providers of health assistance are dichotomized into: 1. Providers of health assistance within the Primary Ergup who may be friends and/or neighbors of the parent(s), one of the brothers or sisters of the adult child partici- pant, the adult child participant, the spouse of the parent(s), and/or relatives of the parent(s). 2. Providers of health assistance within the Secondary Group who may be a social worker, counselor, physician/ dentist, professional nurse, or a community/government worker. (n1 " $6-8. 16 Assumptions For purposes of this study the investigator makes the following assumptions: 1. That the adult child is and continues to be a member of an extended family system that includes aging parents. 2. That as aged parents grow older, they will experience some health needs that require assistance. 3. That the relationship between the adult child and aged parent is regarded as one aspect of the helping network of aged parent(s) and is desirable for success- ful aging of the parent(s). 4. That responses to the questionnaire reflect honestly and accurately the individual's perceptions at that point in time. 5. That the interactions between adult child and aged parent are theoretically such that health needs, expec- tations of health assistance, and persons most likely to help are perceived by both the adult child and aged parent, but not necessarily in the same manner. 6. That care of aged parents is a filial task of most adult children. 7. That perceptions of adult children are influenced by multiple factors (such as values, past experience) within and outside of the extended family system. 17 Limitations of the Study Limitations of the study include the following: 1. This study focuses on perceptions of adult children concerning future health issues that their parent(s) may or may not experience as they grow older. Actual health needs of their parent(s) as well as actual health assistance and providers of health assistance to their parent(s) are beyond the scope of this study. 2. The focus of this study will not be to describe how the aged parent(s) may influence perceptions of the adult child. 3. Expectations of health assistance from persons most likely to help are affected by various factors such as economic status, accessibility and availability of providers, past experiences, past relationships, and knowledge of resources. This study will not control for these variables and will not validate whether or not health assistance has been or will be obtained. 4. This study focuses on one adult child providing information on future health needs of his/her parent(s) and does not include perceptions of other persons as friends, siblings, or professionals. 5. No attempt was made to determine the structure of the relationship or quality of relationship between the 18 adult child and the aged parent(s) within the extended family system (i.e., biological child, step-child). 6. The adult children who agreed to participate in this study may be different from those who refused. Therefore, it is possible that the research findings are not representative of the total population of adult children with aged parent(s). 7. The research findings may not apply in the same way to various ethnic groups or to those persons who cannot read, write, or speak the English language. 8. In this study aged (one or both) parent(s) are 65 years, retired, and live independently from their adult children. Therefore, the research findings may not apply to adult children with aged parent(s) who live in an institutional setting or in the same household. 9. This study does not exclude adult children and aged parent(s) who have chronic disease; no attempt was made to validate medically the health status of either the adult child or aged parent(s). 10. The sample of adult children was voluntary rather than random. All persons who wished to participate and met the criteria were allowed to do so. 11. The questionnaire was administered by mail. Per- sons who respond to mailed questionnaires may have characteristics different from those who do not respond. 12. Since the questionnaire was mailed to the home of . u ‘. af’“ ‘M‘i '(, “I H r r ‘d 19 the participant, neither the setting nor the circum- stances under which the participant completed the ques- tionnaire were controlled. Overview of the Chapters This research study is organized into six chapters. Included in Chapter I are an introduction, purpose of the study, statement of the research questions, conceptual defi- nitions, and a statement of the assumptions and limitations of the study. In Chapter II the conceptual framework is presented. Relationships among the concepts is considered within the context of nursing theory. A review of the literature presented in Chapter III indicates pertinent background information relevant to the research questions and those variables which it addresses. In addition, literature is reviewed to support the use of the particular instrument and method utilized in this study. Discussion of methodology and procedures are presented in Chapter VI. Data collection procedure, instruments, scoring procedures, and human rights precautions are included in this chapter. The data collected relevant to the research questions and general descriptive data are presented in Chapter V. Additional findings are noted. In Chapter VI research findings are summarized and Q C020. m (J f‘ '1') 20 conclusions and recommendations are presented. Implications for professional nursing practice, education, and research are discussed. CHAPTER II CONCEPTUAL FRAMEWORK Introduction In this chapter, a conceptual framework is presented that will provide the basis for examining the research ques- tions and discussing the implications of study findings discussed in Chapter VI. The rationale for use of the particular framework in relation to the study variables will be explored. Although nursing interventions are not a part of the present study, the conceptual framework will be used as the basis from which nursing implications are derived for professional practice, education, and re- search. The conceptual framework utilized in this study is Martha Rogers' theoretical basis for nursing. A conceptual framework or conceptual system is characterized by an interrelated set of postulates having some relevance for some central phenomenon. Out of this conceptual framework, theories emerge directed toward achieving further under- standing of the real world (Rogers, 1970). The concept of extended family system or families with 21 22 older members is well recognized in literature about families and intergenerational relations and in geron- tological literature. Conceptually, the extended family system will not be discussed in these areas. Rather, Rogers' conceptual system provides a way to examine per- ceptions of adult children within the context of the family with aging members. The usefulness of Rogers' theory lies in its sc0pe and its range of applicability to complex nursing problems. Central to Rogers' conceptual system is the construct of Unitary Man which provides a broad perspective of man/human-environment and the human organism's response to various life processes as life, health, illness, and aging (Rogers, 1980). In the following sections, the investigator will address basic assumptions about the nature of man/human organism and how these assumptions relate to Rogers' Principles of Homeodynamics. These assump- tions and principles will be used to conceptually des- cribe the variables in this study, that is, the perceptions of adult children within the context of the extended family system. Unitary Man Four basic concepts compose Rogers' conceptual system: energy fields, a universe of open systems, pattern and organization, and four dimensionality. A brief definition of each concept is necessary to relate the conceptual 23 system to nursing. According to Rogers (1982), energy fields constitute the fundamental unit of both the living and non-living. The term "field" is a unifying concept and energy signifies the dynamic nature of the field. There are two energy fields: the human energy field and the environmental field. In other words, the unitary human field is an energy field, it does not have an energy field. Unitary Man is defined as an irreducible, four dimensional energy field identified by pattern and organiza- tion and manifesting characteristics different from those of the parts and which cannot be predicted from knowledge of the parts. The human and environmental fields flow through each other, they are open. Pattern and organization identify energy fields and the nature of the pattern and organization change continuously and innovatively. Change proceeds by continuous repatterning of both human and en- vironmental fields and reflects the mutual, simultaneous interaction between the two fields at any given point on a space-time continuum. Four dimensionality is concep- tualized as a non-linear domain or a space-time matrix. A "point in time" is a dynamic phenomena in contrast to a static phenomena. A "point in time" is a four dimensional matrix (length, breadth, depth, time) and is the "relative present" or "infinite now" for any individual (man/human- interaction). To summarize, interaction between the human energy field and environmental energy field is such that I 1 - ‘ bet ha 5 5133a o. AK» an FOX. AU \“ ..e: V‘n"._\ ugc.;. L. the ECWGG ". u “this“ 4“ d 24 both are repatterned —- mutually, continuously, simul- taneously, and with increasing complexity in a four dimen- sional time matrix along a space-time continuum. The Principles of Homeodynamics postulate the nature and direction of unitary human development. The Principle of Resonancy refers to the nature of the change occurring between human and environmental fields. Both are identified by "wave pattern and organization" manifesting continuous change, accelerating and decelerating, from lower frequency wave patterns to higher frequency patterns. The Principle of Helicy postulates the direction of the change. The nature and direction of human and environmental change is uni- directional, continuously innovative, accelerating and de- clining, probablistic, and characterized by increasing diversity. Though there may be commonalities in life experiences and reactions, the exact situation never recurs. Pattern and organization manifest itself as "non-repeating rhythmicities." The Principle of Complementarity refers to the inseparability of the human and environmental fields. Although this principle is inherent in the principle of helicy, Rogers emphasizes the continuous, mutual process between human and environmental fields as a contradiction to the notion of causality. In a universe of open systems, mutuality is eXpliCit -- human and environmental fields change together (Rogers, 1980; Rogers, 1982; Whelton, 1979). 25 According to Rogers (1980) the science of nursing studies the nature and direction of unitary human develop- ment which is integral with its environment. Hypotheses of predicted outcomes may be derived from the Principles of Homeodynamics for the development of nursing science (Whelton, 1979). These Principles provide direction to nursing practice and undergird the nursing process. The goal of nursing is human/environment interaction, to redirect and direct (re-pattern) for maximum health potential. Hence, nursing is a dynamic process, actively involved with human and environmental energy fields and is directed toward maximum health potential of both fields. Five nursing concepts are derived from Rogers' basic assumptions about the nature of human beings: wholeness, openness, pattern and organization, unidirectionality, and sentience and thought. Whelton (1979) summarizes the meaning of these concepts: 1. Wholeness -- there exists an individual integrity, an individual physical and psychological uniqueness, that is the person. 2. Openness -- there is a constant interaction between the person and his/her environment. This exchange is ultimately affected by and affects all other inter- action in the universe. 3. Pattern and organization -- as the person develops 26 he/she increases in complexity, his/her life-style and habits grow out of multiple previous human/environ- ment interactions. 4. Unidirectionality -- events in a person's life are unique, they do not come again or repeat themselves. 5. Sentience and thought -- a person has the ability to understand his/her world and his/her experiences in the world (p. 7). In summary, four concepts compose Rogers' conceptual system: energy fields (human and environmental), a uni- verse of open systems, pattern and organization, and four dimensionality. These concepts are manifested as Unitary Man. The Principles of Homeodynamics postulate the nature and direction of unitary human development. The Principle of Resonancy refers to the nature of the change, the Principle of Helicy to the direction of the change, and the Principle of Complementarity to the inseparability of the human and environmental fields. Nursing seeks to study the nature of unitary human develOpment integral with environ- ment and is a dynamic process. In the next section the application of Rogers' concepts and principles to the study variables are discussed. 27 Application of Rogers' Conceptual System to the Study Variables The "extended family system," of which the adult child is a member, is conceptualized to be a "group field" (Rogers, 1982) as depicted by the boxes in Figure 1. Environment is defined as an irreducible, four dimensional energy field identified by pattern and organization, manifesting charac- teristics different from those of the parts, and encompass- ing all that outside any given human field. It follows that the adult child and aged parent(s) can be considered to be the "environment" to one another since each are members of the same group field, or extended family system. The interaction of this relationship is depicted inside the boxes in Figure l. Repatterning of human-environment interactions within the context of the extended family system can be expected to occur as its members seek to accomplish developmental tasks associated with family and individual life cycles (which are necessary for maximum health potential). As the extended family system changes over time (and this change is not constant, but rather accelerates and declines), its members may have common life experiences and reactions but the exact situation never recurs. Simply stated, the extended family system is patterned and repatterned by multiple human-environment interactions that occur over time. Rogers' five basic nursing concepts about the nature of 28 Umm¢ mo samoamo :0 consume Ear—«sag 2.53.8 23338: mosmmH spammm ou Eoummm Hmsummocou m.ummom mo :oflumowaamd .mucmumm .H musmam flammn mp sumo swamp 3.2.332. 3.58.25— ........ . II---“ . . 6E Enoch.— . . u . Bro Grenada 2 m m u m :53. no}. Baggage ....... 4----u--¢.---------v---u--.---n--+-----u--s-uu----.wwmu--mw.-n------------------u------uu----o- " n u n P a .w a u u u " emu“ . . . . ummw " u u u m. n . u , 839»: s. 93 m m m m u. mm H. fish“... m u u m was . . . u. I .53: m m m n n m mm 5.32: can 33m 1 1 n 1 ma w . . . . J m. u m m m u w n. 3.358.885 Son m u n u ....... ..:..2&§5:.: m m m m no: :23. 3:5 :25: 33m 26E 839$ Esau coasts 98.5 95.5 305 36.5 53:25 in:e‘ 55' 1wt, 29 man can be applied to describe the extended family system. The concept of wholeness refers to the extended family system as a unit with members or "group field." The boxes in Figure 1 depict the extended family system as a unit with members which include the adult child and aged parent(s). The concept of Openness refers to the extent or degree of interaction within or outside of the family unit and is indicated by broken lines in Figure 1. Pattern and organization refers to that which gives the extended family system identity (i.e., habits, family themes, and surnames) and is derived from multiple human/environment interactions over time. Unidirectionality refers to events encountered by the extended family system (within and out- side of the family unit), events that are not repeatable. Sentience and thought refer to the capacity of family members to understand, to think, to experience each other, and to perceive each other. The relationship between the adult child and the aged parent(s) at any given point on a space-time continuum is irreversible, non-repeatable, rhythm- ical, and characterized by pattern and organization and by increasing complexity. Since perceptions, judgment, mental actions, and re- actions are not directly observable, inferences are made about these components of human behavior (King, 1981). Within the context of the extended family system, the adult child perceives health issues of his/her parent(s) in a 30 way that is familiar (patterning) and that has evolved over time (re-patterning). Based on Rogers' concepts of "rhythmicities" derived from the Principle of Helicy, change within the extended family evolves in sequential stages and increasing diversity. Re-patterning of the per- ceptions of the adult child can be expected to occur as the adult child seeks to accomplish develOpmental tasks as- sociated with family and individual life cycles (e.g., filial responsibilities). In other words, perceptions of the adult child about the health needs, expectations of health assistance, and who would most likely help his/her aged parent(s) will be characterized by patterning and re-patterning within the context of the extended family system. That is, they can be identified and described by nursing professionals and will change over time. Gathering data and deriving a nursing diagnosis are the first steps in the nursing process (Figure 1). The purpose of this study is to identify and describe percep- tions of a group of adult children concerning health needs of their parents, health assistance required for these health needs and persons most likely to help their parents as their parents grow older. Although this study focuses on one member of the extended family system, an understanding of the adult child's perceptions is necessary to nursing's relationship to the extended family system -- if the adult child is to perform filial tasks that would enhance the 31 health of the parent(s) rather than accelerate the aging process. The manner in which the adult child perceives health needs of his/her parent(s), whether or not health assistance is expected, and who is likely to help, may or may not be similar to the perceptions of the aged parent(s). The degree to which the adult child's perceptions are congruent with those of the aged parent(s), the more likely the process of interaction between adult child and aged parent(s) can move toward maximum health potential. The term "maximum health potential" is considered a value term by Rogers (1982). While this is the goal of nursing, it is not defined by nurses for the recipient of nursing care. Rogers (1980) notes that values change as new knowledge revises old views. Since nurses seek to promote well being, interventions are designed to help the adult child evolve in directions that are valued or deemed desirable (i.e., the filial role) which may change over time as the adult child interacts (or does not interact) with his/her parent(s) as they grow older. Nursing inter- ventions change as perceptions of the adult child change. Evaluation is the final component of the nursing process, the formulation of new interventions for goals not achieved. Rogers (1970) supports a cyclical process of evaluation of nursing interventions stating that the dynamic nature of life signifies continuous revision of the nature and meaning of diagnostic data and concomitant revision of interventional measures. h .c 32 In summary, Martha Rogers' theoretical basis for nurs- ing is utilized to conceptually describe perceptions of adult children about health issues within the context of the extended family system. Based on Rogers' conceptual system and Principles of Homeodynamics, the extended family system is conceptualized to be a "group field" with multiple pat- terns of human/environment interactions, one of which is the adult child/aged parent(s) interaction. Figure 1 depicts nursing's relationship to the study variables. Perceptions of the adult child concerning health needs, health assistance, and persons likely to help parent(s) as they grow older is considered to be one pattern of human/environment interaction and as such identifiable and describable by nursing. Perceptions of adult children will change over time and as the parent(s) grow older. An understanding of these perceptions (commonalities) are necessary to design nursing interventions that maximize and facilitate the health potential of the extended family system and its members (if the adult child continues to be a caregiver to his/her parent(s) as part of the filial role). The results of this study will contribute to nursing knowledge by assisting nurses to identify, des- cribe, explain, and make predictions about patterns or commonalities of human/environment interactions. Further, results of this study can contribute to the practical component of nursing by providing a knowledge base from 1 un- Du. 33 which creative interventions are derived for the nursing care of adult children who have elderly parents. In the next chapter, a review of literature pertinent to the research questions is presented. In addition, literature is reviewed to support the use of the particular instrument and method utilized in the present study. £3 ()1 V‘ \c P) f f‘ (f CHAPTER III LITERATURE REVIEW Introduction The literature reviewed in this chapter focuses on the major constructs of this research and supports its rele- vance to other literature. The major constructs are: per- ceived health needs of aged parent(s), perceived health assistance, and perceived providers of health assistance. Since adult children are considered within the context of the extended family system, literature is presented from this perspective to include the concept "health" as a variable modifying perceptions of intergenerational rela- tionships and the filial relationship. Perceived Health Needs of Aged Parents "Health" as a variable modifying intergenerational relation- ships Results from recent empirical studies suggest that variables associated with the concept of health can be related to certain aspects of the adult child/aged parent 34 35 relationship. Such aspects include: the affective quality of intergenerational ties (Halprin, 1979; Johnson, 1978; Johnson and Bursk, 1977). life satisfaction (Collette- Pratt, 1976; Markides et al., 1981), the amount of stress experienced by adults, especially women, caring for aged persons (Brody, 1981; Egerman, 1966; Medinger, 1981; Robinson and Thurnher, 1979; Smith, 1979) and with filial responsibility expectations and realizations (Seelbach 1980). Johnson and Bursk (1977) interviewed 54 pairs of non- institutionalized white, elderly parents (age 65 and over) and their adult children (age 21 and over) to explore the affective quality of their relationship in four areas: health, finances, living environment, and attitudes toward aging. These areas were related to "family rela- tions" indicator that included a number of questions ad- dressed to both the parent and the child about the open- ness of communication between them, their enjoyment of each other's company, their ability to count on one another, and an actual rating of the relationship. Their findings suggested that the better the elderly parent's health, the better the relationship between parent and adult child. In addition, the better the elderly parent's attitude toward aging, the better the relationship between elderly parent and adult child. One year later, Johnson (1978) reported data from interviews with Italian, older, single mothers (age 60 be. til :1. I ~ C J ‘3 L . Av D ‘3 6.» H 36 and over) and their daughters (90 pairs) designed to ex- amine "good" family relationships using the previously defined life areas of health, finances, living environ- ment, and attitude toward aging. Attitude toward aging was the strongest direct predictor of quality of relation- ships. Living environment had the second highest contribu- tion, while health and finances had an indirect effect through their influence on living environment and atti- tude. The value of Johnson's studies in relation to the present study is that the variable "health" is measured by a group of items in contrast to a single item. As an indexed variable,health was demonstrated to influence attitudes toward aging and ultimately other life areas of the elderly adult, such as the parent/child relationship. Egerman (1966) speculates that this modification of the adult child/aged parent relationship is due to a loss of the usual parent/child relationship, especially as a result of "dependency" problems of the parents. After an exten- sive review of literature on families with older members, Streib (1976) concludes that poor health and economic dis- advantages are among the major sources of problems of fami- lies with older members. Data from other empirical studies support Johnson's conclusions. In a study of patterns of influence between middle-aged adult children (median age 50) and their fi ,1 F; C» LG» HUS H fi \n O :15 av— O I y . h H n1. vu A: . w-.. A V . C. .r. t c “We 37 parents (N = 148), Halprin (1979) concluded that more than half of the adult children tried to influence their parents regarding health issues. Markides et al. (1981) examined perceptions of intergenerational relations and psychologi- cal well-being among elderly Mexican-Americans and found that the variable "health" had a strong independent effect on life satisfaction. Collette-Pratt (1976) studied atti- tudinal predictors of devaluation of old age in a three- generational (young, middle, old) sample (N = 327). Nega- tive attitudes toward poor health significantly contributed to the devaluation of "old age" for all generations. In summary, the variable "health" has been directly or indirectly related to the quality of the adult child/ aged parent relationship. Although "health" was not the major variable of these studies, it was frequently measured and cited with major significant findings. There is little consistency, however, in the measurement of health. The point to be made is that in some way the "health" of elderly parents modifies the adult child/aged parent relationship and it is not clear what health issues are involved. The present study clarifies the concept of "health of aged persons" by differentiating between their health needs, health assistance and persons providing health assistance. Literature generally supports the premise that better rela- tionships between generations are associated with parents who are perceived to have better health and who are (FL fly. .‘.1 HF. Lu 38 perceived to have better health and who are perceived to be functionally able to perform daily activities. Health needs of agedgparents As with all stages of human growth and development, the period of "old age" is accompanied by changes in biologic, psychological, and socioeconomic function. Few empirical studies are reported in the literature about the impact of parental aging on perceptions of adult children. In this section, literature concerning perceived health needs of aged parents will be organized in the following manner. First, a brief discussion of the basis for instrumentation utilized in the present study will be presented. Second, a discussion of empirical studies will be presented to support the need for the present study. The scales used in the present study to measure per- ceived health needs of adult children were adapted from the scales designed by Garlinghouse (1982) who studied perceived health needs of older persons (in Chapter VI, these scales are discussed in detail). Data were collected by means of a self-administered questionnaire from 56 independent older adults age 65 to 89 years who perceived themselves to be in good health and resided in subsidized housing or were volunteer workers in the community. Gar- linghouse concluded that older adults need assistance to direct activities toward meeting physical, psychological, and tut 39 socioeconomic health needs in order to maximize their in- dependence in late adulthood. According to Garlinghouse (1982) physical, psycho- logical, and socioeconomic changes can be expected to occur as aging progresses in the human life cycle. After an ex— tensive review of literature, Garlinghouse summarizes pos- sible expected changes for face validity of each scale. Common biologic changes of aging may include: hypertrOphy of bone at joints, decreased sensory perception in each of the five senses, increased frequency and precipitancy of urination, less restful sleep. Psychological changes that may be associated with the aging process include: minimal change in intellectual ability, changes in roles, a need to leave a personal legacy, continuing supportive family relationships, a need for sexual expression and intimacy, a need to accomplish apprOpriate developmental tasks. Socioeconomic changes vary widely and depend to a great extent on past financial status and expenditures (Ebersole and Hess, 1980; Kalish, 1975). Examples of socioeconomic needs of elderly persons may include pos- sible difficulty paying utility bills or food, or managing personal finances. Like the previously cited studies by Johnson, Garling- house used multiple scales to measure the concept of per- ceived health, specifically, perceived health needs, per- ceived health assistance. In a seminal study most relevant 40 to the present study, Simos (1973) studied the viewpoint of Jewish-American adult children (N = 50, age 30 to 68 years) in relation to problems of their aging parents (N = 60, age 60 to 94). The sample was selected from the clientele of a Jewish family agency after the adult child had re- quested information or services for a problem concerning their parent(s) who lived in the same community. Data were obtained in personal interviews using a semi-struc- tured interview schedule. The range of problems perceived by the adult children were categorized into physical problems of the parent(s), psychological problems, family relationships, social prob- lems, problems associated with a lack of care facilities, financial problems, and housing problems. Using inductive reasoning, Simos identifies three major problems as most dis- turbing to adult children: the failing health of the parent(s) and the resulting need for family and community resources, problems associated with multiple losses, and long-standing interpersonal problems. There are several problems associated with the Simos' study, and caution must be taken with regard to the inter- pretation of results. No attempt was made by the investi- gator to control for characteristics of the aged parents (i.e., institutionalized or living in their own homes). The sample of adult children was taken from a group of adult children who had already decided to seek out a 41 service agency for a particular reason. Because the sample size was small (N = 50), and it was taken from one cultural group, it can be argued that the study is more or less an evaluation study of a service agency and does not offer generalizable explanations. According to Rogers (1970), theories emerge out of a conceptual system through what is typically an inductive process. Polit (1978) notes that in the building of theories, observations are made about natural phenomena or findings from interrelated studies and then links or hypotheses are made to develop a more abstract explanation of relationships. Although adult children continue to provide parent care activities, little is known about their perceptions regard- ing specific health issues of their parents. The usefulness of Simos' study lies in the fact that it pioneered the empirical investigation of perceptions of adult children about health issues pertaining to their parents and it attempted to categorize these health issues according to needs of aging parents as perceived by their adult children. Physical health needs In Simos' study, almost all of the sample of aged parents had physical problems ranging from serious disease (e.g., cardiovascular disease) to serious disability re- sulting from chronic disease (e.g., glaucoma). If physical problems were combined with psychological problems, the 42 adult child had little time to help with other problems their parents may be experiencing. Simos concludes that the study "clearly showed that the aging process itself was responsible for the physical problems of the parent" p. 79). It is not clear what is meant by "the aging process" since the sample of adult children reported changes as- sociated with aging intermingled with physical problems associated with disease or mismanagement of drug therapy. Studies about care of elderly persons by family members report findings that indicate physical problems of the elder are particularly stressful to the caregiver. Smith (1979) studied the effects of role strain on middle genera- tion women (age 40 to 69 years, N = 24) and concludes that the degree of strain experienced was related to the level of care necessary and the degree of confinement they ex- perienced. Similar findings have been reported by other researchers (Robinson and Thurnher, 1979; Townsend, 1965). Psychological health needs In the Simos' sample of adult children, all the parents were perceived to have psychological problems. The parents' general unhappiness was the most frequently reported psychological problem and depression was the second most frequently reported cause of discomfort to the adult child— ren. Both conditions seemed to develop as the parents grew older. One-quarter of the adult children reported 0. (I) n H1 Dr, in '(J '4. m DI 43 warm relationships with no serious rifts or family align- ments, while three—quarters reported a variety of familial problems resulting from "parental aging." Parental mounring was recognized by the adult children primarily when the loss had to do with a significant other, such as a spouse or child, or with a loss of health. Simos concludes that rarely did an individual adult child realize that the parent might also grieve over other losses as loss of a job, a social role, self-esteem, independence, a life-time home, or the failure of bodily functions or sensory acuity. Isolation and denial behaviors used as defenses by the parents were perceived by their adult child- ren as a lack of feeling on the part of the parents. Feelings of helplessness and despair as well as expected reactions to loss were viewed as stubbornness of the parent(s) and/or evidence of senility. Stevenson (1977) suggests that the middle-aged adult child is in a position to help the older generation pro- gress through the later years. This means that the adult child must be familiar with developmental tasks and other psychological needs of later life and, in a way similar to the developmental process pursued with children, act as a growth-enhancing force rather than a growth-impeding force in the older person's life. Too often middle-aged off- spring attempt to control the lives of their elders with authoritarian tactics that promote hostility, dependence, or guilt (Egerman, 1966; Hirschfield, 1979; Rautman, 1972). 44 Much confusion about generational relationships center about the concepts of dependence-independence (Spark and Brody, 1965; Steinman, 1979) and acceptance-rejection conflicts (Steinman, 1979). Simos would add the concept of loss as a psychological and generational problem within families who have elderly members. Socioeconomic health needs In the Simos' study, adult children frequently admitted being unable to distinguish between their parents' actual social problems and what they thought should be their parents' social problems. Adult children felt their par- ents would be happier if they were socially involved and socially active. Some of the adult children stated they felt uncomfortable visiting their parents when "there is nothing to do, we just sit there." In general, adult children did not think they might support their parents emotionally merely by their presence and interest. Another major social problem was the parents' reluctance to socialize because of limited functional impairments as poor vision or arthritis. They were often puzzled by parents who did not initiate social contacts but who might have been outgoing and sociable when they were younger. Adult children tended to blame "the system" for making it financially prohibitive to care for their parents and believed it was society's responsibility to support their 45 parents as payment for past productivity. When parents were relatively healthy, the dread of future illness with the ac- companying medical expenses hovered in their minds as a contingency with which they could not deal because predic- tion or preparation was impossible. In general, adult children felt their primary finan— cial obligation was to their own nuclear family and then to their married children and grandchildren. Most of the sample of adult children were reconciled to the inevit- ability of one or more housing changes as their parents grew older and as the need for comprehensive medical care and nursing care increased. In summary, literature available on physical, psycho- logical, and socioeconomic health needs of aged parents as perceived by their adult children is limited. Gener- ally, physical health needs are perceived by adult child- ren in relation to the level of functional impairment of the parents and the degree of confinement experienced by adult children. The most frequently reported psychological health needs of older parents as perceived by their adult children center around the concept of loss. Adult children fre- quently misunderstand and misinterpret their parents' psychological health needs. In the area of social problems of parents, adult child- ren were most subjective and tended to view their parents' social needs in terms of themselves. Social problems 46 resulted from the children's desire that the parents be socially involved and from the children's inability to accept the parents' difficulty in making new contacts. There appears to be a shift in the adult child/aged parent relationship taking place with deterioration in the health of the parent(s). Adult children consider inter- personal problems as long-standing and resulting from the parents' personality structure which had become solidi- fied by age. Parents were perceived strictly in the present and were perceived on the basis of the parent- ing they had provided or had failed to provide during the adult child's formative years. In many instances, adult children perceive the needs of their parents based on past relationships; present or future relationships were dif- ficult to consider. Perceived Health Assistance for Aged Parents The filial relationship In a study related to the Johnson's studies and the Simos' study, Ames (1982) compared perceptions of elderly parents and their adult children (50 pairs) regarding sup- portive services for the elderly parent via data collected in home interviews. Ninety percent of the adult children visited their parents at least weekly. Adult children perceived they were spending a significantly larger amount 47 of time listening to their parents' problems than did parents. Both generations agreed on the amount of time spent in instrumental activities (i.e., home maintenance). Using a combined measure of physical, emotional, and fin- ancial independence, parents judged themselves signific- antly more independent than did their children. Although the concept of future health needs of the elderly parents was not a major study variable, Ames concluded that there was general agreement between parents and their adult children as to ideal living arrangements and types of services needed and that adult children were providing considerable emotional support to their parents. English (1979) attempted to answer the question "what do grown children owe their parents?" She argues that adult children do not "owe" help to parents as a "debt" of gratitude, but that when there is a close bond between parent and child, then they help one another as friends do. Where friendship is lacking, nothing is owed. Child-parent relations in earlier stages of family de- velopment often are characterized by a superordination/ subordination relationship. Once the child leaves and is freed of this relationship, it is possible to develop mutual respect and caring for one another (Hess and Waring, 1978). English suggests that filial obligations of grown children are a result of friendship characterized by mutuality rather than one of "reciprocal favors." Other 48 investigators would support the need for friendship as a mode of assistance between adult child and aged parent (Cohen, 1978; Hess and Waring, 1978; Johnson, 1982; Troll, 1980). In 1965, Blenkner coined the term "filial maturity" to indicate the adult child's capacity to be "depended on" by his/her elderly parent(s), thus socializing the adult child to his/her own "old age." Due to increased lon- gevity, Blenkner observed that it was "becoming increas- ingly sterile to view the latter two-thirds of life as mere repetition and re-enactment of the first third" (p. 56). Filial maturity is an expected adult transition from "genital maturity" which occurs early in the human life cycle to "old age." Blenkner was concerned with con- ceptual clarity of a developmental sequence in the human life cycle rather than a chronological span of years. A filial crisis marking Childhood's end can be expected to occur for most individuals in their forties or fifties. A filial crisis is characterized by the middle-aged adults' realization that their parents can no longer be viewed as a main support in times of emotional trouble or economic stress but instead need their comfort and support. Per- formance of the filial role, which involves being depended on and therefore being dependable insofar as the individual's parents are concerned, leads to filial maturity of the middle-aged adult. According to Blenkner, performance of 49 filial tasks and assuming the filial role, socializes the middle-aged adult for successful accomplishment of the developmental tasks of old age, the last of which is to die. Through identification with the parents as in child- hood, the middle-aged adult prepares for his own old age. Central to the concept of filial maturity is the con- cept of dependency. Spark and Brody (1965) observe that increased dependency needs of older people have led to unfounded formulations of "role reversal" or the adult child becoming the "parent" to his/her elderly parents. The idea of "role reversal" as prOposed by Rautman, a clinical psychologist, in 1962 is largely theoretical. Rautman assumes that all old peOple become dependent and "aging" is equated with deterioration and disease. Few empirical studies and analysis of demographic trends would support this premise. Blenkner notes that the concept of role reversal is not a normal but a pathological develop- ment in the adult child/aged parent relationship. From a more recent psychological perspective, Weishaus (1979) points out that a frequent reaction to cumulative losses throughout the aging process (i.e., loss of health) is a dependency pattern. The aging person turns to another -- usually a spouse or an adult child -- and attempts to ob- tain from that single source the gratification that pre- viously came from many sources. Empirical research (Egerman, 1966; Shanas, 1979; Sussman, 1974) has demonstrated that aging parents do turn to and depend upon their adult 50 children for help in meeting daily requirements of living. Spark and Brody (1965) modify Blenkner's concept of filial maturity to include consideration of the adult child's life situation (physical, emotional, and social) and con- sideration of the aged parents' capacity to be dependent -- i.e., to permit the adult child to become filially mature. Although the concept of filial maturity is not a well documented developmental sequence from the perspec- tive of adult children, related concepts have been em- pirically studied from the parents' perspective. Seel- bach (1978) reports data concerning filial responsibility expectations and realizations among 595 low—income, elderly parents with adult children. Filial responsibility expec- tations was defined as the level of expectations that older parents had regarding the duties and obligations of their offspring. Behavioral realizations of filial responsibility was defined as the level of filial aid and support re- ceived by the parents. Age, marital status, income, and health of the elderly parent were significantly associated with both filial responsibility expectations and behav- ioral realizations. On the basis of his findings, Seel- bach draws the following conclusions about filial respon- sibility expectations and realizations from the elderly parents' perspective. First, as the parents become older, they tend to expect more from their adult children in the 51 way of filial aid and support. Second, married elders tended to depend more upon their spouses than upon their children, but once the spouse dies, the surviving parent expects more from adult children. Third, parents having lower incomes tend to have more needs and higher expecta- tions than parents with higher incomes. Finally, parents intended to expect help from their children only when aid or support was actually needed, e.g., when health fails. In a similar study (using the same variables and measurement tools) conducted in 1980, Seelbach studied a Philadelphia sample of 442 blacks and 143 white parents over 65 years of age to determine if filial responsibility eXpectations and realizations were significantly higher among blacks than among whites. All of the respondents had low income and were similar in terms of filial expecta- tions and realizations. Data did not support the hypotheses that filial expectations and realizations varied among races. Data supported the notion that what may appear to be racial differences in family structure and functioning may actually be socioeconomic differences. During Johnson's interviews of Italian mothers and their daughters (1978), an interesting observation was made. When participants responded to the question why they thought their relationship was good or bad, 47% of the mothers and 38% of the daughters said that their respective daughter or mother met family role expectations. 52 A second reason for a "good" relationship offered by 46% of the mothers and 43% of the daughters was that their relationship with their respective daughter or mother was cumulative and had been consistent over time. Similar findings were reported by Seelbach and Hansen (1980) in a comparison study of institutionalized elderly persons (N = 160) and community-dwelling elderly persons (N = 207) whose mean age was 79.8 years. While 80% of the sample were satisfied with their family relationships, significant differences were found between the young-old and the old-old, the married and the widowed, as well as between institutionalized and community-dwelling elderly. Brody (1979) states that as with other life crises, filial maturity cannot be achieved in a vacuum unrelated to the dynamic context of the total family. Filial maturity not only involves the parent-child dyad, but spouses, sib- lings, in-laws, other relatives as well and is complicated by their personalities, attitudes, reactions, behaviors. The structure and dynamics of extended family relation- ships affect the outcome of tie filial crisis. Brody states that if the adult child must acquire the capacity to be depended on, the elderly parent must have the capacity to be apprOpriately dependent and thus to permit such growth. 53 Additional characteristics of assistance As noted in Chapter I, Hess and Waring (1978) conclude, after an extensive review of literature on intergenera- tional relations, that the adult child/aged parent relation- ship is in transition, from one based on obligation due to economic interdependence to one that is voluntarily assumed and based on emotional ties. In terms of attitudes toward family responsibilities, the investigators suggest that "extended expectations" are being replaced by "minimal anticipations" of care from adult children. The mainten- ance and sustenance of the adult child/aged parent bond will be increasingly based upon the willingness of both family members to engage in supportive behaviors, and that this willingness often hinges on the quality of the relationship over many preceding decades (Troll, 1980). Robinson and Thurnher (1979) examined the experiences of adult children (ages 39 to 65 years, N = 49) in caring for an aged parent (ages 64 to 97 years, N = 60) over a five year period. Parents with physical and/or psycho- logical disabilities received more help from an adult child. From the perspective of the adult child, gratifying rela- tionships with parent(s) seemed to depend largely on the relative independence of the parent(s) and the values and cherished lifestyle of the adult child. It was not so much the actual instrumental activity involved in the care of the parent which was perceived as burdensome, but the 54 routines and confinement that were brought about by the parents' need. To the extent that changes in the adult child/aged parent relationship across the five-year period of study were mentioned, comments were more likely to be negative than positive. Adult children were providing assistance to their parents in the form of emotional sup- port and activities of daily living; few were providing financial assistance to their parents. From a develop- mental perspective, Robinson and Thurnher observe that the coincidence of the parent's maximum demands with the adult child's own awareness of shrinking futurity exacerbates stress and conflict and underscores the need to identify ways for reducing stress in both generations. Data support other research findings (Brody, 1978; Smith, 1979) that adult children strive to delay the parents' institution- alization at considerable cost to themselves. In addition, prolonged dependency needs of parents increase the stress experienced by the caregiver. In summary, accomplishment of filial maturity involves the capacity or willingness of the adult child to be de- pended on and the parents' capacity to be apprOpriately dependent. While assistance patterns between adult child and aged parent persist, their relationship is in transi- tion, from one based on obligation to one that is based on a volunteeristic model. Assistance provided by adult children tends to be in the form of instrumental help with 55 daily activities (particularly when parents are ill) and in the form of emotional support. Consideration of the life situation of the adult child and level of care re- quired by parents are major factors affecting assistance patterns. Perceived Providers of Health Assistance The family of older persons continues to be the major source of support identified by elderly persons. Eighty percent of all medically-related and personal care ser- vices are provided by family members (0.8. Public Health Service, 1972). Based on national data, Shanas (1979) reports that older peOple are most likely to turn first to family, then to friends and neighbors, and last to social and government agencies, particularly during times of ill- ness. The traditional role of family members as providers of assistance to older persons may be affected by recent sociodemographic characteristics of families such as: geographic mobility, smaller family size, fewer unmarried children, and increased participation of women in the work- force (Treas, 1977). Weeks and Cueller (1981) suggest that major "group differences" exist in the helping networks of older peOple. Using data from a survey of 1139 older persons representing ten different ethnic groups, the investigators found that immigrants were more likely than native-born older persons if (H Cl .' ' p4 f—J 56 to have family members to turn to in times of need. They conclude that although members of family networks may have to assume a more important role in the coming era of dwindling resources, these helping networks are not evenly distributed throughout the older population. Bab— chuk's study (1978-79) of 800 non-institutional persons (age 45 and over) supports the observation that few older persons are isolated from helping networks and that kin are not necessarily part of what the older person con- siders to be his/her "primary group" helping network. In a comparison study of a sample of disabled elderly (age 60 and over) who were residents of public and private homes (N = 534) and those were clients of Home Health Agencies (N= 485), Brody (1978) reports that differential levels of functioning ability did not predict placement of the chronically ill/disabled in institutions or in the com- munity. Rather, the presence of a caring unit (e.g., spouse, children, or other relatives) is the key variable that explains the placement of chronically ill/disabled individuals. The five percent of those persons 65 years and over who live in institutions at any one time are out- numbered two to one by equally disabled older persons living in the community, a proportion that remained stable between 1962 and 1975 (Shanas, 1979). Johnson and Cata- lano's study (1981) of a sample of childless elderly persons (N = 28) suggests that marital status is the major 57 determinant of the quality of support received and the patterns of adaptation in later life. Childless married elderly persons were more isolated and tended to rely primarily upon each other, while the unmarried elderly persons were more resourceful in using a long-term ac- cumulation of social resources to meet their needs. LOpata (1978) examined various support systems of Chicago area widows (N = 1169) by means of two different one-hour interviews. Support systems included economic support system (i.e., gifts of money or food, help paying for rent); service support system (i.e., transportation, care during illness and help with housework); social sup- port systems (i.e., visiting, celebrating holidays); and emotional support systems (i.e., relational sentiments, self-feeling states). The hypothesis predicting an active modified extended family network with exchanges of sup- ports from separate households was not supported for any relatives other than children of the widows. Kin members, such as siblings and relatives not directly in the parent- child line, were not important contributors to the support systems of this particular sample of widows. Friends tended to be regarded as companions in social activities. Other related studies (Shanas, 1980; Sussman, 1974) further demonstrate that aging parents do turn to and depend upon their adult children to help with their daily requirements. Fandetti and Gelfand (1976) report data gathered from .D 6.. Ca \ RI. 4 LL 58 interWJiews composed of an open-ended and structured schedule conduuzted with a sample of Italian and Polish family mem- bers (age 21 to 50 years) in Baltimore. The purpose was to ascertain preferred living arrangements for elderly re1a1:ives, attitudes toward non-family resources, and feelings towaxnd non-ethnic caretakers. A majority of the respondents indixzated a preference for intergenerational household arrangements for ambulatory relatives, a preference for churnsh rather than governmentally operated services, and a Posjstive attitude toward well-trained, non-ethnic profes- sional caretakers. fro explore the attitudes and preferences for service Provmiders among three generations of women, Brody et al. (19759) interviewed family triads (N = 240) of grandmother, adulst daughter, and young adult granddaughter. Two instru- mentms were used: the first, consisted of forty-seven state- men1;s relating to aging, gender roles, dependence/independence, and.:fi1ia1 responsibility in which responses were scored on a Likert scale of one to five, the second instrument elicited the subjects' preferences for service providers based on their own existing or projected needs in old age. sutElects were asked to rank their own preferences for ser- vice providers from six possible sources for each of eight categories of service. Although the investigators reported differences between the generations, certain themes were endorsed by all young I elder : people nd th of won mather data m. Projec- life 5- SeIVat maturi H. (“at d 59 generuations. Attitude data generally supported strong feelings of filial responsibility of both middle-aged and young; women and their willingness to be depended on by the elder“ family member. All three generations agreed that old peoplxa should be able to depend on adult children for help and tunat adult children should keep in close touch with elderly parents. Interestingly, the youngest generation of unamen felt more strongly than their mothers and grand— motkuars about filial dependability. Brody suggests the data.:may reflect the inability of the younger generation to proj ect themselves psychologically and may reflect age and life: stage rather than a generational trend. This ob- serveation would support Blenkner's premise that filial matuzrity is a develOpmental phenomena. Brody emphasizes that. data do not reflect a moving away from the traditional values of family responsibility to older members. In other words, the "new value" of women working has not diminished the '"old.value" of family care of the elderly. The three Generations were more in favor of sons of elderly parents Sharfiing parent-care equally with daughters, an observation made by other researchers (Brody, 1981; Robinson and Thurn- her, 1979) of the changing attitudes with respect to gender- aPPrOpriate roles. There was generational agreement on some preferences for service providers. All generations preferred an adult Child for intimate functions such as help with problems 591V hous gene and 60 (i.e., confidant) and with financial management. Middle generation women preferred "private-pay sources" to "them- selves" for personal care and instrumental services (e.g., housework, home repairs and meal preparation). Middle generation women expressed the need for emotional closeness and confidentiality rather than services that involve time and "hands-on" activity. In all three generations, family bonds and responsibility were seen as quite dif— ferent from money or concrete services. The investigators note that the unpopularity of friends, neighbors, volunteers as service providers should not be interpreted as eliminat— ing them from such roles; childless older persons have been shown to benefit significantly from services provided by friends and neighbors who assume a surrogate family role (Johnson, 1981; Cantor, 1975). Shanas (1979) describes this social support pattern as the "principle of substitu- tion". This principle emphasizes the primacy of filial support; however, it can be extended to suggest that older people will substitute close relationships with more re- mote kin when children are not available. Brody et a1. conclude that their data confirm the fact that "no sim- plistic scheme which sorts types of service into neat cate- gories by apprOpriate providers is applicable to all older people and their families" (p. 29). Rather, the hetero- genity of needs of families with older members requires a diversity of options. CE P .0. C. 5? i9 1 'P.’ f); 61 Archbold (1982) investigated the impact of "parent- caring" on the lives of 30 Caucasian women to identify those factors which influence decisions about parent-caring, analyze caregiving behaviors, describe the strategies used by caregivers, and analyze the consequences of caregiving. Data were collected using a focused interview, participant observation, and a multi-dimensional functional assess- ment. Qualitative analysis of data suggests the existence of three parent-caring roles: care provision (identification of parent needs and provides services directly), care manage- ment (identification of parent need and manages the pro- vision of care by others) and care transfer (transfers all caregiving to another agent). Archbold identifies four factors that influence whether or not an adult child assumes a parent-caring role: socio- economic status, housing arrangements, illness onset of the parent(s), and past eXperience with caregiving. Socio- economic status is of greatest importance; income is the primary determinant of whether and how many services can be purchased. Problems encountered by the adult child were related to the caregiving role assumed by the in- dividual. Adult children who considered themselves to be "managers of care" required skills in both individual and systems assessment as well as in negotiation with the social system. Those who were "providers of care" were too burdened with physical care of the parent(s) to focus on Cu ‘5 A.» new. ts e. E. 62 other types of support. Often care providers experimented by trial and error for long periods before a satisfactory solution to a problem of their parents was worked out and, once established, the solution was rigidly adhered to. Based on an analysis of national data, Brody (1979) notes that the amount of care provided by families to older persons is greater than that provided by formal care and other support systems. Eighty percent of medically- related care and personal care are provided by families as well as activities as household maintenance, cooking, transportation, and emotional support. The vast majority of services are provided by a spouse, if there is one, and by daughters and daughters-in-law (Litman, 1974; Shanas, 1967; Stehouwer, 1965; Sussman, 1965). Care of elderly persons involves complex bureaucracies as well as family members. Litwak (1965) developed the concept of shared functions where formal organizations and families must coordinate their efforts if they are to achieve their goals. It is likely that family and kin networks will play facilitating and mediating roles for their elderly members in dealing with service organiza- tions (Treas, 1977). Sussman (1977) suggests that family members may have to assume a linking role in addition to a caregiving role. The motivations, skills, special interests, experiences, and training as well as the circumstances, situations, age, and sex of members are among the main fac.ors member the lir dealing family tion. may nee pendenc Des relatic thEII F from th ren, me are im 63 factors which determine whether the individual family member takes the initiative in linking. The objective of the linking role is to develop skills and knowledge for dealing with bureaucratic organizations in order to meet family needs and objectives in a particular life situa- tion. It is likely that adult children of aged parents may need to be socialized to the linking role as the de- pendency needs of their parents increase with aging. Summary Despite recent historical changes in traditional filial relationships, adult children continue to provide care to their parents and their parents expect various services from them particularly in times of illness. Adult child- ren, notably middle-aged women, constitute a major por— tion of the helping network of elderly persons although there is some evidence to suggest that male adult children are involved as well. In addition to the willingness of adult children to provide care, several factors affect the quality and quantity of help provided by adult children. Factors that have been identified in available literature include: change in sociodemographic characteristics of families, particularly the increase of women working out- side the home; the health status of the parents; the level of care required by the parents (instrumental, affective); whether or not care is unexpected, normative, or on-time; confin assume Th perce; parent ance i to hel this 5 small future health ‘HA bg‘y 64 the life situation of the adult child; attitudes and feel- ings associated with caregiving, especially feelings of confinement and stress; and the type of caregiving role assumed by the adult child. There is no general agreement in the literature about perceptions of adult children as to what health needs their parents may experience as they grow older, if health assist— ance is expected, and who would be the person most likely to help their parents with a specific health need. In this study, the researcher will describe perceptions of a small population of adult children about their parents' future health needs, health assistance, and providers of health assistance. In the next chapter, the methodology utilized in this study for collection of data is presented. CHAPTER IV METHODOLOGY Overview This descriptive study was designed to identify per- ceptions of adult children concerning health issues of their aged parents. Perceived health needs, perceived health assistance and perceived providers of health assistance were measured as major study variables. It was expected that the results of data analysis could specifically identify and describe perceptions of adult children about their parents': future physical, psychological, and socio- economic health needs, whether or not health assistance would be expected for these health needs, and who would be likely to provide health assistance. Sociodemographic in- formation about adult children and their parents was col- lected to characterize the study sample. A discussion of the methodology and procedures utilized in this research study is presented in this chapter. In- itially, a brief discussion of the study sample is presented followed by data collection procedures, instrumentation, Operationalization of study variables, descriptive 65 variabl cedures cedures 66 variables concerning the adult child and aged parents, pro- cedures for data analysis, and human rights protection pro- cedures. @212 The study participants were a convenience sample of 47 adult children who voluntarily agreed to complete study questionnaires. Because the sample was voluntary and not the result of random selection, the results of this study can be generalized only to adult children possessing characteristics which were similar to those of the sample. Results should not be considered to be representative of all adult children with aged parents. An adult child was defined as an individual who met the following criteria: (1) age 30 up to and including age 64; (2) willing to participate inthe study; (3) able to read and write in the English language; (4) at least one or both parent(s) were living, age 65 or older, retired, and lived outside of a recognized health care institution and separate from the adult child participant. vestigat requeste Child pa and frie the me Pants w‘r. that the Choose t Peers a: tiClpan: V L38m_ 67 Data Collection Procedure Professional peers and friends were contacted by the in- vestigator who explained the purpose of the research and requested names of persons who might qualify as an adult child participant. A written checklist was given to peers and friends stating necessary criteria and preferences of the investigator (Appendix A). Names of possible partici- pants who were not professional nurses (with the exception that the peer or friend who was a professional nurse could choose to participate) were returned to the investigator. Peers and friends were asked not to contact potential par- ticipants and were asked not to discuss this study with them. Peers and friends were asked to co-sign a form-letter (Appendix B) which would be sent with a stamped post-card to each potential participant. In the letter to the po- tential participant, the co-signed party and the investi- gator explained that the purpose of the study was to help nurses learn more about how adult children perceive health, needs of their parents and whether or not health assistance is expected. The research project was being conducted by Barbara Jepson-Taylor, R.N., a graduate student at Michigan State University in the College of Nursing. It was further explained that becoming involved in the study would entail answering questions about health needs and health assist- ance for their parents which would take approximately D) L——J one-h their I would I PO‘ villi: ing "y and q: Stamp: Partic retur: Vithiz ‘Q La e s for t: betYW'EI H \L’) (‘1 ) F4 v 68 one-half hour to complete. Participants were assured that their names and all of the information on the questionnaire would be kept confidential. Potential participants were asked to indicate their willingness to participate in this research study by check- ing "yes" on the back side of the enclosed post-card and mailing it to the investigator. After receiving the post- card, the investigator mailed a cover letter, consent form, and.questionnaire (Appendix C), and a self-addressed stamped envelOpe to each participant within three days. Participants were asked to complete the questionnaire and retmnnlit.to the investigator in the enclosed envelope within five days . Collection of data took place in Fall 1982. Ninety-one letters with post-cards were mailed. Of these potential participants, 47 met criteria, one wished no further con- tact, 15 did not qualify, and 28 did not return post- cards or questionnaires. No attempt was made to follow up those who declined participation. Methodology Recent empirical evidence supports the proposition that the study of "perceived generation differences" is useful fOr'the understanding of developmental phenomena not only between generations (Ahammer, 1972, Bengston, 1979; Green, 1981), but within the context of the extended family system 69 (Collette-Pratt, 1976; Egerman, 1966; Halprin, 1979; Johnson, 1978; Johnson and Bursk, 1977; Johnson, 1982; Robinson and Thurnher, 1979; Seelbach, 1978; Simos, 1973; Smith, 1979; Sussman, 1979). Green (1981) critically re- viewed research on attitudes and perceptions about older persons and concludes there are problems with methodology such as psychometric quality of instrumentation and lack of generalizability. Green suggests that research method- ologies using multiple measures in specific contexts would better clarify the relationship between perceptions and their behavioral implications. Luker (1981) contrasts research methods used in evalua- tion research with the nursing process used in nursing research. Both inherently involve a combination of basic assumptions underlying the activity or object being evaluated and of personal values on the part of those who are doing the research. Hence, the evaluation process and the nurs- ing process begins with a recognition of values which may either be explicit or implicit. After a review of studies of families with older mem- bers, Troll (1980) notes that one viewpoint on generational relations is to look at the transmission of perceptions, of beliefs, values, and attitudes from child to parent and, reciprocally, parent to child. In general, families tend to react to the aging of their members in terms of their shared family theme or value system. The conceptual frame- work utilized in the present study, based on Rogers' 70 theoretical basis for nursing (as described in Chapter II), would support the need to recognize values laden in research implications. The instrument utilized in this study was adapted from that developed by Garlinghouse (1982) to measure perceptions of older persons about their own health needs and health assistance as they grow older. To better understand the concepts of perceived health and wellness of older persons, Garlinghouse designed the instrument primarily based on non-pathological changes and signs and symptoms frequently reported by older persons as aging progresses throughout the later part of the human life cycle. The instrument was chosen by the investigator for its psychometric quality (discussed in Chapter IV) and for its emphasis on per- ceived health issues (health needs, health assistance, and providers of health assistance). To summarize, research methodologies used in studies of families with older members tend to support the need to study perceptions of adult children concerning specific situations involving the adult child and aged parent(s). Methodologies should begin with a recognition of values by the investigator/practitioner which may be implicit or eXplicit, and methodologies should include instruments with psychometric quality so that behavior implications can be derived. Little is reported in the literature about the perceptions of middle-aged adult children regarding health 71 needs of their parent(s) as they grow older, if health assistance is expected, and who would provide health assistance to their parent(s) should they experience a health need. The purpose of this study is to describe a sample of adult children and their perceptions concerning their parents using an instrument with some demonstrated psychometric quality. Instrumentation Development of the instrument The instrument utilized in this study was adapted from that developed by Garlinghouse (1982) to measure percep- tions of older persons about their own health needs and health assistance as they grow older. Items used in the instrument were derived from an extensive review of literature on frequent non-pathological changes experienced by and signs and symptoms usually reported by elderly persons. Table 1 includes items pertaining to physical, psychological, and socioeconomic health needs and the manner in which the items were adapted for use in this study. The Garlinghouse instrument was adopted for use in this research study for the following reasons: its emphasis on perceived health issues and for possible use as a clinical tool in nursing. Garlinghouse reported the following co- efficient alpha computations as estimates of internal consist- ency: Table l. 72 Items Pertaining to Physical, Psychological, and Socioeconomic Health Needs and the Manner Adapted from the Scales Used by Garlinghouse (1982). Health Need Manner Adapted Physical Health Needs 1. 2. 30. 38. 39. 40. 41. 42. 43. 44. pain and stiffness in joint a need to reduce their calorie intake shortness of breath constipation a need to urinate more often inability to hold their urine cold hands and feet numbness of hands and/or feet swelling of hands and/or feet increasing deafness a change in their ability to smell odors visual changes loss of balance daytime tiredness difficulty chewing problems with denture fit increased difficulty doing household tasks changes in their daily routines increased difficulty adapting to extreme changes in weather safety problems at home chronic health problems more side effects from medications brief awakenings during the night sleep loss a longer time to recover from illness more days when they don't do their usual activities symptoms of disease differently from a younger person same altered from "a need to change diet" same same same same same same same same same same same same same altered from problems" same same added added added added added added added added added "denture 73 Table 1. Continued. Health Need Manner Adapted Psychological Health Needs 12. 13. 14. 15. 31. 32. 33. 34. 35. 46. 47. 48. 51. changes in sexual and marital relations increased need for family closeness desire to reminisce difficulty in following any prescribed medication schedule feelings of uselessness some degree of forgetfulness a decrease in their ability to learn new things difficulty making up their mind difficulty thinking through problems taking more time to perform routine activities more times when they will act like children decreased ability to cope with situations a need for parent-like guidance Socioeconomic Health Needs 16. 17. 18. 19. 20. 21. 36. 37. possible difficulty paying for food possible difficulty paying for housing possible difficulty in ability to purchase desired clothing possible difficulty paying for health care services possible difficulty paying for utility bills possible difficulty paying for social activities possible difficulty managing personal finances possible difficulty arranging for health care services same same same same same same same same same added added added added same same same same same same added added 74 Table 1. Continued. Health Need Manner Adapted 45. decreased number of social contacts 49. decreased interest in current events 50. difficulty planning a balanced diet added added added 75 Perceived Health Needs (Total) .91 Perceived Physical Health Needs .86 Perceived Psychological Health Needs .86 Perceived Socioeconomic Health Needs .94 Perceived Expected Assistance with Health Needs (Total) .96 For each specific health need, participants were asked if they expected their parents to require help with the need. To further clarify the variable perceived health assistance, participants were asked to identify the person most likely to help their parents with a specific health need. In the original instrument, a "health activities" section was included because of its relevance to the Gar- linghouse study (1982). Part B of the questionnaire uti- lized in the present study (Appendix C) pertains to health activities that adult children expected their parents to do to maintain health and overcome health problems. Although this part of the questionnaire was not changed from the original except for the stem question, data ob— tained from this section was not used as part of this re- search study. Data were collected from Part B to further validate the instrument at some future date by the in- vestigator. Part A and Part C of the questionnaire (Appendix C) were used in the present study. Part A contained fifty- one health need questions used to measure each of the major variables of this study. The following is a list 76 of study variables and the number of items used to measure variable: Perceived physical health needs 27 items Perceived psychological health needs 13 items Perceived socioeconomic health needs 11 items Perceived health needs (total) 51 items Perceived health assistance for physical health needs 27 items Perceived health assistance for psychological health needs 13 items Perceived health assistance for socio- economic health needs 11 items Perceived health assistance for total health needs 51 items Perceived providers of health assistance for physical health needs -- 12 choices of providers for 27 health need items Perceived providers of health assistance for psychological health needs —- 12 choices of providers for 13 health need items Perceived providers of health assistance for socioeconomic health needs -- 12 choices of providers for 11 health need items Part C of the questionnaire contained questions pertaining to sociodemographic characteristics and other descriptors of the adult child participant (Items 9 through 24) and his/her parent(s) (Items 1 through 8). The format of the instrument was similar to the original and designed to minimize the amount of reading necessary, to avoid lengthy sentences, and to require a minimum of writing skills. Pretest of the study instrument The entire instrument (Appendix C) was pretested for readibility, clarity of directions, length, and time 77 required for completion by two graduate nursing students, two members of the nursing faculty with research expertise, and by four adult children similar to the sample of adult children utilized in the study. All of the pretest sub- jects found the instrument easily completed within thirty minutes. Reliability and validity Reliability of the instrument was assessed by means of an internal consistency measure (Crano and Brewer, 1973). To determine the degree to which items within each of the eight scales were related to one another, internal con- sistency was computed using the coefficient alpha method. The coefficient alpha, or reliability coefficient, reflects the extent to which an instrument is free of variance due to extraneous factors and ranges from 0 to 1.00. The closer a reliability coefficient is to 1.00 the more the instrument is a reflection of the true differences of test subjects on the scale. A reliability coefficient of .70 or above is considered satisfactory for group level comparisons as are involved in correlational research (Polit and Hungler, 1978). Should a satisfactory level of reliability not be obtained, addition of more items positively correlated with the other items of the scale would increase the reliability coefficient. If the coefficient alpha is .80 or higher, the instrument or scale may be considered to possess high internal consistency (Crano and Brewer, 1973). 78 Validity refers to the degree to which an instrument measures the attribute or concept which it intends to measure and is more difficult to measure than reliability. There are several types of validity (face, content, con- current, construct, predictive) and the general purpose or intent of the study dictates the type of validity estimated (Borg and Gall, 1973). It is not possible to develop objective criteria against which to compare measures of abstract traits such as perceived health needs or per- ceived health assistance. Therefore it becomes necessary to depend on subjective criteria to evaluate the face validity of the instrument. Efforts toward assuring a high degree of face validity of the instrument included: adapting an instrument with an established degree of psychometric quality as it is a necessary though not suf- ficient requisite for reliability; using an instrument designed to measure perceptions of health issues; review of literature; consultation with two faculty members with research expertise; pre-testing the instrument; and, judg- ment of the investigator as to the face validity of the items based on previously reviewed literature. Operationalization of Study Variables Perceived health needs (total) Perceived health needs (total) were measured by the use of 51 questions (Part A, Columns 1 and 2 of the 79 questionnaire, Appendix C) concerning specific require- ments of aged parents which must be met if they are to function at their maximum physical, psychological, and socioeconomic potential. The format of the question con- sisted of an initial stem-statement of expectation followed by a health need in the second column and a five-point Likert- type scale in the first column on which the adult child participant was able to indicate his/her agreement or dis- agreement with the statement by circling the apprOpriate number. The degree of agreement was ascertained by assign- ing a numerical score to each of the possible responses such that a low score was indicative of a high degree of agreement. For example: AS MY PARENT(S) GROW OLDER, I EXPECT THEM TO EXPERIENCE: l 2 3 4 5 pain and stiffness of joints 1 4 strongly agree; 2 = agree; 3 = neutral; disagree; 5 = strongly disagree. Subjects received one score which was indicative of their degree of agreement as to whether or not their parent(s) would experience a specific health need as they grow older. Perceived health needs (total) were further categorized into perceived physical health needs, perceived psychological health needs, and perceived socioeconomic health needs. Perceivedgphysical health needs were defined as future changes in locomotion, nutrition, aeration, elimination, 80 circulation, sensation, and rest that the adult child expected his/her parent(s) to experience as they grow older. A total of 27 items were used to measure this variable. In columns 1 and 2 of Part A of the ques- tionnaire (Appendix C), items 1-11, 22—30, 38—44 refer to physical health needs. Perceived_psychological health needs were defined as future changes in individual roles, intimacy, family relationships, self-esteem, memory, desire to remin- isce, ability to learn, and problem solving ability that the adult child expects his/her parent(s) to experience as they grow older. A total of 13 items were used to measure this variable. In columns 1 and 2 of Part A of the questionnaire (Appendix C), items 12-15, 31-35, 46-48, 51 refer to psychological health needs. Perceived socioeconomic health needs were defined as future changes in ability to afford food, housing, clothing, utilities, health care, social activities, and social roles that the adult child expects his/ her parent(s) to experience as they grow older. A total of 11 items were used to measure this variable. In Columns 1 and 2 of Part A of the questionnaire (Ap— pendix C), items 16-21, 36, 37, 45, 49, 50 refer to socioeconomic health needs. 81 Perceived health assistance (total) Perceived health assistance (total) was measured by the use of 51 questions (Part A, Columns 2 and 3 of the ques- tionnaire, Appendix C) concerning the extent to which the adult child expects his/her parent(s) will need help with a specific health need as the parent(s) grow older. Perceived health assistance was measured in the same response format as perceived health needs. Perceived health assistance (total) was further categorized into perceived health assistance for physical health needs, perceived health assistance for psychological health needs, and perceived health assistance for socioeconomic health needs. Perceived health assistance for physical health needs was defined as the extent of health assistance that the adult child expects his/her parent(s) will need help with a specific physical health need as they grow older. A total of 27 items were used to measure this variable. In Columns 2 and 3 of Part A of the question- naire (Appendix C), items 1-11, 22-30, 38-44 refer to physical health needs. Perceived health assistance forgpsychological health BEEQE was defined as the extent of health assistance that the adult child expects his/her parent(s) will need as they grow older. A total of 13 items were used to measure this variable. In Columns 2 and 3 of 82 Part A of the questionnaire (Appendix C), items 12-15, 31-35, 46-48, 51 refer to psychological health needs. Perceived health assistance for socioeconomic health BEEEE was defined as the extent of health assistance that the adult child eXpects his/her parent(s) will need help with a specific socioeconomic health need as they grow older. A total of 11 items were used to measure this variable. In Columns 2 and 3 of Part A of the questionnaire (Appendix C), items 16-21, 36, 37, 45, 49, 50 refer to socioeconomic health needs. Perceived providers of health assistance Perceived providers of health assistance were defined as those persons most likely to provide health assistance to aged parents for their physical, psychological, and socioeconomic health needs as perceived by their adult children. Providers of health assistance were dichotomized into two groups: Providers of health assistance within the primary group were: friend/neighbor of my parent(s), one of my brothers or sisters, myself, spouse of my parent(s); relatives of my parent(s); Providers of health assistance within the secondary group were: social worker, counselor, physician/dentist, pro- fessional nurse, community/government worker. 83 Two additional provider choices were listed: "other" (the participant was asked to specify by writing in the space provided) and "No One/No Helper Needed." After the adult child participant agreed or dis- agreed that his/her parent(s) would experience a health need and stated whether or not health assistance is ex- pected, the participant was asked to choose the person most likely to help by writing in the apprOpriate letter in the space provided in column 4 of the questionnaire, Part A (Appendix C). Descriptive information regarding perceived providers of health assistance was obtained by indexing or counting the number of times a category or provider was mentioned in each of the four scales of health needs (physical, psycho- logical, socioeconomic, total). The scoring technique used to summarize this information is discussed in Chapter V (Data Analysis). Data on five categories of perceived providers of health assistance were reported for each health need (physical, psychological, socioeconomic, total). Cate- gories of providers used to report data include: (1) providers of health assistance within the primary group, excluding the "myself" (adult child participant) category; (2) providers of health assistance within the secondary group, excluding "professional nurse" category; (3) no one/no helper needed; 84 (4) professional nurse; (5) myself (adult child participant). Descriptive variables concerning the adult child and aged parents Questions pertaining to sociodemographic characteristics and other descriptors of the adult child and his/her parent(s) are located in Part C of the questionnaire (Ap- pendix C). Most of the questions required a check mark, others required the participant to write in information. Questions used to describe the adult child and his/her parent(s) are summarized in Table 2. Procedures for Data Analysis Descriptive statistics were utilized to describe phenomena occurring naturally in the environment. Fre- quency distributions and percentages were based on the number of adult children who responded to the particular question and are reported for each major study variable: perceived health needs, perceived health assistance, and perceived providers of health assistance. Specific statis- tical techniques used to elicit data for each research question are discussed in Chapter V. A sample mean was calculated for each scale utilized in the study: perceived health needs (total), perceived 85 Table 2. Sociodemographic and Other Descriptive Variables Used to Describe Adult Children and Their Parents. Variables Concerning the Adult Child Participant Demographic variables age sex marital status racial or ethnic background education occupation income level Other descriptive variables number and ages of children difficulty living on present income sibling rank in family of origin education and occupation of spouse present health status health of household members Variables Concerning Aged Parents Demographic variables number of living parents age of parents estimated number of miles from parents Other descriptive variables parents' difficulty living on income usual type and frequency of contact present health status 86 physical health needs, perceived psychological health needs, perceived socioeconomic health needs, perceived health assistance (total), perceived health assistance for physical health needs, perceived health assistance for psychological health needs, perceived health assistance for socioeconomic health needs. The sample mean was used in this study as a summary measure of the sample scores. To determine the prOportion a particular provider cate- gory was mentioned in each health needs scale (physical, psychological, socioeconomic, total), an index was cal- culated for each participant. To measure central tendency, a mean proportion, expressed as a percent, was calculated for each of the health needs scales. The statistical technique utilized to calculate the mean proportion (percent) was presented in Chapter V (Data Analysis). The Pearson Product Moment correlational technique was utilized to evaluate the relationship between selected sociodemographic variables concerning the adult child par- ticipant (age, sex, education, income, and geographic distance from parent(s)) and each of the eight scales used in the study. Although it was beyond the sc0pe of this study to correlate study variables with all other variables, cor- relational data are presented in Chapter V (Data Analysis) as ”additional findings regarding the study sample". Cor- relation was used in this study to demonstrate functional rather than causal relationships among selected socio- demographic variables. 87 Protection of Human Rights Specific procedures were followed to assure that the rights of study participants were not violated. Approval of the human rights protection procedures was granted by the Michigan State University College of Nursing Human Subjects Review Committee on April 29, 1982. A letter explaining the research study and goals, the approximate time involved in participation and assurances of anonymity was provided to each participant along with a consent form (Appendix C). An identification number was assigned to each questionnaire by the investigator upon receiving the questionnaire to avoid further identifying data. Data were transcribed in aggregate form for computer analysis. Summary A discussion of the methodology and procedures utilized in this research study was presented in Chapter IV. A detailed discussion of the sample, data collection procedures, instrumentation, Operationalization of the study variables, descriptive variables concerning the adult child and his/ her aged parent(s), procedures for data analysis and human rights procedures was presented. In Chapter V, data describing the sample of adult children utilized in this research study and data pertaining 88 to each research question were presented. Reliabilities of each scale and additional findings were also presented in Chapter V. nee of gro fin Var Var chi cry; eh i CHAPTER V DATA PRESENTATION AND ANALYSIS Overview Data presented in this chapter describe the study sample and the perceptions of adult children concerning the health needs, expectations of health assistance, and providers of health assistance for their parents as their parents grow older. For organizational purposes, descriptive findings of the study sample will be dichotomized into: variables concerning the adult child participant and variables concerning the aged parent(s) of the adult child participant. Demographic variables and other des- criptive variables will be discussed for both the adult child participant and the aged parent(s). Following the section on the study sample, a brief ex- planation of the statistical analysis utilized to obtain data for the research questions is presented. Each re- search sub—question with its associated data is discussed. Following this discussion, descriptive findings related to the major research question are addressed. Finally, the reliabilities of the scales and sub-scales utilized in the present study are discussed. 89 90 Descriptive Findiggs of the Study Sample Variables concerning the adult child participant Demoggaphic variables The demographic variables utilized in the present study to describe the adult child participant were: age, sex, marital status, racial or ethnic background, education, oc- cupation and income level. The frequency distributions and percent of those adult children responding to these variables is presented in Table 3. Age. The age of the adult child participants ranged from 31 to 62 years. The mean age was 42.6 years. Sex. Both males and females participated in the study. Two-fifths of the study sample were males and three-fifths females. Marital Status. The majority of adult child par- ticipants were married. Nearly fifteen percent were either single, never married, divorced, or widowed. Racial or Ethnic Background. All of the adult child participants were white. Education. The highest grade completed was obtained from each participant and his/her Spouse. In general, the majority of adult child participants (87.1%, g = 41) and their spouses (80.0%, g = 39) had post-high school 91 Table 3. Demographic Variables Concerning the Adult Child Respondent (age, sex, marital status, racial or ethnic background, education, occupation, in- come level) (N = 47). Number of Variable Respondents Percent Age in years 30-39 20 43.5 40-49 14 30.4 50-59 11 23.8 60-64 1 2.2 Sex Male 19 40.4 Female 28 59.6 Marital Status Married 40 85.1 Single, never married 1 2.1 Separated 0 0 Divorced 5 10.6 Widowed 1 2.1 Racial or Ethnic Background White 47 100.0 Black 0 0 American Indian O 0 Hispanic 0 0 Oriental 0 0 Other 0 0 Income Level (in Dollars) Less than 5,000 0 0 5,000 to 9,999 0 0 10,000 to 14,999 1 2.4 15,000 to 19,999 2 4.9 20,000 to 24,999 7 17.1 25,000 to 29,999 3 7.3 30,000 to 34,999 3 7.3 35,000 to 39,999 8 19.5 40,000 or over 17 41.5 92 Table 3. Continued. Number of Variable ReSpondents Percent Education None or some Grammer school (up to 6th grade) 0 0 Junior High School (7-9th Grade) 0 0 Some High School (10-12th Grade) 2 4.3 Graduated High School, 4 8.5 Technical, Business, or Trade School 8 17.0 Some College (Less than 4 years completed) 8 17.0 Associate Degree Completed 1 2.1 Graduated College (4 years completed 8 17.0 Post Graduate or Professional 16 34.0 Occupation Higher Executives, PrOprietors of large concerns, major professionals 7 19.4 Business Managers, Proprietors of medium sized businesses, and lesser professionals 14 38.9 Administrative Personnel, small independent businesses, and minor professionals 4 11.1 Clerical and sales workers, technicians, and owners of little businesses 7 19.4 Skilled manual employees 3 8.3 Machine operators and semi-skilled employees 1 2.8 Unskilled employees 0 0 In (n (f) 93 education. Of those adult child participants who completed four years of college, 34.0% (2 = 16) achieved post grad- uate or professional level. Of those spouses who completed four years of college, 20.0% (a = 8) had achieved post graduate or professional level. Occupation. Participants were asked to indicate their main occupation, whether or not they were working at a regular job, and whether or not it was full-time or part- time. Three-quarters of the adult child participants were working at a regular job and the majority were work- ing full-time. Of the spouses, 64.4% (B = 29) were em- ployed full-time at a regular job. Nearly 70% of the adult child participants were either executives, business managers or proprietors, administrative personnel, or professional; 30% were clerical or sales workers, tech- nicians, owners of small businesses or skilled/semi- skilled employees. Income Level. Income level was determined by asking each participant to take all sources of money into con- sideration and estimate the amount of their family's combined income before taxes and other deductions in 1981. Of the adult children who responded, nearly 40% had annual income levels below $35,000 while 60% had income levels greater than $35,000. The mean income level was between $30,000 to $34,000. 94 Other descriptive variables Other variables used to describe the sample of adult children include: number of children, how difficult it is to live on their present income, sibling rank in their family of origin, and their present health and health of household members. The frequency distributions and per- centages of adult children who responded to these variables can be seen in Table 4 and Table 5. Number of children of adult child participant. The number and ages of children, including adopted and step— children were asked of each adult child participant. Of those with children, 97.7% (g = 45) had one to six child- ren. The mean number of offspring was 2.7 ranging in age from 1 to 44 years. Of those with children, 71.1% (g = 32) had children under eighteen years of age. Difficulty living on income. One-quarter of adult child participants reported they experienced some difficulty living on their present income. Three-quarters of the participants stated they had little or no difficulty living on their present income. Sibling rank in family of origin. Almost two-fifths (38.2, p = 18) of study subjects were the "youngest child." There were approximately the same number of "oldest child" and "middle child" responses. The category "only child" had the smallest number of responses. 95 Table 4. Descriptive Variables Concerning the Adult Child Respondent (difficulty living on present income, sibling rank in family of origin) (N = 47). Number of Variable ReSpondents Percent Difficulty Living on Present Income Very difficult 0 O Fairly Difficult 0 0 Somewhat Difficult 11 25.0 Not too Difficult 16 36.4 No Difficulty at all 17 38.6 Sibling Rank in Family of Origin Youngest Child 18 38.2 Oldest Child 13 27.7 Only Child 5 10.6 A Middle Child 11 23.4 96 Table 5. Descriptive Variables Concerning the Health of the Adult Child Respondents (N=47) and Household Members (description of healtH, presence of chronic health problems, and health problems eXperienced). Adult Child Household Respondents Members Number of Number of Variable Respondents % Respondents % Health Described As: Excellent 30 63.8 -- ---- Good 13 27.7 -- —-—- Fair 3 6.4 -- ---- Poor 1 2.1 -- ---- Presence of Chronic Health Problems Yes 13 27.7 10 22.2 No 34 72.3 35 77.8 Health Problems Experienced: Respiratory 4 12.9 2 14.3 Cardiovascular 4 12.9 3 23.1 Bones and Joints 4 12.9 2 15.4 Endocrine (includes D.M.) l 3.2 l 7.7 GU/GI 0 0 1 7.7 Neuro/Mental 1 3.2 l 7.7 Skin/BENT 0 0 1 7.7 Metabolic (includes weight, cancer, alcoholism) l 3.2 3 23.1 97 Health of the adult child. Participants were asked to describe their health, state whether or not they had chronic health problems, and what health problems they experienced. A majority of adult child participants des- cribed their health as excellent or good, while less than ten percent described their health as fair or poor. Slightly less than one-third of adult child participants experienced chronic health problems. Of these chronic health problems, respiratory, cardiovascular, and bones and joints problems were experienced most frequently. Health of household members. Each adult child par- ticipant was asked if household members experienced chronic health problems, how many persons, and what health problems were experienced. Slightly over one-fifth of the par- ticipants stated that household members experienced chronic health problems. The mean number of household members who had chronic health problems was 1.1 (2 = 11). Cardio- vascular problems were the most frequently reported chronic health problem followed by reSpiratory and bones and joints problems. Variables concerningythe aged parent(s) of the adult child participant Demographic variables The demographic variables utilized in the present study were: number of living parents, age of parents, and 98 estimated number of miles from parents. The frequency distributions and percentages of adult children who responded to these variables can be seen in Table 6. Number of living parents. Adult child participants were asked if their mother and father were living. Slightly less than half of the adult child participants had one living parent, the remaining adult child par- ticipants had two living parents. Of the living parents, nearly 90% (N = 42) were mothers; nearly 70% (B = 31) were fathers. Of the married adult child participants, the total number of living parents per couple averaged 2.8, the mode 3. Approximately one-third of the couples had one or two living parents, two-thirds of the couples had three or four living parents. Age of parents. The age of mothers ranged from 61 years to 84 years with a mean of 72.8 years. The age of fathers ranged from 65 years to 81 years with a mean age of 73.4. Estimated number of miles fromgparents. Adult child participants were asked to estimate the number of miles they lived from their parent(s) home. The number of miles ranged from 1 to 6,000 miles. The mean number of miles was 2716.77 miles, the mode 1500 miles, the median 200 miles. Slightly more than 60% (2:29) of the adult child participants lived less than 500 miles from their parents. 99 Table 6. Demographic Variables Concerning the Parents of Adult Children (N=47) (number of living parents, age of parents, estimated number of miles from parents). Number of Variable Respondents Percent Number of Living Parents (N=74) Per Adult Child Participant 1 parent 20 42.6 2 parents 27 57.4 Per Married Adult Child Participant, Including Parent(s) of Spouse 1 parent 6 14.3 2 parents 8 19.0 3 parents 16 38.1 4 parents 12 28.6 Age of Parent(s) in Years Mother 60-69 14 33.5 70-79 20 47.8 80-89 8 19.2 Father 60-69 6 19.4 70-79 22 71.2 80-89 3 9.7 Estimated Number of Miles From Parents 10 miles or less 9 19.2 10-50 miles 4 8.4 50-100 miles 7 14.9 100-500 miles 9 19.0 500-1000 miles 4 8.4 1000-2000 miles 11 23.3 2000-6000 miles 2 4.2 100 Other descriptive variables Each adult child participant was asked how difficult it was for his/her parent(s) to live on their present in- come and the usual type and frequency of contact the adult child had with his/her parent(s). Participants were asked to describe their parents' health, state if chronic health problems were present and what health problems their par- ents experienced. Frequency distributions and percentages of those who responded to these questions can be seen in Table 7 and Table 8. Parents difficulty livipg on present income. Slightly more than 70% (2e34) of the adult child participants re— ported their parents had little or no difficulty living on their present income. Nearly thirty percent (2:13) re- ported their parents had some difficulty. Usual type and freqpency of contact with parents. All of the adult children sampled maintained telephone contact with their parents and nearly all of the adult children visited their parents. Three-quarters stated they usually corresponded by letter/mail. The frequency of contact reported for contact by telephone and letter/mail most often was "once a month." Adult children reported visit- ing their parents "about 3-4 times a year." 101 Table 7. Descriptive Variables Concerning the Parents (N=74) of Adult Children (parents' difficulty IIving on income, usual type and frequency of contact with parents). Number of Variable Participants Percent Parents' Difficulty Living on Present Income: Very difficult l 2.1 Fairly difficult l 2.1 Somewhat difficult 11 23.4 Not too difficult 10 21.3 No difficulty at all 24 51.1 Usual Type and Frequency of Contact Telephone 47 100 Nearly every day 11 23.9 About every week 13 27.7 About once a month 17 36.2 About 3-4 times a year 4 8.5 About once a year 2 4.3 Never 0 0 Letter/Mail 3 76.1 5 Nearly every day 0 About every week 7 15.2 About once a month 13 28.3 About 3-4 times a year 6 13.0 4 6 About once a year 8.7 Never 13.3 Visiting 44 93.6 Nearly every day 3 6.4 About every week 11 23.4 About once a month 10 21.3 About 3-4 times a year 15 31.9 About once a year 6 12.8 Never 0 0 102 Table 8. Descriptive Variables Concerning Health of Par- ents (N=74) of Adult Children (description of health: presence of chronic health problems, and health problems experienced by parents). Mother of Adult Father of Adult Child Participant Child Participant Number of Number of Variable Respondents % Respondents % Health Described As: Excellent 13 31.0 9 29.0 Good 17 40.5 17 54.8 Fair 9 21.4 5 16.1 Poor 3 7.1 0 0 Presence of Chronic Health Problems Yes 29 69.0 17 56.7 No 13 31.0 13 43.3 Health Problems Experienced Respiratory 0 0 3 10.0 Cardiovascular 15 36.6 7 22.6 Bones and Joints 16 39.0 9 29.0 Endocrine (includes D.M.) 2 4.9 0 0 GU/GI 3 7.3 2 6.5 Neuro/Mental l 2.4 2 6.5 Skin/BENT 6 14.6 2 6.5 Metabolic (includes weight, cancer, alcoholism) 6 14.6 2 6.5 103 Health of mother of adult childyparticipant. Par- ticipants were asked to describe their mother's health, state whether or not she had chronic health problems, and what health problems she experienced. Nearly 70% (2:30) of the adult child participants described their mother's health as excellent or good, while nearly 30% (2:12) des- cribed their mother's health as fair or poor. Chronic problems of the mother were reported by nearly 70% (3:29) of the adult children of which bones and joints and cardio- vascular problems were the most frequently reported type of problem. Health of father of adult child participant. The same questions concerning the mother's health were asked about the father of the adult child participant. Slightly more than 80% (2:26) of adult children described their father's health as excellent or good. Chronic health problems of the father were reported by slightly more than 55% (2:17) of the adult children of which bones and joints, cardio- vascular, and respiratory problems were the most frequently reported type of problem. Additional Findings Regarding the Study Sample The Pearson Product Moment correlations were utilized to calculate the degree and direction of the relationship between selected sociodemographic variables concerning 104 the adult child participant (age, sex, education, income, and geographic distance from parents) and each scale utilized in this study. The correlation matrix is pre- sented in Table 9. Correlation coefficients (r) range from -1.00 to 1.00. A minus (-) sign preceding the correlation coefficient indicates that as scores on one variable in- crease, scores on the other variable tend to decrease (a negative correlation). When a minus sign is not present the relationship is positive indicating that when scores on one variable increase, the scores on the other variable tend to increase. The magnitude of the relationship is also indicated by the absolute value of the correlation coefficient (r). Correlations were interpreted as value of (r) strength of relationship 0.00 to 0.20 no meaningful relationship 0.20 to 0.35 very slight 0.35 to 0.65 moderate to fair 0.65 to 0.85 marked to fairly high 0.85 to 1.00 high to very high (Borg and Gall, 1979) Correlation coefficients can be tested for statistical sig- nificance. The minimum level of significance considered acceptable was the .05 level. The following statements summarize the statistically significant correlations that are depicted in Table 9 and Table 10. 1. There is a slight negative relationship between age of the adult child and the socioeconomic health needs scale. .Hm>ma Ho.v gnu um bcmoHMflcmHm n «k .Hm>oH mo. on» um unopenecmflm n « 105 mmmo. mmoo. «thm. «kawwm.l «momm.l mamom mocmumflmm< spammm Hobos vomo. tho. ««mHmm. kmmmm.l «khmow.l mamom mUmmz Spammm UwEOCOUm noHoom mom mocmumwmm< spammm vmmo. owao. voua. mowa.n hmmo.| wamom mpwmz spammm HMOflmoHonowmm How mocmumflmw< spammm mmmo.l mmoo.l NNNN. eeammm.l wth.I mamom mvwmz nuammm Hmowmxnm you mocmumwmmd Spammm mmmo. mema.| vooo.| *mmhm.| mmom.| mamom mpomz suamom Hmuoa mmmo. oooa.n mmna. *Nvmm.u «meom.u mamom mpomz guano: owsocoooofloom memo. hmho.n memo.| memo.| memo.u mamom wpmmz nuammm HMOflmoHonoamm mmmo.| mmma.| moma.u «manm.l Hmma.| onom memoz nuamom Hmofimznm mucoumm oEoocH coaumoopm m m mum mamom Eonm xom mocmumfio 2 H owndmumomu .svsum ucommum on» ad poNHHfluD onom comm pom unoccOQmom pafino wasp< may mcwcuoocoo moan6flum> oazdmuaOEmUOAOOm pmuomamm cmo3umm dflnmcoflumHom "xfinumz :OADMHmHHOO .m wanna 106 Table 10. Summary of Statistically Significant Correlations Between Selected Sociodemographic Variables Concerning the Adult Child Respondent and Bach Scale Utilized in the Present Study. Statistically Significant Correlation Between Variables and Scale Direction of Magnitude of Relationship Relationship age and perceived socioeconomic health needs sub-scale negative slight age and perceived health assistance for socio- economic health needs moderate sub-scale negative to fair age and perceived total health assistance scale negative slight sex and perceived physical health needs sub-scale negative slight sex and perceived socioeconomic health needs sub-scale negative slight sex and perceived total health needs scale negative slight sex and perceived health assistance for physical moderate health needs sub-scale negative to fair sex and perceived health assistance for socio- economic health needs sub-scale negative slight sex and perceived total health moderate assistance scale negative to fair education and perceived health assistance for socioeconomic moderate health needs sub-scale positive to fair education and perceived total health assistance scale positive slight 107 A correlation of -.30 (p =<.05) was obtained between age of the adult child participant and the socioeconomic health needs scale. The older the adult child, the lower the scores on the socioeconomic health needs scale. The younger the adult child, the higher the scores on the socioeconomic scale. 2. There was a moderate to fair negative relation- ship between age of the adult child and health assistance for socioeconomic health needs scale. A correlation coefficient of -.41 (p = <.01) was obtained between age of the adult child and health assistance for socioeconomic health needs scale. The older the adult child, the lower the scores on the health assistance for socioeconomic health needs scale. The younger the adult child, the higher the scores. 3. There was a slight negative relationship between age of the adult child and the total health assistance scale. There was a correlation of r = -.25 (p = <.05) between age of the adult child and the total health assistance scale. The older the adult child, the lower the scores on the total health assistance scale. The younger the adult child, the higher the scores. 4. There is a slight negative relationship between the sex of the adult child participant and the physical health needs scale. 108 There was a correlation of r = -.27 (p==<.05) between sex of the adult child and the physical health needs scale. Since males were coded as l and females coded as 2, the relationship between these two variables is such that males tend to have higher scores on the physical health needs scale than females. 5. There is a slight negative relationship between sex of the adult child and the socioeconomic health needs scale. There was a correlation of r = -.33 (p==<.05) between sex of the adult child and the socioeconomic health needs scale. Since males were coded as l and females coded as 2, the relationship between these two variables is such that males tend to have higher scores on the socioeconomic health needs scale than females. 6. There is a slight negative relationship between sex of the adult child and the total health needs scale. A correlation coefficient of -.28 (p: <.05) was obtained between sex of the adult child and the total health needs scale. Since males were coded as l and females coded as 2, the relationship between these two variables is such that males tend to have over-all higher scores on the total health needs scale than females. 109 7. There is a moderate to fair negative relation- ship between sex of the adult child and the health assistance for physical health needs scale. There was a correlation of r = -.37 (p = <.01) between sex of the adult child and the health assistance for physical health needs scale. Since males were coded as l and females coded as 2, the relationship between these two variables is such that males tend to have higher scores on the health assistance for physical health needs scale than females. 8. There was a slight negative relationship between sex of the adult child and health assistance for socioeconomic health needs scale. There was a correlation of r = -.33 (p==<.05) between sex of the adult child and health assistance for socioeconomic health needs scale. Since males were coded as l and fe- males coded as 2, the relationship between these two var- iables is such that males tend to have higher scores on health assistance for socioeconomic health needs than females. 9. There is a moderate to fair negative relationship between sex of the adult child and the total health assistance scale. A correlation coefficient of -.37 (p = <.01) was obtained between sex of the adult child and the total health assistance scale. Since males were coded as 1 and females 110 coded as 2, the relationship between these two variables is such that males tend to have higher scores on the total health assistance scale. 10. There was a moderate to fair positive relation— ship between education of the adult child and health assistance for socioeconomic health needs scale. A correlation coefficient of .39 (p = <.01) was obtained between education of the adult child and health assistance for socioeconomic health needs scale. The more educated the adult child, the higher the scores on health assist- ance for socioeconomic health needs scale. 11. There is a slight positive relationship between education and the total health assistance scale. A correlation coefficient of .30 (p==<.05) was computed between education of the adult child and total health assistance scale. The more educated the adult child, the higher the scores on total health assistance scale. Summary The descriptive findings of the study sample were presented in this section. The specific descriptors of the sample were organized into two major areas: variables concerning the adult child participant and variables con- cerning the aged parent(s) of the adult child participant. 111 Additional findings were presented in this section. Selected sociodemographic variables (age, sex, education, income, and geographic distance from parents) were cor- related with each of the scales used in this study. Des- criptive data for each research question is presented in the next section. Data Presentation for Research Questions In this section each research question will be pre- sented with its associated data. First, each research sub-question is presented followed by the major research question near the end of the chapter. A brief explanation of the statistical techniques utilized to analyze data is addressed initially. Additional statistical techniques utilized to evaluate specific data are discussed under the appropriate research question. Following the presentation of each research question, the reliabilities of the instru- ment are addressed. The chapter concludes with a summary of data analysis. Statistical technique for analyzing data To obtain descriptive information regarding perceptions of adult children, frequency distributions were calculated for each scale used to measure perceived health needs, perceived health assistance, and perceived providers of 112 health assistance. Data are presented as percentages of the total number of responses to each item along with the number of participants responding to each item. For report- ing purposes, the responses "strongly agree" and "agree" were collapsed into one "agree" category. A sample mean was calculated for each scale. The standard deviation was computed to measure the extent to which the distribution of mean scores vary about the sample mean. The Likert method of summed ratings was used to indicate the level of agreement or disagreement with items of each scale. Scores were coded using the following num- erical scale: 1 = strongly agree; 2 = agree; 3 = neutral; 4 = disagree; 5 = strongly disagree. The standard devia- tion, like the sample mean, provides a way of describing the central tendency of the scores from the sample on the basis of a single measure. Research sub-question 1 What are the physical, psychological, and socio- economic health needs of aged parents as per- ceived by their adult children as their parents grow older? Perceived physical health needs. The percentage and number of adult children who expected their parents to experience physical health needs as they grow older can be seen in Table 11. More than 50% (p=23) of adult child 113 Table 11. Percent and Number of Adult Children Who Identified Physical, Psychological, and Socio- economic Health Needs of Their Parents (in des- cending order)(N=47). Perceived Health Needs Number of of Parents Respondents Percent Physical Health Needs (27 items) Pain and stiffness in joints 44 97.7 Visual changes 44 95.7 A longer time to recover from illness 42 93.3 Daytime tiredness 38 82.6 Increased difficulty adapting to extreme changes in weather 36 78.2 Increased difficulty doing household tasks 36 76.6 A need to reduce their caloric intake 33 73.3 Increasing deafness 30 66.7 Symptoms of disease differently from a younger person 29 64.4 Cold hands and feet 30 63.9 Brief awakenings during the night 27 63.0 _More days when they don't do their usual activities 27 60.0 Changes in their daily routines Safety problems at home 26 56.5 Chronic health problems 114 Table 11. Continued. Perceived Health Needs Number of of Parents Respondents Percent Sleep loss 25 54.3 Shortness of breath 24 52.2 Constipation 23 51.1 Loss of balance 23 50.0 Problems with denture fit Swelling of hands and/or feet 22 48.9 A need to urinate more often 21 46.6 Numbness of hands and/or feet 19 41.3 A change in their ability to smell odors 16 35.5 More side effects from common medications 16 34.8 Inability to hold their urine 14 31.1 Difficulty chewing 12 26.1 Psychological Health Needs (13 items) Taking more time to perform routine activities 41 91.1 Some degree of forgetfulness 42 89.4 Increased need for family closeness 40 86.9 115 Table 11. Continued. Perceived Health Needs Number of of Parents Respondents Percent Desire to reminisce 38 80.8 Decreased ability to c0pe with situations 25 55.6 Changes in sexual and marital relations 24 52.1 Feelings of uselessness 23 50.0 Difficulty making up their mind 22 47.8 Difficulty thinking through problems 21 45.6 A decrease in their ability to learn new things 19 41.3 Difficulty in following any prescribed medication schedule 16 34.8 A need for parent-like guidance 13 30.3 More times when they will act like children 13 28.9 Socioeconomic Health Needs (11 items) Possible difficulty arranging for health care services 22 47.9 Decreased number of social contacts 21 45.7 Possible difficulty managing personal finances 19 41.3 Decreased interest in current events 13 28.8 116 Table 11. Continued. Perceived Health Needs Number of of Parents Respondents Percent Difficulty planning a balanced diet 12 26.7 Possible difficulty paying for health care services 11 23.9 Possible difficulty paying for utility bills 11 23.9 Possible difficulty in ability to purchase desired clothing 10 22.2 Possible difficulty paying for housing 8 17.4 Possible difficulty paying for food 7 15.2 Possible difficulty paying for social activities 6 13.1 117 participants eXpected their parents to experience 20 out of a possible 27 health needs as their parents grow older. More than 90% (3:42) of adult child participants expected their parents to experience three physical health needs: pain and stiffness in joints, visual changes, and a longer time to recover from illness. Fewer than 40% (p=16) eXpected their parents to experience: a change in their ability to smell odors, more side effects from medications, inability to hold their urine, and difficulty chewing. The sample mean for perceived physical health needs scale is 2.49. The standard deviation is .37 (Table 12). Perceived psychological health needs. The percent and number of adult children who expected their parents to experience psychological health needs as they grow older can be seen in Table 11. More than 50% (p=23) adult child participants expected their parents to experience 7 out of a possible 13 psychological health needs as their parents grow older. Only one psychological health need was perceived by more than 90% (p=4l) adult child participants: taking more time to perform routine activities. Fewer than 40% (3:16) expected their parents to experience: difficulty in following any prescribed medication schedule, a need for parent-like guidance, and more times when they will act like children. The sample mean for perceived psychological health needs scale is 2.58. The standard deviation is .55 (Table 12). 118 Table 12. Sample Means and Standard Deviations for Scales Used to Measure Perceived Health Needs of Aged Parents (N=47). Sample Standard Scale Mean Deviation Physical health needs sub-scale 2.487 .374 Psychological health needs sub-scale 2.578 .554 Socioeconomic health needs sub-scale 3.375 .797 Health needs (total) scale 2.701 .438 Perceived socioeconomic health needs. The percent and number of adult children who expected their parents to experience socioeconomic health needs as they grow older can be seen in Table 11. No socioeconomic health needs were reported by 50% (3:22) or more of adult child par- ticipants. The most frequently reported socioeconomic health needs were: possible difficulty arranging for health care services, decreased number of social contacts, possible difficulty managing personal finances. Fewer than 20% (2:8) adult child participants expected their parents to experience: possible difficulty paying for housing, pos— sible difficulty paying for food, and possible difficulty paying for social activities. 119 The sample mean for perceived socioeconomic health needs scale is 3.38. The standard deviation is .80 (Table 12). Perceived health needs (total). More than 90% of the adult child participants expected their parents to experience physical and psychological health needs, while less than 50% expected their parents to experience socio- economic health needs as their parents grow older. The five most frequently reported health needs were: pain and stiffness in joints, visual changes, a longer time to re- cover from illness, taking more time to perform routine activities, and some degree of forgetfulness. The sample mean for the total health needs scale is 2.70. The standard deviation is .44 (Table 12). Research sub-question 2 What are the expectations of health assistance for aged parents as perceived by their adult children as their parents grow older? Perceived health assistance for physical health needs. The percent and number of adult children who expected health assistance for their parents' physical health needs as they grow older can be seen in Table 13. More than 50% (2:23) adult child participants expected health assistance for 7 out of a possible 27 physical health needs. The most 120 Table 13. Percent and Number of Adult Children Who Identified Health Assistance for Physical, Psychological, and Socioeconomic Health Needs of their Parents (in descending order) (N=47). Perceived Health Assistance Number of for Health Needs of Parents Respondents Percent Physical Health Needs (27 items) Visual changes 35 79.5 A longer time to recover from illness 35 77.7 Increased difficulty doing household tasks 32 72.7 Pain and stiffness in joints 29 64.5 Chronic health problems 27 61.4 Increasing deafness 27 60.0 Symptoms of disease differently from a younger person 23 53.5 Loss of balance Increased difficulty adapting} 20 46.5 to extreme changes in weather Swelling of hands and/or feet 20 45.4 Problems with denture fit 19 44.2 Safety problems at home Shortness of breath 17 37.8 More side effects from common medications 16 36.4 121 Table 13. Continued. Perceived Health Assistance Number of for Health Needs of Parents Respondents Percent More days when they don't do their usual activities 14 Numbness of hands and/or feet 13 Inability to hold their urine 12 Sleep loss 11 Cold hands and feet 11 Daytime tiredness ( , 10 Difficulty chewing) Constipation 10 Changes in their daily routines 9 A change in their ability to smell odors 8 A need to reduce their calorie intake 8 Brief awakenings during the night A need to urinate more often 5 Psychological Health Needs (13 items) Increased need for family closeness 29 Feelings of uselessness 23 Some degree of forgetfulness 21 32.6 28.9 27.9 25.0 23.9 23.2 22.2 20.9 18.6 17.8 11.1 63.0 54.8 45.6 122 Table 13. Continued. Perceived Health Assistance Number of for Health Needs of Parents Respondents Percent Decreased ability to c0py with situations 19 45.2 Taking more time to perform routine activities 19 43.2 Desire to reminisce 19 41.3 Difficulty making up their mind 18 40.9 Difficulty thinking through problems Difficulty in following any prescribed medication schedule 14 A need for parent—like } 31.7 guidance 13 A decrease in their ability to learn new things 9 20.4 More times when they will act like children 6 14.3 Changes in sexual and marital relations 5 11.1 Socioeconomic Health Needs (11 items) Possible difficulty arranging for health care services 20 45.5 Possible difficulty managing personal finances 19 43.2 Decreased number of social contacts 14 31.8 Difficulty planning a balanced diet 11 25.6 123 Table 13. Continued. Perceived Health Assistance for Health Needs of Parents Number of Respondents Percent Possible difficulty paying for health care services Possible difficulty paying for utility bills Possible difficulty in ability to purchase desired clothing Possible difficulty paying for housing Possible difficulty paying for social activities Possible difficulty paying for food Decreased interest in current events 10 22.2 20.5 18.2 16.3 15.9 124 frequently reported physical health needs the adult child participant expected their parents to need health assist— ance were: visual changes, a longer time to recover from illness, and increased difficulty doing household tasks. Fewer than 20%‘(N=8) adult child participants expected health assistance for: a change in their ability to smell odors, a need to reduce their calorie intake, brief awaken- ings during the night, and a need to urinate more often. The sample mean for perceived health assistance for physical health needs scale is 2.81. The standard devia- tion is .37 (Table 14). Perceived health assistance for psychological health EEEQ§° The percent and number of adult children who ex- pected health assistance for their parents' psychological health needs as they grow older can be seen in Table 13. More than 50% (2:23) adult child participants expected health assistance for two (out of 13 health needs) psycho- logical health needs: increased need for family closeness, and feelings of uselessness. Fewer than 20% (3:6) adult child participants expected health assistance for: more times when they will act like children, changes in sexual and marital relations. The sample mean for perceived health assistance for psychological health needs scale is 2.91. The standard deviation is .48 (Table 14). 125 Table 14. Sample Means and Standard Deviation for Scales Used to Measure Perceived Health Assistance for Physical, Psychological, and Socioeconomic Health Needs of Aged Parents by Their Adult Children (N=47). Sample Standard Scale Mean Deviation Health assistance for physical health needs sub-scale 2.809 .367 Health assistance for psychological health needs sub-scale 2.909 .484 Health assistance for socio- economic health needs sub-scale 3.290 .842 Health assistance (total) scale 2.956 .388 Perceived health assistance for socioeconomic health Needs. The percent and number of adult children who ex- pected health assistance for their parents' socioeconomic health needs as they grow older can be seen in Table 13. The most frequently reported socioeconomic health needs the adult child participant (less than 50%, 2:20) eXpected their parents to need health assistance were: possible difficulty arranging for health care services, possible difficulty managing personal finances. Fewer than 20% (2:8) adult child participants expected health assistance for: possible difficulty paying for housing, possible difficulty paying for social activities, possible dif- ficulty paying for food, decreased interest in current events. 126 The sample mean for perceived health assistance for socioeconomic health needs scale is 3.30. The standard deviation is .84 (Table 14). Perceived health assistance (total). The percent and number of adult children who expected health assistance for their parents' total health needs can be seen in Table 13. The five most frequently reported health needs that the adult child participant expects health assistance are: visual changes, a longer time to recover from illness, in- creased difficulty doing household tasks, pain and stiff- ness in joints, increased need for family closeness. The sample mean for perceived health assistance (total) scale is 2.96. The standard deviation is .39 (Table 14). Research sub-question 3 Who is likely to provide health assistance to aged parents as perceived by their adult child- ren as their parents grow older? Statistical technique for analyzing_perceived providers of health assistance Descriptive information regarding persons most likely to help aged parents with health needs was obtained by calculating frequency distributions and percentages of those who responded and then grouping responses into five categories of providers relevant to this study: 127 (1) providers of health assistance within the primary group, excluding the "myself" (adult child participant) category -- friend/neighbor of parent(s), one of the brothers or sisters of the adult child par- ticipant, the spouse of the parent(s), and relative of the parent(s); (2) providers of health assistance within the secondary group, excluding "professional nurse" cate- gory -- social worker, counselor, physician/dentist, community/government worker; (3) no one/no helper needed; (4) professional nurse; (5) "myself" (adult child participant). The number of participants and percent of those who responded to items pertaining to physical, psychological, and socio- economic health needs for each category of provider can be seen in Table 15. To simplify reporting of data, the investigator arbitrarily decided to report a minimum of three health needs (those with the highest percent response) within each category of provider are discussed in detail. All results for all needs are presented in Table 15. 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to acep.ozm zo.m~op_ z_.Nkv_m o zz.~kvzm zm.~o_ o zm.~vp “it «casemu not: seminars za.m~om1 zo.oovom AN.~CF ze.sooa~ ze.evm o is.evm some t0\o=m mean; to mmmesssz zm.mmosm zm.mmvo. ze.eo~ 11.1mve_ ze.ev~ o ze.evm colomaiomcoo Am.esoom zm.msv_m zm.~vp 1m.oevom zo.eo~ zm.Nv_ zm.~o_ were: times e_oz so suwpismcl z~.kmoo1 1m.mmvsm o zm.mmoe~ zk.¢om o zk.svm aclzmzo so_=oittto z_._moe_ AN.~oom~ zN.~v_ zo.oookm zo.ovm z~.No. ze.evm gamers to mmmcocozm oooomz ooocw omcoz omcsz.eota oootw =wpmmzz= =mpomzz= monotoa mo Loopm: oz zgoocoomm .woga .Poxm xtoewca .Foxm momoz zapomz oo>woocwa \oco oz _muoe osotw papa» ozogw zgmocooom somewga .umscpocoo .m_ magma 131 mucoumwmm< zppoo: eo cmow>ota oo>woocoa zo.movmw zo.mmo__ o zo.m~v__ zm.__vm zm.svm Am.oom coaom_ot Poomtoe oco Posxom cw momcozu z~.oovom zo.sv~ o zo.evN zo.mmv_i z_.ave za.m_vk mazes» 3m: elmm_ op zuwpwom Loony cw ommocooo < zm.mmoe~ zo.eoN o zo.eom zo.amvkz zo.kvm zo.~mvsz escaping oxi— sum _FPz awn» cog: was?» mtoz zm.mmve~ Am.~o_ o zm.~v_ 1w._eow_ Am.aos Am.vae1 wmwoo>aoum scissor section on we?» woos mcwxop zo.kmvk Am.ovm o Am.oom zo.omoo~ zo.m_vo zo.mevo~ mmoczzooomtoo to morass msom zo.mmvo_ Am.mve ze.sv~ ze.evm zo.imom~ Am.mve z_.N¢va_ o_=um;om cotom_oms oos_com -oto zco mcwzoppom cw zupaoweewo zm.a~om_ 14.111m o is.,_vm zk.omom~ za.mpok zm.oeomz mmmcmmmpmms to maca.oma z~.meoa. o o o zm.omomm 1N.m_om zo.wmvkl eels cameo a: scales sopsowttta zo.omo~1 zm.No_ o Am.NoP zo.movom zm.vam_ Am.vam_ oucmu_=a mxo_-o=mtma toe some < z_.smom_ o o o za.mova~ zo.m~opp 1m.osomp waspsoca sasoczo azaleas“ supso_ctio oooooz oootu omczz omozz.woca osocw =cpmmz: gwpomzz= mucoooa mo Loopoz oz zgmocooom .eoca .poxm zooswga .Foxm moomz zapmoz oo>FooLoa \oco oz _mpoh ozogo Peach osoco acmocooom Acoewta .em==_o=oo .m_ m_soh 132 z_.amoo~ zw.ovm o zm.oom z~.smom_ z~.o~va zm.s_vo sewage: toe acizma zoF=Uattwu opswmmoa zo.mmomm za.mve o za.mvs ze.mmoo_ zm.kpom zo.k_vm mp_ws sowz_o= toe mcwzoo zupooaeewo opnwmmoa z_.amvo~ zo.eom o zo.som zm.omoo_ zo.o~va zm.o_vk coat toe actsma sopsuitoau «_simmoa Ao.mmvmm A_._Pvm o AF.__vm Ao.~mvop Am.epvm AN.m—vo moow>tom memo zupooz com seizes sopsuactmo minimmoa Am.mmvvm Ao.evm Am.mvp Am.mvp AN.vao_ Am.mv¢ Amxmmvmp powo ooocopoo o mcwccopo zupaowmwwo Am.mmvsm zN.Nv_ o AN.NVF is.eevo~ zo.som m2 moumocoo meoom Co twosoo oomoocooo Ao.omvm A~.mpvo o A~.mpvo A~.~mvom ho.omvm Au.nmvnp moow>cmm mcoo zopooz to» mcwmcocco zapsowmmwo o—nwmmoa Au.omvmp o o o A~.wovpm AF.FmV¢F Ao.umv~_ moococwm pocomcoo mcwmozoe xupooweeao opnpmmoa moooz zopmo: oweocoooowoom oooooz ooocw mmcaz omcsz.eota ozoco =epomzz= =mpomzz= mucogoa to gonzo: oz zgmocooom .eota ._oxm zgoewta .Foxm moooz zopoo: oo>_oocoa \oco oz Pouch oooto Pouch ooocw zooocooom acoemga mocmumwmm< zupooz mo Loo_>ota oo>wootoa .omseiocoo .m_ o_sma 133 zo.omokm o o o za.m_vo zk.eo~ Am.mve maco>m ucoctoo cw pmogoucm oomoocooa Am.wovom AN.NVP o AN.NV_ Am.Fmvep Ao.omvm Am.Fva mowuw>wuoo Povoom com season sopsootcao upswmmoa zo.oooa~ zo.oom o zo.oom z~.mmom_ 1w.kiom As.m_ok acwzoolu omcwmoo omozocoo o» zowpwno =_ zu~=o_mewo opowmmoa oooomz oootu omtoz omcoz.eooa osocw =epomzz= =epomzz= mucocoa mo coopo: oz zooocooom .moca .poxm zgoewca .poxm moooz zupomz oo>wootma \oco oz Pmooe ooocu Pogo» ooooo Scoocooom zgoewga mucoumwmm< zupmo: mo coow>ota om>woogma .oms:ao=oo .m. apnea 134 participant who responded using the following prOportion: total # items of a particulargprovider categgry total # of responses to items in a scale For example, one participant may have selected primary providers for six items in the physical health needs scale. The same participant's total number of responses to the physical health needs scale was 26 out of a maximum of 27 items in the physical health needs scale. The proportion of primary providers mentioned by this participant in the physical health needs scale is: 11 26 = 0.230 In other words, this particpant selected primary providers for 23% of his/her parent(s)' physical health needs. To measure central tendency, the mean proportion was calculated for each scale (physical, psychological, socio- economic, total health needs scale) by dividing the sum of the proportions by the number of proportions. The mean proportion for each scale was reported as percentages in order to facilitate the comparison of scales. The mean proportion percent for each scale is reported in Table 16. 135 m.Hv o.em o.H o.mm v.5m H.HH m.oa mamom mpomz nuammm Hobos «.mm o.m m.o m.v m.mm m.mH e.mH mamom pmmz spaces oesocoomowoom H.mm w.m m.o m.m >.mv m.ma m.n~ mamom pmmz nuamom Hmowmoaonozmm m.mm m.Hv m.a m.mm H.wa H.m o.HH mamom pmmz guano: Hmoemsno popmmz moouw mwusz omnsz.moum osouo :mammhze emammmz: mamom Hmdaom oz .pcooom .moum .Hoxm auwfiflum .Hoxm pmoz suaomm \oco oz Hobos dsouw Hmuoe dsouw muopcoomm humeflnm .mamom ommz shame: comm canoe: cmuoaaeo uaooa so omeoaucmz moccpmflmme spammm mo mumpw>oum pm>wmoumm mo Aucmoummv cofluuomonm cows .oa magma 136 Results of perceived_providers of health assistance Perceived providers of health assistance forgphysical health needs. (l) Providers of health assistance within theyprimary grpgp. In Table 15 the number and percentage of adult child- ren who mentioned the primary group of providers of health assistance for their parents' physical health needs are depicted. Within the primary group of providers of health assistance (excluding the category "myself"), the adult child expected his/her parent(s) to be helped with: safety problems at home, increased difficulty doing household tasks, and more days when they don't do their usual activities. Within the category "myself," the adult child expects to help his/her parent(s) with the same physical health needs with the addition of: increased difficulty adapting to extreme changes in weather. When these two provider categories were combined, the physical health needs were ranked the same. No providers within the parimary group were eXpected to help parents with "a need to urinate more often." The adult child him/herself did not expect to help his/ her parent(s) with: symptoms of disease differently from a )nounger person, difficulty chewing, constipation, numb- ness of hands and/or feet, problems with denture fit, swelrling of hands and/or feet, and a need to urinate more often . 137 With regard to all physical health needs, the propor- tion of physical health needs that the adult child ex- pected primary group providers, excluding "myself" cate- gory, to help his/her parent(s) was 11.0% (Table 16). The proportion of physical health needs that the adult child selected "myself" category was 5.1%. Over all, the propor- tion of total primary group providers selected for all physical health needs was 16.1%. (2) Providers of health assistance within the secondary grgpp. In Table 15 the number and percent of adult child- ren who mentioned the secondary group of providers of health assistance for their parents' physical health needs are depicted. Within the secondary group of providers of health assistance (excluding the category "professional nurse"), the adult child expected his/her parent(s) to be helped with: visual changes, pain and stiffness in joints, and swellings of hands and/or feet. These physical health needs ranked the same with the addition of the "pro- fessional nurse" category. The professional nurse was eXpected to help their parents with: more side effects from common medications and constipation. No providers within the secondary group were expected t1) help parents with: increased difficulty doing house- hodxd'tasks, safety problems at home. The professional nurese was not expected to help with: increased difficulty dOirlg household tasks, safety problems at home, more days 138 when they don't do their usual activities, increased dif- ficulty adapting to extreme changes in weather, changes in their daily routines, cold hands and feet, difficulty chew— ing, denture fit. With regard to all physical health needs, the proportion of physical health needs that the adult child expected secondary group providers, excluding the "professional nurse" category, to help with his/her parent(s) was 39.5% (Table 16). The proportion of physical health needs that the adult child selected "professional nurse" was 1.8%. Over all, the prOportion of total secondary group providers selected for all physical health needs was 41.3%. (3) No one/no helper needed. In Table 15 the number and percentage of adult children who mentioned no one/no helper needed for their parents' physical health needs are depicted. Within this category, the adult child expected his/her parent(s) to need minimal help with: a change in their ability to smell odors, a need to urinate :more often, brief awakenings during the night. Sixteen out of 27 physical health needs had 50% or less response as no help needed. With regard to all physical health needs, the proportion of health needs that the adult child expected no help for his/her parent(s)' physical health needs was 36.8% (Table 16). 139 Perceived#providers of health assistance for psycho- logical health needs. (1) Providers of health assistance within the primary group. In Table 15 the number and percentage of adult children who mentioned the primary group of providers of health assistance for their parents' psychological health needs are depicted. Within the primary group of providers of health assistance (excluding the category "myself"), the adult child expected his/her parent(s) to be helped with: desire to reminisce, some degree of for- getfulness, increased need for family closeness, decreased ability to c0pe with situations. Within the category "myself," the adult child expects to help his/her parent(s) with: increased need for family closeness, a need for par- ent-like guidance, decreased ability to COpe with situa- tions, difficulty thinking through problems. When these two primary provider categories were combined, the psycho- logical health needs ranked as: increased need for family closeness, desire to reminisce, decreased ability to cope with situations. Five out of 13 psychological health needs had 50% or less response to the primary group of providers. With regard to all psychological health needs, the proportion of psychological health needs that the adult child expected primary group providers, excluding "my- self" category, to help his/her parent(s) was 27.8% (Table 16). The prOportion of psychological health needs that the 140 adult child selected "myself" category was 18.9%. Over all, the proportion of total primary group providers selected for all psychological health needs was 46.7%. (2) Providers of health assistance within the secondary EEEEE' In Table 15 the number and percent of adult child- ren who mentioned the secondary group of providers of health assistance for their parents' psychological health needs are depicted. Within the secondary group of providers of health assistance (excluding the category "professional nurse"), the adult child expected his/her parent(s) to be helped with: changes in sexual and marital relations, feelings of uselessness, decreased ability to cope with situations. The professional nurse was expected to help with one psychological health need: difficulty in following any prescribed medication schedule. When these two categories of secondary providers were combined, the psychological health needs were ranked as: changes in sexual and marital relations, feelings of uselessness, difficulty in following any prescribed medica- tion schedule. No providers within the secondary group were eXpected to help parents with: desire to reminisce, difficulty thinking through problems, difficulty making up their minds. With regard to all psychological health needs, the prOportion of psychological health needs that the adult child expected secondary group providers, excluding the 141 "professional nurse" category, to help with his/her parent(s) was 5.5% (Table 16). The proportion of psychological health needs that the adult child selected "professional nurse" was 0.3%. Over all, the proportion of total secondary group providers selected for all psychological health needs was 5.8%. (3) No one/no helper needed. In Table 15 the number and percentage of adult children who mentioned no one/no helper needed for their parents' psychological health needs are depicted. Within this category, the adult child eXpected his/her parent(s) to need minimal help with: a decrease in their ability to learn new things, changes in sexual and marital relations, more times when they will act like children, taking more time to perform routine activities. With regard to all psychological health needs, the proportion of health needs that the adult child eXpected no help for his/her parent(s)' psychological health needs was 39.1% (Table 16). Perceived Providers of Health Assistance for Socio- economic Health Needs (1) Providers of health assistance within the primary group. In Table 15 the number and percentage of adult children who mentioned the primary group of providers of health assistance for their parents' socioeconomic health 142 needs are depicted. Within the group of providers of health assistance (excluding the category "myself"), the adult child expected his/her parent(s) to be helped with: decreased number of social contacts, possible difficulty arranging for health care services, possible difficulty managing personal finances. Within the category "myself," the adult child expects to help his/her parent(s) with: possible difficulty meanaging personal finances, possible difficulty paying for housing, possible difficulty ar- ranging for health care services, possible difficulty paying for social activities. When these two primary provider categories were combined, the socioeconomic health needs ranked as: possible difficulty managing personal finances, possible difficulty arranging for health care services, possible difficulty paying for social activities. Eight out of 11 socioeconomic health needs had 50% or less response to the primary group of provider categories. With regard to all socioeconomic health needs, the proportion of socioeconomic health needs that the adult child expected primary group providers, excluding "my- self" category, to help his/her parent(s) was 15.7% (Table 16). The proportion of socioeconomic health needs that the adult child selected "myself" category was 16.6%. Over all, the prOportion of total primary group providers selected for all socioeconomic health needs was 32.3%. 143 (2) Providers of health assistance within the secon- dary_group. In Table 15 the number and percentage of adult children who mentioned the secondary group of providers of health assistance for their parents' socio- economic health needs are depicted. Within the secondary group of providers of health assistance (excluding the category "professional nurse"), the adult child expected his/her parent(s) to be helped with: possible difficulty arranging for health care services, possible difficulty paying for health care services, possible difficulty paying for utility bills. These socioeconomic health needs ranked the same with the addition of "professional nurse" category. The professional nurse was expected to help one socioeconomic health need: difficulty planning a balanced diet. No providers within the secondary group were eXpected to help parents with: possible difficulty managing personal finances, decreased interest in current events. With regard to all socioeconomic health needs, the proportion of socioeconomic health needs that the adult child expected secondary group providers, excluding the "professional nurse" category, to help with his/her parent(s) was 4.8% (Table 16). The proportion of socio- economic health needs on which the adult child selected "professional nurse" was 0.2%. Over all, the proportion of total secondary group providers selected for all psychological health needs was 5.0%. 144 (3) No one/no helper needed. In Table 15 the number and percentage of adult children who mentioned no one/ no helper needed for their parents' socioeconomic health needs are depicted. Within this category, the adult child eXpected his/her parent(s) to need minimal help with: de- creased interest in current events, possible difficulty paying for social activities, possible difficulty in ability to purchase desired clothing. Nine out of 11 socioeconomic health needs had 50% or more response as no help needed. With regard to all socioeconomic health needs, the proportion of health needs that the adult child eXpected to help for his/her parent(s)' socioeconomic health needs was 53.4% (Table 16). Perceived providers of health assistance for total health needs. In Table 15, the number and percentage of adult children who mentioned each category of provider of health assistance for their parents' physical, psycho- logical, and socioeconomic health needs are depicted. In Table 16 the proportion of each category of provider mentioned by adult children for each health need are summarized. For all health needs, physical, psychological, and socioeconomic, the prOportion of primary providers, ex— cluding the category "myself", was 16.3%. The proportion for the category "myself" was 11.1%. The prOportion of 145 total primary group providers for all health needs was 27.4% (Table 16). The proportion of secondary group providers, excluding the category "professional nurse", was 23.6%. For the category "professional nurse", the proportion was 1.0%. The prOportion of total secondary group providers for all health needs was 24.6% (Table 16). In the category "no one/no helper needed", the pro- portion of health needs was 41.3%. Additional findings: written comments from adult child participants. Ten adult child participants (4.7%) wrote comments on the questionnaire to the investigator. Seven females and three males corresponded. The following are summary statements. One participant stated that the "family" should help :ahen they can and that when they are unable to help, ‘professional persons should be sought. For any physical problem, a doctor should be consulted. Two participants identified themselves or a sibling who was geographically closer to their parents would be the person most likely to help their parents. Four participants expressed difficulty answering the questionnaire since their parents were active, independent, self—reliant, and in good health. Two participants 146 mentioned that for divorced parents there was difficulty answering the questionnaire, although each stated their answers referred to one parent. Two participants were concerned about "timing" of their parents' needs. One suggested that instead of the question "as my parents grow older" the question could read "in the next ten years" or "during the ages 60 to 70 years". One participant expressed difficulty knowing when to help parent(s) and when not to since they felt that "doing things" would encourage dependent behaviors that would eventually affect the parent(s)' self esteem. Major research question How do adult children perceive health issues of aged parents as their parents grow older? Data pertaining to the major research question of the present study has been reported in the two previous sec- tions: descriptive findings of the study sample and sections following each research sub-question. In this section, data will be highlighted and presented in a general manner. The sample utilized in the present study consisted of ‘white middle-aged adults whose age averaged 43 years. .Males and females were represented on a near equal basis. The majority of adult children were married with at least two offspring who were under eighteen years of age. The 147 majority of adult children had post-high school education, had achieved a higher occupational level and had an annual family income of greater than $35,000. Three-quarters of the adult children reported little or no difficulty living on their present income. Categories of sibling rank in their family of origin were represented. The majority of the adult children considered their own health and the health of household members to be excellent or good. More than half of the adult children sampled (p=27) had two living parents. Approximately two-thirds (3:28) of the married adult children had three or four living parents per couple. The average age of both the mothers and the fathers of the adult children was 73 years. Ap- proximately sixty percent (pé29) of the adult children lived less than 500 miles from their parents. The majority of adult children reported their parents to have little or no difficulty living on their present income. All of the adult children maintained contact with their parents by telephone usually one time a month; the majority visited their parents about 3-4 times per year and corresponded by letter or mail one time a month. The majority of adult children described their mothers' health and their fathers' health as excellent or good. Approximately 70% (p=29) of the adult children reported their mothers to have chronic health problems, 56% (p=l7) reported their fathers to have chronic health problems. The most frequently reported health problems of their 148 parents were: bones and joints, cardiovascular, and respiratory problems. There were some additional descriptive findings concerning the study sample of adult children. Selected sociodemographic variables concerning the adult child participant (age, sex, education, income, and geographic distance from parents) were correlated with each scale. "Age" was significantly correlated with socioeconomic health needs sub-scale, health assistance for socioeconomic health needs sub-scale, and total health assistance scale. "Sex" was significantly correlated with physical health needs sub-scale, socioeconomic health needs sub-scale, total health needs scale, health assistance for physical health needs sub-scale, health assistance for socioeconomic health needs sub-scale, and with total health assistance scale. "Education" was significantly correlated with health assistance for socioeconomic health needs sub-scale and with total health assistance scale. The majority of adult children expected their parents to experience physical and psychological health needs while less than half expected their parents to experience socioeconomic health needs as their parents grow older. The majority of adult children expected health assistance for physical health needs of their parents. Approximately three-fifths expected health assistance for psychological health needs,less than half of adult children expected health assistance for their parents socioeconomic health 149 needs. Adult children reported persons most likely to help their parents with physical and socioeconomic health needs were providers of health assistance within the secondary group. Less than 2% reported the professional nurse as the person most likely to help their parents with health needs. Help with psychological health needs was reported to be providers of health assistance within the primary group. Adult children perceived themselves to be providers of health assistance primarily for psycho- logical health needs of their parents and least of all for their parents' physical health needs. Reliability of the Questionnaire The procedure utilized for determining reliability of the scales used to summarize perceived health needs and perceived health assistance was the coefficient alpha. Coefficient alpha was computed for each of the major scales: perceived health needs (total) and perceived health assistance (total). Coefficient alpha was also computed for each of the sub-scales: physical, psycholog- ical, and socioeconomic health needs and health assistance. No items were deleted from the scales. Table 1? summarizes the reliabilities of each scale utilized in the present study. 150 Table 17. Summary of Reliabilities of Each Scale Using Coefficient Alpha. Number of Reliability Scale items Coefficient Health Needs (total 51 .93 Physical Health Needs 27 .86 Psychological Health Needs 13 .83 Socioeconomic Health Needs 11 .91 Health Assistance (total) 51 .91 Health Assistance for Physical Health Needs 27 .84 Health Assistance for Psychologi- cal Health Needs 13 .80 Health Assistance for Socio- economic Health Needs 11 .87 The reliability coefficient for perceived health needs (total) was .93. Reliability coefficients for the three sub-scales are: perceived physical health needs sub-scale .86, perceived psychological health needs sub-scale .83, and perceived socioeconomic health needs sub-scale .91. The reliability coefficient for perceived health assistance (total) was .91. Reliability coefficients for the three sub-scales of perceived health assistance are: perceived assistance for physical health needs sub-scale .84, perceived health assistance for psychological health 151 needs sub-scale .80, and perceived health assistance for socioeconomic health needs sub-scale .87. Intercorrelations of the scales utilized in the present study were obtained and are depicted in Table 18. Results of factor analysis on physical, psychological and socioeconomic health need items are presented in Table 19. These findings are summarized and interpreted in Chapter VI. Summary In Chapter V data were presented that described the study sample. Additional descriptive data were presented which correlated selected sociodemographic variables with each scale. Data pertaining to perceived health needs of aged parents, perceived health assistance for aged parents, and persons most likely to help aged parents were or- ganized according to each research sub-question. Data pertaining to the major research question was summarized in a general manner. Reliabilities of each scale used to measure perceived health needs and perceived health assistance were reported. In Chapter VI, the study findings will be interpreted and summarized. Implications will be discussed in relation to the conceptual framework utilized as the theoretical basis for the study and in relation to nursing practice, nursing education, and the need for further research. 152 oooo.~ “Fem. mpnm. mama. mnmo. mooF. mpmom mummz ;p_mm: oweocoom -owuom row mucm numwmm< cupmmz oooo.F mmmo. “mom. Pome. momm. upmom mummz supmmz _mowmxga tow mucm numwmm< z»_mm: oooo.p “mow. musm. omen. mpmum mummz ;u_mm= _mu_m -opoguzma Low mugs numwmm< cupmm: oooo._ “_om. mmmm. mpmum mummz ;a_mm: uwsocoumowuom oooo.~ ammo. wpmum mummz ;u_mw= _mu_m»:a oooo.F mpmum mummz gppmmz Pmuwmoposuxma m_mom mFaum mpmom mpmum memom mpmum mummz supmm: mummz mommz sppmm: muomz gppmm: mummz mummz cppmm: uwsocoumowuom su_mm: _mowmo_o;uxma uwsocoumowuom gupmm: Pmuwmopoguxma Lol.umwmm< quwmxca tom .umwmm< _muwmxga supmm: Lol.umvmm< :ppmm: smew: cupmm: .xuaum ucmmmga on» :_ umNWPwp: mmpmum co mcowumpmrtougmucH ”xwgumz =o_um~mggou .m_ oFam» 153 Table 19. Factor Matrix of Health Need Items Within Each Scale. Factor Loading Physical Health Need 1 2 3 4 5 6 Daytime tiredness 64* 12 10 16 l 24 Swelling of hands or feet 62* l7 l3 -2 -l7 -9 More days when they don't do their usual activities 58* l4 18 20 26 24 Changes in their daily routines 56* -15 -4 0 45 9 Increased difficulty adapting to extreme changes in weather 55* -4 ll 19 40 6 Increased difficulty doing household tasks 55* - 7 20 28 20 -21 Shortness of breath 53* 39 -9 -l7 7 6 Constipation ll 50* -16 28 —4 -9 A need to urinate more often -3 47* 13 9 -4 6 Loss of balance 35 44* 2 -12 36 -39 Cold hands and feet 12 42* 3 -12 39 12 A change in their ability to smell odors 1 40 64* 6 6 10 Increasing deafness 2 -9 57* 4 2 ll Numbness of hands and/ or feet 19 47 53* ll 15 —23 Difficulty chewing 41 13 52* -16 15 24 Problems With denture 43 _5 52* 1 14 10 fit Visual changes 11' 3 -13 66* 14 -3 Brief awakenings during the night 25 19 18 52* -3 50 Longer time to re- cover from illness 0 l -22 49* 32 -10 Pain and stiffness in joints 2 9 9 43* 0 14 154 Table 19. Continued. Factor Loading Physical Health Need 1 2 3 4 5 6 Need to reduce their calorie intake 8 0 28 39* -6 23 Safety problems at home 6 -2 18 ll 74* 16 Inability to hold their urine 16 44 26 13 52* _ -4 Chronic health problems 44 37 -16 13 45* 12 Sleep loss 48 18 l4 14 13 58* Symptoms of disease differently from a younger person 0 —10 12 12 13 56* More side effects from common medications 27 37 8 -12 21 38* Proportion of Variance .13 .08 .08 .06 .08 .06 Psychological Health Needs 1 2 Decreased ability to cope with situations 76* 12 Difficulty thinking through problems 78* 31 Difficulty making up their minds 67* 42 A decrease in their ability to learn new things 65* 26 More times when they will act like children 61* 5 A need for parent-like guidance 60* 34 Feelings of uselessness 50* 7 155 Table 19. Continued. Factor Loading Psychological Health Needs 1 2 Taking more time to perform routine activities 27* -7 Increased need for family closeness -10 67* Desire to reminisce 18 62* Changes in sexual and marital relations 19 52* Some degree of forgetfulness 8 47* Difficulty in following any pres- cribed medication schedule 36 37* Prgportion of Variance .25 .15 Socioeconomic Health Needs Possible difficulty paying for housing 92* 26 Possible difficulty paying utility bills 92* 20 Possible difficulty paying for food 91* 26 Possible difficulty paying for health care services 90* 13 Possible difficulty paying for social activities 85* 7 Possible difficulty in ability to purchase desired clothing 64* 52 Possible difficulty arranging for health care services 45* 43 Difficulty planning a balanced diet 12 72* 156 Table 19. Continued. Factor Loading Socioeconomic Health Needs 1 2 Possible difficulty managing personal finances 28 68* Decreased interest in current events 9 67* Decreased number of social contacts 10 67* Proportion of Variance .43 .23 CHAPTER VI SUMMARY AND IMPLICATIONS Overview In Chapter VI a summary and interpretation of the study findings are presented for the study sample and for each research question. The implications of the findings for nurs- ing practice and nursing education are discussed and recom- mendations for further research are presented. Descriptors of the Study Sample Age. Sex of the participant. Marital status. Number of offgpring. The mean age of the adult child participant in this study was 43 years. The majority was between the ages 30-50 years, an age span described by Stevenson (1977) as the core of the middle years. Within the con- text of the extended family system, the typical participant in this study can be considered as the middle generation. Recent studies of the "middle generation" in extended family systems report ages of subjects over 30 years. Brody (1979), for example, studied attitudes and 157 158 preferences for service providers in a sample of 80 family triads where the middle generation ranged in age from 34- 62 years with a mean age of 47.9. A few studies do report using respondents younger than 30 years of age (Johnson, 1977) but in general the delineation of middle generation as over 30 years of age used in this study is consistent with past work. Four-fifths (81.1%) of the study participants were married. Of those with offspring, the mean number of children was 2.68, approximately three-quarters (71.0%) were under eighteen years of age. Compared with national data based on the 1980 census (Current Population Reports, 1981), about sixty percent of all American households were maintained by persons who were married. Thus, the sample contained a larger number of married persons than in the typical American household. Although the number of male and female study participante were approximately equal, no attempt was made to determine the householder (a term used by the Bureau of Census to designate the head of the household). In contrast, most empirical studies of adult children report samples that are either all female (Brody, 1981) or predominately fe- xnale (Johnson, 1977). Since women have traditionally assumed parent-care roles, it is not surprising that available literature focuses on female samples. No studies ‘were found concerning males and their relationship with 159 their elderly parents. Findings from this study regarding sex of the participant are therefore, less subject to sampling bias. In summary, respondents constituted the middle genera- tion within their extended family. The majority were middle-aged persons with an average of three offspring of their own under eighteen years of age. In contrast to other studies that focused on female participants, the adult children in this study included equally represented male respondents. Race or ethnic background. All participants were Caucasian. One person stated she was Jewish. No other Specific racial or ethnic background was identified by any of the participants. National data based on 1980 census (Current Popplation Reports, 1981) show that ninety-one percent of married-couple families are main- tained by white persons. Sampling bias may have occurred because most of the peers of the investigator who provided names and addresses of potential participants were highly educated and white. Education. Occupation. Income level. Nearly three- quarters of the adult child participants were executives, business managers or proprietors, administrative personnel, or professionals. Over half (60%) reported incomes of 160 $35,000 or above. These two findings are consistent with the respondent's level of education. The majority (70%) of adult children and one-fifth of their spouses (20%) had some college education or had completed post- college education. It was anticipated that perceptions of financial adequacy could affect answers, therefore respondents were asked as to how difficult it was for their family to live on their combined family income. One-quarter expressed some difficulty living on their present income, while three- quarters expressed little or no difficulty. This finding is consistent with their relatively high reported income level and with the fact that three-quarters were employed full-time. In addition, many spouses were employed (64.4%) as well. These findings may account for why they did not perceive difficulty living on their family income. The study sample, if compared to the population of adult children, was biased with respect to the variables of education, occupation, and income level. Sibling rank in family of origin. There was no cluster- ing within categories of sibling rank. The proportion of subjects within each category were: forty percent were youngest children, twenty-five percent were oldest children, ten percent were only children, and twenty-percent were middle children. Although sibling rank has been used as 161 a descriptor of adult children samples (e.g., Robinson, 1979), this variable has not been associated with major study findings. Based on national data, there are more aging parents and fewer adult children to share the care of the parent as the parent grows older (Treas, 1979). It is, therefore, difficult to make inferences about study find- ings. Regardless of sibling rank, with fewer adult child- ren available, the amount of parent-care involvement may increase; particularly those adult children who live geographically closer to their parents (Bengston, 1976). In addition, if one of the siblings is unable to provide parent—care (e.g., unwilling, or unable due to geographic distance), remaining siblings may experience more in- volvement. Health of adult child participant and their household members. Almost all (91.1%) of the adult child participants described their health as good or excellent. Nevertheless, approximately one-third experienced chronic health problems such as respiratory problems, cardiovascular, and problems with bones and joints and one-quarter reported that members of their household had chronic diseases. These findings are not unusual when compared to literature on the general health of middle-aged adults. Middle-aged adults have a higher incidence of disease, especially chronic problems, than do young adults under age 40 (Diekelmann, 1977). 162 Since the mean age of study participants was 42.6 years, it was expected, although not measured, that their own experience with the aging process might alter their perceptions of their parents' future health needs. The relationship between the adult child's experience with his/ her own aging and related health needs and the perception of his/her parents' future health needs is not specifically addressed in the literature and findings from this study would suggest a need to explore this area. This subject is addressed in the discussion on reliability and validity of the scales later in the chapter. The finding that one-quarter of the participants re- ported chronic disease among household members may have in- fluenced their perceptions of health care needs in general. Other study findings may have altered the responses of the study sample. An observation was made by the in- vestigator while reviewing answers to the question if chronic health problems were exPerienced. Most of the respondents identified disease problems, e.g., asthma, and mentioned few personal risk factors such as obesity, stress, alcohol intake. Perhaps the sample of adult children interpreted the question about chronic health problems to mean chronic disease. The study sample may not be aware that personal risks or those risks determined by family history, post-medical problems, occupational habits, and personality (Hake, 1978) are chronic health 163 problems. There may exist a need for increased public awareness of personal risks associated with health of middle-aged adults and a need for greater public visibility of services that can be provided to middle-aged adults by professional nurses. Number of living parents. Age of parents. Approximately one—half the study sample had one living parent and the other half had two living parents. Of the married adult child participants, the number of living parents including their spouse's parents was 3 or 4 living parents for two- thirds of the couples and l or 2 for the remaining one- third couples. Although the total number of living parents per adult child are generally reported in empirical studies (Robinson, 1979; Simos, 1973), no studies are reported that identify the total number of living parents among married adult children. It would appear that the adult child who has lost one of his/her own parent(s), or a spouse's parent, has a greater awareness of the health needs of the remaining parent(s). EXperience with health problems of aged parents :may influence their perceptions of future health needs of their parents. In addition, the adult child may perceive increased involvement (e.g., health assistance) with the remaining parent(s). Although these factors are not Ineasured in the present study, study findings would support the need to assess their influence on the 164 perceptions of adult children on a practical level. For both the mothers and fathers of the participants in this study, the mean age was nearly 73 years. Other studies report the age of the elderly parent to be over 70 years (Brody, 1979; Robinson, 1979). Using national data, Brody (1979) notes that there is a rapid and persistent increase in the size of the oldest segment of the elderly population. By the year 2000 the number of those elderly persons 85 years and over is expected to double, while those persons 75-84 years will increase by 57%, and the 65-74 year old group will increase by 23%. Since the parents are living longer and there are fewer adult child- ren to help, each child might expect to be involved with parent-care for longer time and to a greater extent. There is no consensus in the literature regarding the onset of "old age". Stevenson (1977) considers age 70 as the beginning of late adulthood. Neugarten (1979) distinguishes between the young-old and old-old. The Bureau of Census considers age 65 and over as the older population. Age 65 was chosen as the minimum age for an aged parent because of its general acceptance in our society as the "onset" of old age. Recent literature suggests that this cultural norm may be changing. The adult children in this sample perceived their parents to be in relatively good health and of the aged parents lived outside of an institution. These factors, although not directly measured, may have 165 influenced their responses since the parents may not yet have experienced health needs requiring health assistance. In summary, the number of living parents per adult child participant and per married couple in the present study are consistent with reports available. The mean age of the parents of adult children in this study can be interpreted as an "old" or an "elderly parent" and therefore would be likely to experience future health needs. Geggraphic distance from parents. Three-fifths of the adult children reported living less than 500 miles from their parents or less than a day's drive from them. Nearly one-fifth reported living ten miles or less from their parents. Findings in the present study would support observations about national trends. Most of the literature on geographic distance from parents is based on national surveys. For example, Olsen (1980) notes that most older parents have adult children within easy visiting distance. Although research studies often use geographic distance as a des- criptor (e.g., Robinson, 1979), it is not reported with lnajor findings. Shanas (1979) notes that the proportion of elderly parents and adult children living in the same household has declined in the last twenty years, from 36% in 1957 to 18% in 1975. At the same time there has 166 been a consistent proportion of older persons living within ten minutes of an adult child: 56% in 1957, 61% in 1962, 52% in 1975. Geographic distance will be dis- cussed in more detail in the section, additional findings regarding the study sample. Usual type and frequency of contact. Nearly all of the adult children in the study sample usually contacted their parents by telephone or visited them; three-quarters usually corresponded by letter/mail. There was no cluster- ing in categories of frequency of contact; most reported a frequency of contact ranging from about every week to three or four times a year. In general findings in the present study would tend to support national surveys and empirical studies. Using national data, Shanas (1979) reports no decrease in visit— ing between older parents and at least one of their adult children in a twenty year period (1957 to 1975): daily, weekly, and monthly visiting patterns have remained stable. Robinson's study (1979) of adult children caring for their parents lends support to findings in the present study: in her study, 47% of adult children reported visiting their parents weekly or daily, 13% saw them at least one time a month, 40% saw them less than one time a month. In the present study fewer adult children reported visiting their parents weekly or daily (29.8%), more reported seeing their 167 parents at least one time a month (21.3%) and approximately the same number saw their parents less than one time a month (44.7%). Difficulty of parents living on their present income. Three-quarters of adult child participants perceived their parents to have little or no difficulty living on their present income. This finding is unusual when considered with the fact that one of the criteria to be a participant in this study was that one or both parents were 65 years or older and retired. It was expected that more adult children would perceive that their aged parents would experience difficulty since the present cohort of older persons often-times live on fixed incomes and the economy is relatively inflationary. Caution must be used when interpreting this finding since actual socioeconomic status of the parents is not known. Garlinghouse (1982) notes that the present cohort of older adults have lived through two World Wars and a major economic depression and that perhaps the older person of today has learned to adapt to unstable economies. Perhaps their adult children were able to perceive their parents' efforts to maintain financial stability and in- dependence despite economic hardships. In general, older persons do not wish to be financial burdens to their families (Silverstone, 1981). Perhaps the adult children 168 in this sample perceived their parents' desire for financial independence. On the other hand, the sample of adult children were of relatively high socioeconomic status and may be projecting their own socioeconomic security onto their parents' situation (the sample were of higher socioeconomic status). In summary, the fact that three-quarters of the sample of adult children perceived their parents to experience little or no difficulty living on their present income, regardless of why, is an important finding in relation to the research questions. It can be concluded, within the sc0pe of this study, that the adult children may not perceive financial difficulty of their parents should their parents actually experience socioeconomic health needs in the future. Parents' health. More adult children reported their fathers than their mothers to be in good or excellent health. More mothers than fathers were reported to be in fair or poor health with a higher incidence of chronic health problems, 69.0% and 56.7% respectively. The two most fre- quently reported chronic health problems for both parents were cardiovascular problems and problems with bones and joints. Parents' health is discussed further in the sec- tion following Research Sub-question l. The incidence of chronic disease increases with age; after 75, more limitations resulting disabilities have 169 been reported (Kovar, 1977). Brody (1981) notes that ap- proximately only 7.1% of older persons between the ages of 65 to 74 are in institutions, however, one-third of non- institutionalized older persons need supportive services for functional impairments. The incidence of cardiovascu- lar problems and problems of bones and joints of older parents have been reported in studies of other adult child- ren samples (Robinson, 1979; Simos, 1973). In general, study findings about parents' health are consistent with other reports on the health problems of older persons who are also elderly parents. In summary, a small sample of forty-seven adult child- ren with aged parents has been described using demographic and other descriptors. Descriptive findings are similar to other samples of adult children. Compared to the pOpu- lation of adult children, the study sample consisted of all whites, highly educated, and were of a relatively higher socioeconomic status. In the next section, addi- tional findings relevant to the study sample will be presented. Additional Findings Regarding the Study Sample Selected sociodemographic variables concerning the adult child participant (age, sex, education, income, and geo- graphic distance) were correlated with each scale utilized in the present study. In Chapter V, results of Pearson 170 Product Moment Correlations were reported for statistically significant relationships (Table 9). In this section, data are summarized and interpreted for statistically sig- nificant relationships. Age. There was a negative relationship between age of the adult child participant and three scales utilized in the present study: socioeconomic health needs, health assistance for socioeconomic health needs, and the total health assistance scale. As the age of adult children increased, they perceived fewer socioeconomic health needs for their parents and less need for someone to provide assistance for their socioeconomic needs. As age in- creased, they perceived less health assistance for their parents' total health needs. Younger adult children per- ceived more socioeconomic health needs, more health as- sistance for socioeconomic health needs, more health assistance for their parents' total health needs in general. Although these relationships are statistically signifi- cant, their practical significance must be considered along with other descriptive findings of the present study. For example, sample means and standard deviations for each scale (Table 12 and Table 14, Chapter V), would suggest that the average score for these scales was neutral or near neutral. Three-quarters (72.4%) of the adult children reported their parents to have little or 171 no difficulty living on their present income and, there- fore, a significant correlation might be expected for this sample of adult children. Perceptions of their parents' health needs may have been influenced by their own sense of economic security and ability to meet their own socioeconomic needs. As previously noted, the study sample consisted of a large number of highly educated persons with relatively high income levels. No studies were located in the litera- ture that established a relationship between age or educa- tion level of adult children and their perceptions of specific health needs or health assistance concerning their parents. The findings from this study vary from the Simos' study (1973) which suggested that adult children (ages 30-68 years) were able to identify socioeconomic problems of their parents (for example, financial problems, paying for health care) not only in the context of current realities but also in terms of future expectations of need. The fact that older participants tended to have lower scores on these scales could be due to their sense of financial security. Perhaps older participants do not consider socioeconomic health needs as part of the health care of their parents. Younger participants, however, may be projecting their own sense of financial insecurity on to their parents' future socioeconomic health needs. The reliabilities for the three scales were high, as was the level of significance of the correlations, resulting 172 in confidence that the correlations were unlikely to have been the result of chance. In similar samples of adult children (who are highly educated and of higher socioeco- nomic status), it is likely that a negative relationship exists between age of the adult child and the three scales. S35. There was a negative relationship between sex of the adult child participant and six out of eight scales utilized in the present study: physical health needs, socioeconomic health needs, total health needs scale, health assistance for physical health needs, health as- sistance for socioeconomic health needs, and total health assistance scale. Males tended to have higher scores than females in this sample of adult children. Studies of other adult children samples report sex as a descriptor but not as a variable related to major find- ings. Johnson (1978) studied the affective quality of the relationship between elderly mothers and their daughters. Simos (1973) and Robinson (1979) each studied male and female adult children but did not report differences in parent care based on sex of the subject. Brody (1981) observes that although empirical studies on older persons in need of help look to their daughters rather than sons for assistance and daughters reSpond, such data do not imply lack of responsibility or family feeling on the part of sons. Rather, data reflect the cultural assignment of gender-appropriate roles. Sons are more likely to experience 173 the repercussions of parent-care through the effects on their wives. L0pata (1973) found that sons of widows help with financial management and with funeral arrangements. Findings from this study would suggest that sons do perceive health needs of their parents, particularly their physical and socioeconomic health needs. Sons also expect to provide health assistance for their parents' health needs in general and particularly, health assistance for their physical and socioeconomic health needs. The relationship between sons and their elderly parents and the role of sons in parent care are topics not specifically addressed in the literature and findings from this study would suggest a need to explore this area. Findings from this study suggest a need to involve sons more in the general health care of their parents. Each of the six scales that correlated with sex of the participant had a high reliability. In addition, the level of significance of the correlations resulted in confidence that they were unlikely to have been the result of chance. These findings have some practical value. In similar sam- ples of adult children, the investigator can be reason- . ably confident that negative relationships exist between sex of the participant and each of the six scales. Education. There was a positive relationship between education of the adult child participant and two scales 174 utilized in the present study: health assistance for socio- economic health needs and total health assistance scales. As the level of education increased, adult children per- ceived more of their parents' socioeconomic health needs and a greater need to provide health assistance for their par- ents' health needs in general. Program evaluation studies reported by Johnson and Spence (1982) and Silverman (1977) suggest that education of adult children regarding expected changes that occur as their parents grow older is an effective intervention for adult children. Over 87% of the sample had post- high school education and it would seem likely that more scales should have positively and significantly correlated with education. Based on study findings, education of adult children about future health needs of their parents would be necessary in such programs regardless of the educational background of the adult child. Income level. None of the scales utilized in the present study correlated significantly with the variable income level. In contrast to study findings, literature suggests that filial responsibilities may be related to socioeconomic status (Seelbach, 1978; 1980). Confounding variables such as size and characteristics of the sample may have in- fluenced the relationship between income and scales uti- lized in the present study. Repeated use of the scales 175 in other samples of adult children whose income level is widely varied may yield different relationships. Perception of health needs and health assistance may be one aspect of the general term "filial responsibilities." The term is used in literature in a broad, somewhat vague manner. For future research, findings from this study would suggest a need to Operationalize the term as it relates to the relationship between perception and actual care of parents. For example, income level of adult children may be positively related to ability to purchase services for their parents rather than their perception of the need for the services. Geographic distance from parents. None of the scales utilized in the present study correlated significantly with the variable geographic distance. Recent empirical studies (Egerman, 1966; Jonas, 1980; Shanas, 1979; Sussman, 1974) have demonstrated that aging parents do turn to and depend upon their adult children to help in meeting daily requirements of living and in times of illness. Since most of the adult children relatively close to their par- ents, the lack of significant correlations is considered unexpected. Confounding variables such as size and characteristics of the study sample may have influenced the relationship between geographic distance and perceived health needs and perceived health assistance scales. 176 Bengston et a1. (1976) postulates that the variable geographic distance is positively related to the amount of contact possible, or association, between family members and the helping behaviors among the older and middle generations. The adult children in this study were highly educated and of higher socioeconomic status which could be confounding variables. For example, an adult child may perceive a health need of his/her parent and may perceive health assistance. The adult child in this sample could possibly afford to go to the parent or bring the parent closer to the adult child for help. Hess and Waring (1978) conclude, after an extensive review of literature on intergenerational relations, that maintenance and sustenance of the adult child/aged parent bond will be increasingly based on the willingness of both family members to engage in supportive behavior. Willingness of the adult child to provide parent care may be a confounding variable affecting the relationship between geographic distance and perception of health need and health assistance. This willingness often hinges on the quality of the relationship over many preceding decades (Troll, 1980). Study findings suggest the need to explore the relation- ship between "willingness" of the adult child to provide care and their perception of the care needed by their parent(s). Archbold's qualitative analysis (1982) of parent care, 177 as cited earlier, suggests the existence of three parent-care roles: care provision, care management, and care trans- fer. Four factors influenced whether or not the adult child assumed a parent-care role: socioeconomic status, housing arrangements, illness onset of the parent, and past eXperience with caregiving. Socioeconomic status was the primary determinant of whether or not services could be purchased. Based on findings from this study, it is possible that adult children perceived their parents' health needs and health assistance regardless of geographic distance from their parents. Perhaps their "perceived role" in parent- care may be related more to the variable geographic dis- tance. Findings from this study would suggest a need to explore the manner in which perceptions, behavior, and selected sociodemographic variables of adult children are related to their parents' health needs and health assist- ance. Summary of additional findings regarding the study sample. Statistically significant relationships between selected sociodemographic variables concerning the adult child participant and each scale utilized in the study (were summarized. Data were interpreted in relation to cm\eaaso uaso< man mo 3:: 3:: mgwuuuc.Pumi- ;i1liiiiiluiiuiiliiiiuiluiiuiw «tau «umt_u Ampmocmm_o m=_mg:zv acmscogp>cu m.c—_:o upzu< ucm uppso up=u< co ucmEmmomw< mcflmuoz .N ousmflm cw a bumt_o mcwccuumtmuca «.mmtaz :o_HQOOtma mucmtma ammo cw mmocm tow mucoum_mmm a: mo utmmuwu can 3 Shaw; to 35°“ ”.5 352223. mmwmwmmn cuwww“ mama: gupamg Soc—oguaa ac, soumam .mvom: gupamz- m—xummmpb- u_sacoooo*OOm nuowucmtmucwu »__smu mmOLSOm .—uuwmo_onoxma meow: carom: concouxo cp acutaa -mg »__smu- mucuum_mmm .pmupnga mama: gupmwg upeocoum mawzmcowua_ name a up.gu ;u_om; to tmuw>ota ;u_x apm; uwsocouooPOOm -OPOOm .pau -OL vm>waugaa upauu sup: mxmou .mucmumwmmm :u_um; o» a_ox¢_ .Paupmopo;oxma -Fmopogoxma mcvuspu:_ apsmcopuu_om- poucosao—m>oo- .mumm: gupumx- umos m=Omtoau _muwmxga Lou- .—uu_m>;a- Stoum_g x—_suu- Amvucmtma ch mucmu.m_mm<— soumzw mugs: cowuoauwm tm>_mmtoo zupuu: co mucuumpmm< muomz appeal co owoa 7 new; mo whom mtuup>OLa ;u_ao: :u—mo: uaucmuxu _ _ . . . _ m:o_uamugwa :zo mo mmocmtox< m.umt:z taupe iota sash ma mucmtaa mc_ctmu:oo mmamm_ r: gu—amz co meowuamutma I..-) Oppsu up=o< 38 £238 \\-.\ mummmmm< omtaz \..:u mucosa; vum< ‘1 II‘ _ 228 findings, adult children did not expect health assistance for all of their parents' health needs. 3. The adult children who participated in this study expected minimal health assistance from the professional nurse for their parents' health needs. Assessment must include perceptions of adult children regarding the role of the professional nurse within the extended family system. On a theoretical level, a nurse must assess whether or not his/her presence is perceived by the adult child as a man/human-environment interaction des- cribed by Rogers (1970). On a practical level, a nurse must be aware that although nurses have traditionally pro- vided health care and health assistance to elderly persons, their adult children may not be aware of the nurses' role. Nurses need to involve adult children in nursing situations with elderly persons, particularly for their health needs. The nursing profession, particularly nurses in advanced practice, may need to "market nursing care" or become more "visible" to middle-aged persons who desire to provide health care to their parents. Anticipatory guid- ance would be an apprOpriate nursing intervention. 4. For maximum health potential of the family with Older members, the nurse must be cognizant that percep- tions of adult children concerning health issues of their parents may differ from perceptions of the parents and other members within the extended family system. 229 Therefore, perceptions of each member must be assessed separately and interventions mutually agreed upon for maximum health potential of all members within the ex- tended family system. 5. According to Rogers (1970) "the nurse is an en- vironmental component for the individual receiving services and is always a factor in the intervention process" (p. 124). The nurse, therefore, should remain aware that as an individual interacting with an adult child, he/she may affect perceptions of the adult child. For example, from a theoretical and practical standpoint, the in- vestigator intervened with 47 adult children who participat- ed in this study as a human/environmental interaction described by Rogers). Based on study findings, the nurse must articulate her professional role and tasks associated with that role (i.e., coordinating, teaching, facilitating direct care) to the adult child since the adult child perceived a traditional role for the professional nurse. It is possible, based on study findings, that the adult child may not perceive him/herself as a provider of health assistance to his/her parents. In a situation like this, perhaps the apprOpriate intervention might be to facili- tate a helping network for the parents. On the other hand, based on study findings, the nurse must not assume that the adult child does not wish to care for his/her parents. 230 6. Nurses must become knowledgable about community agencies and resources available to adult children with aged parents and actively create a network of resource persons with whom to consult or collaborate. In this manner, the nurse can assist the adult child to utilize the health care system for situations other than acute, episodic care. 7. Nurses, eSpecially those in eXpanded practice, must take the initiative to establish practices in settings which would allow for greater visibility as autonomous health care providers to families with older members. Referral to and participation by nurses in programs such as "As Your Parents Grow Older" (Johnson and Catalano, 1981) is an apprOpriate intervention supported by find- ings from this study and by program evaluation studies. 8. The adult children utilized in this sample were typically middle-aged adults and, therefore, the nurse must be cognizant of the limitations (i.e., available resources) that adult children have in relation to their role in parent-care. Nurses must become politically active to obtain policy changes favoring support for adult children who provide health assistance for their parents both financially and philOSOphically. 231 Implications for NursingyEducation Implications for nursing education may be drawn from study findings as they relate to the conceptual framework upon which this research was based. Fundamental concepts of the framework of this study will be presented, fol- lowed by pertinent study findings and their implications. Patterns exist in the perceptions of adult children about health issues concerning their aged parents which are the product of their membership and interaction in the extended family system. 1. Study findings have produced a profile of the per— ceptions of a group of adult children about health issues concerning their aged parents. Common perceptions are enumerated in the section entitled Major Research Ques- tion on page 215. Nursing curriculum at all levels must include information regarding perceptions of adult child- ren which are the result of many factors including structure of and interaction within the extended family system. This information is important for the nurse's understanding and involvement with adult children who desire to care for their parents. Using common perceptions as a base, the student will better understand the effect of differences encountered by individual adult children with aged parents. 2. Nurses must examine their traditional role and their own perceptions of the adult child/aged parent 232 relationship and about families with older members in general. Nurses need to utilize knowledge of gerontology, family, adult health to guide interventions and recognize their influence or lack of influence on perceptions of adult children. 3. Curriculum and service programs should include instruction on how to obtain information from and col- laborate with community agencies. The nurse can then assume the "linkage role" between the adult child and support systems for their parents or educate the adult child as to the role. Pooling of available resources should be a priority. 4. Included in the curriculum at each level of nursing education should be material relating to middle- aged persons, their resources and limitations, who desire to provide parent-care. Too often, the nurse is socialized to institutional care of elderly persons or expect adult children to provide ongoing health assistance. Elderly persons generally prefer and use family members, particu- larly adult children, as their first resource when help is needed. 5. There is additionally an implication for the develop- ment of in-service programs for nurses working with fami- lies with Older members to increase their understanding of adult children with whom they interact and disemination of study findings in professional literature to accomplish 233 the same purpose. In the area of graduate education it is important that further research (e.g., use of refined scales) be encouraged in an effort to expand the level of understanding and add to the knowledge base of nursing. Individual differences of percpptions about health issues concerning aged parents exist which must be assessed when planning nursing care. l. The fact that differences in perceptions of adult children do exist and may be assessed and measured should be an integral part of the curriculum in the education of nurses at all levels. Assessment skills in these areas should be taught in both schools of nursing and in work- shops and in-service programs for practicing nurses. The tools for the assessment of these differences in adult children should be shared both with practicing profes- sionals for direct use with adult children and also with other researchers so that understanding of these differences may be advanced and added to the body of nursing knowledge. 2. Sensitization of the nurse to the specific life situation of the adult child is an equally important facet of the educational process. As Garlinghouse (1982) points out, too often clinical experience in gerontology is limited to the frail, ill elderly persons in short-term or long-term institutions. Since the majority of older persons continue good health and experience "normal aging" 234 outside of institutions, how much more apprOpriate for the student to gain clinical experience with families who have healthy, active elderly members. 3. An additional implication is for the development of standards for care of adult children who desire to provide health care for their parents which take into consideration both commonalities or patterns and the need to understand and assess differences between individuals. Perceptions of adult children with aged parents are in- fluenced by a number of factors and the interactions of those factors in their lives. 1. Study findings, as well as a review of pertinent literature, support the view that perceptions of adult children are influenced by numerous factors. Demographic and other descriptive variables have been used to describe adult children with results similar to other adult child- ren samples with the exception that the sample used in the present study were highly educated, and were of higher socioeconomic status. There is a clear and strong implica- tion for the continuation of research efforts at all levels to quantify and eXplain the inter-relationships among those factors which influence perception of health issues. Additionally, awareness of those factors known to influence perceptions of adult children should be included in nursing curriculum at all levels of education. 235 2. There is also a need for nurses to participate in community programs for education and support of adult children who desire to care for their parents in order to increase public awareness and understanding of the various roles adult children can assume in the helping network of their parents. Implications for Nursing Research Maximum health potential for the family with older members necessitates effective participation of the adult child in the health care of aging parents. The nurse must act to enhance health by utilizing knowledge of both patterns in perception and differences in perceptions of each adult child. While no finding in this study offers direct support for this assumption which was an integral part of the framework upon which the study was based, there are, nevertheless, implications for further re- search. The American Nurses' Association (1981) identified research priorities for the current decade among which include "decreasing the negative impact of health prob- lems on COping abilities, productivity, and life satis- faction of individuals and families" and "promoting health, well-being and competency for personal health in all age groups." A number of implications for further 236 research may be derived from this study and are enumerated below. 1. The use of random selection and larger sample size would increase the generalizability of findings. 2., Stricter control of the environment in which the questionnaire was completed would be recommended. Filling the questionnaire out at home in the presence of spouse or other family members may result in responses affected by social desirability bias. 3. Not only should similar samples of adult children be surveyed but researchers should seek patterns or com- monalities and differences among other samples of adult children with aged parents (i.e., those with institution- alized parents or adult children with lower education levels and lower socioeconomic status). Similar results from various samples of adult children would strengthen any political effort to obtain funding for financial and sup- port programs for adult children who desire to care for their parents. 4. The high alpha coefficients of the scales developed for the study imply that effort should be directed toward further refining the instrument to improve internal con— sistency and to evaluate for construct validity. Garling- house (1982) also Obtained high alpha coefficients for similar scales used on a population of healthy older adults. Further testing on various populations and 237 subsequent factor analysis to identify concepts within scales utilized in the present study is recommended. Should further research prove the instrument both reliable and valid, it might be utilized in research directed toward Optimizing health for all members of the extended family system. 5. For use as a practical clinical assessment tool not requiring sophisticated analysis, or for program evalua- tion, the instrument must be simplified and tested in various clinical settings. A checklist format rather than use of a Likert scale may be sufficient to identify in- dividual and group needs for clinical interventions, thereby further incorporating nursing research into nursing practice. 6. Utilization of refined scales as outcome measures is recommended for evaluation of possible changes in per- ceptions concerning health issues of aged parents in educa- tion and support programs for adult children with aged parents. 7. Because of the present limitation of funding re- sources and highly competitive market for those limited funds, nurses must sutdy and publish the cost effective- ness of involving family, primarily adult children, in the health care of older persons. 8. There is a need to formulate hypotheses to further understand under what circumstances adult children will provide health assistance to their parents, resources 238 and limitations of adult children in parent-care, what specific factors influence perceptions of adult children. Additionally, studies designed to compare perceptions of adult children with perceptions of their parents regarding health issues as described in this study would add valu- able information upon which nurses could develop knowledge- able interventions for the family with older members. Other areas for further research include: under what circumstances are adult children able to meet their parents' health needs; what is the nature of the relationship be- tween sons and their elderly parents? 9. There is a need for a longitudinal study of how perceptions of adult children are altered when real health needs of their parents exist. Summary In Chapter VI a summary and interpretation of study findings was presented. Findings were related to the conceptual framework of this study. Recommendations for nursing practice, education, and research were presented. APPENDICES APPENDIX A LETTER OF EXPLANATION WITH CHECKLIST OF CRITERIA FOR STUDY PARTICIPANTS GIVEN TO PEERS AND FRIENDS OF INVESTIGATOR 239 240 Thank you for helping to identify possible participants for my study. I will need the names and addresses of persons who meet all of the "Necessary Criteria" listed below. Use the back of this sheet for this purpose and return it to me. I will also need you to co-sign the letter that I will mail to these persons. The letter will explain the pur- pose of the research project, how to participate, and a consent form. If you would like to participate in this study and you are a Registered Nurse, you may include your name and address. However, please do not suggest names of other Registered Nurses since a large number of nurse participants could seriously bias the results of this study. As a suggestion, use this sheet as a worksheet. Simply put a check next to each item to be sure the person meets all of the necessary criteria. CRITERIA FOR SELECTION OF ADULT CHILDREN Necessarngriteria l. Literate 2. Age 30 to and including 64 years. 3. One or both parents are living. 4. One or both parents are 65 years of age or Older. 5. One or both parents are retired. 6. One or both parents do not live in a recognized health care institution as a nursing home or with a family member. 7. One or both parents presently live in their home or residence for senior citizens. 8. Person is not a Registered Nurse, unless it is yourself. 9. Name of person is not obtained through a recognized health care setting. Preferences of the Investigator l. 2 males, 2 females. 2. May live outside Michigan. 241 3. Prefer various occupations. 4. Prefer various ethnic backgrounds. 5. Prefer various income levels. APPENDIX B CO'SIGNED LETTER OF EXPLANATION TO STUDY PARTICIPANTS 242 243 MICHIGAN STATE UNIVERSITY (XJLLEGE OF NURSING EAST LANSING ' MICRIGAN ' 63824 Dear One of my nursing colleagues, Barbara Jepson-Taylor, is conducting a research prbject at Michigan State University on how adult children perceive health needs of their parents as they grow older and whether or not health assistance is expected. The research project is part of the requirements for a Master's Degree in Nursing, Family Clinical Nurse Specialist Program. The subject is an important one since adult children frequently care for their parents, as well as their own families, and receive little or no recognition or help from society. I feel this subject may be of interest to you. Results of this study will be useful to help providers of health care as well as policy makers formulate decisions and policies that would enhance family support of older persons. I want to assure you of your anonymity and the confidential nature of this study. To indicate your willingness to participate in this project, please complete the information on the back of the enclosed post-card and mail it. After receiving the post-card, a questionnaire will be mailed to you by Barbara Jepson-Taylor. The questionnaire will take approximately one-half hour to complete. Your help is greatly appreciated. WWv/flfdz ’«K 'IEVestigator Enclosure MS U is - ”(imam-e Action/Equal Opportunity Inuit-tion APPENDIX C LETTER OF EXPLANATION, CONSENT FORM, STUDY QUESTIONNAIRE 244 245 MICHIGAN STATE UNIVERSITY COLLEGE OF NURSING EAST LANSING ' MICHIGAN ° 48824 Dear Participant: Thank you for agreeing to participate in my research project. I h0pe the outcome of this study will be used to enhance family support for the care of aged persons. There are three parts to the enclosed questionnaire. Part A requests information about health problems you might expect your parent(s) to experience as they grow older. Respond to the statement the way you would expect your parent(s) to possibly experience the problem in the future. Part B requests information about activities that your parent(s) do or should do to stay healthy and overcome health problems. In Part C I have requested some additional information about you and your family. There are no right or wrong answers. I would ask that you complete the questionnaire by yourself and that you do not consult with anyone until the questionnaire is completed. The questionnaire will take approximately one-half hour to complete. Please return the questionnaire to me in the enclosed stamped envelope within five da 5. If, for any reason, you are unable to complete the questionnaire please return it to me per mail. Attached is a Consent Form; it outlines your rights as a participant in this study. Please read it, sign it, and return it with your questionnaire. Thank you for your help in this study. W 9%“ ¢W Barbara JepsonaTaylor, R.N., InvestTgator Candidate for Master's Degree in Nursing Family Clinical Nurse Specialist Program Enclosures MSU is on ”humour! Arum: "Equal ( Opp. ”unity mitotic. 246 CONSENT FORM In order to insure your anonymity and the confidential nature of this study, please read the following consent statements: --I have freely consented to take part in a research study being conducted by Barbara Jepson-Taylor, R.N., Graduate Student, Family Clinical Nurse Specialist Program, College of Nursing, Michigan State University. --I understand that I am free to discontinue my participation in the study at any time without penalty. Withdrawal from the study will not effect the care my family or myself are receiving. --I understand that the results of the study will be treated in strict confidence and that I will remain anonymous. Hithin these restrictions, the general results of the study will be made available to me at request. --I understand that my participation in this study does not guarantee any beneficial results to me directly. --I understand that I will not be paid or receive any direct form of gratuity for participation. Please sign to indicate your understanding of the consent statements. ‘Participant 2‘47 .apm; o» Npmxwp umos comcma on“ uuo_mm ou pmxmm ace :0» .Em—a0ta capzumucoa a gov: a—O; p—aou mcomcwa _mcw>mm nmaogup< .cwp_>oca m=_p on» co csapou cacao. me» e, caboo— muowgaocnau as» mums: .pouow: m_ Lon—m; o: c. to sm_aocq one ;u_: apes ca 38.: S8... 3 2:2. 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Illlu ooo mum u ooo mum moo a» on ooo n» Azu ouuuao Assumed-on one coo o-ooo- uaoa .00: «on no «:1! gas» on uozno «cm uogu om hug-avom no cacao-9a no vows nos: .aa. oom.¢Nw cu ooo.oN» ooo.n» unnu noun Auzo sumauo ~_oa_ om oooouuaoov nosuo no. candy «.3qu oloucm cacao-on 35.—ulna So» no) gas) .oomuouoomucou ouow hocol no oouuaoo "do nomads .o. uncouuoououo no cacao-unnuooo .IIII «an uhuzoo “poo o-aoo- moo» noon Avoaouolou and.» co enouuou ova-avouu duo: no coho unn3o «no oxuo: unsou- uoo» couuooauuo can! on» no nos: .no. oo~o~ol¢u oouoov ouowuou-o Aoououoloo .uooh c coca condo coonmou «loo 5. zonawnoo mm o0 no. a no. mzoupmuaa as oo uooao. coon» no caveman; .uoumosuou .9 Arunonmmv uozuo alwutuunmllll «oonoo and: vouoovouu nos-luloa sound-«v «lug anon Ron-u. =u~_-o.o goose. gum: una.nnuu. «no no.” a no vououoloo: Assn». snouho dooau. and: nomcaa Amzo nounuo +u o: .oa goo-no sue on any gooau- uni-nun «no. no coo: o. zoupmusa on oo ml: odaauodna- uoc.. I Auzo “guano «Avouodanou ov-ua o.osumgo Auzo gonzo. "non was 0.903. uaou on: moouoosuo coal to: .m— uogsuou o no so: wouxuo: mason. woo» -~ .0. 2651 Hum .z.¢ .uo~>ohlcoooon annouon .oooo can» no soon osu so u».: so» cane-Ion moo ought o» oouu noou o-ooum .oovmpoun oooaoooo «so no magma-on no noon on um ouauou ooooum .oumoooouu-oac .msu ououoIOu ou oluu one ocmxou now so» xoosh .2“ manuao ~a.oao~aoua sud-o: “as: .ne~ AzH uhuzso soda-woo soul to: .ocu A. on cox Auzo xuuzuo «olodooun guano: umoousu an: o>on vuosoooo: uooa uo unease! as. oo .uovou no u< A2” xhuxzo ~o>oz so» on .avauunoua soon»; .as: ..o» UH ..n~ .cN oo ookllll Auzo uou=oo ~A.V-o_aoua sugaog umoounu ao- ooos :o» oo .onou no u< noomllll coon uuou oceanoouo Anzo summoo «sum-on woo» unauu-oo :oa vuoos 3o: .aovou no o< o nudge c sumac N uumsu n cause n amuse _ vuusu odaauddan- an: “no usuuzo «oouvaugu noon uo coon one on. ans: Ac news: .uzoz no .Zu uhnxno ~ooos oo» oo .cououuau no». on. vouoovo mouoouoou .ouuv—«su soul so: uuaomuuuo ungauao. ago an »ugsoouuwe o: “dauuuuou afium-u ._=uouufio cog no: “daumuumv has; Anzo gumzuo «cloned goo-«um use» co o>w~ ou humlou woo» a so» how am no udauwuuuo no vuos 3o: .uouooom cu .nN .NN ._N .oN .o. 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