Introduction
The Butterworth monograph on Social Support and Aging (Chappell, Reference Chappell1992) appeared in early 1992, presenting a synthesis of existing knowledge generated in the 1970s and 1980s, primarily within Canada and the United States. In those early years, gerontologists documented both the existence and importance of social support; in particular, they focused on: basic and instrumental assistance, or activities of daily living (ADL); emotional support (e.g., from both confidantes and companions); and support in the form of information and advice from others. As the area grew in the 1980s, social support was recognized as complex, multidimensional, and for the most part, beneficial for older adults.
While the 1980s in particular saw burgeoning gerontological interest in both social support and the related, but narrower, concept of informal caregiving, the 1992 monograph documented gerontological research as far back as the 1970s into the types, extent, and sources of social support in older age (Chappell, Reference Chappell1992). For instance, this research confirmed that most older adults (except for a relatively small proportion) are well embedded within and connected to social networks, debunking the popular myth that older adults were socially isolated and abandoned by their families. This early research also documented the importance of reciprocity and bi-directional exchanges; the now well-known gender differences in social networks; the importance of marriage, sibling bonds, and intergenerational relations in later life; and the limited attention to non-kin supports (i.e., friends and neighbours). Further, this early body of research established the importance of social support, operating in complex ways through both direct and indirect pathways, for the well-being of older adults. The subjective perception of social support was identified as key for its benefits as experienced by older adults. To a lesser extent, the recognition of potentially negative aspects of social interactions and the receipt of social support were also studied.
Informal care from family and friends, which is a special type of social support, was identified in the 1992 monograph as a major gerontological interest, including care provided by spouses, children, other family members, and non-kin. Caregiving was conceptualized as a kind of social support “provided to seniors because their health has deteriorated and they can no longer function independently in areas where they previously did” (Chappell, Reference Chappell1992: p. 31). This contrasts with a broader use of the term social support as, for example, including all resources provided by other persons (Cohen & Syme, Reference Cohen, Syme, Cohen and Syme1985) and encompassing help with emotional and informational needs as well as tangible support such as assistance with ADLs.
Other researchers at the time tended to blur the distinction. Pearlin (Reference Pearlin, Cohen and Syme1985) included three aspects of social support: (a) social networks (i.e., everyone with whom the individual has contact), (b) group affiliation (i.e., those with whom the individual has an attachment), and (c) interpersonal interaction (i.e., active affiliations involving trust and intimacy). House and Kahn (1985) referred to (a) social networks (i.e., the structures that exist among a set of relationships), (b) social support (i.e., the functional content of interactions including emotional concern, instrumentality, and information), and (c) social integration. Cobb (Reference Cobb1976) defined support to include, variously, emotional support, information that leads one to believe he or she is valued, and a feeling that he or she belongs to a network of communication and mutual obligation.
Gerontologists in the 1970s and 1980s established that informal care was the dominant care system in old age. The perceived stresses of caregiving received much more attention than perceived rewards during these early decades. The complementary relationship between the informal and formal care systems was confirmed; conversely, the idea that formal care substitutes for informal care was debunked; the societal contributions of family and friends in the provision of care to older adults were estimated in monetary terms, and it was demonstrated that family members use formal services judiciously, not recklessly. The 1992 monograph concluded with an appeal for social support to be conceptualized as a social determinant of health, and as deserving attention at the policy level.
Post-1992
Since 1992, the field of research and practice knowledge in aging has grown in leaps and bounds in Canadian universities and professional and practice circles; the Canadian Institutes of Health Research’s Institute on Aging has been established, as have several specialty associations in areas such as Alzheimer’s disease and related dementias, palliative care, and caregiving. Interest in both aging and caregiving exists at various levels of government, stemming in part from growing awareness of the large and aging baby boom generation, the first of whom turned 65 in 2011 and who are currently immersed in providing support and care to their parents, who are today’s older adults. In other ways, interest in aging has waned as well: we no longer have a division of seniors within the federal government; some university-based research centres on aging have closed (such as the one at the University of Guelph); and home care and continuing care, both of which are important for an aging society, no longer exist as separate units within provincial health ministries but have been absorbed under an amalgam of “other services” (Hollander & Chappell, Reference Hollander and Chappell2010), which reflects a redirection of attention away from aging to the broader issue of health.
Definitions and Conceptual Issues
The definitions used today do not differ substantially from those used 20 years ago, and a distinction between social support and caregiving is often not made – or if it is, there is no consensus in the literature. For instance, Novak and Campbell (Reference Novak and Campbell2006) defined social support as “help and assistance we give to and receive from others” (p. 291), and informal support as “the unpaid help given by friends, neighbours, and family” with a variety of basic and instrumental ADLs, emotional support, and visiting (p. 296). McPherson and Wister (Reference McPherson and Wister2008) likewise noted that “social support involves a variety of activities and services” including emotional support and assistance with ADLs, but they also defined it as including help with “rehabilitation and assistance during convalescence from an acute illness or surgery, or long-term care for the highly dependent older person” (p. 362). Thus social support, in their definition, includes more casual forms of assistance (including “monitoring” and visiting), as well as caregiving that involves “a regular commitment to help a person with specific health or care need … if it is required and is requested …” (pp. 363-364). These authors also consider social support as including help from professional, paid care workers. Invoking a different definition altogether, McDowell (Reference McDowell2006) defined social support as “the availability of people whom the individual trusts, on whom he [or she] can rely, and who make him [or her] feel cared for and valued as a person.” Baines, Evans, and Neysmith (Reference Baines, Evans, Neysmith, Baines, Evans and Neysmith1998) used a similar definition for care: “the physical, mental and emotional activities and effort involved in looking after, responding to, and supporting others” (p. 3).
There is now greater awareness of the complexity of drawing parameters around the concepts of social support as well as caregiving. This recognition is fuelled in part by empirical findings that suggest many of those providing support to older adults do not define themselves as caregivers, nor what they do as “work” (Henderson & Forbat, Reference Henderson and Forbat2002; O’Connor, Reference O’Connor2007; Rose & Bruce, Reference Rose, Bruce, Arber and Ginn1995). The diverse terms appearing in the literature are often used interchangeably and without definitional consensus (e.g., caregiving, caring, assistance, interaction, support, informal caregiving, family caregiving). While caregiving has been conceptualized as a specific type of social support (Chappell, Gee, McDonald, & Stone, Reference Chappell, Gee, McDonald and Stone2003; Segall & Chappell, Reference Segall and Chappell2000), this distinction is typically not maintained, and when it is, the point at which support becomes caregiving is not clear. Even caregiving as a concept has been challenged, either as ignoring or excluding the “normal” assistance that occurs within reciprocal exchanges, negotiations, and interdependencies within family relationships and interactions or, conversely, as including normal exchanges of social support as caregiving (Barry, Reference Barry1995; Henderson & Forbat, Reference Henderson and Forbat2002; Martin-Matthews, Reference Martin-Matthews, Mandell and Duffy2000; Martin-Matthews & Campbell, Reference Martin-Matthews, Campbell, Arber and Ginn1995). More recently, distinctions between informal and formal (paid) care appear to be blurring, as family caregivers take on more of the “skilled” work traditionally performed by formal providers (Ward-Griffin & Marshall, Reference Ward-Griffin and Marshall2003), and as formal care providers describe emotional, even “family-like” connections with clients (Chappell, Reference Chappell2008; Lan, Reference Lan2002). Further, some elderly persons indirectly or directly pay informal caregivers, or receive formally organized but unpaid volunteer support.
More recently, research on social participation has embraced the concept of social capital (Hyyppa & Maki, Reference Hyyppa and Maki2003; Kreuter, Lezin, Young, & Koplan, Reference Kreuter, Lezin, Young, Koplan, Rootman, Goodstadt, Hyndman, McQueen, Potvin and Springett2001; Sundquist, Lindstrom, Malmstrom, Johansson, & Sundquist, Reference Sundquist, Lindstrom, Malmstrom, Johansson and Sundquist2004; Veenstra, Reference Veenstra2000) as extending the older concept of social support. It is seen as a contextual level resources (e.g., at the community or neighbourhood level) that generates health and other benefits for individuals, emanating from positive relationships and connections. According to Fuchs, Shapiro, and Minnite (Reference Fuchs, Shapiro, Minnite, Saegert, Thompson and Warren2001), it stems from “being part of a community where neighbours talk to one another … and foster norms for reciprocity, trustworthiness, and collective capacity beyond the association” (p. 290). It leads to cooperation for mutual benefit. However, the difficulty of arriving at conceptual and measurement consensus regarding the term, together with inconsistent findings and the tendency to operationalize the concept as social participation and trust (Chappell & Funk, Reference Chappell and Funk2010), have led Lynch, Due, Muntaner, and Smith (Reference Lynch, Due, Muntaner and Smith2000) to suggest that the term is nothing more than a new label for what used to be called social support (Veenstra, Reference Veenstra2000). Nevertheless, some see potential in the concept as offering, in part, an alternative pathway (other than social support) for explaining how social relationships can positively impact personal well-being. Research, including that by Theurer and Wister (Reference Theurer and Wister2010), has found that social capital enhances altruistic behaviour, which in turn improves the well-being of older adults.
Individual Focus
Much interest within the social support and caregiving literature remains focused at the individual or micro level. The substantive interest in the relationship between received social support and older adults’ health continues. Gerontological studies on social support confirm, in contemporary contexts, the benefits and protective effects, on an individual level, of social support for health and well-being in older age. Although the type and measurement of social support and outcomes differ, beneficial reductions are evident in various outcomes, including: (a) distress (Corna & Cairney, Reference Corna and Cairney2005); (b) stress (Helgeson, Reference Helgeson2004); (c) loneliness (de Jong Gierveld & Dykstra, Reference de Jong Gierveld and Dykstra2008); (d) depression (Antonucci, Lansford, & Akiyama, Reference Antonucci, Lansford and Akiyama2001; Penninx et al., Reference Penninx, van Tilburg, Deeg, Kriegsman, Boeke and Van Eijk1997); (e) cognitive decline (Zunzunegui, Alvarado, Del Ser, & Otero, Reference Zunzunegui, Alvarado, Del Ser and Otero2003); and (f) cumulative biological risk (Seeman, Singer, Ryff, Dienberg Love, & Levy-Storms, Reference Seeman, Singer, Ryff, Dienberg Love and Levy-Storms2002). In addition, there are positive associations with (a) life satisfaction (Antonucci, Lansford, & Akiyama, Reference Antonucci, Lansford and Akiyama2001; Penninx et al., Reference Penninx, van Tilburg, Deeg, Kriegsman, Boeke and Van Eijk1997); (b) psychological and self-rated health (Grundy & Sloggett, Reference Grundy and Sloggett2003); (c) cardiovascular, neuroendocrine, and immune function (Uchino, Reference Uchino2006); (d) functional ability (Hays, Steffens, Flint, Bosworth, & George, Reference Hays, Steffens, Flint, Bosworth and George2001; Travis, Lyness, Shields, King, & Cox, Reference Travis, Lyness, Shields, King and Cox2004); (e) survival (Giles, Glonek, Luszcz, & Andrews, Reference Giles, Glonek, Luszcz and Andrews2005; Woloshin et al., Reference Woloshin, Schwartz, Tosteson, Chang, Wright and Plohman2007); (f) cognitive function (Seeman, Lusignolo, Albert, & Berkman, Reference Seeman, Lusignolo, Albert and Berkman2001); and (g) adjustment to institutionalization (Gladstone, Dupuis, & Wexler, Reference Gladstone, Dupuis and Wexler2006).
The need still exists, however, for greater theoretical development linking social support and health outcomes at the individual level. Uchino (Reference Uchino2009), for example, recommended a life span perspective that clearly distinguishes between the contributions of perceived and received supports, and how these change over time to influence disease risk and various types and stages of disease. More broadly, Berkman, Glass, Brissette, and Seeman (Reference Berkman, Glass, Brissette and Seeman2000) presented a conceptual model that describes how social and cultural contexts influence the formation and maintenance of social networks, and how, in turn, these social networks, and their functional aspects, influence social and interpersonal behaviour (for instance, through the provision of support). Models such as these hold considerable potential for illuminating our understanding of explanatory pathways, yet they tend to be underutilized in empirical research on health and social support.
Much of the caregiving research continues to be dominated by a practical or social problems orientation (Dannefer, Stein, Siders, & Patterson, Reference Dannefer, Stein, Siders and Patterson2008) at the individual level. Such research tends to confirm previous findings in contemporary contexts, while refining and expanding the knowledge base in important ways. For instance, the informal network remains the care source of first resort when health declines. The family, in particular, is and has historically been a major, even predominant, source of interpersonal support and care in old age and indeed, throughout the life course (Keating, Fast, Frederick, Cranswick, & Perrier, Reference Keating, Fast, Frederick, Cranswick and Perrier1999). Emotional aspects (such as “caring about” and “emotion work”) are considered a distinguishing element of informal caregiving, and researchers are paying more attention to this aspect of caregiving (Calasanti & Slevin, Reference Calasanti, Slevin, Calasanti and Slevin2001; MacRae, Reference MacRae1998; Wenger, Grant, & Nolan, Reference Wenger, Grant, Nolan, Minichiello, Chappell, Kendig and Walker1996).
A major interest in the effects of caregiving on the caregiver (many of whom are themselves elderly) continues unabated, and is especially visible in studies concerned with caregiver burden. Indeed, an emphasis on stress and burden has been constant since the early years of research in this area. More recent research confirms the risk of negative health impacts on family members who provide care to elderly persons, particularly for some individuals. Providing care for an ill, disabled, cognitively impaired, and/or frail elderly family member has been identified (often in longitudinal studies with non-caregiving control groups) as increasing the risks for emotional distress (Anderson, Linto, & Stewart-Wynne, Reference Anderson, Linto and Stewart-Wynne1995), depression and anxiety (Canuscio et al., Reference Canuscio, Jones, Kawachi, Colditz, Berkman and Rimme2002; Cochrane, Goering, & Rogers, Reference Cochrane, Goering and Rogers1997), and psychological and mental ill-health (Hirst, Reference Hirst2005; Ho, Chan, Woo, Chong, & Sham, Reference Ho, Chan, Woo, Chong and Sham2009; Ory, Hoffman, Lee, Tennstedt, & Schulz, Reference Ory, Hoffman, Lee, Tennstedt and Schulz1999).
Physical impacts include (a) higher levels of cortisol production and stress markers (Davis et al., Reference Davis, Weaver, Zamrini, Stevens, Kang and Parker2004; Kiecolt-Glaser et al., Reference Kiecolt-Glaser, Preacher, MacCallum, Atkinson, Malarkey and Glaser2003); (b) negative changes to neurohormonal and inflammatory processes (Fredman et al., Reference Fredman, Cauley, Satterfield, Simonsick, Spencer and Ayonayon2008); (c) self-reported physical health problems (Ory et al., Reference Ory, Hoffman, Lee, Tennstedt and Schulz1999); (d) increased risk of coronary heart disease among caregiving wives (Lee, Colditz, Berkman, & Kawachi, Reference Lee, Colditz, Berkman and Kawachi2003); (e) “frailty syndrome” (Von Kanel et al., Reference Von Kanel, Dimsdale, Mills, Ancoli-Israel, Patterson and Mausbach2006); and (f) premature mortality (Christakis & Allison, Reference Christakis and Allison2006; Schulz & Beach, Reference Schulz and Beach1999). In a meta-analysis of 23 studies, Vitaliano, Zhang, and Scanlan (Reference Vitaliano, Zhang and Scanlan2003) concluded that caregivers have a higher risk of negative physical health outcomes, particularly with respect to stress hormones, antibodies, and global reported health.
Individuals might be subject to greater risk of negative outcomes if they experience (a) caregiver strain (Schulz & Beach, Reference Schulz and Beach1999); (b) difficulty providing care (Navaie-Waliser et al., Reference Navaie-Waliser, Feldman, Gould, Levine, Kuerbis and Donelan2002); (c) burden (Sherwood, Given, Given, & von Eye, Reference Sherwood, Given, Given and von Eye2005); (d) a situation in which the care recipient has particularly poor mental and/or physical impairment, in conjunction with dementia-related behavioural problems (Pinquart & Sörensen, Reference Pinquart and Sörensen2003; 2007); or (e) if they provide more extensive levels of assistance (Pinquart & Sörensen, Reference Pinquart and Sörensen2003; Nijboer, Triemstra, Tempelaar, Sanderman, & van den Bos, Reference Nijboer, Triemstra, Tempelaar, Sanderman and van den Bos1999; Shaw et al., Reference Shaw, Patterson, Semple, Grant, Yu, Zhang, He and Wu1997). Others who might be at increased risk include (a) low-income caregivers (Bakas & Burgener, Reference Bakas and Burgener2002; Nijboer et al., Reference Nijboer, Triemstra, Tempelaar, Sanderman and van den Bos1999; Robison, Fortinsky, Kelppinger, Shugrue, & Porter, Reference Robison, Fortinsky, Kelppinger, Shugrue and Porter2009); (b) those with lower levels of formal education (Navaie-Waliser et al., Reference Navaie-Waliser, Feldman, Gould, Levine, Kuerbis and Donelan2002); (c) older caregivers (Navaie-Waliser et al., Reference Navaie-Waliser, Feldman, Gould, Levine, Kuerbis and Donelan2002); and (d) women (Canuscio et al., Reference Canuscio, Jones, Kawachi, Colditz, Berkman and Rimme2002; Ho et al., Reference Ho, Chan, Woo, Chong and Sham2009).
Although the research on the positive aspects of caregiving at the personal level is growing, there continues to be less attention paid to this aspect relative to other aspects of care. Nevertheless, almost all caregivers express having acquired self-affirmation, enjoyment, and a sense of satisfaction from this role (Mockler, Riordan, & Murphy, Reference Mockler, Riordan and Murphy1998; Braithwaite, Reference Braithwaite1998; Tarlow et al., Reference Tarlow, Wisniewski, Belle, Rubert, Ory and Gallagher-Thompson2004). In fact, as suggested by Andren and Elhmstahl (2005) and Gold et al. (Reference Gold, Cohen, Shulman, Zuccehero, Andres and Etezad1995), both negative (and burdensome) and positive (and rewarding) perceptions of family caregiving can co-exist simultaneously. In addition, Chappell and Reid (Reference Chappell and Reid2002) demonstrated that caregiver burden, while related to overall well-being, is a separate concept; caregivers can be burdened in that role while nevertheless experiencing good overall well-being. Much of the caregiving research has tended to imply that “caregiving” is the only role of import in these individuals’ lives; this is not always the case. However, it is not known the extent to which positive reports of caregiving reflect either social desirability (e.g., an idealization of family care) and/or family caregivers’ active attempts to cope with the difficulties of care provision by focusing on the positive (Funk & Stajduhar, Reference Funk and Stajduhar2009).
Much more of the caregiving literature has focused on the care provided to older adults than on the support older adults provide to others (Keefe & Fancey, Reference Keefe and Fancey2002). Older parents help, for instance, with daily chores, child care, financial support, and personal care. Stone, Rosenthal, and Connidis (Reference Stone, Rosenthal and Connidis1998) reported that support from parents to children peaks when parents are between 55 and 64 years of age. In examining why older Canadian parents provide financial transfers to their children and grandchildren, researchers Ploeg, Campbell, Denton, Joshi, and Davies (Reference Ploeg, Campbell, Denton, Joshi and Davies2004) found a desire on the parents’ part, out of love and commitment as well as a family history of helping, to help the younger generations establish secure lives and futures. Further, in a longitudinal study, Brown, Nesse, Vinokur, and Smith (Reference Brown, Nesse, Vinokur and Smith2003) indicated that providing, rather than receiving, instrumental and emotional support might be more beneficial for prolonging mortality (see also Liang, Krause, & Bennett, Reference Liang, Krause and Bennett2001). This potential outcome is consistent with Chen and Silverstein’s (Reference Chen and Silverstein2000) finding that, in China, the provision of instrumental support to children by elderly parents enhances the older adults’ sense of well-being.
Social Institutions: the Meso Level
Research on social support and caregiving has of course extended our knowledge about interaction at the individual level. Further, research has extended to the meso level, where researchers are interested in (a) the relevance of social institutions, such as the family or wage labour, (b) day-to-day negotiations with respect to social support and caregiving wherein individuals exercise agency, and (c) the context of constraints and opportunities afforded by larger social structures. For much of the 1970s and 1980s, a meso-level analysis was typically limited to demographic transitions and changes in family structure, and to their implications for the function and structure of elderly persons’ social networks, including the availability of care and the well-being of both care providers and care receivers. Such analysis is still of interest, although gerontological research over the past two decades has witnessed increased attention to the social institutions within which support is enacted, received, and experienced.
The 2006 Canadian census pointed to a proliferation of “non-traditional” family forms (Milan, Vezina, & Wells, Reference Milan, Vezina and Wells2007) and the concomitant implications for social support and caregiving. The census showed substantial increases in the number of common-law couple families; lone-parent families headed by men; same-sex couples; grandparents raising grandchildren; and older women living alone. For the first time, in 2006 there were more census families without children than with children. Keefe, Légaré, & Carrière (Reference Keefe, Légaré and Carrière2004) projected a steady increase in the proportion of older women without any surviving children, which could potentially translate into less available support. Larsson and Silverstein (Reference Larsson and Silverstein2004) found that childless older adults tend to lack informal support; public home help services do not compensate for this lack. Unmarried elderly persons are another concern: in a U.S. study of unmarried persons over 40 years of age (Keith, Kim, & Schafer, Reference Keith, Kim and Schafer2000), “the oldest never married may have the greatest potential needs for affective and instrumental support” (p. 221).
Interest in the family situations of older adults extends to their living arrangements (Connidis & McMullin, Reference Connidis and McMullin2002; Turcotte & Schellenberg, Reference Turcotte and Schellenberg2006), the quality of relationships with children (Connidis & McMullin, Reference Connidis and McMullin2002; Pillemer & Suitor, Reference Pillemer, Suitor, Silverstein, Giarrusso and Bengtson2005), and the changing nature of relationships with grandchildren, as grandparents are healthier and often are still in the labour force (Kemp, Reference Kemp2003; Uhlenberg, Reference Uhlenberg, Silverstein and Schaie2004). Diverse social arrangements are becoming topics of interest; such arrangements include grandparents raising grandchildren, common-law and “living apart together” relationships, and gay and lesbian older couples (Brown, Lee, & Bulanda, Reference Brown, Lee and Bulanda2006; Cruz, Reference Cruz2003; de Jong Gierveld, Reference de Jong Gierveld2004; MacKenzie, Brown, Callahan, & Whittington, Reference MacKenzie, Brown, Callahan and Whittington2005). These social arrangements remain under-researched, however. We continue to gain new knowledge about transitions in family life in the later years, especially widowhood and widowerhood, where differences between women’s and men’s experiences are often marked (van den Hoonaard, Reference van den Hoonaard2001), leading to different social support needs.
Care relationships will likely continue to change: for instance, more men may assume caregiving roles, and we may also see new forms of unrelated individuals living with one another, supporting each other in old age. Whether current rates of chronic conditions (such as obesity) will result in even greater need for care in future generations is as yet unknown; the possibility of a “compression of morbidity” in future cohorts of older adults is a possibility (Hubert, Bloch, Oehlert, & Fries, Reference Hubert, Bloch, Oehlert and Fries2002) but far from assured. Even if the proportion of older adults requiring assistance were to remain stable, the increasing number of older adults means the expected decrease in available support will likely lead to an absolute and relative increase in the need for formal support. In part motivated by policy makers’ concerns with the availability of non-formal sources of care, there is ongoing interest in potential changes to social support, networks, and support quality over the life course, including the risk of social isolation.
Consensus on these various changes has yet to emerge. Lang and Carstensen (Reference Lang and Carstensen1994) noted that the social networks of people aged 85 to 104 tend to be nearly half as large as those of people aged 70 to 84, though with no differences in the number of very close relationships. In contrast, van Tilburg (Reference van Tilburg1998) found stable total network size to be evident among Dutch older adults over time, with increased instrumental support received and emotional support given. Similarly, Gurung, Taylor, and Seeman (Reference Gurung, Taylor and Seeman2003) found that social support increases over time, especially among those with many pre-existing social ties.
Martire, Schulz, Mittelmark, and Newsom (Reference Martire, Schulz, Mittelmark and Newsom1999) reported small yet significant increases over time in some aspects of support, and no changes in family or close-friend contacts, confirming yet again that “late life is not typically characterized by a decline in important social resources” (p. S302). Further, Grossman, D’Augelli, & Hershberger (Reference Grossman, D’Augelli and Hershberger2000) described lesbian/gay/bisexuals over 60 years of age as having diverse and rich social networks and with various kinds of support from informal sources. Some older persons, however, may prefer and seek out extra-familial or formal sources of support to maintain their independence (Aronson, Reference Aronson1992; Barry, Reference Barry1995; Cox & Dooley, Reference Cox and Dooley1996; Estes, Reference Estes, Estes and Minkler1999); and some seniors in particular are at risk of social isolation (Cloutier-Fisher & Kobayashi, Reference Cloutier-Fisher and Kobayashi2009; Kobayashi, Cloutier-Fisher, & Roth, Reference Kobayashi, Cloutier-Fisher and Roth2009).
Considerable research on employment has focused on work-family balance, especially with respect to caregiving for elderly family members (Martin-Matthews & Rosenthal, Reference Martin-Matthews, Rosenthal, Maddox and Lawton1993; Rosenthal, Martin-Matthews, & Keefe, Reference Rosenthal, Martin-Matthews and Keefe2007), revealing mixed results. Whether employment for caregivers is beneficial (Edwards, Zarit, Stephens, & Townsend, Reference Edwards, Zarit, Stephens and Townsend2002; Penning, Reference Penning1998) or negative (Covinsky et al., Reference Covinsky, Eng, Lui, Sands, Sehgal and Walter2001; Dautzenberg et al., Reference Dautzenberg, Diederiks, Philipsen, Stevens, Tan and Vernooij-Dassen2000; Lee, Walker, & Shoup, Reference Lee, Walker and Shoup2001) depends on factors including the needs of the care recipient, e.g., whether they have behavioural problems (Reid, Stadjuhar, & Chappell, Reference Reid, Stadjuhar and Chappell2010), and the specific form of caregiving involvement, e.g., whether they are involved in the overall “orchestration” of care from formal as well as other informal sources (Rosenthal, Martin-Matthews, & Keefe, 2007).
Rosenthal, Hayward, Martin-Matthews, and Denton (Reference Rosenthal, Hayward, Martin-Matthews and Denton2004) reported that employment does seem to reduce the extent of care provided to parents and parents-in-law. Ward-Griffin and colleagues (Reference Ward-Griffin, Keefe, Martin-Matthews, Kerr, Brown and Oudshoorn2009) further concluded that family caregivers who are simultaneously employed in health care professions have lower well-being and mental health (due to a “blurring” of professional and personal roles). The blurred spaces between work and home life are referred to as the intersections of labour force involvement and social support and caregiving, and are just starting to be understood; interest in this area will increase as more women enter paid employment (Phillips & Bernard, Reference Phillips, Bernard, Martin-Matthews and Phillips2008).
Longer Structural (Macro) Forces
Larger macro-level structural perspectives have also become recognized over the past 20 years in research on caregiving and social support, expanding beyond interest in demographic shifts, family structure, and the impact of paid employment to include consideration of social locations, such as ethnicity and gender, that intersect with age. This research has focussed on structural forces that pattern social relations – for instance, by influencing social institutions such as family and employment. Some of this research has shifted the emphasis in ethnic and gender studies in old age. Early research frequently viewed ethnicity as an important cultural factor in the provision of support and care, especially family care.
More recent studies are revealing the complexity of ethnicity when considering support and care in old age. For example, it has been suggested that ethnic identity serves as a resource for “drawing upon social support” (Blakemore & Boneham, Reference Blakemore and Boneham1994, p. 7) and that this support may buffer some of the impacts of low income (Chappell et al., Reference Chappell, Gee, McDonald and Stone2003). In cultures where interdependence in families is highly valued, receiving intergenerational support may be particularly beneficial for elderly care recipients (Zunzunegui, Béland, & Otero, Reference Zunzunegui, Béland and Otero2001). Tomaka, Thompson, and Palacios (Reference Tomaka, Thompson and Palacios2006) reported that subjective loneliness and low levels of family support are more consistently associated with disease diagnoses among Hispanics than Caucasians, whereas interactions with friends and social groups were associated with more disease diagnoses among Caucasians. However, in a Canadian study of foreign-born elderly persons, Wu and Hart (Reference Wu and Hart2002) – while noting a negative association between health problems and social support – posited the potential for reverse causality or possibility that health problems could erode social supports as seniors disengage from their networks.
The patterning of social relations is reflected in cultural beliefs and values concerning social support and caregiving – Dilworth-Anderson, Goodwin, and Wallace Williams (Reference Dilworth-Anderson, Goodwin and Wallace Williams2004) reported that “cultural justifications for caregiving” predict future psychosocial health outcomes among African-American caregivers. The provision of support and care among some ethnic minority groups, however, has been identified as associated with worse physical health and depression (Pinquart & Sörensen, Reference Pinquart and Sörensen2005). Further, Lai and Leonenko (Reference Lai and Leonenko2007) documented the considerable employment and economic costs of family caregiving among Chinese-Canadians.
The intersection of ethnic status with social class is not well understood: to what extent does a lack of economic resources lead to the necessity for family care, and to what extent do cultural norms and values lead to family care; is it both and how do the two intersect? Many ethnic groups tend to be characterized by both low socioeconomic status (an established predictor of poor health) yet also by strong family-supportive networks in old age (related to better health – see Bajekal, Bland, Grewal, Karlsen, & Nazroo, Reference Bajekal, Bland, Grewal, Karlsen and Nazroo2004; Chappell, Reference Chappell, Mollenkopf and Walker2007; Moriarty & Butt, Reference Moriarty, Butt, Walker and Hagan Hennessy2004). This apparent paradox has yet to be explored in empirical research – that is, for which groups and under which circumstances do strong supportive ties result in better health despite lower social class?
Wu and Hart (Reference Wu and Hart2002) found that the social support networks and contacts of more recently immigrated foreign-born elderly Canadians are not in fact disadvantaged, suggesting “that immigrants may actively restore their social networks once they arrive in the host society, and some may begin building support networks before leaving their home country” (p. 407). Further, Ng, Northcott, and McIrvin Abu-Laban (Reference Ng, Northcott and McIrvin Abu-Laban2007) found that among South Asian immigrant seniors living in Edmonton, Alberta, those who immigrated later in life tend to be less likely than those who immigrated earlier to live alone or only with their spouse. Much remains to be learned about how ethnicity, aging, and social support and care are interrelated. Such knowledge is increasingly important given the changing cultural mosaic in Canada; yet surprisingly, relatively little gerontological attention has thus far been directed to this area.
Gender, another fundamental organizing force that patterns individual interactions and societal institutions, has long been established as an important factor for the receipt of support and care in old age. Gender differences in the receipt and provision of care are well-established. Social support from friends and family may serve a greater buffering role for the well-being of women than men (Walen & Lachman, Reference Walen and Lachman2000), whereas men tend to receive more emotional support from spouses (Gurung, Taylor, & Seeman, Reference Gurung, Taylor and Seeman2003). Using Canadian data on the unmarried childless elderly, Wu and Pollard (Reference Wu and Pollard1998) reported that women tend to be advantaged with respect to the exchange of support. Male caregivers tend to provide more instrumental and women more expressive forms of support.
Although some recent attention has been directed to male caregivers (e.g., Campbell & Martin-Matthews, Reference Campbell and Martin-Matthews2003), it has long been recognized that women dominate both as caregivers and care receivers. For example, in a meta-analysis by Pinquart and Sörensen (Reference Pinquart and Sörensen2006), women caregivers were found to provide more hours of care, including more personal care. Women also nurture and sustain much of the social capital that bonds group and community members together (Bezanson, Reference Bezanson2008) and participate to a greater extent in the preservation of collective community goods (Son & Lin, Reference Son and Lin2008). Gender is also of concern because of higher levels of burden and depression, and lower well-being and health, among women caregivers (Pinquart & Sörensen, Reference Pinquart and Sörensen2006; Yee & Schulz, Reference Yee and Schulz2000); women are also more likely to report negative effects of caregiving on employment and long-term career opportunity costs (Martin-Matthews & Campbell, Reference Martin-Matthews, Campbell, Arber and Ginn1995).
While caregiving has long been recognized as a woman’s issue, a feminist perspective was introduced to gerontology only recently, offering a critical perspective to the area. It was in the early 1990s when this perspective became evident in the aging literature with works such as those by Hooyman (Reference Hooyman, Biegel and Blum1990) and Circles of Care: Work and Identity in Women’s Lives, edited by Abel and Nelson (Reference Abel and Nelson1990), leading the way. Since that time, the number of those applying this perspective continues to increase (Armstrong & Armstrong, Reference Armstrong and Armstrong2001; Aronson, Denton, & Zeytinoglu, Reference Aronson, Denton and Zeytinoglu2004; Chappell & Penning, Reference Chappell, Penning and Johnson2005; McMullin, Reference McMullin2000). The “hidden” nature of caregiving within the private sphere, the continuing demands on women to be “nurturers”, and the essential yet often undervalued role of caregiving in supporting the larger economic order is receiving attention (McDaniel, Reference McDaniel2002). Researchers have been exploring societal structures (e.g., government policies, employment practices, and insurance rules) insofar as they limit the availability of alternative sources of help, and ideological factors (gender role norms; the division of labour) facilitating women in the role of primary caregiver (Aronson, Reference Aronson, Coburn, D’Arcy and Torrance1998; Baines, Evans, & Neysmith, Reference Baines, Evans, Neysmith, Baines, Evans and Neysmith1998; Calasanti & Slevin, Reference Calasanti, Slevin, Calasanti and Slevin2001; Walker, Osgood, Richardson, & Ephross, Reference Walker, Osgood, Richardson and Ephross1998).
There are also concerns for the gendered implications of changes to Canada’s health care system within the current political and economic context. At the end of the 20th century, informal caregivers and community care emerged as the cornerstones of a widely accepted vision for health care reform. This fact drew attention to understanding caregiving for informing policies and programs – that is, caregiving became politicized. This politicization occurred for two reasons (Chappell, Reference Chappell, Smelsen and Baltes2001): heightened awareness that caregiving had been largely invisible within the private domain, stemming in large part from a feminist perspective; and the prolonged economic recession of the 1970s and 1980s that drew attention to a perceived crisis in health care funding and, along with it, a new neoliberal political rhetoric. However, governments’ recognition of caregivers also allowed cost shifting from the public purse to the private sphere, namely caregivers, who are largely women. When alternative sources of care are not available, increased demands fall to the family (Chappell & Penning, Reference Chappell, Penning and Johnson2005). Ongoing cutbacks to services and increasing privatization, begun in the 1990s and continuing today, lend credence to this view (Deber et al., Reference Deber, Narine, Baranek, Sharpe, Duvalko and Zlotnik-Shaul1998; Williams, Deber, Baranek, & Gildiner, Reference Williams, Deber, Baranek, Gildiner, Armstrong and Coburn2001).
Although a political and economic perspective on aging is not new (e.g., Estes, Reference Estes, Estes and Minkler1999; Estes & Binney, Reference Estes and Binney1989), recently interest has renewed in understanding care for older persons within the context of broader social, economic, and political changes such as economic globalization and the associated restructuring of systems of national health insurance and health care (see Gee & Gutman, 2000, on apocalyptic demography). The structuring of economic and political conditions has profound effects on the conditions and relations not only of paid work but also of unpaid caregiving. Yet we see little gerontological research on the links between macro-structural and micro-individual levels of analysis. Nevertheless, health reform occurs within a context of the globalization of capitalism, and within the commodification and privatization of health care services. Instead of expanding public investment to ensure adequate services for an aging society, health care reforms implemented since the early 1990s appear to strengthen social class, gender, and racial/ethnic inequalities in health and access to care (Chappell & Penning, Reference Chappell, Penning and Johnson2005).
Attention to broader demographic, political, economic, and social contexts of caregiving has coincided with research into formal service provision for older adults and how it intersects with care networks, including family (Carrière, Martel, Legare, & Morin, Reference Carrière, Martel, Legare and Morin2005; Sims-Gould & Martin-Matthews, Reference Sims-Gould and Martin-Matthews2010). Changes to formal service delivery have important implications for the receipt and provision of support and care among older adults. Penning and colleagues (2002), examining reforms in British Columbia, revealed a long-term shift to the provision of more intensive home care for sicker and fewer clients; Williams and colleagues (Reference Williams, Deber, Baranek, Gildiner, Armstrong and Coburn2001) revealed similar shifts taking place in Ontario.
Another key issue in the care literature continues to be the relationship between formal and informal care, and (less often) between formal, informal, and self-care. While more evidence is needed to clarify the nature of the relationships, overall, the consensus is that formal care is most appropriately described as supplementing and/or complementing care from self and informal sources, rather than substituting for it (Penning & Keating, Reference Penning and Keating1999; Penning, Reference Penning2002). The now-familiar rhetoric concerning multi-sectoral partnerships contributes to a blurring of the boundaries between public and private. We also see increasing formalization, regulation, bureaucratization, and commodification of informal care (Heaton, Reference Heaton1999; Henderson & Forbat, Reference Henderson and Forbat2002; Ungerson, Reference Ungerson1997) – for instance, through systems of payments for care (which in turn shape relationships between care recipients and caregivers).
Recent efforts to embrace caregiving as a public health concern (Lee, Reference Lee2007; Schulz & Martire, Reference Schulz and Martire2004; Talley & Crews, Reference Talley and Crews2007) relate to the emergence of caregiving as relevant for social policy, to the recognition of social support as a health determinant, and to the concern for how to support caregivers’ health and capacity. For instance, caregiving has been established as a priority area within the Public Health Agency of Canada. As a public health concern, the particular focus of research is on population-based health outcomes among caregivers, specifically to document the prevalence and incidence of family caregivers, the risk to their health and well-being, the costs to society, and the identification of opportunities for prevention, including supportive interventions and policies to alleviate and mitigate these impacts. A public health focus thus directs attention to health promotion, both for caregivers and care recipients, overall well-being, and access to care.
Berkman (Reference Berkman1995) argued that health promotion interventions should promote social support and strong and supportive social relationships; indeed, it is no surprise that health promotion and intervention research among family caregivers has, in general, emphasized the important role in well-being potentially played by caregivers’ own social supports (Choi & Marks, Reference Choi and Marks2006; Connell, Janevic, & Gallant, Reference Connell, Janevic and Gallant2001; Gold et al., Reference Gold, Cohen, Shulman, Zuccehero, Andres and Etezad1995; Grant et al., Reference Grant, Elliott, Weaver, Glandon, Raper and Giger2006; McCullagh, Brigstocke, Donaldson, & Kalra, Reference McCullagh, Brigstocke, Donaldson and Kalra2005; Malone Beach & Zarit, Reference Malone Beach and Zarit1995). Bass, Noelker, and Rechlin (Reference Bass, Noelker and Rechlin1996), in defining community services as a type of social support, reported that such services can reduce the risk of depression in informal caregivers. Formal services can be viewed as a type of social support, as can the assistance provided by third-sector organizations such as churches, non-profit agencies, and so forth, although traditionally this is not how the gerontological literature conceptualizes social support.
Gerontological research traditionally has tended to construct and reinforce the idea of a dichotomy between informal and formal as well as public and private sources of support and care. A concept of social support that encompasses supports and care from both informal and formal sources may more appropriately recognize public sources of support as “social” in nature and origin. The concept of collective responsibility and interdependence (McDaniel, Reference McDaniel2002) includes social responsibility between individuals at a broader level, as institutionalized for instance in social welfare supports and formal government services. This would be consistent with the study of social support noted in Chappell’s Reference Chappell1992 monograph, as one that seeks to explain and understand interdependencies between individuals across their life course.
Conclusions
The past two decades have seen remarkable growth in research on social support and aging. Social support continues to be an important area of research within and outside of gerontology. Moreover, social support is now recognized as an important social (non-medical) determinant of health and well-being for older persons. The lack of conceptual clarity and consensus surrounding the meaning of social support and caregiving continues, however, with much inconsistency in the use of these and similar terms as well as in the way these factors are measured.
Many unanswered research questions remain, including those considering the implications of changing and diverse demographic, ethnic, political, and economic conditions. What are the implications for the social support needs of seniors, seniors’ patterns of support and caregiving for others (ranging from spousal caregiving to intergenerational transfers to social participation), structural features of their social networks, seniors’ social integration, and available social resources and the quality of seniors’ interactions and relationships? For example, with increasing unemployment and under-employment among all individuals, what are the implications for the support that older adults might normally receive from coworkers? What are the impacts of increasing childlessness on the social support of older adults? A major challenge lies in how to enhance the social support networks of seniors in order to enhance their well-being (e.g., support groups for seniors at risk of social isolation) while simultaneously preventing negative outcomes for those who provide such support – family caregivers in particular. Adverse outcomes could be prevented either by offering caregiver supports directly, or by reducing the need for family caregiving through strengthening formal services (without one emerging as more cost-effective than the other). In Britain, Pickard (Reference Pickard2001) has calculated the cost of both options; in Canada, governments appear not to be considering the latter option of enhancing formal services. There is much we do not understand about balancing the needs of both caregiver and care recipient.
The social support literature includes an interest in older adults both as recipients of support and as providers of that support; both areas of research inquiry tend to share a focus on health and well-being. Importantly, health impacts tend to operate differently for support providers and recipients. For instance, the social support provided to seniors generally (but not always) enhances their well-being. Although the provision of social support might also enhance the well-being of caregivers, when support provision becomes intensified, as it does when caregiving is provided over a considerable length of time, the risk for negative outcomes tends to increase. Simultaneously, emphasis is lessened on negative outcomes of social support for recipients and on positive outcomes for the providers.
Research on negative aspects of receiving social support challenges the idea that social support is universally beneficial for well-being. Although we still know little about the circumstances under which negative outcomes occur for those receiving support (Barry, Reference Barry1995), research highlights potential power inequalities, negative interactions, the effects of feeling dependent on others, and care recipients’ concerns with protecting the well-being of caregivers (Calasanti & Slevin, Reference Calasanti, Slevin, Calasanti and Slevin2001; Gurung, Taylor, & Seeman, Reference Gurung, Taylor and Seeman2003; Krause, Reference Krause1995; Silverstein, Chen, & Heller, Reference Silverstein, Chen and Heller1996). We need much more multi-level research on social support and caregiving to examine how micro, meso, and macro contexts influence the processes, courses, and outcomes involved in social support and caregiving. More attention to the intersection of gender, ethnicity, social class, and age in terms of social support and caregiving is also needed.
While we know that the Canadian population is aging within a changing social, cultural, political, and economic context, we do not know the consequences of many of the changes taking place for social support and old age in the future. Will changing technologies (e.g., webcams, Skype) mean the provision of support from a distance will be enhanced and become increasingly common? Will enhanced security concerns and the continually increasing price of oil mean that air travel becomes out of reach for many families to visit older relatives? Will the ending of mandatory retirement see some individuals working longer, or for those who need the economic resources to survive, will retirement be a less and less realistic option? Will Canada witness compression of morbidity in the future? For instance, a declining trend in severe disability is evident in the United States, Italy, and the Netherlands, but it is stable in Australia and Canada and increasing in Sweden and Japan (Manton, Reference Manton2008; Organization for Economic Cooperation and Development, 2009). Increases in the prevalence of obesity threaten this trend.
What does seem certain is that families, friends, and neighbours by and large are there for one another when need arises in old age. This has been true throughout history, and remains true today. Further, there is no indication that this reality of social support and care will change in the future, although the particular forms and manifestations of such support will, of necessity, continue to evolve.
