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/lp/wiley/dependency-and-aged-care-in-spain-tensions-and-contradictions-in-a-pQlfc0iBQc
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- Wiley
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- © 2022 The Society for the Psychological Study of Social Issues.
- ISSN
- 1529-7489
- eISSN
- 1530-2415
- DOI
- 10.1111/asap.12310
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Abstract
INTRODUCTIONLong‐term care constitutes a social challenge in modern society. The demographic, economic, technological, and socio‐cultural changes witnessed in recent decades have revealed the transformation process and conflicts surrounding the social organization of care and human services, both internationally and in Spain (Deusdad et al., 2016; Spasova et al., 2018). Long‐term care policies are regulated by the Act 39/2006 of 14th December on Promotion of Personal Autonomy and Assistance for Persons in a Situation of Dependency (Dependency Act or DA) in Spain. Article 2.2 defines dependency as: “The permanent state of a person who, due to age, illness or disability, and the lack or loss of physical, mental, intellectual or sensory autonomy, requires the care of other people to cope with daily life tasks such as personal care, household tasks, mobility, recognizing people, objects, and orientation.” The original aim of the dependency care system was to guarantee the universalization and professionalization of care services, recognizing the subjective right to receive care, as well as to reduce the burden that family members and other unpaid caregivers, predominantly women, assume (Aguilar‐Hendrikson, 2019).Demographic and social transformations such as changes in family structures, the massive incorporation of women into the labor market, a growing sense of autonomy, and socio‐political demands have stimulated the debate on dependency‐related policy and care models, traditionally based on the Mediterranean‐familistic model (Ranci & Pavolini, 2015; Rodriguez‐Cabrero & Marbán‐Gallego, 2013). Feminist literature in the field lays bare the care crisis – that mainly affects Western countries – in supporting the increasing dependency and care needs in society, which are more significant during old age. In this regard, the roles and social exchanges between family, community, institutions, and market, as well as the distribution of care between women, men, and generations are real issues to be addressed in the social organization of care (Comas d‐Argemir, 2019; Theobald & Luppi, 2018). Dilemmas and fears about who, how, and where people would like to be cared for seem central to people's notions and expectations about their dependency and the care of others close to them in the near future. These disputes become significant in a context where socio‐cultural beliefs regarding the family, community, and institutional structures are changing from traditional views (Tanskanen et al., 2018; Tomassini et al., 2007). Therefore, people must cope psychologically with tensions between values and ideas when facing new situations in increasingly ageing and caring societies (Eurostat, 2019; Priego‐Hernandez, 2017). In this regard, it is worth asking: What are the problems and difficulties people face in their daily lives concerning dependency in aged care contexts? Which tensions and contradictions are generated by this issue? How are socio‐cultural changes surrounding dependency and care practices reflected in social representations?This study aims to analyze how people represent dependency in the socio‐cultural context of the Basque Country (north of Spain) to understand how people manage and make sense of the phenomenon in their daily lives. To study how people engage with the phenomenon, this study draws on the theory of social representations (Moscovici, 1984). Social representations are the sets of ideas, beliefs, and feelings that communities share and co‐create about relevant social issues through communications and interactions with others (Markova, 2003). Through social representations, people familiarize and naturalize the meanings of the context in which they live, making possible the communication and interaction among people and groups in a particular situation (Moscovici, 1984). According to the theory, social representations are built and transformed through anchoring and objectification processes. Thus, the construction of everyday knowledge about dependency could be understood by referring to the role played by anchoring and objectification processes in the creation of socio‐cultural and collective meanings (Wagner & Hayes, 2005). With the process of anchoring, people familiarize the meaning of dependency, basing this knowledge on previous cultural values and beliefs. With objectification, the represented object materializes into concrete ideas, symbols, and metaphors of reality, making the unknown familiar and tangible for people. A clear example of the objectification of the meaning of dependency in the Spanish context is the institutional assessment of dependency, regularized by the Act 39/2006. In this way, people associate the idea of dependency with individualized and medicalized situations, as is the case of people who cannot look after themselves and live independently on a daily basis (Dant, 1988; Torres et al., 2015).Previous studies have shown that people deal with ambivalent conceptions of ageing and aged care in different socio‐cultural contexts (Brito et al., 2018; Nagel et al., 2011). Ageing is understood positively in relation to older adults’ wisdom and life experience; in contrast, negative aspects include illness, dependency, loneliness, and institutionalization, along with the loss of abilities, family bonds, productivity, and autonomy regarding receiving social care (de São José et al., 2015; Torres et al., 2015; Veloz et al., 1999). Quality of life in old age tends to be understood from biomedical and productivist perspectives that emphasize the importance of functional independence and personal autonomy, also dominated by discourses advocating care receivers’ self‐determination choice and independence (Medeiros, 2017; Nolan et. al, 2004). On the other hand, care comprises a corporal and emotional dimension, including social and family relations, driven by positive and negative feelings (Aguiar et al., 2011). Studies show that the central nucleus of care consists of feelings of love, patience, and health. Peripheral elements are concerned with the availability of family members, hygiene, daily tasks, responsibility, and dedication (Hedler et al., 2016; Scopinho & Rossi, 2017). Negative aspects of care are related to the burden, stress, and overload experienced by caregivers (Aguiar et al., 2011). Moreover, the meaning associated with aged care should be understood concerning class and gendered beliefs, where stereotypical and naturalized ideas about femininity, family duties, and low professional status prevail (Batthyány et al., 2013; Ravenswood & Harris, 2016). In this regard, studies show that people hold different conceptions depending on the social organization of care in each country, based on the role assumed by families or governments in care provision (Brito et al., 2018).As previously claimed in the literature, the notion of dependency is complex and controversial. It includes diverse discourses, voices, and positions of both care recipients and caregivers, usually expressed in the balance of power existing in interdependent relationships (Fine & Glendinning, 2005). Therefore, the social representations of dependency could be understood jointly from those who give and receive care as a relational and situated concept (Jovchelovitch, 2007). According to the dialogical approach of social representations, the meaning of dependency is socio‐culturally constructed, revealing the inherent tensions, conflicts, and interdependence between different ideas (Markova, 2003). From this perspective, social representations are created and negotiated in intersubjective and communicative exchanges (Jovchelovitch & Priego‐Hernandez, 2015; Linell, 2009). Several studies on social representations reveal the dynamic and changing nature of social knowledge (Jovchelovitch, 2007). The concept of Cognitive Polyphasia initially used by Serge Moscovici (1961) refers to this socio‐cognitive process. According to the “tension thesis” of Cognitive Polyphasia, diverse and even contradictory forms of knowledge about the same object coexist, both in the same context and the individual mind. Cognitive Polyphasia could be understood as the knowledge encountered and the “battle of ideas” around the represented objects (Moscovici, 1961). The studies conducted by Jovchelovitch and Gervais (1999) in a Chinese community in England and by Wagner et al. (2000) in Patna in northern India revealed that people in those contexts deal with various forms of knowledge about health and illness. These studies show the coexistence and contradictions between traditional and western knowledge of health and psychiatry (Jovchelovitch & Gervais, 1999). According to Marková (2008), Cognitive Polyphasia should be seen “as a presupposition enabling the researcher to discover conditions, which facilitate, hinder, provoke, or lead to the transformation of different ways of thinking and knowing in society” (p.479), suggesting the internal plurality and situated nature of socio‐cognitive systems (Jovchelovitch, 2007). Consistent with this theoretical approach, studies conducted about relevant social issues, such as mental illness, blood donation, sexual health, or homelessness, show the importance of Cognitive Polyphasia research for identifying the socio‐cultural characteristics and processes that form the basis of everyday knowledge. This view is fundamental to understanding how people think, feel, behave, and decide about dependency in specific situations and cultural contexts (Arthi, 2012; Moloney et al., 2012; Priego‐Hernandez, 2017; Renedo & Jovchelovitch, 2007).In this study, the theoretical approach of social representation is used to contribute to a deeper understanding of the socio‐cultural rooted meanings about dependency in care contexts, analyzing the tensions and contradictions by which representations are constructed. Therefore, we expect everyday knowledge about dependency to be grounded in the existing transformations and public debates around the care system.METHODStudy settingsThis study was conducted in several municipalities in the Basque territory of Gipuzkoa. Various agents involved in care practices were considered to analyze the conflicts and tensions that people experience regarding dependency in their daily lives. Analyzing the social representations from the perspective of the people involved allows us to explore lay thinking about the phenomenon, examining how values and views that people hold are socially discussed — in contrast to expert and professional discourses. Moreover, this approach allows us to determine how social representations are dialogically shared and constructed from individuals’ diverse positions, voices, and experiences.Following a snowball technique, relatives with care experience within the family were recruited according to age (older than 18 years), years of care experience (longer than 1 year), and gender distribution (50% women). Home care workers with more than 1 year of experience in old‐aged care services were also recruited. All of them were paid for their services and assisted people in their own homes on a daily basis. To collect older adults’ experiences, we contacted a gerontology research institute. Recruitment from institutions ensured that the participants were officially/juridically regarded as people in need of assistance. Inclusion criteria for the study were to have a personal involvement with the issue, to be over 18 years old, and to be able to maintain a conversation and preserve cognitive skills. In the case of older adults living in nursing homes, the main researcher contacted the centres’ managers, and professionals proposed the candidates for the interviews based on the inclusion criteria. All participants were presently living in Gipuzkoa and were provided with an information sheet that outlined the nature of the study as a research project. Participation was voluntary, and there were no incentives or compensation for their involvement.The ethical committee of the University of the Basque Country approved the study before starting the fieldwork (M10_2018_228). Furthermore, all the participants gave their voluntary written consent and were informed about their rights related to the research process.Data collectionSemi‐structured interviews were conducted to obtain information on the participants’ views about dependency. Interviews were conducted individually using a previously prepared interview guide. The leading author conducted all the interviews either in the participant's homes or in public spaces, that is, in community sites or nursery homes. In the case of older adults living in nursing homes, the interviews were conducted in their rooms or the private spaces provided by the centres. If participants gave their approval, the interviews were recorded, and for the two participants who refused to be recorded, information was collected in writing. All the participants were free to speak either in Basque or Spanish.Following previous studies on social representations (Joffe & Elsey, 2014), the interview started with a non‐leading question that could reveal the naturalistic thoughts of the participant regarding the representation object, namely dependency (i.e., What comes to your mind when you think about dependency in old age? What feelings and thoughts does dependency evoke in you?). Only after obtaining a reply to these questions were the following questions introduced (i.e., How do you experience dependency and care on a daily basis? What does the increasing long‐term care needs suggest to you?). The same questions were administered to all participants since we were interested in how the community collectively constructed the meaning of dependency. The interviews lasted from 30 to 45 minutes and were conducted during May 2018 and January 2019.Data analysisThe interviews were transcribed verbatim in the original language. Data analysis was conducted using thematic analysis (Braun & Clarke, 2006). Thematic Analysis is considered an appropriate qualitative method for identifying, analyzing, and reporting patterns (themes) in data and facilitates the interpretation of the themes’ meanings in the context in which they are produced. Through the elaboration of themes, thematic analysis allows for identifying and interpreting people's underlying ideas and assumptions regarding an issue (Joffe & Yardley, 2004).First, the main author read and re‐read in depth all the interviews. Then, she semantically coded the information using Atlas‐ti software. The analytical procedure consisted of a preliminary inductive approach, literally reading and coding the data and without leaving room for interpretation. Thus, the coding process was applied to the raw data without fitting it into a pre‐existing coding frame (Braun & Clarke, 2006).Second, more abstract categories were created based on the initial coding, interpreting the first coding scheme and including it in a theoretical framework based on the literature review. This was a deductive process that aimed to achieve a theoretically oriented analysis. As a result, the data were organized according to the psychosocial perspective (Doise & Pires, 2015). This allows for adopting a multi‐level approach that considers the articulation among cultural, organizational, and relational dimensions operating in social representations. Once the categories were distributed according to the psychosocial perspective, the researchers returned to the categories to look for the main issues that were expressed as contradictions or tensions and suggested polyvocality.The adequacy of themes was tested and discussed among the research team and compared with previous literature. Data analysis was conducted reflexively and flexibly, relying on the active and creative role of researchers in the emergence of social representations (Braun & Clarke, 2006). Throughout this research we adopt the position of situated knowledge, assuming that the way of approaching this study is undoubtedly affected by the context and the subjectivity of those who produce it (Haraway, 1988). Therefore, the authors of this paper acknowledge that their approach to the study is conditioned by their position as feminist and white women from the Basque Country (north of Spain). According to the criteria in qualitative paradigm, the quality of this study lies in the trustworthiness and relevance of the data. The clarity of the procedure and researchers’ subjectivity as analytic resource is emphasized for this purpose (Bauer & Gaskel, 2000; Braun & Clarke, 2020).RESULTSA sample of 26 people living in the Basque Country participated in this study. Participants included people who experienced the care of an older adult in the family (n = 11), home care workers (n = 7), and older adults residing in nursing homes, which had some degree of legally recognized dependency (n = 8). Among the participants, 16 were female, and 10 were male, with the youngest being 25 years old and the oldest 93 years. There was no family or professional relationship between the participants, and they were all born either in Spain or South America (Table 1).1TABLESociodemographic characteristics of the participantsParticipantsGenderAgeOrigin1. Relative (daughter of older adult)Female25Spain2. Relative (daughter of older adult)Female40Spain3. Relative (grandchild of older adult)Female25Spain4. Relative (grandchild of older adult)Female28Spain5. Relative (grandchild of older adult)Female38Cuba6. Relative (son of older adult)Male57Spain7. Relative (son of older adult)Male63Spain8. Relative (son of older adult)Male66Spain9. Relative (son of older adult)Male67Spain10. Relative (grandchild of older adult)Male39Spain11. Relative (nephew of older adult)Male42Spain12. Home care workerFemale29Nicaragua13. Home care workerFemale31Nicaragua14. Home care workerFemale39Nicaragua15. Home care workerFemale41Nicaragua16. Home care workerFemale52Bolivia17. Home care workerFemale36Spain18. Home care workerFemale36Spain19. Older adultFemale77Spain20. Older adultFemale87Spain21. Older adultFemale91Spain22. Older adultFemale91Spain23. Older adultMale70Spain24. Older adultMale78Spain25. Older adultMale85Spain26. Older adultMale93SpainThis study revealed that the social representations of dependency in care contexts were articulated around seven themes classified into three dimensions. From a constructionist perspective, the themes — beyond individual experiences and the positions of participants — illustrate the debates and tensions circulating in the socio‐cultural context of the Basque Country (Braun & Clarke, 2006).Cultural dimensionTheme 1: Familism versus individualismThe most prevalent tension evident among people was related to family responsibility when it comes to caring. The results showed the coexistence and conflict between traditional views and practices of care in the family and new values that challenge the obligation of care in the family context. This is illustrated in the following quote:Now the lifestyle is changing. Parents were cared for at home before, but nowadays each of us have our lives, we live in different places and life gets complicated. So now, it's not the same as some years ago and you don't have family support because sons and daughters live away, one in China and the other in Japan…. (Male, 67, relative)Participants talked about traditional and current forms of organizing care, discussing the difficulties in supporting care within the family and their own beliefs and expectations about family and reciprocity. In this regard, some participants expressed their preference for care within their families, pointing out that family care is the most natural and desirable model for dealing with dependency needs. The familiarist views of care are illustrated in the following quotes:I remember that there was never a complaint. Because in the end this person is from your family, and you have to take care of them. It is a return, right? When you are a child, parents take care of you, and you have to take care of them. It's up to you to return what they did for you. (Male, 39, relative)My grandmother died at the age of 100 and my aunts took care of her until the end of her days. In our mind, we don't conceive of taking a relative to a nursing home just to make our life easier. (Female, 41, care worker)In addition, in the following quote an older person expresses to some extent her complaint toward her children, as living in the nursing home means living separated from her family and children as a source of care, when in the past she cared for them:Dependency…well, in my case means living apart from my family, living away from my home. We live as we can and we would want to live happy. And the children, as they leave, then they return, and we have to support them. (Female, 91, older adult).In contrast, the duty of family care was questioned, pointing out the psychological, personal, and socioeconomic costs involved in caring for older people in caregivers. In this regard, participants consider other resources for attending to dependency needs and aged care. This is expressed in the following quote:You have the right to make your life in the end and not to charge so much, don't you? If I had children now, as I have been a caregiver now, I would not want to influence their lives. I don't want that. I don't want to be a burden to my family, nor to affect my friends or the people that I love. (Female, 36, care worker)Theme 2: Production versus reproductionA second systematic tension concerns the difficulties people experience when balancing their employment, care of the older adult, and personal life. The concept of “social reproduction” theorized by Harris and Young (1981), allows for understanding the everyday dynamics and conflicts those participants experience when balancing the time they spend in the labor market — production of goods and services — and family life — the reproduction of life. Thus, it is observed that how the time of care is organized is determined by the priority given to the productive sphere. The following quote reflects this idea:My children already know, one day one and another day another. Except on Tuesday, someone comes to visit and help me every day. They organise the schedule themselves because they are all employed. That's how we organise everything. (Male, 93, older adult)In addition, participants frequently mention family disputes and the incompatibility of care work with their personal and professional lives. Life and work incompatibility, overload, loss of freedom, and lack of resources for caring are frequently mentioned, as illustrated in the following quotes:But in the end, I gave an ultimatum to my family. I couldn't go on sleeping every day four or five hours, every weekend at home, unable to move at all, and without a life. When we decided to take my father to the nursing home, we got a little bit of freedom in our lives, and we decided to visit him every day… (Male, 57, relative)“In the current situation we have to work, and there is not enough time to take care of a person who is dependent and assist him/her in the conditions we would like to do.” (Female, 25, relative)The tensions between productive and reproductive spheres are also visible in the unequal distribution of dependency and care responsibilities depending on gender, class, and immigration. Many people mention the devaluation of care, the precariousness, and the stigma derived from being in a job that nobody wants to do. This is illustrated in the following quote:Although many families can pay a good salary to the care workers, they do not do it, and that is why we are trying to fight and claim that this is a difficult job. The families do not realise how hard the work is, and they do not value our work which is the work the majority of the families do not want to do. Sometimes some people tell you: if it is wasn't for you, who came to this country and worked in this role, who would work in these types of jobs? (Female, 29, care worker)Theme 3: Dependency versus autonomyUnlike autonomy, the normative notions of dependency in the context of ageing play a core role in the everyday conceptualization of the subject, revealing the imaginaries and feelings people construct mainly about dependent old age (Cerri, 2015). While the participants deal with ambivalent representations of both old age and dependency, there is an apparent tendency to hold a negative view of dependency. The prevailing view of dependency emphasizes people's physical and cognitive decline, their need for help, their impotence, and anguish generated in such situations. The following quotes:Old age also has its charm. It provokes tenderness on me, but then I am anguished. Maybe you are giving your best and you realise that the other person…is not having the effect you want, or the expectations you have. At this moment that is what is happening, because the person has already reached a level where it is not going to go further, on the contrary. (Female, 41, care worker)From now on unfortunately I need much more care, because day by day I'm getting worse and I have declined a lot in the last few years. I eat a lot and I still lose weight. (Male, 85, older adult)Participants mentioned the idea of dependency concerning self‐sufficiency, feeling useful, and not being a burden or an obstacle for the family, as illustrated in the following quotes:When thinking about dependency I consider important carrying daily activities on my own and being able to do them by myself. (Male, 63, relative)Well, the words that come to my mind are, it is thanks to God that I can still defend myself. Self‐sufficiency? That's it. I always ask God for all those things. And that I'm useful, that I'm worthy, right? I think … useful. I clean myself, and I wash myself, I dress myself, I put on my stockings myself, the only thing that I can't do is take a shower alone. They often tell me, but I don't need anyone at the moment. Why am I going to be bothering? (Female, 87, older adult)In addition, ideas related to the need for prolonged autonomy, active lifestyle, and decision‐making capacity are mentioned in the face of the risk of dependency. These ideas are illustrated in the following quotes:He was getting worse day by day, he had to take a lot of medication and so on. And in the end it is a big impotence to see how the person was consumed. We assist him in everything, changing his diapers, taking a shower… I think the situation in the last year went on too long, because given that he had always been a mountaineer and he was in a wheelchair, he didn't understand how he could get to be like that. My uncle has been always on the move, without ever getting sick. (Male, 42, relative)Fear and insecurity of not being able to act by myself and not being able to express my feelings and decisions. (Female, 39, care worker)Finally, participants mentioned that increased longevity produces challenges in ensuring the quality of life and well‐being in later life (Medeiros, 2017). Furthermore, the association between dependency and end‐of‐life care and death leads to reflections on the extent to which it is worth living in such a situation of extreme frailty. In this regard, one of the participants discussed the idea of euthanasia, as shown in the following quote:I doubted as to whether it was worth living the last year or two because my mother suffered and so do the others. In addition, there weren't minimum possibilities of improvement. In my opinion, it is not worth living with artificial breathing, when you are already at the end of your life. Here there is no euthanasia or, if you have used the euphemism you want, it is not legalised and, in those cases, you don't know how to do it Even Doctors don't give solutions, and not everyone in the family has the same opinion. (Male, 67, relative)Organizational dimensionTheme 4: Natural versus professional laborThe fourth theme concerns the meanings associated with care work and its strong naturalization in women and love (Hansen & Kamp, 2016). Again, the participants’ views reflect the coexistence and tensions between naturalized and professionalized notions of care provision. In this regard, most participants mentioned the sentimentality involved in care work, conceptualizing aged care as a job based on love and patience, provided typically by women in the private sphere. These ideas are reflected in the following quotes:Now it is not the same as it used to be. Women didn´t work in the past, right? Well, they had their little jobs, but if someone was sick, women used to take care of him/her. (Male, 66, relative)The assistants and all the people who take care of us are phenomenal and we have to give them credit for that. Do you know how affectionately they treat people who don't even know who they are? The poor girls must be so patient… I value them, the patience those poor women have to have. (Female, 87, older adult)Along with the naturalization of care, people also mentioned the need for professional and qualified caregivers. Care work is a growing professional sector in Spain where the minimum training requirements are increasing (Moreno‐Colom et al., 2017). This demonstrates that care work is a task that increasingly requires professional skills and public recognition. The transition toward the professionalization is reflected in the following quote:I also know that actually they are asking qualified people to work with dependent people, and I think that it is positive because anyone can say “we are going to take care of someone” without any qualifications. All of us know how to clean and can care for someone, but the person that we are taking care of also has their own mind and feelings, even if we do not realise this. (Female, 25, relative)The coexistence and tensions between these visions of care have implications for the construction of the professional identity of caregivers, as it is a task that transits between domesticity, servitude, and professionalization (Hansen & Kamp, 2016). In this case, conflicts are expressed in terms of caregivers’ social recognition and workers’ rights in care provision spaces, for example, the private and informal household sphere or the public and formal sphere (Bulloch & Morales Waugh, 2004). This is illustrated in the following quote:In this type of work at home no, no longer…I don't see myself in this job for a long time because as I tell you, it's not well valued and I prefer to work in an organization or in a company, for instance. Now, that I have got my degree, I will pursue my career in a residence or something like that. I know that it is within the same field of caring, but it is different. At home the relationship is closer, but I prefer to see myself in another context. (Female, 29, care worker)Theme 5: Home care versus nursing homesAnother prevalent theme concerns the institutionalization and care models adopted in nursing homes. On the one hand, participants mentioned their preferences and wishes regarding the care model they would like to have if needed. On the other hand, following the main cultural aspiration of ageing in place, most participants express their preference to continue living in their own homes close to family and the community. However, they are aware of the difficulty of remaining at home when care needs increase. In this case, the option of living in nursing homes is accepted, as illustrated in the following quotes:I think that whenever possible, the help that should be given is so that the person continues living in their own environment, not in the nursing homes. I understand that there are situations that are so difficult, but the challenge is to follow living in the own home. There is a need for more resources, we know that there are nursing homes, but there is a lack of that I say: to keep people in their own environment and caregivers will come to the home. (Female, 36, care worker)In most cases, living in a nursing home is usually the last resort, and it is accepted only when living at home with autonomy becomes difficult. This could be linked to the inherited negative social representations about institutions in terms of end, rupture with the family and community life and imprisonment (Daniel et al., 2019). Participants struggle with these ideas and fears associated with institutionalization, as expressed in the following quotes:At first it was absolute denial. But as the situation was becoming more and more difficult, he entered the nursing home due to family pressure. We told him: what other options do you have? (Female, 28, relative)My parents always told me that this was the last option, that it was something for very poor and not self‐sufficient people. But a moment came that I was worse. It was very difficult to accept that I couldn´t live that way. I decided to come here, where I´m attended to 24 hours a day. (Male, 70, older adult)Frankly I'm alone. There should be much more care, not as individual we are, because the residences exist to pick up abandoned people. (Male, 78, older adult)The desire to continue living at home or at least feel as if that were the case, is an important aspect of the views, preferences, and satisfaction that people have toward care in a situation of dependency. In this respect, older adults emphasize the satisfaction they feel living as if they were in their own home, as expressed in the following quote:It is my home … The residence for me is my home, and I feel like a duck on the water! The assistants and all the people who take care of us are great, and we must value that. (Female, 87, older adult)In contrast to the perceived impersonal service provided by traditional nursing homes, participants expressed the need for more personalized and warm attention that resembles one's own home. This reflects the growing social debate concerning changing care models in institutional settings (Diaz‐Veiga & Sancho, 2013). This is shown in the following quotes:Society will have to give more serious solutions to this issue. One is to build more centres for the elderly. Nowadays they exist. However, more centres, which are better organised and based on a different model are required. I think that there would already be some good models in the world, right? (Male, 67, relative)I see that the population is ageing, an inverted pyramid is being created, and this will change the needs of society. Hence, they must start to value another type of service, because the nursing home is not a desirable solution, but instead, they can take care of you at home or in a small apartment. (Female, 36, care worker)Relational dimensionTheme 6: Communal sharing versus market pricingA core element in the social representations of dependency is the relational models operating in care practices in terms of kinship, job, and reciprocity (Comas d‐Argemir, 2017; Walsh & Shutes, 2013). Drawing from Fiske's relational models’ theory (Fiske, 1992), we can distinguish between “communal sharing” and “market pricing” social relations. “Communal sharing” is based on having something in common with a partner, such as familiarity, kinship, friendship, and an emotional connection. In addition, people are expected to be altruistic and unconditional. However, “market pricing” relations are configured around a logic of proportionality of exchanges, typically by the exchange of services and money. The literature suggests that when those models coexist in the same context, relationships tend to be conflicting because people do not have clear expectations about the relationship (Fiske, 1992). The coexistence and tensions between both models are shown in the expected affectivity and mutuality in a dependency situation, where family support is considered difficult to replace, as illustrated in the following quote:My family wanted to provide me with a caregiver, but I didn't want to. Here, on Tuesdays, I am alone, but also with friends. The support is not the same as what my children give me, but at least I have a friend to play with and go for a walk on Tuesdays. (Male, 93, older adult)Simultaneously, caregivers experience the tension of having a market relationship with the family and the older person, but they also become effectively concerned with them. This is illustrated in the following quote:Besides, being with her family, I think she will feel more protected, won't she? With people that she loves…Maybe I am not even able to give the affection that she needs, because dependent people need a lot of affection. But it must be recognised that they also leave you a little bit empty because of this…this job it makes you sick. (Female, 41, care worker)When you can manage your affections and carry all this forward, you do better. But what happens to those who say: After given so so so much affection and time, this is how they reward me. (Female, 52, care worker)Furthermore, it is observed that people, in their everyday life, hold contradictory expectations and wishes regarding the kind of care and bonding they would like to have in a situation of need. Being loved, supported, and feeling warmth are important factors mentioned by the participants, as they fear depersonalization, loneliness, and being treated in a practical way. People often must struggle with contradictory thoughts, moral values, and desires about the care, questioning the obligation, responsibility, and commitment expected from family and caregivers. This is expressed in the following quotes:I would like to be cared for by a person who I pay, but not by a stranger. I frequently see situations in which the older person in the wheelchair and their caregiver don't even speak to each other! So, I would like a close person, although deep in my heart I would rather be with my children. It's like a "I want to and I can't. (Female, 25, relative)If one day I must go to a residence, then I will go. But I don't want people who visit to come obliged. I want them to feel that they come because they love me. Not because today is Tuesday and it's his/her turn, and them to be looking at the clock waiting for the time to leave. (Female, 28, relative)Theme 7: Instrumental versus emotional careThis last theme emphasizes the dualities that operate in care relationships and the type of assistance provided to the person in a situation of dependency. According to theories of care, two main dimensions of care can be distinguished: practical care and emotional care (Kittay & Feder, 2002). Practical care refers to instrumental and embodied attention given to a dependent adult, such as bathing, intimate contact with ageing bodies, mobility, giving medicines, and cooking, as expressed in the following quote:The help of another person is necessary to carry out the body hygiene of the older adult. (Female, 25, relative)It would be to take care of food, medicine, calm, rest, and so on. A person is simply dependent when he/she needs you to have shower or get dressed. (Female, 31, care worker)Emotional care refers to the personal affective involvement between people. For instance, participants mentioned features associated with caring, such as empathy, patience, giving love and companionship, and considering the psychological‐relational needs of others (Scopinho & Rossi, 2017). This is illustrated in the following quote:If you are a dependent person, of course you need affection, respect, and empathy. For me it is essential. If he/she is able to really care for me, I don't mind if it is a job or not. But if your job is to care for people you should know that person a little bit. (Female, 36, care worker)Of course we can't predict the future, but I realise that my colleagues who are much older than me are disabled, and as I see that they are well cared for, it's very satisfying. Well, now I can defend myself, but in the future…all we know each other here, and I think that I´m nice for them, maybe not for all of them, but they all kiss me and give me affection… I´m not scared for the future, I´m at peace. (Female, 77, older adult).According to the emotional meaning of care, tensions and contradictions were identified concerning relationships between caregivers and care receivers, based on instrumental or emotional ties. People deliberate on the tasks caregivers do, some complex to manage, such as personal or emotional care. Tension is associated with establishing the limits and the degree of emotional involvement the caregiver should hold toward the cared person. These ideas are illustrated in the following quotes:I often think that we work quickly, we have to arrive and keep our timetable. I also see that there are people who are not qualified for this job. I'm not saying that the people who work there are bad people, but we are diverse, and we work differently. For example, some people are more emotional, while others are more like a machine. (Female, 36, care worker)I would like above all, to say that I value the fact that caregivers are more or less nice and loving people. I would like a little more understanding perhaps. Logically we know that there are people who are not empathetic, so we need to consider the characteristics of the person, that´s what we need in principle. (Male, 70, older adult)DISCUSSIONThe present paper aimed to explore the collective construction of the meaning of dependency from the point of view of relatives, home care workers and older adults living in nursing homes. Considering the socio‐cultural changes and transformations in the Spanish care system, this study provides an insight into the debates by which the phenomenon of dependency is represented. Based on a dialogical approach of social representations, the analysis of Cognitive Polyphasia contributes to understanding the processes by which different meanings about dependency coexist and confront each other in both the social context and individual minds (Jovchelovitch & Priego‐Hernandez, 2015).This study identifies the tensions and contradictions between the issues, suggesting the presence of a deep public debate about dependency in situated context. Previous literature in the field highlights the socio‐cultural transformations, including the decline of the gendered family structure and the difficulties individuals face when balancing productive and reproductive functions in their daily lives, along with the struggle between paid work and care needs at home (Deusdad et al., 2016). Moreover, the responsibility of care still falls on impoverished and immigrant women, being a low‐paid and undervalued profession (Moré, 2018). On the other hand, demographic changes and increased longevity have led to the growing debate on ageing, health, and traditional care models in institutions, leading to a shift toward community‐based and person‐centred perspectives (Martínez Buján, 2019; Nolan et al., 2004). As several studies suggest, dependency situations and the need for assistance represent the dark and feared side of ageing (Torres et al., 2015; Wachelke & Contarello, 2010). Concerning these processes, our study shows the tensions and conflicts that people experience in their daily lives, reflecting the presence of Cognitive Polyphasia at the cultural, organizational, and relational levels of social representations.First, within the cultural dimension of representations, psychological tensions concerning socio‐cultural values and practices are made visible. According to previous findings, ideas associated with family duties, care burden, work‐life balance, disease, and the importance of autonomy and remaining active are at the basis of people's aged care and ageing conceptions (Brito et al., 2018; Camargo et al., 2014; Contarello et al., 2016; Linell, 2009; Medeiros, 2017). Our results reveal that people deal with these ideas in a conflicting way. The confrontation between family duties and values of autonomy, the incompatibility of employment with care and its demands on personal life, and the confrontation between the negative meaning of dependency and the invisibility of care are shown. In addition, and as particularly observed in the theme named “dependency versus autonomy,” people mostly express the official or institutional discourse provided by Dependency Act 39/2006, sharing definitions that, according to a biomedical approach, assimilate the deficient and problematic nature of dependency associated with age, disability, and disease (Cerri, 2015). Thus, the participants’ discourses show how expert and normative knowledge has been disseminated in lay thinking about dependency (Moscovici, 1961, 1984).Second, the tensions associated with the meaning of care work and institutionalized care have been observed within the organizational dimension. Consistent with previous studies, the clash and coexistence between the traditional and gendered love‐based ideas as opposed to professionalized views is shown, which is a source of recognition, better working conditions, and professional progression of care workers (Hedler et al., 2016; Moreno‐Colom et al., 2017; Scopinho & Rossi, 2017). On the other hand, traditional and impersonal models of care are questioned (Daniel et al., 2019; Diaz‐Veiga & Sancho, 2013; Koren, 2010). In line with global trends of social policy and the cultural aspiration of “ageing in place,” we reflect tensions regarding the expectation that care institutions maintain the autonomy of individuals, along with a sense of belonging and the ability to make decisions in later life (WHO, 2017; Wiles et. al, 2012).Third, within the dimension of social relations, the tensions and contradictions that people face in care relationships become visible (Fiske, 1992). In line with previous studies about the perceptions of care relationships, people experience tensions in the meaning of care relationships in terms of closeness, kinship, friendship, and the mutuality expected from each other (Siira et al., 2019; Walsh & Shutes, 2013). Moreover, these confusions increase on the household level when people deal with professional and personal relationships, leading to tough emotional conditions and an unequal distribution of power between caregivers and care recipients (van Bochove & zur Kleinsmiede, 2019). Finally, we show the tension in interpersonal relationships between caregivers and care recipients, based on managing instrumental and emotional bonds (Tronto, 2013). This involves establishing the degree of emotional involvement that the caregiver experiences toward the person being cared for. This is relevant if we consider that the configuration of care networks is increasingly complex and differentiated in terms of technical and affective, formal and informal care practices (Comas d‐Argemir, 2017).From the socio‐representational approach, we argue that, in the present study the social representations of dependency are anchored in the coexistence and conflict between diverse meanings and types of knowledge (Jovchelovitch & Priego‐Hernandez, 2015; Markovà, 2003). Thus, a theory is put forward for understanding how people cognitively integrate and familiarize the meaning of dependency in the socio‐cultural context of the Basque Country. Challenging the cognitive reductionism of the theory, the situated nature of social representations of dependency is sustained, reflecting socio‐cultural transitions (Jovchelovitch, 2007; Wagner & Hayes, 2005). Focusing on contents and processes of social representations, an innovative theoretical approach for analyzing how knowledge transformations occur in the care context is provided.According to the dialogical approach of Social Representations Theory, the tensions between meanings and the opposing themes reflect the heterogeneous and dynamic nature of the social representations. According to Markova, the tension and the interdependence between oppositional taxonomy known as “Themata,” have prompted the genesis of social representations and public debates (Markova, 2003; Moscovici & Vignaux, 1994). In light of this idea, the themes that constitute the social representations of dependency could be interpreted as practical manifestations of culturally rooted antimonies that rely on the processes of anchoring and objectification of social representations (Li Liu, 2004). As shown in the literature, latent historical conflicts and tensions in the meaning of care, ageing, and health are concerned with cultural constructions such as production‐reproduction, public‐private, rational‐emotive, independence‐dependence, active‐passive, self‐other, health‐illness, and life‐death (Cerri & Alamillo‐Martinez, 2012; Medeiros, 2017; Tronto, 2013). To the extent that they manifest these tensions, our results could be useful for further research related to socio‐cultural meanings, values, and assumptions about the issue. Furthermore, these themata could play a key role in everyday conceptualizations of dependency and care related questions, driving the formation of social representations (Markova, 2003; Smith & Joffe, 2012).Similarly, from a dialogic perspective of the phenomenon, we suggest that social representations are constructed concerning the plurality of voices, discourses, and positions that relatives, care‐workers and older adult care recipients have about the phenomenon, understanding dependency as a relationally and collectively constructed concept (Dant, 1988; Fine & Glendinning, 2005). Beyond the prevailing individualistic approach of social cognition, this study helps understand how people internalize and redefine the meanings of dependency concerning socio‐cultural context and their stance on the phenomenon throughout life (Voelklein & Howarth, 2005). Thus, having a holistic perspective of the diverse voices and positions on the phenomenon promotes a more inclusive view of dependency, recognizing the dialectics between different meanings by which the representations are constructed and making visible the positions of the “other” in social interactions (Jovchelovitch, 2007). This is essential to improve communication, mutual understanding, and trust among social actors, recognizing our existence as deeply vulnerable and interdependent (Linell, 2009; Tronto, 2013).At an applied level, we provide a contextualized view for understanding people's thoughts and behaviors concerning dependency, helping to cope more positively with the ageing process and often dilemmatic care views and practices (Foster & Walker, 2015; Montgomery et al., 2017). Finally, the themes elaborated provide some keys to addressing the collective challenges and debates already under discussion in society, including: Who should oversee the care of the older adult? How can we balance the various relationships and care provided by relatives, professionals, and institutions? How can we promote a more positive view about aged care and dependency situations?LimitationsSince social representations are socio‐historically and socio‐culturally situated, the results of this study should be interpreted with caution. The authors recognize the limitations regarding the selection of participants for the interviews. Although, the study was designed to understand social‐cultural transformations in the care context and we decided to primarily focus on debates regarding the management of daily care practices, a more extant vision of the debate would include other voices, such as the personnel of care institutions and community members. Future studies are needed to delve deeper into how socio‐cultural transformations in the care context and modern lifestyles lead societies toward developing new care practices, and the attendant consequences for all of us when it comes to living a good and dignified life.Ethical standardsThe ethical aspects of this research have been carefully considered. Informed consent and the free participation of all participants were always ensured, along with confidentiality and the adequate treatment of data. At the end of the study, the return of individual results was guaranteed. Therefore, the study was approved by the ethical committee of the University of the Basque Country (M10_2018_228).ACKNOWLEDGMENTSThe authors are grateful to all the participants in the study. They are also grateful for the collaboration of Matia Gerontological Foundation and Mizpirualde Bergara.CONFLICTS OF INTERESTThe authors declare that there is no conflict of interest with respect to the research, authorship and/or publication of this article.FUNDINGThis research was made possible thanks to financial support of the Vice Rector for Basque Language for PhD students of the University of the Basque Country (EHU‐UPV).AUTHOR CONTRIBUTIONSAll authors have fulfilled the conditions required for authorship. All authors designed the study. The first author conducted all the interviews and performed the data analysis. The other authors provided critical guidance throughout the data collection and analysis process. 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Journal
Analyses of Social Issues & Public Policy – Wiley
Published: Aug 1, 2022