living arrangement preferences among the quebec elderly: findings and policy implications

Canadian Public Policy

Living Arrangement Preferences among the Quebec Elderly: Findings and Policy ImplicationsAuthor(s): Francois BelandSource: Canadian Public Policy / Analyse de Politiques, Vol. 12, No. 1 (Mar., 1986), pp. 175-188Published by: University of Toronto Press on behalf of Canadian Public PolicyStable URL: http://www.jstor.org/stable/3550727 .

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FRANCOIS BELAND Departement de sante communautaire, Cite de la Sante de Laval and Groupe de recherche interdisciplinaire en sante, Faculte de medecine, Universite de Montreal

LIVING ARRANGEMENT

PREFERENCES AMONG THE QUEBEC

ELDERLY: FINDINGS AND POLICY

IMPLICATIONS*

e programme de services a domicile du Ministere des Affaires sociales du Quebec

se fonde sur quatre postulats courants: 1) les personnes agees pr6ferent vivre a domicile plut6t que d'etre institutionalisees; 2) les

incapacit6s fonctionnelles plutot que I'6tat de sante expliquent les desirs des personnes agees de quitter leur domicile; 3) I'aide d'agences gouvernementales et de mouvements communautaires peut, efficacement, permettre aux personnes agees de continuer a vivre a domicile malgr6 leurs incapacites fonctionnelles; et 4) la famille n'est plus la source d'aide qu'elle a d6ja ete dans le passe. L'Etat et les agences communautaires sont donc des substituts a I'aide familiale. Des donn6es empiriques obtenues a partir de trois echantillons de personnes agees non- institutionalis6es de trois villes du Quebec sont utilisees pour v6rifier si les postulats de la politique du ministere des Affaires sociales sont fondes. Les conclusions de

I'analyse sont: 1) la proportion de personnes. agees qui d6sirent vivre ailleurs qu'a leur domicile est plus importante que prevue, 2) I'6tat de sante, plutot que les incapacites fonctionnelles, expliquent les d6sirs

d'hebergement des personnes ag6es, 3) I'aide offerte par les agences gouvernementales et communautaires est peu importante et semble avoir peu d'impact sur les d6sirs de

quitter ou non le domicile; enfin, la cohabitation des personnes iages avec un membre de leur famille est un des facteurs

he Quebec Ministry of Social Affairs'

comprehensive home care program is based on assumptions usually found in other

programs of this type: 1) elderly persons prefer to live in their community rather than be institutionalized; 2) functional disabilities, rather than health status, explain the wishes of the elderly to leave home; 3) help from

governmental or voluntary agencies can be efficient in maintaining elderly at home; and 4) the family is no more a source of help than it used to be, so the State and other community agencies have to substitute for unavailable

family help. These four assumptions are examined here to test whether they are

empirically based. Using three random samples of non-institutionalized elderly, it is shown that these assumptions do not hold true. In fact, health status and cohabitation with children are

among the main factors explaining the wishes of the elderly to leave or to stay at home.

Consequently, it is suggested that home care

programs should be oriented towards helping families take care of their frail elderly member and that an important part of a policy toward the elderly should consider their need for an environment which meets their requirements for limited, but vital, support in activities of daily living and social integration.

Canadian Public Policy - Analyse de Politiques, XI 1:1:175-188 1986 Printed in Canada/lmprime au Canada



les plus importants pour expliquer les desirs

d'h6bergement. En consequence, il est suggere que les programmes de services a domicile soient concus comme des supports aux families qui h6bergent et aident leurs membres agees atteints d'incapacites et de maladies chroniques. De plus, une composante importante des

I Introduction

n recent years, the practice of institutionaliz-

ing the elderly has come under heavy criticism. In Massachusetts, Hill et a. (1978) observed that 36 per cent of the old people in extended- care institutions should not have been there.

Doherty et al. (1978), in reviewing studies on institutions for the aged, reported that 14 per cent of their residents should have been living at home. As much as possible, therefore, institutionalization is to be avoided (Kane and Kane, 1980). Humanization of care and services, to-

gether with concern over efficient use of re-

sources, dictate extreme caution regarding institutionalization (ANA, 1978; Doherty etal., 1978; Chappel and Penning, 1979; Berg eta/., 1970, 1974; Stewart, 1979).

Institutions have been described as places reminiscent of concentration camps, where the individual gives up his or her identity and adopts the only identity possible for survival; that of a patient (Goffman, 1961). People in institutions are said to suffer from depersonalization, isolation, alienation; they lose their identity and their social and political rights (Bell, 1973; Liberman, 1969; Liberman and Lakin, 1963; Spasoff et a/., 1978). These difficulties are

thought to be directly attributable to the basic characteristics of institutions themselves, name-

ly: (1) an agglomeration of many individuals; (2) standard treatment for everyone; (3) formal rules of administration applied by a body of

professionals; and (4) planning on a rational basis (Chappel and Penning, 1979; Kleemeier, 1963). However, a recent study, using a group of non-institutionalized people with the same characteristics as residents of nursing homes, came to an unexpected conclusion: those living in an institution had better morale and more

politiques etatiques vis-a-vis les personnes agees devrait etre I'habitation prot6ege ou des personnes agees pourraient trouver I'aide

minimale, mais vitale, qu'elles requierent pour poursuivre leurs activites quotidiennes et un milieu favorable a leur integration sociale.

social interactions (Myles, 1978; 1979). The social and psychosocial situations of institutionalized elderly also appear to be closely linked to their situation before entering the institution (Scott, 1955); this suggests that people's ex-

perience of life in an institution depends as much (if not more) on their past life as on the conditions in the institution (Liberman, 1969).

In this context, home care and home aid services have appeared to be one of the principal ways to readjust the use of institutional, medical and social resources to individual needs (Wenkert et al., 1969). Various experiments in home care for the elderly have been done in North America and some European countries. Each method has involved more or less exten- sive home health and aid services co-ordinated or dominated by a medical or social perspective (Barry, 1975; Brickner et al., 1976; MDEA, 1976).

In response to concern over institutionalization, the Ministere des Affaires sociales du Quebec (MAS) has proposed a home services

policy whose overall objective is to allow people affected by any kind of loss of autonomy to remain in their usual living environment (MAS, 1979); this objective is common to many home

help and home care programs now operating in Canada (Nestman and Bay, 1977), the US (Barry, 1975; Brickner et al., 1976; Doherty et a., 1978; MDEA, 1976; Tolkoff-Rubin etal., 1978) and France (Cang and Clarke, 1978).

In this paper we shall test whether this ob-

jective is well-founded, using data from three

samples of elderly people randomly chosen from three catchment areas of three different home care and home help programs in the Prov- ince of Quebec.

Before presenting the results, we shall sum- marize the policy of the Ministry and its

176 Francois Beland



orientations compared with the current trends in the field of home care policy development. The hypothesis of the study will then be defined and the model of the analysis described.

II The MAS Home Health and Aid Services

Program

Generally speaking, home health and aid services (HHAS) can play many roles. They can be an extension of hospital services (AHPO, 1967; Besner, 1969), in which case HHAS users suffer either from acute disorders that have often

required hospitalization, or from chronic illnesses that require continuous care. Although various services are available (Adams and

Tolhurst, 1969; Bodenheim Parris, 1974; Cang and Clarke, 1978; Katz etal., 1972), they exist within the framework of a program intended for the ill. These types of services have been called 'co-ordinated' whenever administered by a central authority. Basically, however, they are medical services (AHPQ, 1967; Tolkoff-Rubin

etal., 1978). A broader conception, used especially in

gerontology, defines HHAS as systematic aid

designed to allow old people to compensate for

any loss in their ability to function, whether the causes or effects of the loss are social, psychological, or physical (Doherty et al., 1978; Isaacs and Neville, 1976). The objective of these

programs is to enable the elderly to remain in their usual environment and to avoid institutionalization (Barry, 1975; Bell, 1973; Berg et al., 1970; Brickner et al., 1976; Chappel and

Penning, 1979; Hill et al., 1968; MDEA, 1976; Shanas, 1971). HHAS are thus expanding their horizons: the goal is no longer simply to im-

prove or stabilize people's physical health, but to maintain and broaden the range of social roles accessible to the elderly (Susser, 1969), with a view to both prevention (Morris, 1969) and cure. More and more, the principal function of HHAS is to avoid any kind of dependence and especially institutionalization, the ultimate form of dependence (Beattie, 1976).

While the first conception of home services described above is predictably dominated by a medical ethic (since the objective is to cure the

patient or stabilize his/her condition), the second

conception requires a multidisciplinary team that can carry out different types of intervention in order to maintain or reintegrate the

elderly in a network of satisfying activities, re-

sponsibilities and social interactions. Of course, any necessary specialized or general palliative measures are also provided, according to the situation and the wishes of the user (Stewart, 1979).

The MAS HHAS policy is based on the second conception as shown by the following definition: 'The term "home services" refers to all activities designed to provide moral, material and medical support in the person's home, so as to compensate a loss of autonomy, to prevent or remedy a crisis situation, and to avoid or shorten the person's stay in an institution'.

(MAS, 1979:7.) Through these services, old

people in particular are able to remain in their usual environment 'when they are experiencing a loss of autonomy,' thereby avoiding 'hasty recourse to a nursing home'. (MAS, 1979:7-8.) The policy on home services is therefore based on 'respect for people's natural milieu and their

autonomy'. It tries to focus government intervention on 'mobilization of the individual's resources and milieu' rather than on institutionalization (MAS, 1979:13). To this end, the MAS has pointed out the necessity of a consid- erable increase in the resources available to home services (MAS, 1979:23), and called for a re-

organization of these services, their creation wherever absent (MAS, 1979:15-17), and a modification of the kind of resources available

(MAS, 1979:17-22). It also stresses the importance of using community resources (MAS, 1979:13,14,23,27).

HHAS are an important element in enabling old people to continue living in their homes, and the elderly constitute the target population in the analysis that will follow. These services are not provided solely by the government; homemakers, nurses, social workers, and that

portion of the MAS staff which is assigned to home services are only some of the workers

helping elderly people who have lost some of their autonomy. When problems of health, physical ability, social isolation or psychological well-being arise, the individual's dependence

The Elderly in Quebec and Their Living Preferences 177



should not necessarily lead to government in-

tervention, whether in the form of institutionalization or some other form. Reiterating the

opinion of Neilson et al. (1972), the MAS sets out a sequence of interventions to mobilize the resources of the individual and the community before the government intervenes (MAS, 1979:13):

a) Self-help; when the individual can control or

modify his/her behaviour to remedy the loss of autonomy.

b) Assistance from the spouse, family and relatives if they are willing and able to provide the needed support.

c) A community solution whereby society provides arrangements and programs which enable its members to count on receiving assistance.

In its policy statement, the MAS expresses some hesitation about considering the family an important source of assistance to the aged: 'There is another factor in favour of intervention

focusing first on individual and community responsibility, especially with regard to home services for the aged: it is the inevitable dispro- portion between the needs created by the

disappearance of the family as a resource and the alternatives available' (MAS, 1979:14).

II Hypotheses of the Study

The study does not address the specific effect of HHAS programs, but rather the effectiveness of certain types of social action emphasized by home services in delaying the institutionalization of the aged. The basic postulates of HHAS, and not the effects of their operations, will be assessed.

The policy regarding HHAS defines them as a key element in a policy which allows the aged to continue living at home. The objective of this

study is to determine to what extent the basic

postulates of the policy conform to the observed

living conditions of elderly people. We shall then be able to judge whether home services deserve such an important place among all the activities designed to enable elderly people to remain at home. The basic postulates of the MAS policy,

which serve as the hypotheses for this study, are as follows: 1) Most elderly want to remain in their usual

residence. 2) The loss of autonomy experienced by the

elderly because of isolation, physical handi-

caps or living arrangements is one of the

major reasons for their wanting to enter a

nursing home (MAS, 1979:8,18). 3) The aid distributed by volunteer or govern-

ment HHAS organizations can 'provide personal and material assistance without which the elderly, because of their physical, psychological or social dependence, would be obliged to enter a nursing home' (MAS, 1979:8).

4) In modern society, the family is no longer adequate as sole source of support, although it should be used for assistance first, if available. Generally alternatives must be found where formal agencies of intervention take the main role in the support of frail elderly (MAS, 1979:13-14). These four postulates can be conceived as a

causal system whereby the Ministry explains the wishes of the elderly to remain at home. The home care and home help policy is in-

tegrated into this causal system as an inter-

vening variable that modifies the links between the variables in the system, and thus the distribution of the wishes of the elderly to leave their usual residence or to remain there. In figure 1, the causal system is described in three parts. Panel A shows that the loss of autonomy, as defined in the very general terms used by the

Ministry, causes elderly people to wish to leave home. In panel B, family help is an intervening variable that reduces the links between the loss of autonomy and wishes to leave home. This

relationship will hold if the family is willing and able to provide the required help. In panel C, the supportive function of the family is shown to be reduced or totally absent; hence home care and home help programs intervene. The negative sign placed between family help and program interventions indicates that the Ministry sees these programs as a substitute for family environment.

We shall test specifically: 1) the extent to which the components of the loss of autonomy

178 Francois Beland



A) When no support is provided

loss of autonomy (+)

]~ wishes to leave home

B) When family help is available

loss of autonomy --- -.- wishes to leave home

family help

C) When governmental help substitutes for family help

Figure 1 Three causal models explaining the wishes of the elderly to leave home according to the ministerial policy statement

have an effect on the wishes of the elderly to leave home; 2) whether social support from co- resident persons or from persons living outside the home of the elderly have an effect on their wishes to leave home; and 3) whether help from the family and from professionals servicing the

community has an effect on the desire to leave home.

IV Method

We studied three groups of people randomly selected from the list of beneficiaries of the Canadi- an universal old age pension plan.Three groups of pensioners, mostly aged 65 or over, are represent- ative samples of the non-institutionalized elderly

in Hull, Trois-Rivieres, and the Hochelaga- Maisonneuve district in Montreal, respectively. A study on the representativity of the samples is available (Beland, 1980b).

These three territories were chosen on the basis of a project to evaluate the impact on the

elderly of three different types of home services: a social reintegration program in the Hochelaga- Maisonneuve area of Montreal, the homemaker and nursing services offered in Hull, and the home nursing services in Trois-Rivieres (where volunteer organizations are particularly active). Data were also gathered on samples of the en- tire elderly population, in order to ensure a valid comparative base for the analysis of user

groups. The latter data are used in this study.




The elderly were interviewed in their homes. Since the construction of the questionnaire has been discussed elsewhere (Beland, 1980a), we shall simply state the ten major sectors of observation for which data were collected: (1) Sociodemographic variables including sex,

age, marital status, occupational status before retirement (measured according to Blishen's scale) (Blishen and McRoberts, 1976), years of schooling, and availability of income other than the federal old age pension.

(2) Housing conditions measured by legal status (owner, tenant or boarder), accessibility of the dwelling from outside, degree of com- fort on the inside, whether or not anyone else lives there (spouse, children, relative, stranger), floor of residence, quality of lay- out and space available per person.

(3) Physical and psychological health measured

by indicators of health (Bellocet al., 1971). (Number of chronic illnesses, subjective estimation of health, reduced activities because of health), and psychological well-

being (Neugarten et al., 1961; Adams and Tolhurst, 1969; Wood et al., 1969; Brad-

burn, 1969; Wylie, 1970) (Bradburn's affective balance scale, mental status questionnaire and subjective estimation of memory capacity).

(4) Functional disability, using indicators based on the work of Katz et al. (1963; 1969; 1972) and an indicator to measure difficulty in pursuing activities outdoors during winter. To measure these variables, respondents were asked whether or not they could per- form a number of activities of daily living. These variables are indicators of the sub-

jective evaluation by the elderly themselves of the extent of their functional impairments.

(5) Social integration within the neighbourhood, (number of years of residence in the

dwelling and in the neighbourhood), the

family (number of visits to children and relatives, travelling time, telephone calls, letters), and a network of friends (oldest acquaintances, number of visits and telephone calls, presence or absence of intimate friends, member of a group of friends),

as well as participation in community organizations and the number of formal interactions with various members of society such as merchants. These measures are based on Petrowsky (1976), Powers and Bultena (1976) and Blau (1961). Quality of social interactions (Lowenthal and Robinson, 1976) was dealt with only incidentally, but contacts with old acquaintances and close friends by definition take into account the duration and intensity of the relationship.

(6) Use of medical services, hospitals and drugs as reported by the individual (presence of family physician, time elapsed since last appointment, number of visits to physician, number of days in hospital, time elapsed since last hospitalization, number of prescribed and non-prescribed drugs taken).

(7) Degree of responsibility with respect to a set of household tasks.

(8) Assistance received from various members of society (children, relatives, friends, volunteers, governmental agencies, emergency help available at home, from a neighbour, or from a non-resident relative).

(9) Desire to live with people other than those with whom he/she is now living.

(10) Desire to enter a home for the elderly, measured by two indicators: a) affirmation of having applied for admission to an institution (e.g., low-rental hous-

ing, intermediate care facility (ICF), extended care facility (ECF) for the elderly); and b) expression of a wish to live in his/her current place of residence, in apartments reserved for old people, or in an ICF or ECF.

The variables from these ten sectors of observation were analysed with discriminant analysis,1 and with other statistical procedures, to determine whether the basic postulates of the home care and home help policy of the Min- istry could stand up to empirical testing (Beland, 1980b; 1981; 1982; 1984a; 1984b). The results of the discriminant analyses will be used here, but the results reached with other procedures will also be reported if they add insight into the analysis.

The dependant variables were the two

180 Francois Beland



indicators of the desire to enter a home for the

elderly. The first indicator of these desires dis-

tinguishes between two groups: a) those who did not apply for admission to an institution and b) those who did apply. The second indicator discriminates between three groups: a) those who want to live in their current place of

residence, b) those who want to live in an apartment building reserved for the elderly, and

finally, c) those who choose an ICF or an ECF. Discriminant analysis is a multivariate tech-

nique. Thus the effect of help on the desire to leave home will be estimated taking into account

sociodemographic variables, housing conditions, physical and psychosocial health,functional disa-

bility, social integration and the use of services2.

V Examination of the Postulates

a) Most old people want to live in their usual residence Table lb reveals that approximately 52 per cent of those interviewed wanted to remain at home. Table la shows that applications for admission to institutions had been submitted by about 15

per cent in Trois-Rivieres, Hull and Hochelaga- Maisonneuve, despite the availability of home health and aid services, or social reintegration

programs for the aged in the latter two territories. Moreover, if living with one's adult children can be considered a secure arrangement, about 12 per cent of those interviewed were in favour of such an arrangement or were satisfied enough at the time of the interview to prefer it to any other form of accommodation.

About one quarter of the respondents wanted to live in apartments reserved for old people (Table Ib), whereas a slightly smaller percentage of respondents wanted to live in an ICF or ECF. Studies carried out in the US have shown that at least 20 per cent of people aged 65 or over would like to live in 'public' accommodations, i.e., administered and funded by a public organization responsible to an elected body (Carp, 1976). The type of alternate living arrangement desired most frequently by the elderly is not

necessarily the most structured, but the one in between their present arrangement and the tra- ditional institution.

By any standard the number of respondents

Table 1 Preferred living arrangement

Trois- Hochelaga- Hull Rivieres Maisonneuve

a) Have applied to a home

Yes 55 49 55 (16.5%) (12.9%) (16.6%)

No 279 330 277 (83.5%) (87.1%) (83.4%)

Total 334 379 332

b) Preference:

Extended- care facilities 23 98 17 (ECF) (6.9%) (12.6%) (5.2%)

Intermediate care facilities 36 50 41 (ICF) (10.8%) (13.2%) (12.5%)

Senior 79 104 78 housing (23.7%) (27.4%) (23.8%)

At home 195 178 192 (58.6%) (46.8%) (58.5%)

Total 333 430 328

wishing to leave their home should be considered

extremely high and very surprising. In the questionnaire construction phase, many practitioners whom we consulted told us we should not ex-

pect that more than 5 per cent of the elderly would wish to leave their home. If the antici-

pated results had been obtained the dependent variable of the study would not have had enough variance.

Although our findings run counter to practitioners' expectations, we can be confident that they reflect a real phenomenon, rather than an idiosyncrasy, since they appear in the three random samples and relate sensibly to some of the variables.

b) The elderly wish to enter institutions because

they have lost some of their autonomy As regards the elderly population, the objective of the MAS is 'to increase the number of elderly living at home in conditions they consider satis-

factory' (MAS, 1979:12). Since the purpose of




Table 2 Summary of the results from the discriminant analyses of the two indicators of the desire to leave home

Sectors of observation Direction of the effect (1) Level of significance and the significant a) on filling out an b) on wishes to (2) variables application for leave home

accommodation

a) Sociodemographic variables

a.1 Sex (female) + ,015* a.2 Education (from low

to high) ,132 a.3 Occupation before retire-

ment (Blishen scale) - - .008* a.4 Age + .026* a.5 Widow + ,001* a.6 Income 185

b) Housing conditions

b.1 Tenant + + 000* b.2 Floor of residence (from

Ist to more) + + .100 b.3 Space available per person - - .066 b.4 Lives with a child - - .001* b.5 Lives with a stranger ,073

c) Physical and mental health

c.1 Number of chronic diseases (from low to high) + .034*

c.2 Subjective estimation of health (from low to high) + .171

c,3 Diminished memory capacity - - 001*

d) Physical impairments

d.1 Limitation on mobility outside home in winter + .078

e) Social and psychological variables

e.1 Number of years of residence .084 e.2 Travelling time to nearest

relative (short to long) + + .048* e.3 Letters to family members

(few to many) + .121 e.4 Number of old acquaintances

of the same age (few to many) -+ .074 e.5 Telephone calls to family

members (few to many) + .064 e.6 Number of meetings with

friends (few to many) + .012*

f) Medical services utilization

f.1 Number of appointments with physician in the last six months (few to many) + .002*

f.2 Number of non-prescription drugs used (few to many) + +

182 FranCois Beland



Table 2 contd.

Sectors of observation Direction of the effect (1) Level of significance and the significant a) on filling out an b) on wishes to (2) variables application for leave home

accommodation

g) Help coming from inside the home (no effects significant at the .20 level)

h) Help available from outside the home

h.1 Emergency help available from a non-resident relative - - .066

h.2 Help received from a relative .112 h.3 Help received from a volunteer

or governmental agency + .116

% of variance common to predictors and predicted 34.9% 34.2% variables (3) 18.3%

* Significant at the .05 level (1) The plus or minus sign indicates the direction of the effect of the variables on the two dependent variables. (2) When a variable is included in both discriminant equations, the lowest absolute value of P is the one shown in

this column. (3) Two discriminant functions are significant here. Thus the two percentages give the respective variance associ-

ated with each function.

home services is to provide personal and material assistance to old people experiencing loss of

autonomy, the policy supposes that the loss of

autonomy is the reason for their wishing to live in an institution.

Loss of autonomy is a general term which covers a multidimensional reality. The Ministry of Social Affairs, through the home care and home help program, focusses more explicitly on one aspect of loss of autonomy. We refer here to functional impairments in the activity of daily living, although the MAS is also preoc-

cupied with the social isolation of the elderly. The MAS has a theory about the loss of auton-

omy. According to this theory, the inability to

do everyday tasks, rather than illness itself, is the

reason why the aged wish to leave their homes. To the MAS, illness is one, and only one, of the causes of loss of autonomy. Thus the correlation between illness and loss of autonomy is not per- fect, and is mediated by the environment of the

elderly. Table 2 shows that the three indicators of

health status (sector'c') are related either to the

filling out of an application for accommodation

or to the desire to leave home. Also, psychological well-being measured by the Bradburn affective balance scale is not a significant con- tributor here. Nor is the Katz scale of functional

impairments in the activity of daily living related to the two indicators of the desire to leave home (thus, it is excluded from Table 2). Among physical impairment indicators, only difficulties in

mobility outside the home in winter is related to the dependent variables.

Another component included in the concept of loss of autonomy is social isolation. As el-

derly people lose contact with peers and

relatives, their ability to live autonomously is diminished since they cannot rely on their own social contacts to maintain their social life or generate help from informal sources when needed. This is why the MAS home care and home help policy statement asserts that lonely elderly should receive psychosocial help from professionals or volunteers. Table 2 (sector 'e') shows the effect of different psychosocial variables on the desire to leave home. It is to be noted that frequent contacts with friends, and the number of telephone calls or letters to and




from family members all predict higher desires to leave home. The number of direct contacts with family members living outside the elderly home is not significant here. A great number of

years of residence in the dwelling, short travel-

ling time to nearest relative and the number of old acquaintances of the same age living in the

neighbourhood are all associated with the

elderly having not filled out applications for accommodation. But the number of old ac-

quaintances is linked with a wish to live in an

apartment building for the elderly. Thus, psychosocial variables of an 'active' type (e.3, e.5, e.6), indicating frequency of contacts, predict the desire to leave home in the 'wrong' direction. The more 'passive' type of psychosocial variables, (e.1, e.2, e.4) indicating a

familiarity with the neighbourhood, rather than an active participation in a social network, predict the desire to leave home in the expected direction. The point is that psychosocial programs are usually aimed at increasing participation in social networks. They would meet with

great difficulties, if not sheer impossibility, if

they were to define their objectives in terms of the 'passive' variables.

Thus the causal model in panel A of figure 1 has to be rejected on the basis of these results. Yet it must be reiterated that this model repre- sents the foundation on which the policy of home care and home help rests.

The environment of the elderly and the resources available are of great importance in pre- dicting the desire to leave home. In particular, the occupation held before retirement (sector 'a'), the fact of being a tenant (sector 'b') and of living with a child (sector 'b') are of the ut- most importance. These predict the two indicators of the desire to leave home at the .05 significance level at least.

c) Home aid helps avoid institutionalization The assistance provided by MAS policy is distributed by agents who, by definition, do not reside at the same address as the user. These

agents may be employees of organizations within the social affairs network, volunteers, or other community workers. For the purpose of this study, home aid coming from outside the home was measured by the support received from any

of the above-mentioned agents and by family members in the execution of one or several of 22 specific activities during the six-month period preceding the interview. But aid can also come in a form other than support from outside the home; a co-resident can assume a given house-

keeping task. Here eleven activities of daily living have been used to form a scale of house-

keeping responsibilities. The number of tasks for which a co-resident is responsible is the indicator of availability of in-home help.

From Table 2 (sector 'h') it is clear that help received from a volunteer or a governmental agency increases the probability of an elderly person having filled out an application for accommodation, while receiving help from a non- resident relative is associated with a decrease in the wish to leave home. Thus the source of help, rather than help itself, has an effect on the desire to leave home. Of course, the number of

elderly receiving help from a volunteer and/or a governmental agency is low. The distribution is badly skewed, and the results should be in-

terpreted with care. However, a cross-tabulation of help from a formal source and one or the other of the indicators of the desire to leave home confirms these trends.

Help available from inside the home (sector 'g') is not related to the desire to leave home. Results from a log-linear analysis of the same data in a multiway contingency table (not included here) have shown that there is an effect of this type of help when the activities involved are classified according to where they are exe- cuted: in the home or outside. They only have an effect on the desire to leave home for an apartment building for elderly.

Emergency help available from outside the home reduces the desire to leave home. But the correlation between the different indicators of availability of emergency help is so high that emergency help available from inside the home has been excluded from the equations in the stepwise procedure. There would be, it seems, some potential here for action by formal agencies. Yet why should they intervene, when all of the elderly already have a source of emergency help from their informal social network? This is the case here for the sampled elderly.

Help available from formal sources does not

184 Francois Beland



reduce the desire to leave home. Ironically, volunteer or governmental agencies have the same

impact on these desires as the number of appointments with physicians. It can be hypo- thesized that having contact with these formal

providers of services gives access to other services. They are a footstep to other services, rather than a substitute for them.3

d) The role of family and friends With the goal of maintaining the elderly at home, MAS policy takes for granted that help from the informal network can be replaced with formal help when needed. However, we have just seen that it cannot because: 1) the reason help is made available to the elderly through home care and the home help program is not the reason that explains the desire to leave home, and 2) formal help when given seems to increase this desire to leave home rather than to decrease it.

On the one hand, the effect of family help on the desire to leave home is revealed by the fact that living with a child is one of the variables that has the most important effect on the desire to leave home (p = .001); while help received from a relative not living at home has a low effect (p = .112). On the other hand, the number of contacts with family members living outside the elderly home has no bearing on the desire to leave home, while telephone calls and letters are linked with an increase of this desire. These last two indicators can be surrogates for the long travelling distance between the elderly and his relative.

Thus, the many dimensions of family social

relationships do not have a uniform impact on the desires to leave home. Overall though, the

family situation of the elderly reduces this desire while professional help does not.

This suggests that professional help cannot

replace family help, as the MAS policy statement sees it. Rather, professional intervention should be directed toward helping any family responsible for a frail elderly person. This con-

junction of resources might achieve some suc- cess in reducing a frail elderly person's desire to leave home for a longer period of time than

expected if only family help is available. When

family cannot participate actively in the support

of elderly, functionally impaired, chronically ill and/or socially isolated persons, the ability of home care and home aid programs to maintain them at home can be seriously questioned. However, this does not mean that the nursing home is the solution. Other forms of housing might be more appropriate in such cases, as

suggested by the 23 per cent of the elderly in the three samples that wish to live in an apartment building for the elderly.

VI Conclusion

The elements that effectively encourage the

aged to continue living at home depend on factors related to the events in their lives, to their

personal and social background. The wish to enter an institution stems from factors beyond the immediate circumstances of old age, such as the loss of autonomy. Depending on the resources available to the elderly, the everyday context in which this loss is experienced either

provides or does not provide the conditions necessary for maintaining the person's potential for autonomy. Housing conditions, familiarity with the physical and social environment, and the type of cohabitation are circumstances which do not happen spontaneously or by chance.

Conversely, home aid services, as provided by government organizations, volunteers or even children residing elsewhere, seem to be considered by the elderly as unstable events over which

they have little control and with which they are unfamiliar. When control and familiarity are absent, a desire to move away from home is observed. More popular than the institution, apartments for old people were frequently chosen. In this type of place, responsibility can be exercised and independence preserved, but

people can also obtain support from the environment when needed. The wish to live in such

apartments or in an institution can be interpreted as a desire for a supportive milieu that is con- comitant with the living facilities.

In the light of our analysis, the real question seems to be the following: under what conditions are the elderly ready to give up institutionalization for their home? It is not enough to ask old people whether they want to continue

living at home. We must know the conditions




under which they will do so. A policy with the objective of preserving the

autonomy of the elderly is therefore not neces-

sarily a policy designed to keep them at home. We must differentiate between these two objectives. The desire to continue living at home can be perceived as a consequence of an effort to preserve independence, but the opposite is not necessarily true. In this context, the question is no longer what services are needed so that an elderly person can remain at home, regardless of whether the person is functionally incapac- itated, but rather in what social, psychological and physical environment (Rosow, 1967) and with what kind of support can the person pursue all the activities of which he/she is capable?

The policy of keeping people at home must be reoriented towards a policy of preserving their autonomy. Unlike the former, the latter can include moving away from home as a measure that can allow people to preserve and exer- cise their real abilities, though adequate alternate semi-autonomous forms of living arrangements are not well-known (Streib, 1978). Nevertheless some experiments seem promising (Oltman, 1981).

In conclusion, a note of caution. The data used here come from three random samples of

French-speaking urban aged. Generalization to other populations may not be warranted. Also, a study of clients of home care programs is underway. Specific conclusions may be reached for this group which contradict those reached here. As for the efficacy of home care in reduc-

ing institutionalization, the results of Weissert et al. (1980a and b), obtained in another context than the one used here (Home care program clients selected in an experimental design in four American, English-speaking cities), are in line with ours.

Notes * This work was carried out while the author was

at the Ministry of Social Affairs, Quebec. Part of this work was made possible by the support of the Fonds de la recherche en sant6 du Quebec. The author wants to thank three anonymous reviewers and J.R. Ponting for their helpful com- ments. Editorial assistance was provided by Louise Valois.

1 Discriminant analysis is a statistical analytical technique wherein the researcher designates two

or more groups (e.g., respondents who wish to leave their homes versus respondents who do not wish to leave their homes) and then determines what other variables differentiate the groups statistically.

2 The independent variables were entered in block in the two discriminant equations in the order in which they are listed above. When they were found significant at the level of their first entry in the equation, they were kept at subsequent stages even if they fell beyond the significance level. The level of significance was set high (P = .20) to include all possible significant effects, even if they are weak.

3 The reader is reminded here that needs variables and environmental variables (e.g., physical and mental health indicators, sociodemographic factors, housing) have all been statistically controlled.

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TWO FACULTY VACANCIES IN CANADIAN PUBLIC POLICY

UNIVERSITY OF BRITISH COLUMBIA

1. REGIONAL DEVELOPMENT To teach graduate courses in the Planning School and conduct policy relevant research on planning for Canadian regional development.

2. NATURAL RESOURCES To teach interdisciplinary graduate courses in the Planning School and conduct policy relevant research in the Westwater Research Centre. Experience in institutional analysis and evaluation methods desirable.

These are tenure track Assistant Professor positions, Ph.D. required. Salary depends on qualifications - minimum $32,000. Starting date, September 1, 1986, negotiable. Apply by May 20, 1986. For further information, contact: Brahm Wiesman, Director, School of Community and Regional Planning, or, Andrew Thompson, Director, Westwater Research Centre, University of British Columbia, Vancouver, B.C., V6T 1W5. In accordance with Canadian immigration requirements, this advertisement is directed to Canadian citizens and permanent residents. Appointment is subject to final budget approval. U.B.C. offers equal opportunity for employment to male and female candidates.

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living arrangement preferences among the quebec elderly: findings and policy implications

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