Introduction: the role of paid foreign carers
Because in many western countries there is a growing shortage of family members available and willing to provide unpaid care for those who are sick or frail, more and more families employ paid care-givers. Given the low status and prestige associated with care-giving, round-the-clock home care, mainly provided by foreign women, has become common worldwide (Ehrenreich and Hochschild Reference Ehrenreich and Hochschild2000). The arrangement is growing, partly because it is cheaper than institutional care (Aronson and Neysmith Reference Aronson and Neysmith1996), and also because it enables a dependent older adult and his or her family members to continue living in his or her own home, which fulfils the aspirations to remain in a ‘natural’ family environment (Gott et al. Reference Gott, Seymour, Bellamy, Clark and Ahmedzai2004). Although employing foreign home carers is a universal social phenomenon, there have been very few studies of its forms and implications for the participants. Whereas foreign home-care workers come from many third world countries, people of Asian descent, particularly Filipinos, are considered worldwide as natural care-givers (Constable Reference Constable1997; Salazar Parrenas Reference Salazar2001).
Many Asian countries encourage emigration because workers (primarily women) send remittances back to their country of origin. In fact, in some third world countries, such as the Philippines, care providers have become the number one import earner, accounting for 3.4 per cent of the gross domestic product, equivalent to interest payments on the country's national debt (Freedom from Debt Coalition 1995). This estimate includes remittances by the many thousands of trained nurses whom the Philippines purposively train to work in other countries (Brush and Sochalski Reference Brush and Sochalski2007). Their working circumstances are very different, however, for most of them work in hospitals, although not in Israel for its current immigration policy does not allow foreign professional workers into the country. The only type of foreign carers given work permits are live-in workers who provide personal care, e.g. bathing, feeding and grooming, to frail individuals in order to maintain and prolong their residence in their own homes for as long as possible (Heller Reference Heller2003).
Several authors have portrayed home-care workers as friends, fictive (or surrogate) kin and family members of the care recipient (Karner Reference Karner1998; Piercy Reference Piercy2000). These positive attributes help care recipients maintain a sense of privacy and intimacy and allow them to feel as if care remains in the private realm (Karner Reference Karner1998). Being ‘part of the family’ contributes to the blurred boundaries between professional and personal care, but requires many home-care workers to perform emotional duties and other extra work without additional pay (Aronson and Neysmith Reference Aronson and Neysmith1996). Being in a family-like relationship can also be rewarding for the paid care-givers and help them cope with the challenges of their work (Berdes and Eckert Reference Berdes and Eckert2007; Karner Reference Karner1998; Stacey 2005). Other studies have shown, however, that even though domestic workers are in limited ways seen as part of the family, in many respects they are discounted or ‘invisible’ – their presence is acknowledged only when problems arise (Ehrenreich and Hochschild Reference Ehrenreich and Hochschild2000). This allows both families and care recipients to be simultaneously highly dependent on the home-care worker and separate, different and independent. Home care by foreign paid domestic workers has also been portrayed as a way of maintaining gender, class and racial divisions in western societies. According to Anderson (Reference Anderson2000), they ‘free’ western women of their domestic duties and accord them a social standing that is superior to the servants from third world countries. In this way, while the gender division of roles in the home does not change, it does change hands.
Israel's exceptionalism
In Israel, foreign home-care workers are primarily women from Asia and Eastern Europe. Currently there are approximately 38,000 documented foreign home-care workers, and it is estimated that another 30,000 are undocumented. These women provide personal care, such as bathing, cooking and grooming, to dependent older adults in their own homes (Heller Reference Heller2003). The Israeli case has several unique characteristics. First, almost all round-the-clock home care is provided by foreign workers, i.e. non-Jewish temporary migrants, to Jewish older adults (non-Jews tend to rely on informal assistance). It is plausible that the intense contact with older adults and their family members promotes high levels of affiliation between the parties, but the foreign workers differ from the Israeli families they serve in many ways, not least in religious beliefs and cultural practices. Moreover, Israel, as a Jewish state, makes every attempt to limit their stay in the country and offers foreign workers very few opportunities to become full citizens. Further, to limit their stay in the country, foreign workers are not allowed to bring their family members with them (Borowski and Yanay Reference Borowski and Yanay1997).
The home-care industry in Israel is well established as a major source of formal long-term care assistance and is partially subsidised by the welfare system (Heller Reference Heller2003). As a result, home-care services are provided for a substantial proportion of Israeli older adults with disability. To be permitted to employ a foreign worker, an older adult has to be completely dependent in both the physical and instrumental activities of daily living. In these cases, the foreign home-care workers are employed by the care recipient, not the welfare system, although a private nursing agency is usually involved in this care-giving arrangement. The agencies connect the care recipient and the foreign home-care worker and provide some supervision of the appropriateness and quality of the delivered care (Weisblay Reference Weisblay2005). Research has shown that in comparison to families in European countries, Israeli families enjoy high levels of intergenerational solidarity, characterised by very close if often conflictive relationships. This strong intergenerational solidarity continues despite the availability of publicly-supported services for frail older people (Daatland and Lowenstein Reference Daatland and Lowenstein2005).
The study
There have been very few studies of foreign home-care workers in Israel and none have focused on the interactions and transfers between them and the family members and care recipients. Given the increasing worldwide prevalence of round-the-clock foreign home care and the little that is known about it, there is a need for exploratory research. The overall goal of the present study was to identify the characteristics of the family and family-like systems, and the types and quality of instrumental and emotional transfers in these care arrangements. It was decided to collect the views of both the family members and the carers about their situations and to compare them.
Methods
Given the difficulty of recruiting appropriate informants – there is no national register of paid foreign care workers – it was decided to carry out interviews and focus groups with a convenience sample. The inclusion criteria were: for family members, self-identification as the primary care-giver of a family member aged 60 or more years who receives round-the-clock home care by a Filipino paid worker (both adult children and spouses who defined themselves as primary care-givers were included in the study even when they did not live in the same household as the care recipient); and for paid carers, being a Filipino home-care worker who provides round-the-clock care to a person aged 60 or more years. The study was limited to Filipino home-care workers because they are the largest group of foreign home-care workers in Israel. Care recipients were not interviewed due to severe cognitive and physical limitations. Participants were approached in adult day-care centres, social services centres, at neighbourhood events, and through snowballing. I attempted to maximise variations in gender and geographical location. Interviews took place throughout the country and involved residents of major metropolitan areas and rural areas including kibbutzim. There was an attempt to interview both male and female workers as well as both male and female care recipients and family caregivers.
Between February 2006 and November 2007, 22 interviews with family members of older adults cared for by a Filipino home-care worker were conducted.Footnote 1 The majority (12) were women, and of them 10 were daughters of the care recipient. There were five spouse care-givers, two being wives. None of the child care-givers interviewed for this study lived with the care recipient, although in two cases another child, who did not participate in the interviews did share a residence. Eleven spouse care-givers lived with the care recipients, although some spontaneously mentioned living in separate rooms or even units of the same household. The family carers' ages ranged from 38 to 84 years. Most (12) of the care recipients were female. As for the Filipino home-care workers, 29 were interviewed, seven individually and in-depth. In addition, three focus groups of two to 11 participants were conducted. The majority (24) of the paid carers were female (so henceforth they will be collectively referred to as Filipina), and their ages ranged from 18 to 56 years. Their duration of stay in Israel ranged from several months to 11 years. Legal status was not directly evaluated and only one home-care worker reported having formerly been undocumented.
All the interviews were conducted by experienced qualitative interviewers. Those with family members were conducted in Hebrew, whereas those with the Filipino home-care workers were conducted in either English or Hebrew, whichever they preferred. The questions put to family members encompassed the decision to hire a foreign home-care worker, changes that took place following the care worker's arrival, similarities and differences between foreign and Israeli home-care workers, and views about the most appropriate person to provide care for a dependent older adult. The foreign home-care workers were asked about their decision to come to Israel, the challenges and advantages of the work, differences between them and Israelis, and their beliefs about appropriate care of frail older people. Feedback from the initial interviews led to modifications of the questions. The interviewers were instructed to use a ‘funnel approach’, that is, to start with broad questions and follow-up with more specific ones. The interviews lasted between one and three hours. They and the focus groups were tape-recorded and transcribed verbatim, with the exception of one focus group because of a technical hitch.
The analysis
The interview data were analysed by three independent raters. All are experienced in qualitative research, and one was blinded to the research question and study rationale. The data were coded in stages, with each stage introducing more complex conceptual categories (Strauss and Corbin Reference Strauss and Corbin1998). Each interview was first coded thematically for major content areas. Next, commonalities and differences across interviews were evaluated and the themes were regrouped to represent the content areas that received considerable attention from the participants. The data were not forced into preconceived themes, but instead an ‘open coding’ approach was employed, so that the data guided the creation of the categories (Creswell Reference Creswell1998). Having searched for inter-theme consistencies and contradictions, descriptive and then interpretive categories were created. The final stage was selective coding, which involved the identification of core categories to create a story line (Strauss and Corbin Reference Strauss and Corbin1998). These categories were subsequently reconciled with previous published findings. We maintained an audit trail by recording the data analysis process and keeping records of all stages of analysis (Rodgers and Cowles Reference Rodgers and Cowles1993). Given the large volume of complex data that was generated, this paper focuses on the main themes identified by the family members, which are compared and contrasted to the Filipina home-care workers' viewpoints. A subsequent paper examines in greater detail the Filipina home-care workers' expressions (Ayalon Reference Ayalon2008).
The results
Three major themes emerged from the interview data. The first, (a) concerned the adapted family (or family-like) arrangements that were established with the arrival of the round-the-clock foreign home carer. The others were consequences of the changed family structure: (b) the family members' roles, and (c) the complementary roles of the Filipina home-care workers. Each theme is examined in turn.
The adapted structure of the family household
Beginning with the perspectives of the family members on the care situation, one recurring construct was of the care recipient as a powerless infant. Many family members described a change in their position, from being a child or a spouse of the care recipient to a de facto parent of the care recipient, who was commonly portrayed as an infant or a child – and several family members also used other, more degrading metaphors. The apparent role of these metaphors was to emphasise the powerlessness of the care recipient and the increasing responsibility of the family care-giver. The change in the family role was attributed primarily to the care recipient's cognitive decline, but even those who had only physical disabilities were described using child-like terms. As one informant said:
I turned from being a daughter to being a parent to my parents; it is really a change of roles. It means [one has to do] everything. It means dealing with their finances. I have to manage their bank account, grocery shopping, the payments. … It is really the same as having a baby. A baby cannot do anything for himself. A baby cannot stay alone for a minute. Moreover, when babies are newborns, they all look alike: bald headed and fat. When people grow older and become old. Have you noticed? They once again look the same.
A second common change was that the Filipina home-care worker had become part of the family. Many family members mentioned their initial concerns about allowing a stranger into their house, but also explained that, after a while, the Filipina home-care worker had become a close friend, and many even portrayed the worker as a family member. The inclusion of the Filipina home-care workers in family events such as holidays and birthday parties was emphasised, and many referred to giving gifts and extra money as signs of the inclusion of the worker in the family. Other expressions supported the notion of the Filipina home-care worker as a family member, particularly when describing the worker's behaviour and demeanour. There were references to the worker displaying friendship, care and affection towards the care recipient, and using the words ima and aba (mother and father in Hebrew). As one family member said:
On Rosh Hashana (a Jewish Holiday), he [the worker] came with his girlfriend. We all sat by the table and they were like everybody else, and when we all finished eating, they got up and helped us clean the dishes and take everything off the table. But they sat with us like the entire family, part of the family, and when I go abroad [on my return] I give him gifts too. He is a part of the family.
Some referred to the inclusion of the worker in the family system to emphasise that they provided good working conditions for the Filipina, in contrast to the abuses seen in other families. The advantages of treating the Filipina home-care worker as part of the family were amply explained: once this was accepted, the principle was maintained that intimate care should be provided not by a stranger but by a family member. Another advantage was to legitimate the idea that the worker could supplement or replace family members' emotional care. Some of the older family members described a revised family structure, in which they took a leading role and in a sense ‘parented’ not only their older parents but also the Filipina home-care worker.
Turning to the perspectives of the Filipina home-care workers, as with the family members, during the interviews and focus groups they described the difficulties they had experienced in adjusting to the family and the care tasks, and also spoke of their relationships with family members and the care recipients in family-like terms, with frequent references to love and care. One way in which they emphasised the strength of the relationships was by using familial terms, such as aba, ima, saba and safta (father, mother, grandfather and grandmother), and by comparing their relationships with the care recipients with their relationships with their own family members. As one said, ‘I feel that ima [the care recipient] is my mother. I treat her well not only because of the money. I love her. They give me what I need.’
To emphasise the quality of their family-like care, several Filipina home-care workers expressed their wish to be cared for or to have their own parents cared for in the same way as they cared for the care recipient. Nevertheless, the Filipina home-care workers also used less positive terms to describe their relationships with the care recipient and the family, such as being treated as a machine or slave, or in other cases providing care like a nurse. These expressions revealed ambivalence about the family-like relationships. Many workers also mentioned their keen regret at being so far away from their biological families. Furthermore, many attributed their move to Israel and their work as home-care workers to their wish to support their families in the Philippines.
Family roles
Many family members, particularly adult sons and daughters, described their role as care managers, of being in charge of all aspects of the life of the care recipient. These statements included managing his or her care, and running the house, the finances and the Filipina home-care worker. In contrast, very few adult children mentioned providing financial support to the care recipient. As one daughter who was her mother's primary carer and who lived half-an-hour's drive from the care recipient said:
I manage all her [care recipient's] financial business. I make sure I get money from whoever is capable of providing support. I pay the salary, I do the grocery shopping, everything. All the management, as you call it. I visit and I make sure my kids visit her.
Almost all the family members described a decline in the quality of their emotional and social relationships following the illness of the care recipient and the arrival of the Filipina home-care worker. Whereas some attributed the decline to the care recipient's loss of cognitive functions, others attributed this to their increasing role as care managers. Furthermore, to many family members, the arrival of the Filipina home-care worker into the family allowed them to maintain separate households. One daughter argued that employing the worker did not allow her to spend more ‘quality/emotional time’ with her dependent father because she was still responsible for many instrumental tasks:
My engagement with daddy is really intensive. If I go and get him prescriptions, or give him medicine, or things like that, then this of course takes away our time together, the time that we could have spent talking.
Because many of the care recipients were not proficient in English and novice workers rarely spoke Hebrew, family members often took on the role of translators. This also applied when the older adult was unable to communicate because of dementia or other cognitive impairments. The family members also transmitted values and traditions. The majority of the adult children, without being asked, described specific taboos around care-giving. The most prominent were about changing diapers and bathing. Whereas the men said they should not perform personal care tasks because of their gender, daughters argued that their position in the family meant that they should not be performing intimate personal care. Wives, in contrast, were more likely to expect to perform personal care, and many continued to provide some, even when a home-care worker was employed. As a daughter explained:
To me, there was no change [with the arrival of the male worker], because first of all, there was no other situation. The Filipino did not take away my tasks, because I got myself into a situation in which all assignments are on me, and I am totally dedicated to this goal. He is in the picture, taking care of the physical tasks, things that I never did and will never do – they are taboo. I will never change diapers, and I will never clean the house, and I will never cook. I mean, I will buy food and take food, but I will not be part of the ongoing routine of the house.
Many family members described transfers from the care recipient to other members of the family in the past, but very few mentioned that they continued. In contrast, several family members mentioned financial and emotional transfers from the care recipient to the home-care worker. In only one case were the transfers from care recipient to the home-care worker described as a reflection of a true friendship, and most were characterised as financially and emotionally abusive, in which the home care worker took advantage of the care recipient's need for emotional support and in return requested supplementary financial compensation. As one daughter related:
She [home care worker] did not speak Hebrew, maybe a word or two. Because she was so smart and wise, in a very short period of time, she learned Hebrew. My father bought her a dictionary, and she would be awake at night and learn, and in a very short period of time she looked better (more competent) than you or me. She learned everything very easily, the family arrangements, power differences. … My father became very dependent on her. … My mom was saying that she is stealing things, that she is trying to incite arguments … and then, my father gave her his credit card, we knew she was celebrating with this card, but she was good to him. She was taking good care of him. We didn't know what to do.
Most of the Filipina home-care workers saw the family members as managers. Some also recognised their roles as mediators, bearers of tradition and the ones in charge of familiarising them with Israeli customs. As one explained, ‘I learned how to cook Romanian food, that's what I learned here. I learned from the old man's sister, and I loved it, because I learned something and maybe when I go back to my country I will cook there Romanian food.’ The Filipina home-care workers rarely described the personal care roles of the family members directly, but all acknowledged the benefits of family care. A frequent explanation was that the Israeli family member had roles outside the house, and therefore could not provide all the required care for the older adult. As one reasoned:
It's better that their families will be taking care of them because they know better what to do – and he or she is their father or mother, so it's better they're taking care of them. But because everyone in the family has work and they are busy, they have no choice but to pay someone to take care of them.
Family-like roles
The family members described the Filipina home-care workers as being in charge of everyday activities, including taking care of the physical tasks, the daily schedule of the care recipient, and the maintenance of the house. Although emotional care was not part of the ‘job description’, it certainly featured among the expectations of almost all the interviewed family members. Even for those older adults who were completely impaired cognitively, family members still wished to see emotional exchanges between the Filipina home-care worker and the care recipient. As one son of a care recipient said:
You see the [care worker's] concern for mommy. I don't think this is a trick that they do, calling her mother. I believe a lot of Filipinas, Filipinas really do this and mean this, being part of the family. I really believe this is an expression of care. But if my Filipina is doing this … I am not sure about it, I am not sure at all.
Interestingly, in those families with a healthy spouse care-giver, a change in roles took place with the arrival of the Filipina home-care worker, who was described as assisting the spouse more than the care recipient. This assistance was portrayed as primarily emotional and social. Finally, many family members described the Filipina home-care worker as having brought ‘peace of mind’ and a major improvement to their quality of life. Some used expressions to the effect that the home-care worker had ‘given them their lives back’.
The majority of the Filipina home-care workers saw their demanding household tasks as distinguishing them from Israeli home-care workers. For several, these tasks were the most challenging aspect of the work. In contrast to the family members, however, the paid workers discussed the personal care they provided in matter-of-fact terms, with no negative emotions or distaste associated with such tasks such as changing diapers, feeding or bathing – the tasks that were viewed by adult sons and daughters as taboo. Many of the Filipina workers described providing emotional care to care recipient as part of the job. In contrast to many family members, Filipina home-care workers tended to raise their emotional giving if the care recipient's cognition declined. Some did, however, report difficulties in maintaining the relationships with the family members and the care recipient when care demands increased. As one care worker who had had several jobs in Israel said:
I have had to practise patience, especially in my second job. The old man there was always complaining, shouting. I think his mind was not working well. [To care for] a person like that needs patience. When I take care of people like that I am patient. So one thing that I have learned is patience, and another is not just to take care of them but care for them with emotion, with love, because they are in that situation, they are already old … so what I need to do is understand them, to show patience towards them and to care with love, just like I care for my parents … those are the things I learned from them.
Discussion
This study has evaluated family and family-like transfers in round-the-clock foreign home- care situations in Israel. As expected, the constellation of family members, a care recipient, and a Filipina home-care worker was described in family-like terms by both the formal and family care-givers. By their expressions, the family members tended to embrace the Filipina home-care worker into the family, whereas the Filipina workers were more ambivalent about becoming part of a ‘family’. When talking about their own family relations, many Filipina home-care workers explained that the reason they were working in Israel was to support their family in the Philippines. This difference between the two views may be because the Filipina home-care workers have more to lose if they accept the status of ‘honorary’ family members. Among the implications that they perceived was that then they are expected to perform additional tasks and to provide emotional care with no additional payment, and they are expected to detach themselves physically and mentally from their own relatives in the Philippines. They are expected to become a surrogate daughter (or son) in the family that employs them, and to suppress their identity as a daughter (or son) of their own parents and parents-in-law. For family members, on the other hand, treating the Filipina home-care worker as part of the family has many benefits. It sanctions the presence of a stranger in their home and the assignment of the most intimate care-giving roles to the stranger.
This study has shown that family members do not relinquish their care-giving role when a paid home-care worker arrives. The majority stated that they provided care to the maximum of their capacity, and that in the absence of a foreign home carer, they would have had to place the care recipient in a long-term care residential institution. Nonetheless, the roles of the family members changed both as the dependency of the care recipient increased and once a Filipina home-care worker joined the family. The role that is preserved and elaborated through these transitions by the family members, particularly by adult children, is that of the care manager. They supervised almost every aspect of the life of the care recipient and the Filipina home-care worker, whereas day-to-day aspects of care were slowly relinquished to the paid worker.
Many family members reported that the emotional and social exchanges within the family had declined with the progression of the disease and the arrival of a Filipina home-care worker. Furthermore, even prior to the arrival of the Filipina home-care worker, many adult children saw intimate care as taboo and unacceptable. In fact, distaste for these tasks was often described as the trigger for bringing a Filipina home-care worker into the family. A slightly different picture was portrayed by the wife care-givers, for they tended to describe the ‘circles of care-givers’. If a wife is healthy, she provides for most of the physical, emotional and social needs of the care recipient. Once a Filipina home-care worker arrives, she or he shares the physical care with the spouse, but most often the wife continues to fulfil the care recipient's emotional and social needs, and the Filipina home-care worker ends up meeting some of the wife's social and emotional needs. A second circle of care-givers that includes the adult children was also described. They usually take on an instrumental and care-management roles and to provide limited social and emotional support. Adolescent and adult grandchildren, if present, tend to take on a subsidiary role by providing infrequent social support. These findings are similar to those of Montgomery and Datwyler (Reference Montgomery and Datwyler1990) and Montgomery and Kosloski (Reference Montgomery and Kosloski1994), who showed that spouse care-givers tend to provide substantial personal care, whereas adult children primarily provide instrumental assistance.
As an earlier study found (Piercy Reference Piercy2000), the Filipina home-care workers took on not only the physical tasks but also the emotional and social tasks of care-giving. An unexpected finding, however, was the importance of the emotional and social support provided by the Filipina home-care workers to the spouse carers. The findings suggest that the type of support needed by spouse care-givers is very different from the overt purpose of round-the-clock home care. All spouse care-givers viewed the Filipina home-care worker as a major source of social and emotional support. They described relationships that partly substituted for the deterioration in emotional and social exchanges with the care recipient. These findings call for a change in the delineation of paid home-carers' roles, to include emotional and social care as important tasks for not only the care recipient but also the spouse care-giver.
The present findings supplement previous understanding by revealing that, in response to the cognitive decline of the care recipient and the engagement of a Filipina home-care worker, both adult children and, to a slightly lesser degree, spouse care-givers reduced their social and emotional contacts with the care recipient. This raises several questions. First, are the changes the consequence of different attitudes towards care-giving that derive from east-west cultural differences? It has been shown, for example, that people of Asian descent tend to perceive dementia as a normal part of old age (Ayalon and Arean Reference Ayalon and Areán2004), and the norm of filial responsibility is widely believed to be stronger in Asian countries (Sung Reference Sung1990). Furthermore, a recent survey of Israeli social workers and care managers who work with Filipina home-care workers revealed a widespread view in the country that foreign workers who have been in Israel for many years are ‘damaged goods’, because their work ethic and views about personal care have assimilated Israeli norms. The professionals described such workers as more outgoing and demanding, more concerned about their rights and social lives, and less concerned about the care recipient, than those who have recently arrived (Ayalon, Kaniel and Rosenberg Reference Ayalon, Kaniel and Rosenberg2008). If this is the case, with increasing globalisation, in the future western societies may face not only a shortage of indigenous informal care-givers but also a shortage of migrant formal care-givers with the desired deferential and accommodating attitudes.
A second question raised by this study concerns the differences between adult-children and spouse care-givers. Because of the cross-sectional design, it is unclear whether the differences are attributable primarily to a cohort effect or to their different position in the family. If the differences primarily stem from modernisation effects, the shortage of available informal care-givers is likely to increase. Evidence from Israel's higher education institutions may be relevant: business administration programmes are inundated with new applicants, but nursing schools persistently face unfilled places and are being closed. The indicators from this small study are that in coming years there will be an abundance of family members willing to be care managers but a growing shortage of informal care-givers willing to provide personal and emotional care.
There is considerable evidence that women are more likely to have care-giving roles throughout their lives (e.g. Neal, Ingersoll-Dayton and Starrels Reference Neal, Ingersoll-Dayton and Starrels1997; Roth et al. Reference Roth, Haley, Wadley, Clay and Howard2007). The care-giving literature also suggests that women are more likely to provide personal and household care (e.g. Miller and Cafasso Reference Miller and Cafasso1992). The present findings, in contrast, show a stronger distinction between adult children and spouses than between men and women. Given the small sample size, this finding should be tested in larger studies, but nonetheless it is possible that the arrival of a paid worker in the family changes family relations so substantially that the traditional gender role-division becomes less evident, because both personal and emotional care-giving roles are assigned to the worker. Interestingly, we found limited evidence for gender differences in the care-giving roles among foreign home-care workers as well. Once again, this could be partially attributed to the small sample, but similar findings have been reported from interviews with social workers that supervise this care-giving arrangement. According to the social workers, not only are male Filipino home-care workers as capable as female workers to perform all care-giving roles, but very often they are more motivated to keep their job. Reportedly, because Israelis prefer women as care-givers, male Filipino home-care workers have to work harder to prove themselves and they tend to be more accepting of expanded home-care roles.
Another question raised by this study is the nature of elder abuse in connection with financial transfers to foreign workers. Whereas several family members described such financial transfers as abuse, one family member described both financial and emotional transfers from the care recipient to home-care worker as a sign of family-like relations. Is it the amount of the payments, the cognitive status of the care recipient, or direct requests for financial support by the home-care worker that prompt family members to construct the transfers as financial abuse? Understanding family members' and home-care workers' definitions of the two would assist in the correct specification and prevention of elder abuse.
The present study has several limitations that should be taken into consideration when interpreting the findings. First, it used a convenience sample assembled from multiple sources. This approach can raise variation in the sample, but provides no information about the response rate or the characteristics of non-responders. The legal residence status of the workers was not established, as this would probably have deterred consent to participate. It is possible, however, that the workers' legal status has a great impact on their experiences. Secondly, the interviews with the Filipina home-care workers were conducted in Hebrew or English by Israeli research assistants because Israel's immigration rules do not permit the employment of Filipinas outside their defined position (i.e. home care). This might have prevented workers from expressing their opinions more openly. To accommodate this, interviews were conducted by trained interviewers at the interviewees' preferred locations. Thirdly, this study did not collect the views of the care recipients, because most were unable to participate in interviews. This gap should be corrected in future research. In addition, the study focused on the major themes, or storyline, that emerged from the interviews with family members. It is important to note that many important topics have been omitted from this paper to preserve the coherent story line. The distinctive perspectives of the Filipina home-care workers are reported in another paper (Ayalon Reference Ayalon2008). Finally, this study did not follow participants longitudinally to assess change over time.
Despite these limitations, the paper has provided new information about family and family-like transfers in round-the-clock paid home-care situations. Family members view themselves as care-managers. As the cognitive functioning of the care recipient deteriorates, they relinquish to the Filipina home-care worker not only personal and intimate care, but also social and emotional support and care. A particularly interesting finding is that in many cases, the foreign home-care worker's social and emotional support for the spouse carer was as substantial and seen as more important than the personal care provided to the care recipient. This finding has public policy implications and suggests that, in order to support the care recipient in his or her home, more services need to target the emotional and social needs of spouse care-givers.
Acknowledgement
This study was supported by a grant from the German-Israeli Foundation for Scientific Research and Development.
