1. Introduction
Given current trends, it is estimated that those aged over 65 in Taiwan will increase to 20% of the population by 2025 (11.5% in 2014) [1]. To address social, economic and health care problems related to an aging population, it is acutely understood that community care services need to be further expanded with a focus on long-term care. Little attention has been paid to the importance of day care services in Taiwan. The purpose of this study was to explore the use of day care services for older people in Taiwan. The research initially sought to develop an understanding of how and why Taiwanese people come to make decisions about using day care services. It was proposed that exploring the experiences and perceptions of older people and family caregivers related to day care would generate a better understanding of the social processes that either encourage or inhibit access and use. In addition, this research provided greater insight into the needs of clients who use the service.
2. Literature Review
With an increasing ageing population and the growing financial cost of institutional care, the need for greater development of noninstitutional long-term care has become acute in industrialized nations [2,3]. Enabling older people to stay at home as long as possible is what individuals, families and governments desire. Studies have confirmed that community based services which allow long-term care services to be community based generate superior life satisfaction and quality of life for elders than do the traditional institutional care settings [4,5].
The traditional practice of filial piety, or the responsibility of adult children to look after elders, remains deeply ingrained in Taiwanese culture. Living arrangements in Taiwan are very different to those in Western countries with the majority of older people living with their adult children. The extended family has been an important support system for older people. According to a survey by the Taiwanese Ministry of Health and Welfare [6], 37.5% of Taiwanese aged 65 and over live in three generation families that consist of grandparents, adult children, and grandchildren, while 25.8 % of the aged live in two generation families, 20.6% live with spouses, and 11.1% reside independently. More than half (65.7%) of those elders surveyed thought the optimal situation was family care provision. The survey also showed that 20.8% of older people believed they needed help in ADLs such as bathing, dressing, toileting, transferring, continence, and feeding ; however, only a very small proportion of older people (3.4%) resided in institutional facilities [6]. When older adults become ill and require care, the majority of care-givers are family members (son 36.3%, daughter 24.4%, and daughter-in-law: 12.6%, pay carer 8.5%, foreign carer 8.6%). Thus we see that family members assume a critical role in care-giving [6].
Studies [4,7,8] show that carers of frail older people do not generally use available respite support. Vecchio’s [8] study found that a greater proportion (88.6%) of informal carers had never used respite services and Brodaty et al. [9] found that one in three caregivers of people with dementia and memory loss were not accessing services because they perceived no need. It has also been was reported that caregivers are reluctant to use services because they viewed caring as part of their duty or role even though those caregiver experiences were characterised by high levels of burden, poor health and a lack of informal support [9]. Jeon et al. point to some factors that influence the utilisation of respite care services such as carer’s lack of understanding of respite care, carer’s passivity towards respite care, care recipient’s attitudes towards respite care, and inadequate respite care services and related resources. Other scholars have indicated that an important reason respite services are rejected is because they effectively usurp the carer’s role by removing the central character in the carer–recipient dyad. In addition, Vecchio’s [8] study found that carers from non-English speaking countries were 1.2 times more likely to be non-users of respite than those born in Australia. The study concluded that the reason for lower utilization rate of respite services was because people from non- English speaking backgrounds received more informal support than those from Australia or mainly English-speaking countries [8].
Dysart-Gale [11] argued that the concept of promoting time off and time away from care recipients, as it exists in North America and Europe, might not be applicable to other parts of the world. This is because attitudes toward respite care are culturally embedded and hence not universal [4,11]. For example, Dysart-Gale [11] investigated caregivers on the Caribbean island of St. Kitts and found that family caregivers rejected respite care. Similarly, studies in the US [12,13] found that respite services, including day care centers, were least utilized by African American and Asian-American elders.
Nonetheless, what has been widely demonstrated are the advantages of using day care services in supporting family care givers? The most noted of these is that such facilities enable fulfilment of the traditional cultural practice of caring for older parents at home when they become sick. However, the rate of utilization is much lower than capacity in Taiwan. To the best of the researcher’s knowledge, no previous qualitative research exists that explores the processes whereby families come to a decision to admit an older relative to day care in Taiwan. It is also important to understand the significance and meaning of using the services from the perspectives of Taiwanese older people. This research provides greater insight to understand the needs of clients.
3. Methodology and Method
The methodology of grounded theory informed the conceptualization and processes of this research. This framework was considered particularly appropriate for a study area about which little is known because it provided the researcher with the very strategies to build theoretical propositions about an under-explored area of inquiry [14]. The focus under consideration here is how frail elders come to use day care services in Taiwan. The services are in a developing stage in Taiwan and little is known about the social dimensions of their utilization. Thus the research study sought to generate an understanding of the meanings people attributed to day care centers and why and how people come to use such services in Taiwan.
The concept of developing theory from data has its roots in symbolic interactionism, a broad area of knowledge that seeks to explain the reciprocal relationship between human life and the social world [15]. Strauss [16] did ultimately acknowledge that the philosophical bases that informed the development of grounded theory have their origins in the traditions of pragmatism and the Chicago School of Sociology. Indeed, when finally situating grounded theory within the interactionist tradition, Strauss’s central argument was that assumptions change as a constant characteristic of social life and thus inquiry needs to be focused on social interaction and social processes [16]. In other words, and in adhering to an interactionist explanatory framework, Strauss asserted that researchers need to understand interaction, process, and social change.
This study was framed within the Strauss and Corbin methodological interpretation of grounded theory and the methods as articulated by these authors. The primary reason is that the proposed study sought to explore the dimensions of the social processes of coming to use day care services. Secondly, the work of Strauss and Corbin, in addressing both the micro and macro sociological processes, enabled an interpretation and analysis of the broader social context. Finally, the Strauss an emphasis on research questions and the paradigm model to guide data collection and analysis provided more structure for the study.
3.1 Data collection and analysis
In-depth interview with 30 older people from three different adult day care centres in South of Taiwan. The criteria for recruitment of older people who used the day care services are as follows: were aged 60 and over; had used day care services for more than three months; were able to communicate clearly; and were able to give informed consent.
3.2 Open coding
Open coding, the first step in data analysis, commenced soon after initial data collection [17]. Conceptualizing data by labelling phenomena is the first step in analysis and the researcher may find dozens or even hundreds of conceptual labels [17,18].
3.3 Labelling phenomena
Unrefined data are analyzed by using line-by-line coding to disaggregate the data [17]. This method is most important at the start of a study because it helps the researcher to generate as many categories as possible and those categories become the basis of theoretical sampling that guides subsequent interviews [17]. Following line-byline coding, open coding moves to sentence or paragraph coding, which means the researcher sought to identify the major idea in a sentence or paragraph [17,18]. This form of coding is most useful when the researcher has identified some concepts and wants to code particularly in relation to those concepts [17,18].
3.4 Categorising
The next analytical phase of open coding involved grouping those codes, like with like, which is termed “categorizing” [17,18]. When doing the grouping, names were given to resultant concepts. The names were drawn from different sources such as the pool of concepts from the data, literature, or in vivo codes [17,18]. After a concept is identified, the researcher begins to develop specific properties and dimensions [17,18]. Strauss and Corbin [18] define properties as the “general or specific characteristics or attributes of a category” and dimension means “a property along a continuum or range”.
3.5 Axial coding
Following open coding, data are put back together in new ways by way of producing a category and its connected subcategories [17]. During this stage, the researcher links sub-categories to a category through what Strauss and Corbin [18] referred to as the paradigm model. What this means is that during axial coding, researchers seek to link subcategories to a category within a framework constituted of relationships denoting conditions, action/interaction strategies, and consequences.
3.6 Selective coding
Selective coding is the final phase of coding and includes two most important components; the integration and refinement of categories [18]. In the process of integration, the researcher sought to identify the connections between a core category and categories [17]. By writing the storyline, constructing diagrams, and reviewing or sorting memos, the overarching core category that gives a sense of the full complexity of the dimensions of the study phenomenon is Reconstructing identity in a shifting world.
4. Result
Reconstructing identity in a shifting world is the core category of the study and reflects a process of reframing whereby older people came to new definitions of social responsibility and independence within the context of the day care center. The older people, rather than seeking to be relieved of social responsibilities, worked very hard to frame and reframe a social role. Rather than letting the institutions undermine or disrupt their identity, the older people worked to actively negotiate and redefine the meaning of self. Thus, although reluctant to come to use the services at the outset, they found a way to manage their lives independently. Social roles and responsibilities as older parents were retained.
4.1 Feeling abandoned
They did not want me anymore
A feeling of abandonment undermines a person’s self-esteem and quality of life [19]. The feeling of abandonment is a perception of the extent to which a person feels that his or her children have failed to fulfil duties under cultural norms [19]. The day care centre was symbolic of abandonment by families. It implied that the elders were no longer wanted or valued as members of society. One participant described feelings of fear and anxiety in the following terms:
When my family first sent me here, I was afraid that they did not want me anymore. I was afraid my family would not come to pick me up. Most older people felt the same at the start and felt anxiety in the afternoon…. If they did not see their family after four o’clock they would think their family did not want them. Many older people felt that their families were going to abandon them here. (Interview 4)
Yet it was not only fear of abandonment but a feeling of guilt for trouble caused. The older participant explained that they would rather die than cause too much trouble for their children.
People don’t want to live to be too old. I am 84 years old. Old people do not need to live to be too old. For people like us, it is better we don’t live too long. I have to be dependent on my children now, but I don’t want them having too much of a caring load because of me. (Interview 40)
Furthermore, as grandchildren were considered important so it was wasteful to spend money on services for older people.
I don’t want to come to here because it is a waste of money. The money for paying the fees here should be used for my grandchildren, for their better education and not for older people like me. (Interview 29)
In this study, being able to contribute to the family provided a secure elderly life. Being admitted to day care, however, evoked a sense of being a burden on the family and the elders began to view themselves as valueless persons.
4.2 Losing autonomy
We cannot break the rules…
A day care centre is an institutional facility and loss of autonomy is an inevitable feature of the experience of the institutionalised. Here Goffman’s concept of institutionalisation is draw to explore the erosion of autonomy in the day care setting. Goffman [20] explained that total institutions such as large commercial, industrial, or educational establishments differ where the provision of human needs are organised for the masses [20]. A day care centre does not reflect a total institution as such because the elders return home at night. Nonetheless, the day care centre shares some features with total institutions. There existed “house rules” that an individual was expected to conform to following admission [20]. Here the older participants participated in group life, could not leave without permission and were expected to engage in daily activities that were carried out in a group and were tightly regulated by staff. Thus day care reflected a form of institutional regulation. In the outside world, the older participants could decide what to eat, when to eat, when to toilet, or when to sleep; however, such rights within day care centers were largely absent.
For example, all consumed the same food provided by the centers. Morning tea, lunch, and afternoon tea were scheduled at the same time every day and all had to congregate in a common location to eat. Toileting time followed each break for most residents and particularly for those who needed staff help in toileting. As such, the elders were treated alike and required to participate in the same daily activities that were fully scheduled and designed by day care centre staff.
I cannot stand well now but I still have to participate in the Wai Dan Gong (one kind of exercise similar to Tai-Ji.). The exercise is for people whose physical functions are still good but not for people who are like me. (Interview 12)
A total institution does not substitute for a person’s own unique culture that has been already formed. The older participants had their own presenting culture prior to admission to day care.
I could eat what I wanted to eat or go out to buy what I liked at home. I told my son I did not want to come because I did not want to eat the food they provided. (Interview 9)
Losing autonomy within the day care facilities was first emphasised by the older participants; but after a long stay in the day care what Goffman [20] called “disculturation” occurred, where the elders reached some level of acceptance. However, this is not to say that the elders simply accepted or adapted to the lack of autonomy. Rather, the elders negotiated their loss of autonomy within the day care centre.
4.3 Reconstructing identity in a shifting world
Mead’s [21] idea of the human mind as an instrument for seeking an adjusted relationship between people and their environments. A day care centre is redefined as a place that meets (some) social needs and maintains social responsibilities for the older people. In the outside world, an individual plays out his/her roles in everyday life in a taken-for-granted way without major disruption to continuity from the imposition of new norms. Both the ageing process and institutional care meant that home-based roles for the elders, such as being a parent and grandparent, were becoming less well defined.
My daughter is going to have a baby soon and I told her I could help her look after her baby if she allowed me to stay at home…I wish I could stay at home and not come here when her baby is born. (Interview 29)
Older people have few prescribed roles because most are no longer employed in paid work and few are responsible for young children. Importantly, transition related to role change alters identity [22] and role loss causes lower prestige and reduces an individual’s status [23].
The master narrative in the day care centers was based on the assumption that relief from social responsibility created a space for unencumbered enjoyment. Yet, on the contrary, the continuity of responsibility of caring for families was integral to the day care centre experience. The dynamic of external continuity, or the maintenance of links with what has gone before, is essential for self-esteem and security [24]. Where the older participants were initially reluctant to use day care, preservation of identity became critical and this meant identity work was undertaken in the new context. The result was that the experience of coming to day care shifted from regret to demonstration of social responsibility in enabling family members to continue in waged work. People make or create roles by making behavioral choices or decisions, and engaging in negotiation, compromise or conflict [25]. Here, new roles were created in the process of transition to day care.
My family do not need to worry about me because I can still manage myself when I come here. (Interview 4)
Far from identifying as care-receivers, the participants identified themselves as independent of care from their adult children and spouses. Thus, an independent identity was preserved. Coming to day care was now perceived as a way of retaining a valued social role in the family context.
I feel relieved that my children can go out to earn money, so I don’t need to worry about them too much. Otherwise, as a parent, I won’t feel good if they can’t have a normal life. (Interview 31)
While attendance at day care threatened to erode the roles of the elders, the day care system also allowed for the maintenance of independence that had been lost when the elders were cared for at home.
All of my family has to work and I come here so that they can work. I told myself I must not be a bother and so I came here. (Interview 42)
There are commonly viewed stereotypes of aged people. In this study, the older people perceived that they were devalued and their social roles and responsibilities were disengaged from society. However, the participants clearly resisted disengagement from former social roles and responsibilities. Participation in the social world might change due to ageing, but continuity of social relationships and of social roles remains vital.
For the elders, the decrease in biological status and becoming dependent was not only a physiological process but also a social process. As part of this social process, the older people were stigmatized as a social burden. Adult day care presented a negative stereotype as a place for older people who are unproductive, dependent, unprofitable, and valueless. Although the older people had a decreased biological status, they did not passively accept the meaning given by society about using the services. In contrast, these older people were activity participating in social roles and taking social responsibilities that created new meanings in using the services.
5. Discussion
A move to an institutional setting for the aged, however, set the older people apart from the families and deprived them of a sense of continuity of role. Within a changing world, the identity of the older people was thus challenged and the social map no longer fitted the social landscape. This shift in identity to one of dependent person was accompanied by fear of abandonment by family.
The very act of placement in a day care centre reinforced the identity of the older participants as no longer self-determining. The elders were held in great esteem within their families; however, being sent to day care was indicative of a shift in role from career to care-receiver. The perceived loss of status within the family undermined the sense of identity. Thus, the transformation of identity was not a passive and linear process as such a view might suggest, nor is it simply externally imposed.
The identities of the elders were influenced by others in the social context. Family care-givers and those working in the day care centers interpreted the situation of the elders differently. The elders were defined as dependent by family care-givers and assumed to be dependent by those working in the centers. Social identity is never unilateral because how people think about us is as important as how we think about ourselves.
Such perceptions gave legitimacy to the act of admission to a day care centre and it was this act that most symbolised a significant change and brought about a transformation of identity. In institutions, individual roles are routinely disrupted. Indeed, the centers in this study overtly encouraged older people to relinquish, and families to relieve elders of, social responsibilities. The emphasis was on compensation for caring needs rather than maintenance of social roles. Role dispossession occurred in the institutions and the elders’ roles at home as valued and wise family leaders were eroded.
An emphasis on becoming dependent and being relieved of one’s social role was equated with being old and useless and it was not then surprising that there was a clear reluctance to attend day care. Yet this study most importantly reveals the ways in which the older people worked to actively renegotiate and redefine the meaning of coming to use day care. As symbolic interactionism emphasises, meaning comes from social interaction and can be “handled in, and modified through, an interpretative process” that people interact with in their everyday life [26]. Despite physical limitations, the older participants worked to regain some control over their lives.
Coming to the day care centre represented self-management and self-control in maintaining independence from families. Thus, identity was part of a continually forming self where the older person was an active agent and one who shaped interactions, as well as being shaped by them. Although there was reluctance, there also was understanding. Going to a day care centre was the assertion of independence and it helped to frame a role of continuity in the sense of doing what would benefit the whole family.
Goffman’s work on the ways in which institutional structures shape the transitory identities of the individual to explore how a day care centre removed the self from the elder participants and reinforced an identity shift. Others [27-29] have asserted that people are not passively molded by an institution (or society) but rather individuals actively experience changes in identity. Certainly, the present study does not shed light on the extent to which identity change was also institutional change. But the proposition that the social order and the individual are at once constituent of change is an assumption that underlies the analysis in this study.
The meanings in identity standards do change but the change may be slow [30,31]. Identity from this perspective is treated as selfmeaning that defines who one is and identity change as changes in these meanings [30]. Identity change is ubiquitous, but in everyday circumstances the changes are more likely to be small and slow [30].
But in institutions, an individual’s social identity changes more obviously and more rapidly. The elders brought identity claims of their own to day care centers; they did not willingly divest of their social roles as anticipated by the institution. In seeking to sustain a significant role within the family context, the older people reframed the day care experience as an affirmation of independence. This meant independence in actively not intruding upon their children’s lives, rather than a passive adaptation to institutional care. Although it met caring needs, the day care setting also became the setting for the appearance of a new and alternative identity of independence. Similar findings by Nilsson and colleagues [32], from research in Bangladesh, indicated that the meaning of being independent was interpreted by older people as not being a burden on family. The process of redefinition in this study did not see a relinquishment of responsibilities. Rather, the participants reframed the day care experience as one of continuing to assume responsibility for the family. The social obligation that was sustained was one of preserving the fabric of the family.
The preservation of an identity linked to a past role sat in contrast to the identity imposed upon the day care residents by the institution itself. The development of identity and the maintenance of that identity are not tied to the roles we play or take, but to a process of negotiation in which we define ourselves and have those definitions reinforced or resisted by others. The older participants worked hard to retain a social role and to fulfil the associated responsibilities, despite those being taken away by the institutions. Hence, rather than perceive day care as a space where they were relieved of social responsibility, day care symbolised a new independence. The coming to day care was transformed from an act of abandonment to one of performing a social responsibility. The older participants created, enacted, and changed the meaning of use of the services.
6. Conclusion
This study explored the process of meaning construction of day care use and the ways in which this process entailed a reconstruction of the identities of the participants. The older participants did not passively accept their fate but actively created meaning in the interaction process. What we understand is how the elders in the research context came to make sense of the experience of day care. In giving meaning to the experience, their cultural and social knowledge and so too their histories, were critical. The implication of the findings is that the older people, rather than seeking to be relieved of social responsibilities, worked very hard to frame and reframe a social role. Rather than letting the institutions undermine or disrupt their identity, the older people worked to actively negotiate and redefine the meaning of self. Thus, although reluctant to come to use the services at the outset, they found a way to manage their lives independently. Social roles and responsibilities as older parents and spouses were retained.
Competing Interests
The authors have no competing interests with the work presented in this manuscript.
Author Contributions
Both the authors substantially contributed to the study conception and design as well as the acquisition and interpretation of the data and drafting the manuscript.
Acknowledgments
A special acknowledgement is given to Kaohsiung Chang-Cing Day Care Centre, Senior Citizen Centre for Day Care, and Foundation of Tainan Young Men’s Christian Association (YMCA) for their permission to undertake my study in their institutions.