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The effect of homemaking services on established measures of perceived well-being in community-dwelling… Reilly, Eileen Dianne Dougall 1993

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THE EFFECT OF HOMEMAKING SERVICES ON ESTABLISHED MEASURES OFPERCEIVED WELL-BEING IN COMMUNITY-DWELLING ELDERLY.AN EXPLORATORY DESCRIPTIVE STUDYbyEILEEN DIANNE DOUGALL REILLYB.A., The University of British Columbia, 1990B.S.W., The University of British Columbia, 1992A THESIS SUBMITTED IN PARTIAL FULFILLMENT OFTHE REQUIREMENTS FOR THE DEGREE OFMASTERS IN SOCIAL WORKinTHE FACULTY OF GRADUATE STUDIESSchool of Social WorkWe accept this thesis as conformingto the required standardTHE UNIVERSITY OF BRITISH COLUMBIASeptember 1993© Eileen Dianne Dougall Reilly, 1993In presenting this thesis in partial fulfilment of the requirements for an advanceddegree at the University of British Columbia, I agree that the Library shall make itfreely available for reference and study. I further agree that permission for extensivecopying of this thesis for scholarly purposes may be granted by the head of mydepartment or by his or her representatives. It is understood that copying orpublication of this thesis for financial gain shall not be allowed without my writtenpermission.(Signature)Department of  S   c.„) The University of British ColumbiaVancouver, CanadaDate ^'I 0 clq_3 DE-6 (2/88)11ABSTRACTThis exploratory study examines of the effects of homemaking services on establishedmeasures of perceived well-being in community-dwelling seniors who have been assessedby Case Managers as qualifying for homemaking services. A hypothesis regarding theeffects of homemaking on perceived well-being was developed and tested on an availabilitysample of elderly clients over 65 years of age who were cognitively competent. Face-to-face interviews using Reker and Wong's 1984 Revised Perceived Well-Being Scale wereconducted on 28 subjects before homemaking was provided. Six homemaking visits later afollow-up interview using the same PWB scale and a qualitative questionnaire wereconducted to investigate subjects' opinions of the homemaking service. It was anticipatedthe results might reflect the importance of emotional and social support factors as well asthe physical support elements of homemaking services on the perceived well-being ofsubjects. Quantitative data was analyzed for changes in measures of perceivedpsychological, physical and general well-being of clients. Qualitative data was analyzedfor themes associated with changes in well-being measures as a result of the service.Descriptive data reveal the average age, gender, culture, education, income, and chronicillness of the sample. Research suggests a strong correlation between perceived well-beingand health status. If well-being and perceived client health are improved by homemakingservices, there could be important implications for the distribution of health-care servicesfor our elderly. Data may also suggest a range of options for Continuing Care andimproved measures for evaluating the effectiveness of other health-care programs.111TABLE OF CONTENTSABSTRACT^TABLE OF CONTENTS^ iiiLIST OF TABLES ivLIST OF FIGURESACKNOWLEDGEMENTS^ viDEDICATION^ viiCHAPTERI. INTRODUCTION AND OBJECTIVES OF THE PRESENT STUDY^ 1II. LITERATURE REVIEW^ 4III. CONCEPTUAL FRAMEWORK 21IV. METHODOLOGY 27Sample ^ 27Homemaker Profile 32Data Collection 35Design Limitations 43Advantages of the Methodology^ 45Data Analysis^ 46V. RESULTS 54Description of Sample^ 54Findings 61Emerging Themes from Qualitative Data^ 70VI. DISCUSSION AND CONCLUSION^ 85BIBLIOGRAPHY ^ 102APPENDIXES 110Appendix A: Letter Inviting Subject Participation^ 111Appendix B: Letter Explaining Study^ 113Appendix C: Letter Requesting Agency Permission 115Appendix D: Pretest Format for Qualitative Interview^ 117Appendix E: Perceived Well-Being Scale 119Appendix F: Scoring Instructions for Perceived Well-being Scale ^ 121Appendix G: Letter of Permission to use Perceived Well-Being Scale ^ 123Appendix H: Agency Consent Letter^ 125Appendix I: Ethical Approval Letter UBC 127Appendix J: Richmond and Lower Mainland Continuing Care Stats ^ 129Appendix K: Telephone Follow-up Conversation^ 131Appendix L: Qualitative Questionnaire^ 133Appendix M: Thankyou Letter to Respondents 135ivLIST OF TABLESTable 1 Age Structure of the Population Aged 65+^ 5Table 2 Homemaker Characteristics Richmond Agencies 1993^ 34Table 3 Cumulative Frequency Distribution:Ages of Respondents 54Table 4 Highest Education Level Reported^ 57Table 5 Levels of Care by Age, Gender, and Marital Status^59Table 6^Personal Characteristics of Respondents^ 60Table 7 Differences Between Psychological, Physical, and GeneralWell-Being Scores Before and After Homemaking Services^61Table 8 Changes in Pre-Posttest GWB Scores^ 64VLIST OF FIGURESFigure 1^Conceptual Model^ 22Figure 2^Age Groups of Subjects 55Figure 3^Marital Status of Subjects^ 56Figure 4^Income Level of Subjects 56Figure 5^Education Level of Subjects^ 57Figure 6^Chronic Conditions of Subjects 58Figure 7^Psychological Well-Being Scores Before and AfterHomemaking Services^ 62Figure 8^Physical Well-Being Scores Before and After Homemaking Services ^ 63Figure 9^General Well-Being Scores Before and After Homemaking Services^ 63Figure 10^Response to Statement: "I have peace of mind"^ 68Figure 11^Response to Statement: "I'm in good shape physically"^ 69viACKNOWLEDGEMENTSI wish to acknowledge my colleagues and friends at the Richmond HealthDepartment Continuing Care Division who offered their encouragement, advice, andsupport throughout this study. Special thanks to Director, Beverly Latrace, and to GeneDurnin, Manager, who provided me with generous access to anything that helped mewith this project.The support of Ms. Adeline Pasichnyk and Dr. Les Lewchuk of Strategic ConceptsInc. will always be appreciated and fondly remembered. They gave so much of their timeto help me realize my dream.I am grateful to my advisor, Professor Elaine Stolar. Her unrelenting pursuit ofperfection challenged me to new heights. To Professor Mary Hill, a wealth of knowledgein the field of the aged, many thanks for giving so generously of your valuable time.I also wish to thank Dr. John Crawford, Professor at Simon Fraser UniversityGerontology Research Centre, whose sage guidance and emotional support saw methrough the finishing line.And finally, I would like to thank all my elderly clients who shared so generouslyand enthusiastically their thoughts, feelings, and opinions. Your contribution to thisresearch project made a difference.DEDICATIONI dedicate this thesis to my cheering team: Dr. YackReitry,Ms. Kim Tappay and Mr. James DougartTo _lack, my husband, best friend, mentor and coach, who,for the past eight years, sacrificed his own dreams so Icould realize mine. You were always there to encourage mewhen I faltered and catch me when I fell, and it was yourstrong faith in me that enabled me to continue to the end.I hope I can give you backsome of your dreams.'lb U(im, my daughter, best friend, and study partner. Youwere always there with an encouraging word and a hug,even when I wasn't always there for you. I am so proud tosee that my efforts have inspired you to be the best you canbe. It was such a privilege to go to university together.And to my father, Jim Dougaff --- the best example ofgraceful aging I have ever known.Thankyou all "for your unconditional love, encouragement,and support. You truly are the wind beneath my wings.vu1Chapter IINTRODUCTIONMy interest in the topic of this thesis is a result of my life-long fascination withaging. Along with my attraction to old people, I view the aging process with greatintrigue. Later in my life this fascination led to my studies in psychology, gerontology, andsocial work, as well as considerable practical experience which I gained from workingwith old people. As a Case Manager for the Continuing Care Program in Richmond, Igained further knowledge of the increasing population of elderly clients for whom weprovide services. Homemaking is one of the services which we, as Case Managers, assesscommunity-dwelling elderly people as eligible to receive.It is my own and many of my colleagues' opinions that when we assess elderlypeople for eligibility of homemaking services we frequently perceive an increased sense ofemotional well-being in many of our clients. While we cannot attribute the apparent lift inmood solely to our presence, we feel there are positive aspects of our interactions and ouroffer of potential homemaking assistance which facilitate this 'lift' in affect. The idea thatthe mood of clients could be positively affected through interactions with Case Managersmay be extended, and I became curious about the possibility of homemakers elicitingsimilar positive responses, and affecting client well-being. Because researchers (Kozma etal., 1991; Larson, 1978; Milsum, 1984; Matthews and Wakefield, 1984; Lee and Ishii-Kuntz,1988; Chappell and Badger, 1989; Berkman and Syme, 1984; suggest strong correlationsbetween well-being, health status, and delayed institutionalization, as a result of socialsupport, the implications for this intervention of homemaking may have more significancethan we realize.As I reviewed the literature, I wondered if it was the emotional and social supportthat clients receive from their homemakers which contributes to their sense of well-beingmore so than the instrumental support of housecleaning. This was my bias as I entered theinvestigation. I was curious to learn whether the service we were providing was appropriate2to client need. Are vacuuming the rugs and doing the laundry as important as the socialand emotional support many homemakers are known to provide (Matthews and Wakefield,1992; Revicki and Mitchell, 1990; Larson, 1978)?Because client perceived well-being and homemaking services provided byRichmond's Continuing Care Program had not been evaluated, and because clients havelimited input into the services provided them, this study sought to gain understandingabout homemaking service and client well-being by investigating the question: Dohomemaking services affect the perceived well-being of community-dwelling seniors who sufferfrom chronic health conditions?This study investigates the effect of the intervention by homemaking services onmeasures of perceived well-being of elderly people whom the Continuing Care Programhas assessed as eligible for such service. Continuing Care is interested in improvingservices to clients and working conditions for Case Managers while at the same timemaintaining fiscal accountability.However, the primary objective of this study is to measure chronically ill clients'perceived well-being before and after the intervention of homemaking; how the latteraffects their sense of well-being, and to explore their opinions and feelings about theirhomemakers and the service. The premise is that these elderly clients are the experts inliving with chronic conditions and, as a result, can offer, through the descriptions of theirown experience, reliable information about how chronic conditions affect them, what theirrequirements from homemaking services are, and what it is that contributes to theirperceptions of well-being. Because one of the responsibilities of a social worker is toadvocate for clients, it is also my intention with this study to encourage and stimulatemore elder 'voice' in the services we provide rather than simply allowing them to be thepassive recipients of our program. This study is an exploratory, descriptive study.In order to collect and analyze the appropriate data for this research, the quantitativeRevised Perceived Well-Being Scale (PWB), (Reker and Wong, 1984) was used to measureperceived psychological, physiological, and general well-being of 28 elderly subjectsbefore and after homemaking services were introduced. Feelings and opinions about the3homemaking service were explored by asking open-ended questions in a posttest qualitativeinterview.The biopsychosocial model of health serves as the theoretical foundation for thisstudy. This perspective implies that health and illness are caused by multiple factors andproduce multiple effects, and that the mind/body clearly influence a person's state ofhealth (Kleinman, 1980; Chopra, 1993).This study will attempt to link the concepts perceived well-being, perceivedhealth, and social support, (homemaking service). If this study contributes to otherresearch which suggests formal caregiving services, like homemaking, contribute toperceived well-being, and to improvements in subjective health status as a result, theremay be important implications for the delivery of health services to the large numbers ofchronically ill aged people who will require such care in Canada.Chapter II will discuss some of the salient research findings in the areas of well-being, social support and the elderly.4Chapter IILITERATURE REVIEWChanges in rates of birth, mortality, and immigration have brought about anincrease in the aging of our population (McDaniel, 1986; Chappell, 1990; McPherson,1990). Birth rate refers to the birth of new individuals in our society, or the number ofchildren born per 1000 women of child-bearing age (Havens, 1981). Women are havingfewer babies today for a number of reasons: contraception, economics, and changingvalues and attitudes about family (Eichler, 1988; McDaniel, 1986; McPherson, 1990).Although mortality typically refers to the loss of life, in the context of our agingpopulation, demographers talk about increased life expectancy whenever they refer to theterm mortality. For example, in the early 1900's the average individual lived to be about 48years of age, whereas today we are living well into our mid 70's (McDaniel, 1986). Morespecifically, Canadian men have a life expectancy at birth of 70.2 years and women, 77.5years (Statistics Canada, 1985). According to Havens (1981), this increase in life expectancyis the result of social, economic, and medical progress.Immigration refers to the movement of persons in and/or out of our society, andtoday immigrants are older (McPherson, 1990). According to Gutman (1982), the medianage of immigrants entering Canada has increased, as opposed to earlier in the centurywhen immigrants were primarily young males; therefore these older immigrants contributeto the increase in the aging segment of the population.This large proportion of the elderly in Canadian, and indeed, North American andother developing societies, is an intriguing and challenging phenomenon. In 1901, only14.6% of the aged (65 and over) were over 80 years of age. These 80 year olds represented0.7% of the total population of Canada (Statistics Canada, 1985). However, demographersproject that by the year 2001, those over the age of 80 will comprise approximately 24.5%of the aged population, and will represent 3.3% of our total population in Canada (Healthand Welfare Canada, 1990). Other researchers like Chappell (1990) and McPherson (1990)5suggest that by 2031, 45% of old people in Canada will be 75 years of age or older. Thismeans that almost one half of seniors in Canada will be 'old'. The 1991 Census forStatistics Canada reports 12.9% of the population of British Columbia are 65+; this makesup 13.3% of the population aged 65+ in Canada (Statistics Canada, 1992). Table 1 illustratesthe most current projections for age structure of the British Columbia population of thoseaged 65 and over for the years 1991, 2001, and 2011.Of particular interest to the present study is the age distribution of Richmondresidents. This distribution has changed dramatically since 1966. Richmond's populationTable 1Age Structure of the Population Aged 65+: British Columbia, 1991, 2001, 20111991 2001 2011Age^% of PopulationAged 65+% of PopulationAged 65+% of PopulationAged 65+65 - 69 32.9 27.5 30.270 - 74 26.4 25.0 23.075 - 79 20.1 20.9 18.280 - 84 20.1 14.4 14.185 - 89 5.8 8.2 9.090+ 3.0 4.0 5.5Total 100.0 100.0 100.0Source:For 1991:Statistics Canada. 1991 Census. Age. Sex and Marital Status, Catalogue 93-310, July 1992.For 2001 and 2011:Statistics Canada. Population Projection1990 - 2011 Based on Recent Changes in Fertility Levels and RevisedImmigration Targets. December 1991.shows a general aging trend which is expected to continue as a result of the aging of thebaby boom generation of the 50's. The majority of the Richmond population currently fallsinto the 30 to 40 age group. However, there is a growing number of middle-aged adults inthe 45 to 64 range, as well as a substantial increase in the proportion of seniors aged 65 andolder. The number of school aged children has remained stable since 1981, but the6proportion of young people aged 5 to 19 has decreased dramatically since 1966, as aproportion of the total population (City of Richmond Economic Development OfficePamphlet Jan. 1992).The aging of the Richmond population is reflected in the median age, which was34.3 years in 1986. The median age is expected to reach 40 years by 2004. This means that50% of the population of Richmond will be over 40. While the population of the LowerMainland is also aging, the median age is not expected to reach 40 until 2011. In 1986.Richmond residents over 65 years of age represented 9% of the total Richmond population.They are expected to make up to 13% of the population by 1996, and 16% by 2006. Thoseover the age of 80 are expected to make up 2.67% of the total projected population ofRichmond in 2006 of 159,600 (City of Richmond Economic Development Office PamphletJan. 1992).In one sense, according to Butler et at (1991), "this 'demographic revolution'should be seen as a triumph of survivorship rather than as a cause for despair" (p.8).However, we cannot deny that the number of aged in the population affects society.Researchers, policy makers, health professionals, and gerontologists are concerned aboutthe impact of increasing numbers of elderly on income maintenance and particularly onthe cost of health care to support such a burgeoning older population (Butler et al., 1991).It seems pertinent to clarify the term "old" for purposes of this study. How old isold? The selection of 65 years of age is a peremptory one. As a consequence of sociallegislation in the late 19th and early 20th centuries, sixty-five has become the demarcationbetween 'middle' and 'old' age (Guest, 1985). This 'traditional age' has been maintainedover the years for social purposes: a means of determining eligibility for various old agepensions and suggested times for retirement from the work place (Guest, 1985). The age of65, however, has more limited relevance in describing concepts such as well-being, health,creativity, endurance and so on. The concept of "old" seems vague in many ways, andmore recently, gerontologists have attempted to deal with this concept by dividing old ageinto three groups: the young old, middle old, and the old old: 65 to 75, 75 to 85, and 85+(Neugarten, 1974). The point is, that age can be a convenient but imprecise indicator of the7physical and mental status of a person, but a rather poor indicator of itself and perhaps itshould not be so heavily relied upon for information about human beings.Many elderly people, however, would not argue that growing old can often bedifficult (Rodgers et al., 1988). Though poor health is not necessarily associated withaging, compared to younger people, the elderly suffer a greater share of chronic conditionsand psychosocial distress (Revicki and Mitchell, 1990). According to Atchley (1989),serious chronic illnesses such a arthritis, high blood pressure, and heart disease, tend toincrease after fifty years of age.Although the greater majority of older people do not sufferseriously impairing chronic conditions, 7 out of 8 report having one or more chroniccondition, 4 in 10 experience restrictions on their ability to perform such activities aspersonal care, and almost 1 in 10 is bedridden and house bound (Rice, 1985). Havens(1981) suggests that: "25 percent of the total Canadian population will require long-termcare sometime during their life" (p.27). She continues in her article Population Projections:Certainties and Uncertainties that "on average six percent of the population aged 65 andover, at any given time in Canada reside in a long-term care facility" (p.27), while Nett(1984) suggests that "one in five Canadians will spend time in some type of long-term carefacility" (p.5 in Family Ties and Aging, 1989).However, despite functional declines in some physiological capacities, what issignificant is not that these gradual declines occur, but rather that the majority of olderindividuals adapt amazingly well to these changes. Comfort (1990) suggests thatapproximately 86 percent of people over 65 remain in their homes and communities anddemonstrate adequate coping behaviour in meeting the challenges of everyday life.While this researcher acknowledges the fact that many elderly live their livesindependently despite possible declines in functional ability due to chronic illness, therestill are many who need support (in addition to aid from family and friends), because theseverity of their disability precludes self-sufficiency. In fact, a study by Forbes et al. (1987)reports that about 12 percent of community-dwelling elderly over 65 years of age needsome assistance with activities of daily living, and approximately 25 percent require helpwith shopping and housework. Formal caregiving agencies are frequently called upon to8assist older people maintain as much of their independence in their homes and thecommunity as possible by performing tasks such as house cleaning, personal assistance,shopping and so on.By employing the services of third party commercial homemaking agencies, theContinuing Care Program in British Columbia strives to provide such assistance. Ourelderly population is of great importance to the Continuing Care Division (CCD) of theRichmond Health Department. The Division's philosophy states:The Continuing Care Division (CCD) is committed to promoting thewell-being, dignity, and independence of clients and their families.CCD strives to promote the well-being, dignity, and independence of 1,320 clientsthrough the provision of 15,969 hours of service per month. Appendix J illustrateshomemaking statistics for Richmond, Lower Mainland, effective February 1993.Theoretically, this mandate has been satisfied; however, in practice, the concept of 'well-being' and its relationship to the intervention of formal support has not been investigated.As previously suggested, a proportion of the older population may becomechronically ill and disabled, and in the past, when there were fewer elderly in thepopulation, we often institutionalized our old people when they could no longer liveindependently (Pallan and Young, 1992). However, with the projected growth rates forthose over 65 in Canada, of 30 to 52 percent by the year 2000, and with the increase in lifeexpectancy at birth, (70.2 years for males and 77.5 years for females) we are forced toconsider alternatives to institutionalization because of the cost of such care (Havens, 1981;Government of Canada, 1983).There has been considerable evidence to support the advantages of enabling olderindividuals to remain in their homes. According to Forbes et al., (1987), elderly peoplemuch prefer this alternative to institutional care. In fact, this was a stated goal of theCanadian Medical Association in a report of a study in 1983/84 on our health-care system.The task force investigated and acknowledged the impact our aging population wouldhave on future demands for health services and concluded that we need to move awayfrom institutional solutions toward "a new program of care . . . which emphasizes9independent and productive living at home." (Rachlis and Kushner, 1989, p.41). Studiesalso report an increased sense of well-being in those individuals who are notinstitutionalized (Blazer, 1982; Cobb, 1979; Crandall, 1980; Williams, 1989). Kozma (1991)and Larson (1978) report a strong correlation between well-being, health status, anddelayed institutionalization; that is, psychological and social health is associated withsubjective physical health .In spite of the above general findings, there is a paucity of research which exploresthe relationship between homemaking services and perceived well-being in the elderly.Brothers and Mullaney (1980), two students of social work at the University of BritishColumbia (UBC), conducted a survey of 90 clients of the Richmond Long Term Care homesupport. The survey concentrated on feelings of satisfaction/dissatisfaction of the recipientsand families of the program, and revealed that 92% of clients were satisfied with thehomemaking service.In 1982, Stark et al. investigated long term care data by level of care, and assessmentprocess. The study revealed that inter-rater reliability was high when assessment levels bydifferent assessors were compared. In other words, assessors were consistent in theirassessment of client care levels (Stark et a1.,1982). Other researchers have investigated thedegree of satisfaction clients express about homemakers by employing qualitativetechniques (Fashimpar and Grinell, 1978; Eustis and Fischer, 1991; Barer, 1992) while somehave explored the concept of well-being in the elderly by employing established quantitativemeasures (Lawton, 1972; Lawton, Kleban and diCarlo, 1984; Reker and Wong, 1984).Bowling and Browne, (1987) investigated the emotional well-being and social networks of620 elderly in London, England and found that although associations were found betweensocial network variables and provision of informal help, health status explained more ofthe variation in emotional well-being of subjects.Findings from a longitudinal study of approximately 2000 elderly by Krause (1990)report that formal support reduces the harmful effects of perceived health problems. Aconflicting study by Weissert et al., (1988) however, implied that home care does notproduce a marked improvement in health status of the elderly, nor does it delay1 0institutionalization. "What it does produce is an improved degree of satisfaction andcontentment among the elderly" (p.368). This seems an ironic contradiction. It could beargued that improved degree of satisfaction and contentment produces improvements inperceived health, and therefore well-being, although I am sure this is not always the case.A more recent study by Matthews and Wakefield (1992) of the GerontologyResearch Centre at the University of Guelph in Ontario, examined characteristics ofhomemakers and aspects of satisfaction between 137 homemakers and 155 clients over atwo year period. Findings revealed an overall client satisfaction with homemaking service,and a slight improvement in overall health status (Matthews and Wakefield, 1992).There are many studies which do not examine home care service and clientfeelings but rather the cost effectiveness of home care programs (Weiler, 1974). WhenHerdman and Kerr (1975) and Walton and McNairn (1978) conducted cost benefit analysesof home care, they discovered when analyzing the data that not only was home care foundto be cost effective, it was also beneficial to clients in terms of continuity of independence,and improved health status.Because of the disabilities caused by chronic conditions, a small portion of ourelderly population is often forced to seek the help of formal supports such as homemakingin order to continue to live in the community as normally as possible (Sutherland andFulton, 1988). Chronic illnesses affect and are affected by perceived well-being of elderlypeople (Barrett, 1972; Callahan, 1990). Perceptions of well-being are also associated withsocial support (formal and informal), which is believed to serve as a buffer against adversehealth effects of stressful events throughout life (Burdman, 1986; Callahan, 1990). Much ofthe research on well-being and social support focuses on populations of average age,while many studies investigating our elderly tend to explore perceived well-being andformal support separately (Krause, 1990; Eustis and Fisher, 1991; Barer, 1992; Lawton etal., 1984; Bowling and Browne, 1987; Blanford and Chapell, 1990). Researchers such asKozma et al. (1991) investigated correlates of well-being in the aged; Matthews andWakefield (1992) examined sources of satisfaction in the relationships between elderlyand formal and informal support, and Brearley (1977) discusses well-being of11institutionalized elderly. Unfortunately, there are few, if any, studies in British Columbiawhich have actually investigated the effect of formal support services, namely homemaking,on perceptions of well-being.In this chapter, a review of some of the most salient studies of perceived well-beingin the elderly as they relate to this author's research will be acknowledged. Further, thenext few paragraphs will briefly discuss chronic illness because often it is the chronicillnesses and conditions of older people that often cause them to seek out formal support(i.e. homemaking, Meals-On-Wheels, volunteer shoppers). Chronic conditions frequentlycreate a decreased mobility and flexibility which prevents individuals from performingthose tasks which otherwise might have been performed without problems before theindividual was affected. For example, conditions of the joint, heart, respiratory system, orterminal disease (Kart et al., 1992).In essence chronic illness is THE challenge of this era to hospitalsand public health officials, and to the medical, nursing, and otherprofessions concerned with sickness, disability .... {It is} America'sNo. 1 health problem . . . . (In Chronic Illness and the Ouality ofLife, p.1)The above words of L. Mayo, then chairman of the Commission on Chronic Illness,were spoken at a conference on chronic illness in 1956 (Strauss and Glaser, 1975). TheCommission had just completed a report on chronic illness. Most health professionalsagree that the definition used in that report still holds today:All impairments or deviations from normal which have one ormore of the following characteristics: are permanent, leave residualdisability, are caused by non-reversible pathological alteration,require special training of the patient for rehabilitation, may beexpected to require a long-period of supervision, observation, orcare. (In Chronic Illness and the Ouality of Life,  p.1).This author will adopt this definition for purposes of this study.Although many elderly die today as a result of heart disease, malignant neoplasms,and cerebro -vascular diseases, it is the chronic diseases that last (Fillenbaum, 1984). Theprevalence of chronic disease among the elderly is higher than among younger persons(Kart et al., 1992). For example, the reported prevalence rates among the elderly for heart12conditions, hypertension, arthritis, diabetes, visual and hearing impairments and urinarydiseases show the most substantial differences when compared with the prevalence ratesof these chronic conditions among the younger population (Kart et al., 1992). Approximately21.2% of elderly respondents to a National Health Survey questionnaire in 1984. reportedhaving two or more of the following illnesses: cardiovascular disease, arthritis, osteoporosis,stroke, cancer, respiratory disease, and dementia (Alzheimer's). Chronic conditions arelong lasting, and their irreversible pathology is causes their slow steady progression (Kart1990).Gifford (1988) reports "most health survey data show a pattern in which vigorousold age predominates, but where there is a clear association of advancing age with poorerfunctioning" (p.33). Harris (1978) estimated that 45.4% of American aged with chronicconditions suffer some form of restriction on their activities because of their condition, andChappell (1990) suggests that less than half (38.1%) of seniors in Canada suffer from someform of limitation in their functioning as a result of chronic conditions.The good news is that function can be maintained well into old age, and Manton(1989) claims that elderly vary in the rate at which functional losses occur. It is importantto keep in mind that the elderly are experts at adapting to conditions associated withaging. As previously suggested, the great majority of elderly live in the community, arecognitively intact and independent in their activities of daily living (ADL), despite the factthat they have had or are currently experiencing a chronic condition. However, there arecertain conditions which cause such irreversible damage and decreased function andmobility that a small percentage of old people are forced to appeal to those from formaland informal support groups for help which will enable them to stay in the community intheir homes. This form of social support is known to affect the well-being of thosereceiving it (Larson, 1978; Cassel, 1974; Callahan, 1990).13THE CONCEPTS OF SOCIAL SUPPORT AND WELL-BEINGSocial SupportThe motive behind this writer's investigation was curiosity about a service weoffer to elderly people: homemaking services. I wondered whether the intervention ofhomemaking had an effect on the perceived well-being of chronically ill communitydwelling seniors who were assessed by Case Managers to receive such service. One mightassume such services positively affect clients if we (society) are offering the service.Although Continuing Care strives to promote and enhance the well-being of clients, andthe mandate is satisfied theoretically, in Richmond, the effect of homemaking services onclient well-being has not been evaluated. Researchers have examined other aspects ofclient/formal support relationships but to the best of this writer's knowledge, the conceptof well-being and homemaking have not yet been thoroughly investigated, and this studymay, in part, serve to address this gap. Research shows a strong correlation between socialsupport (formal and informal), perceived well-being of elderly people, and perceivedhealth status (Blazer, 1982). This fact provides the thrust of the writer's investigation.It is not only social support but also the quality and quantity of such support that isrecognized as important determinants of well-being, health and even mortality (Fillenbaum,1984; Cassel, 1974). This connection is especially strong for the elderly because of the highprevalence of dependency among them. Without the proper social support loneliness canbe a pervasive influence in the lives of elderly sick people.Loneliness means different things to different people, but for the elderly it can bedefined as a wish for contact with other people which cannot be achieved. It is anunpleasant disposition, related to unhappiness, which may be experienced in the communalsituation as well as in isolation (Dychtwald, 1990). Old people are eight times more likelyto live alone than are people under 65, but very old people are rather less likely to be ontheir own than the newly retired (Tunstall, 1966). Tunstall (1966) found a link betweenloneliness and isolation: those who are more isolated in the sense of having fewer contacts14are more likely to say they are lonely. Kart (1990) suggests that loneliness may becounteracted through social contact from either formal or informal caregivers.More recent research found that social activity with friends was more important inreducing loneliness and improving morale in elderly than interactions with neighbors.Interactions with family (informal support) were found to be unrelated to well-being (Leeand Ishii-Kuntz, 1988). This rather disconcerting finding may be explained by data froman earlier study. Larson et al. (1986) found that the influence of friends and family is afunction of the time-frame used in a study. Over a short period, feelings of immediatewell-being were found to be influenced more favourably by time spent with friends thanby time spent with family; however, over the long term, it appears that the family contactsprovide more stable sources of physical and emotional support than friends.Disability due to chronic health conditions, poverty, and widowhood contributesto the sense of loneliness older people may experience. The most striking effect of morbidityin the aged, as compared with younger adults, is the resulting chronic disability (Woodruff-Pak, 1988). Adults over the age of 65 in 1980 experienced 50 percent more restrictedactivity days per year than adults age 45 to 64 (Flaherty, 1987). Homemakers, as formalcaregivers, assist disabled elderly people in many ways, but it is the reports of theusefulness of the emotional and social support given to clients by homemakers that is ofsignificant importance (Burdrnan, 1986).Social support is thought to serve as protection against adverse health effects ofloneliness and stressful events throughout life (Krause, 1990; Cassel, 1974; Callahan, 1990).It facilitates adaptation to changes and crises, and since the elderly experience a greaternumber of stressful events and losses than any other age group (grieving the death of aspouse, widowhood, loss of friends, illness, retirement, decreased income), the existenceof social supports could clearly influence their quality of life (Kane and Kane, 1981).Cobb (1979) suggests depression is less frequent in the presence of social support;adaptation following bereavement is improved by the availability or provision of socialsupport; recovery from various diseases (cardiac failure, tuberculosis, psychosomaticillness, and psychiatric illness) is accelerated or facilitated by high levels of social support.15Social support from family members can decrease the risk of institutionalization ofdependent elderly relatives, according to Shanas (1979). Data from the 1975 NationalSurvey of Non-Institutionalized Community Elderly show that an elderly person's spouseand a child living in the household are the major sources of help to the elderly duringillness (Shanas, 1979). Chappell and Badger (1989), however, found that being childlesswas not related to well-being or life satisfaction, indicating that those who are isolated (nothaving children) need not necessarily experience lower psychological well-being. Peoplemay have many children and friends yet feel isolated. Conversely a person may have fewfriends and not feel emotional loss or isolation.Findings from two longitudinal studies that assessed risk factors leading toinstitutionalization among the elderly also show the protective effects of social support.Vincente et al. (1979) report that married persons are least likely to go into a long-term carefacility before they die. Findings suggest that the effect of marital status, however, isindirect (Larson, 1978). This may be because the primary effect of marital status falls onother predictors of perceived well-being such as social activity. It is often the friends andsocializing that marriage brings that can predict well-being as opposed to the relationshipitself, or, perhaps the fact that you have someone to look after you so you are notinstitutionalized.Some researchers have questioned the assumption that social support is aunidimensional entity (Blazer, 1982; Hogue and Gorton, 1981). Blazer (1982) proposed athree-parameter model of social support. Its components include: 1) roles and availablerole attachments, 2) perceived social support, and 3) frequency of social interaction.Hogue and Gorton (1981) differentiate social support from social network, stating thatsocial network is the quantitative characteristic of an individual's social and communityties, whereas social support is the psychological characteristic of an individual's socialnetwork. Both of these studies separate the subjective and the objective aspects of socialsupport, and both suggest that the subjective part is the key health promotive factor.Blazer (1982) hypothesized that social support may influence health in a variety of waysbut always through the mechanism of the perception of social support.16As mentioned previously, Krause (1990), Cassel (1974) and Callahan (1990) reportthat social support serves as protection against adverse health effects of stressful eventsthrough life, and the elderly are a group of people who experience stressful events in theirlives, probably more so than other people in younger age groups (Crandall, 1980). Socialsupport, therefore, is believed to facilitate adaptation to the crises and changes whichoccur during this period in life.Kasl and Berkman (1981) linked social support to mortality in adults. Evaluation ofthe Alameda County sample of adults showed significantly fewer early deaths amongpeople with large social networks. This inverse relationship between social network andmortality held even when controlling for health status, and health practices known toincrease mortality: smoking, overeating, alcohol consumption, and lack of physical activity.Unfortunately, these studies lack comparative information regarding the role of socialsupport in different populations like widowed people, groups from different cultures, andelderly with varying health care needs.According to Revicki and Mitchell (1990), elderly people who receive what theyrefer to as "instrumental" social support: help with homemaking and householdmaintenance, tend to have less emotional distress and psychosomatic complaints.Social support studies of the elderly show two things: they exemplify the beneficialaspects of social support in terms of lower mortality, decreased institutionalization, andhigher morale (Lawton, 1972), and they support the theories of the multidimensionalnature of social support (Blazer, 1982).Well-BeingPerceived well-being is a term that seems to be implicitly understood by all who usethe term, but all too often, vague inconsistent definitions inundate the literature. Perceivedwell-being subsumes several constructs such as affect (Bradbum, 1969), happiness (Wilson,1967), adjustment (Graney and Graney, 1973), morale (Lawton, 1972), satisfaction(Neugarten, et al., 1961), but these terms do not appear as a well-articulated conceptual17system for understanding certain life or quality-of-life issues. Instead, this author likeKozma et al. (1991) found the literature to be "full of terminological inconsistencies andconstruct overlap" (p.3). As well, I felt vindicated when I read a recent document by theInstitute of Health Promotion and Research at UBC, which evaluated measurements ofwell-being. In this report, Dr. Carol Herbert and Dr. John Milsum (1990) claim: "Severalproblems were confirmed by the literature review, which we had previously suspected.Both the literature and our consultations with the Advisory Team and other experts makeit clear that no explicit definition of 'well-being' exists" (p.56). According to Kozma et al.(1991), one factor which contributes to this inconsistent terminology is that constructmeanings adopted by researchers reflect their differences in philosophical, conceptual andmethodological procedures.Defining 'well-being' was a difficult task, because it means so many things to somany people, particularly researchers. Well-being encompasses a gamut of terms whichindude: morale, satisfaction, happiness, affect, adjustment, mental health, mood andphysiological and subjective well-being, and, as has been strongly suggested, no researcherhas ever really defined the term satisfactorily. The author felt it would be appropriate toidentify these more common terms in the dictionary in an attempt to gain a clearerunderstanding of what other researchers may consider for workable definitions of well-being. Following is a list of definitions taken from the Oxford Dictionary of CurrentEnglish (1985):Morale^mental attitude or bearing of person or group, as regards confidenceSatisfaction^fulfil expectations or desires, content, pleased, thing that satisfies desire orgratifies feeling, thing that settles obligation or debtHappiness^feeling or show pleasure, or contentment; fortunate, pleasingAffect^mental state, mood, feelingMental Health mental soundnessMood^state of mind or feelingWell-being^welfareSubjective^conscious or thinking or percipient subject as opposed to real or external18Reker and Wong (1984, p.24). who constructed the Perceived Well-Being Scale usedin this study define psychological well-being as:the presence of positive emotions such as happiness, contentment,joy, and peace of mind and the absence of negative emotions suchas fear, anxiety, and depression.Physical well-being is defined as:self-rated physical health and vitality coupled with perceivedabsence of physical discomforts.General well-being is defined as:the composite of psychological and physiological well-being.Because the PWB Scale is used in this study, the above definitions of well-being have beenadopted by this writer.There is a multitude of well-being scales which measure anything from lifesatisfaction, to morale and agitation, to perceived physical and psychological well-being;however, for the purposes of this research this investigator has chosen to use a Canadianmeasurement especially devised for use with elderly subjects. The writer concurs withother research (Burdman, 1986; Callahan, 1990; Krause, 1990), and because of her ownexperiences, that perceived well-being is affected by social support, and that this subjectiveperception of well-being, in turn, affects both subjective and objective health as well as thepsychological status of people. As mentioned earlier in this paper, there is a strongcorrelation between well-being and perceived health (Kozma et al., 1991). The importanceof well-being has many implications for the delivery of health care in our country,particularly to our expanding elderly population.Well-being is a relative term which probably varies with age, among other things(Barrett, 1972). The well-being of an individual is dependent upon the way he/sheperceives his/her health, socioeconomic status, functional ability, housing arrangements,and the availability of services (Phillips and Gaylord, 1985). Well-being is also influencedby those life events that are frequently part of an aged person's life: widowhood, relocation,retirement (Harris, 1978). Past events and current events also impact on perceived well-19being. In many studies, both physical and psychosocial factors were found to predictlongevity (Palmore, 1969; Wingard, 1982; Palmore and Stone 1973; Kasl and Berkman,1981). As previously mentioned, social relations are known to affect well-being. Thequality and numbers of social relations are recognized as very important determinants ofwell-being, health and mortality (Kozma et al., 1991). Perhaps it is the perception ofcompanionship itself rather than the emotional or other types of support provided by itthat is the important factor in the relationship.According to Kozma et al. (1991), there has been little support for gender differencesin perceived well-being and when gender differences have been found they tend to besmall (Diener, 1984). Gender has been found to interact with such variables as health andincome in their relationship to perceived well-being (Medley, 1976).A very small positive relationship has been estimated in a review by Larson (1978)regarding age and well-being. Other studies found near zero correlations for both zero-order effects and first-order effects (Herzog and Rogers, 1981; Stock et al., 1983.). Theaforementioned studies suggest that age has little direct effect on perceived well-being,but may have important interactive effects with other predictors such as race (Kozma etal., 1991).The research on age and perceived well-being requires longitudinal data before anaccurate assessment of their relationship is possible, according to Kozma (1991). Basedupon the cross-sectional data available, young people appear to be as happy as olderpeople. The age similarity suggests that a person's level of well-being remains stable overtime until the early 70's (Rodgers et al., 1988).According to Larson (1978), education has little influence on perceived well-being,rather it appears to be the lifestyle that an education can provide (higher income level,better housing, etc.) that influences the perceived well-being of elderly people.Well-being and social support are important constructs which can influence thehealth and psychological state of an individual in many ways. The idea that the mind/body together may determine health and illness implies a biopsychosocial model forstudying this issue, as opposed to the dominant model in medicine today: the biomedical20one. The biomedical model assumes that psychological and social processes are largelyindependent of the disease process (Kasl and Berkman, 1981).As the name biopsychosocial implies, the fundamental assumption states that healthor illness outcome is a consequence of the interplay of biological, psychological, and socialfactors (Kleinman, 1980; Chopra, 1993). As such, both macro-level processes such as theexistence of social support or the presence of depression, and micro-level processes suchas chemical imbalances and/or cellular disorders interact to produce either a state ofhealth or a state of illness (Herbert and Milsum, 1990). The biopsychosocial model impliesthat health and illness are caused by multiple factors which produce multiple effects. Themodel further maintains that the mind and the body cannot be distinguished in matters ofhealth and illness because both so clearly influence one's state of health (Cousins, 1979).The biopsychosocial model emphasizes health and illness, rather than viewing illness as adeviation from a steady state. From this perspective, health becomes something oneachieves through meeting biological, psychological, and social needs, instead of somethingthat is taken for granted (Kleinman, 1980; Chopra, 1993).Reviewing the literature points to the importance of social support as an essentialcomponent for sense of well-being. Previous studies have explored the importance ofsocial support and well-being but studies to date have not supplied data about the effect ofthe formal support system, homemaking, on elderly client well-being. In this study theauthor hopes to further the study of the social support homemakers provide and theperceptions of client well-being, and thus contribute to the gap in the literature.Perceived well-being will be measured before and after homemaking services totry to determine whether these services affect perceived well-being of clients; and recipientsof service will be asked to share their opinions about the service. From this research wemay be able to report a positive relationship between homemaker support and theperceived well-being of subjects. If changes occur as a result of the social support receivedfrom homemaking, Continuing Care will be able to consider the mandate satisfied inpractice. This research may provide the impetus for further exploration and evaluation ofother social health-care services by other social workers and others in the field.21Chapter IIICONCEPTUAL FRAMEWORKFigure 1 depicts a conceptual model that was designed by this author to investigateassociations between the chronic health problems of elderly respondents, formal support,perceived general well-being, and perceived health status of community-dwelling elderlywho receive the intervention of homemaking services.The biopsychosocial model of health has influenced this writer. This modelmaintains that health and illness are determined by physiological, psychological, andsocial factors, and multiple effects are produced as a result (Kleinman, 1980; Chopra,1993). The interaction of these variables are addressed through the systems theory approachto health and illness (Herbert and Milsum, 1990). Systems theory holds that all levels oforganization are linked to one another hierarchically, therefore a change in one levelcreates changes in all the other levels (Turner, 1986). This suggests that the micro levelprocesses such as cellular pathology are intertwined within the macro level processes,such as societal values and beliefs; and that micro level changes can have significant macrolevel effects. Consequently, health, illness, and medical care are all seen as interrelated andinterdependent processes which involve interacting changes within the individual and onthese various levels (Milsum,1984).For the purposes of this conceptual framework there are two elements of existence:the self (Block A) and everything else - the environment that self experiences (Block B). Inparticular this study is interested in exploring the elements of this environment related tohealth (well-being).Block A of the map depicts the individual; the self-concept. The self-concept accordingto Milsum (1984) "can be viewed as the current accumulation of our sense of self and ourpurpose" (p.35). Phenomenologists see the self as the "I" or the "Me". Our self-concept isdynamic and receives information from many other processes. The self experiencescombinations of physical, mental, social and spiritual health. These factors have beenENVIRONMENTPositiveReinforcersSubjective Evaluationof Well-BeingNegative^PositiveStressors ReinforcersFigure 1Conceptual Model of Self Interacting with Environmental Factors23adopted for this conceptual framework from the theoretical base of the World HealthOrganization (1974) which recognizes health, in the broad definition, to be "total well-being":Health is a state of physical, mental, and social well-being, and notmerely the absence of disease and infirmity. (WHO, 1974).For purposes of this research, the writer will assume that the word "mental" in the abovedefinition of health includes emotional, spiritual and psychological well-being.In this conceptual model, the self will be viewed as an individual who exists in thestate of chronic illness (respondents of this study) preceded by a 'normal aging' state.According to Atchley (1989), normal aging refers to the usual patterns of human aging;that is to say, a lack of mental or physical disability. Aging often slows people down, butdoes not always disable them. Although the conditions that elderly people face as a resultof illness are very real and the adjustments they must make are complex, their ability tocope with the many difficulties are impressive. However, this study is not investigating"normal aging" but the concept is acknowledged, and writers such as Chopra (1993),Comfort (1990), Crandall (1980), Dychtwald (1990), and Kastenbaum (1964), contribute tothe plethora of literature about normal aging processes.Many feel the self-concept to be poorly understood. On one hand, people oftenhave stable self-image and stable levels of self-esteem, but events like chronic illness in oldage can produce drastic changes in self-concept and self-esteem. Many of these changeswill be temporary, and some will be permanent.Although many researchers measure global self-esteem, it is important to rememberthat the self-concept is a composite of self-evaluations. Block C - Subjective Evaluations ofWell-Being, suggests we have the intellectual capability to evaluate how we're doing in themany aspects of our lives. Some of these aspects are involved in the disease process andinclude body image, achievement, social functioning, and self-identification (Milsum,1984).Block D - Health Resources, is a component of health which refers to physical,mental and social resources that may either optimize or minimize well-being. For example,24our gene pool can either benefit or hinder our physical and psychological states. Anexample of social health resources might include number of friends and family size.Block E depicts another component of health, Health Dynamics: physical, mentaland social. For example, physical dynamics might include the opportunity for exercise orthe ability to obtain adequate nutrition. Psychological dynamics might be affected by thelevel of education we receive and the consequences of such on the way we think of ourhealth. Examples of social dynamics might include interactions with family and friendsand participation in social activities and organizations.Blocks D and E, Health Resources and Health Dynamics, are the components ofhealth subjected to modifiers. The map displays two categories of conditioning factors ormodifiers in the environment: positive ones will be called Reinforcers and negative onesare called Stressors. Examples of positive reinforcers which tend to impact upon HealthResources could include a large family, memberships in clubs and organizations, socialsupport, access to medical care. Whether or not self capitalizes on these reinforcersdepends on the dynamics.Stressors, the negative modifiers, might include chronic conditions which result inpoor health, economics, lack of family, no friends, widowhood. Resources and dynamicsreflect back and forth between one another as do reinforcers and stressors. The arrowsindicate interactions between factors.The coping level leads to a state of Functional Well-Being (objective or subjective).Functional well-being feeds back, as do all the other elements within the environment ofhealth-related factors, to the self and modifies the baseline subjective well-being. Thiscycle continues throughout life.To summarize: Block A refers to the self who, with increasing years, experiencesvarying degrees of chronic illness and/or disability. The self may adopt successful copingstrategies and function with the illness and disability or may experience negative outcomesas a result of physical and environmental stressors which may result in varying degrees ofloneliness, depression, decreased independence and mobility, social isolation, and possiblyearly institutionalization. Both negative outcomes and successful coping strategies affect25the perceived well-being of the individual.Well-being can be described, discussed, defined, conceptualized and evaluated ashaving subjective or objective components. The applied definition suggests that operationalassessments of well-being usually resort to a description or measure of subject(s) functionalcapabilities and/or limitations. Established literature in many inter-related disciplinessuggest intimate relationships between these two perspectives as well as between elementswithin each individual category: e.g. you are as young or old as you feel.Perceived well-being is an accepted (at least previously used) subjective measurewhich may correlate with perceived health (another subjective) and just possibly mightexert an effect on associated accepted objective measures of well-being (e.g. physicalexamination).Perceived general well-being is a relative term which probably varies with age(among others). It may be affected by:1. the existence of chronic physical illness2. the availability and degree of support resources which may be:a. formal - provided by care agenciesb. informal - provided by family and friendsThis study is designed to explore the possible effect of the provision of formalsupport homemaking services on Reker and Wong's (1984) Perceived Well-Being Scale(PWB), and to investigate resulting implications on subjects' perceived health and changesin their state of chronic illness. A thorough review of the literature reveals there is asignificant effect between formal and informal social support and perceived well-being.The measures of formal support used in this study reflect instrumental assistance byhomemakers given specifically in response to the health problems and functional disabilityof elderly subjects. As is depicted in the model, formal and informal support in the form ofreinforcers may affect a person's perceived well-being. Thus the thrust of this research:homemaking - does it act as a reinforcer and affect perceived well-being? The literaturesurvey suggests strong correlations between social support systems, perceived well-26being, and subjective health status (Blazer 1982; Hogue and Gorton, 1981; Kozma et al.,1991; Cassel, 1974).Perceived well-being is measured by an established scale - The Revised PerceivedWell-Being Scale (Reker and Wong, 1984). Perceived well-being is divided into psychologicalwell-being, and physical well-being; the sum of the two resulting in a general well-beingmeasure. Well-being and social support are important constructs which are thought toinfluence the health and psychological state of people in many ways. Many studiessuggest a strong correlation between perceived well-being and health status (McNeil andHarsany, 1989; Stoller, 1984; Reker and Wong, 1983, 1984; Cassel, 1974). If well-being doesaffect perceived health status of individuals positively, the model depicts a possiblebalance to the problems of loneliness, depression, decreased independence, social isolation,and early institutionalization. In turn, a reduction in these problems of aging may allowmany elderly people to remain independently in their homes, and to participate activelyin the community.27Chapter IVMETHODOLOGYThis study is an exploratory descriptive study, the objective of which is to:1. measure perceived well-being of subjects before and after homemaking services.2. determine whether homemaking services affect the perceived well-being ofsubjects.3. determine subjects' feelings regarding their homemaker and the service.Although this study employs primarily a quantitative methodology, an attempt ismade to elucidate the data through the administration of 4 qualitative questions. Theprinciple of triangulation may be used in data collection to balance each method'sweaknesses and strengthen study design (Patton, 1990; Rubin and Babbie, 1989; Cozby,1985). Subjects were interviewed using an established measure (PWB-Revised Scale)(Reker and Wong, 1984) comprised of statements rated on a 7-point Likert-type scalewhich ranged from 'strongly agree' to 'strongly disagree'. Qualitative questions wereasked at posttest to obtain respondents' feelings about the homemaker service. Becauseresearch of this kind has not been done at Richmond Health Department's ContinuingCare Program, the author's decision to conduct an exploratory descriptive study is anattempt to 'explore' whether a relationship or association exists between subject perceivedwell-being and homemaking services, and to 'describe' the sample demographically.SAMPLEDue to time constraints and feasibility of access to subjects, the sample was basedon the availability of 30 people registered with the Continuing Care Program and assessed28to qualify for homemaking services. In general, non-probability sampling methods areregarded as less reliable and not generalizable. Because subjects had to be recruited asthey came into the program to meet the criterion of being clients who had not yet receivedhomemaking help, the researcher decided to use a convenience sample for this study.Other criteria for participation in the study were the age of 65+, a minimum of 26/30 onthe Mini Mental Scale administered by the researcher at time of assessment, and living inthe community. This was essential because the focus of the study was to measure perceivedwell-being before and after the intervention of homemaking services. The writer verballyconfirmed the physical conditions of all subjects with their physicians as part of the initialqualification for service assessment was completed.The British Columbia Long Term Care/Continuing Care Program defines fivedifferent levels of care to clients. Each level of care can be provided at home or in a facility.Referrals are received by Continuing Care from physicians, nurses, social workers, familyand friends. Decisions about level and place of care are based upon assessments performedby trained CCD staff - either social workers or other experienced community healthprofessionals.Subjects in this study were assessed at various levels of care. These levels of careassist in determining the amount and frequency of assistance to be allotted the client, andthe rate of payment for residential care and facility placement. Care levels are determinedby established criteria and not on the basis of perceived need. For example, a clientassessed at the Personal Care level (PC) is independently mobile, with or without mechanicalaids; mentally intact or suffers only minor mental impairment. The PC client requires onlyminor assistance with self-care but does not require regular medical supervision.Persons assessed at the Intermediate Care 1, (IC1) level of care, are independentlymobile, like those requiring Personal Care, but require some health supervision and someassistance with activities of daily living. Estimates suggest that people in this category ofcare require 75 minutes of individual attention per day: fifteen minutes from a professional,and 60 minutes from a non-professional.Client characteristics at the Intermediate Care 2 level, (IC2), resemble those in theIC1 level of care, however, the estimated amount of care needed increases to 100 minutes29of daily individual attention: thirty minutes by a professional and 70 minutes by a non-professional.There are two other levels of care: Intermediate Care 111 (IC3), and Extended Care.The former was designed to recognize the client with severe, continuous behaviouralproblems, who needed more daily care, and the latter provides round-the-clock supervisionof clients.The subjects in this study ranged from PC (personal care) levels to IC2 levels(Intermediate Care 2). Some subjects received homemaking once a week, while othersreceived homemaking every other week, depending upon their assessed levels of care.Fourteen of the subjects were assessed at the PC level of care, and received homemakingservices every other week for about 2 hours, 11 subjects were rated at the IC1 level of careand received homemaking once a week for 2 hours, and the remaining 3 subjects wereassessed at the IC2 level of care and received homemaking once a week for 2 .5 hours. Thehigher the level of care, the more assistance usually required. Each subject was interviewedafter 6 homemaking visits. In some cases this meant after 6 weeks and in others it meantafter 10 to 12 weeks. This had the potential to complicate the study because of elapsedtime; however, careful attention to interviewing and review of significant events andchanges that occurred over the span of several weeks served to minimize effects ofextraneous variables.Initial RecruitmentThe original plan was to have Case Managers from the department assess allclients for homemaking services after which they were to either ask them or present myletter inviting their participation in the research (Appendix A). If clients did agree toparticipate, a more detailed letter (Appendix B) was then presented by the Case Managerexplaining the study and methods. Clients were not required to sign a consent form to bepart of this research project. Verbal agreement was acceptable to Ethics Committee in thisregard. This original plan did occur with four of the subjects, but heavy caseloads and30other priorities prevented Case Managers from assessing and interviewing clients withinthe researcher's time constraints. As a result, the author was engaged by Continuing Care,and she recruited the other 26 subjects by asking them to participate in her study andshowing them the explanatory letters (Appendix A and B) after assessment-for-serviceinterviews. A positive verbal response to this request constituted subject consent as in theprevious 4 subjects assessed by other Case Managers. Sample size was limited to 30 due tosubject availability and time constraints of this study. Although 30 subjects were initiallyrecruited, two were withdrawn from the study because of acute illness, hospitalizationand cancellation of homemaking services.Because of the convenience sample, it is not possible to generalize the results toother populations, but it is anticipated that data may be similar to that of other clients inthe Continuing Care Program and may serve as a basis for further evaluation of theprogram.Recruitment ProceduresThere was 100% positive response when the thirty clients were asked if they wouldlike to participate in this research. This may have been because this age cohort is known tobe desirous of reciprocation particularly if they feel they have been the recipients ofassistance, kindness or aid from others (Rodgers et al., 1988). In her 1989 study, sociologistHazel MacRae, noticed that: "as respondents talked about themselves and their lives,'doing for others' was such a pervasive reference . . . . that it appeared to be a fundamentalelement in the ideology that was shared by many, if not most of these women" (p.263). Theinternationally renowned psychiatrist, Viktor E. Frankl (1962) wrote about the importanceof discovering meaning in life by "doing a deed" or fulfilling what one interprets as task orpurpose in life. The researcher explained at time of recruitment that participation in thisstudy could render valuable data which may serve to improve the quality of services notonly to themselves but also to others who utilize the Continuing Care services, and thatthis study was part of the writer's master's thesis. This explanation seemed to render a31willing positive response, and I perceived that their doing things to help others appearedto be an important aspect of their interpretation of their meaning in life, and the part theywere going to play, just as FranId (1962) suggested in his book The Meaning of Life.Another interpretation of the excellent response rate of subjects in the presentstudy is the possibility that clients may have felt threatened by thoughts of potential lossor withdrawal of homemaking services if they did not participate, particularly as theresearcher was also the assessor. Appropriate steps were taken to acknowledge thesepotential problems and although it did not appear to be required, subjects were reassuredmany times throughout the interviews that services would not be affected if they chose notto participate further in this study.The principal characteristics of age in Erik Erickson's (1964) theory influenced thiswriter who had hoped at the outset to be able to appeal to older adult's sense of generativity;in other words: "involvement in establishing and guiding the next generation. It entails anexpansion of ego interests - a giving of oneself to those who are younger or to involvementin work deemed of personal value and set as a goal" (Burdman, 1986, p.90). Butler et al.(1991) refers to this as the 'elder function' which they describe as "a natural propensity forthe aged to share with the young the accumulated knowledge and experience which theyhave collected" (p.80). It is important to the self-esteem of an elder to be acknowledged byyounger individuals and to have his or her life experience seen as interesting and valuableto others. We perceived 90% of the subjects at Time 1 to be enthusiastic because theyreported the experience to be enjoyable. Several subjects expressed delight at being thetopic of such an important area of investigation and felt they had a vested interest in thestudy.When subjects agreed to participate during the assessment, the author arranged tomeet with them in their homes at mutually convenient times before the homemakingservice started in order to record a baseline measure of their perceived well-being. No oneraised any negative concerns about the research or his/her participation; the researcherperceived respondents at Time 1 to be enthused by at the prospect of being involved in aresearch project. Six homemaking visits later, or six to twelve weeks after homemakingRepeated Measures DesignTime 1 Interview^PWB Scale ->Homemaking ^>Time 2 InterviewPWB + Interview6 HOMEMAKING VISITS32services began, in some cases (because of assessed levels of care), subjects were contactedby telephone to arrange for the second administration of the well-being measurement anda qualitative interview, regarding their feelings about the service. All interviews wereconducted by this writer. The following diagram displays the repeated measures design.Following is a description of the homemakers and objectives of the service, and Table 2illustrates the Richmond Homemaker Characteristics.HOMEMAKER PROFILEObjectives of the ServiceHomemaking services, often regarded as "a promising alternative toinstitutionalization" (Barer, 1992, p.130), provides care with a view to enhancing quality oflife by encouraging the self-worth and dignity of people, helping them to attain thehighest level of 'well-being' possible, and by facilitating as much independence at homeand in the community as possible. These goals are achieved through several tasks:1. Meal preparation2. General house cleaning (vacuuming, kitchen and bathroom cleaning, laundry,mopping floors, dusting, window washing)3. Assistance with personal care (hands-on bodily care such as bathing, hairwashing, dressing)334. Social contact and emotional support5. Activity assistance (toileting, transferring in and out of bed etc.)All 28 subjects in the present study were receiving general cleaning services whichinvolved vacuuming of rugs and floor, mopping floors, washing of sinks, tubs, and toilets,washing the kitchen sink, surfaces, window cleaning, stove, oven, and refrigerator cleaningand defrosting, laundry and special tasks designated to assist disabled clients. For example,one rheumatoid arthritis sufferer needed her kitchen cupboards cleaned and re-organizedbecause of her inability to lift her arms over her head, and the homemaker did thisespecially for her. Twenty-one percent of subjects (6) received assistance with bathing,hairwashing, dressing and undressing, and toileting. Meal preparation was performed fortwenty-five percent (7) who required help with preparation of a light sandwich at lunch,or some vegetable peeling which painful arthritic joints prohibited. Five subjects (18%)required assistance with transferring in and out of bed. The writer will presume that allsubjects received social contact.Homemaker CharacteristicsThe two homemaking agencies in Richmond were contacted by the writer toobtain demographic information about the homemakers' age, gender, education, incomelevels, marital status, cultural background and the average number of clients seen bythem. Table 2 illustrates a brief summary of such variables: this is a general overview ofsome of the characteristics of the homemakers who work for the Richmond agencies, andrepresentative of the type of homemaker who performed services for the subjects of thisstudy.The actual homemakers themselves were not considered in this study, rather itwas the measures of perceived well-being of clients after receiving homemaking servicesthat were the primary focus. The variables in homemaker may well have had an effect onthe well-being of clients, but since this study was less interested in the homemaker per se34Table 2Homemaker Characteristics - Richmond Agencies, 1993Variable Category PercentAge 30 years of age or less 1730 - 45 3645 - 55 38Over 55 9Gender Females 98Males 2Race European 15Filipino/Chinese 16Indo/Pakistani 15Japanese 1Caucasian 53Education High School 36Postsecondary 27Health Care Related 37Marital Status Single 22Married 62Widowed 5Divorced 9Other 2Support Worker Categories License Practical Nurse 2Home Support Aid 29Uncertified Home Support 0Worker 66Registered Nurse 3Each homemaker has an average of 5 clients.and more interested in the effect of homemaking services on client well-being, thesevariables were not taken into consideration for this study. Time constraints and resourcescontributed to this decision. A study comparing the homemaker demographics with clientcharacteristics may yield some very important data to contribute to this relatively newarea of research. A number of researchers (Barer 1992; Brothers and Mullaney, 1980; Eustiset al., 1991; Fashimpar and Grinnell, 1991; Matthews and Wakefield, 1992; Tobin et al.,1983; and Chichin, 1992) have contributed to the sparse knowledge on this topic.35DATA COLLECTIONData in the study were gathered by means of face-to-face administration of thePWB (Perceived Well-Being) Scale before and after 6 homemaking visits. In conjunctionwith the administration of the PWB Scale at Time 2, a qualitative interview was used inthis repeated measures design. The researcher travelled by automobile to each of the thirtyrespondents' homes at pre and posttest. (30 at pretest and 28 at posttest).The reason for face-to-face interviewing was twofold: 1) acknowledgement ofother researchers' reports of very poor response rates to mail-out questionnaires (Rubinand Babbie, 1989), and 2) telephone interviews were discouraged by the Ethics Committeeat the University of British Columbia. Although self-administered questionnaires guaranteeanonymity, in-depth information and people's views from face-to-face interviewingtechniques often enrich the data (Cozby, 1985) and enhance research quality. As well, dueto the explanatory nature of this study it was important to begin to find out how thesubjects felt about their homemaking services.As was discussed in the previous chapter, subject recruitment was not difficult.Contact with subjects was pleasant, although time-consuming during both Time 1 and 2.Appendix K illustrates an example of the sheet I read when I telephoned subjects for theinitial appointment after other assessors completed the four qualification-for-serviceinterviews and gave a standardized introduction to the study (Appendix A). The telephoneintroduction in Appendix K was not used for the remaining 26 subjects after I was hired asassessor. Because I assessed the remaining 26 clients for services personally, I asked themat that time to participate in my study after I had completed the assessments. Specifically,I offered each client the following explanation:Mrs/Mr :As well as working as an assessor for Continuing Care, I am also a full-time student atUBC and am currently working on my masters thesis. My research involves the effect of homemakingservices on clients like yourself. I would like to invite your participation in this study becauseinformation you offer may help us to improve the quality of services not only to you, but also toothers who utilize the Continuing Care services. I have a more detailed letter of introduction of mystudy that you may like to read and if you would like to participate we could make arrangements foran interview appointment at your convenience.36During Time 2, subjects willingly responded when I called for follow-up interviews,and with the exception of two ladies, who were not as enthusiastic as the first time, theposttests took place without problems or hesitation on the part of subjects. The two ladieswho were not as enthusiastic were experiencing a downturn in their health, and werefeeling apprehensive about upcoming diagnostic tests and outcomes. They did, however,agree to finish part two of the survey, and I spent some extra time with them afterwards inde-briefing sessions to make sure they were not further traumatized by the interview.Quantitative MeasureThe Revised 16-statement Perceived Well-Being Scale (PWB) (Reker and Wong,1984) illustrated in Appendix E was utilized in this study. Each statement was rated on a 7-point Likert-type scale ranging from "strongly agree" to "strongly disagree". This 16-itemscale allows for the separate assessment of psychological and physical well-being inelderly people. The author considered other scales available for measurement of well-being, but few were designed with the geriatric in mind. It was deemed that researchinstruments be compatible with the elderly in terms of length and comprehension. ThePWB Scale according to Reker and Wong (1984), "is brief enough to make it a usefulscreening device to identify the elderly who are either low or high on the wellness/illnesscontinuum" (p.30) The PWB was chosen for this study not only because of its brevity, butalso because of the two categories of psychological and physical well-being, which mostother measurements of well-being do not include.This brief 16-item scale was constructed particularly for community-dwelling andinstitutionalized elderly people. Reker and Wong (1984) constructed the PWB because ofthe apparent need for an instrument that was " broad in scope but sharp in focus" (p.29).Additionally, in an attempt to inject Canadian content into this study, this instrumentfrom Trent University in Ontario met with this researcher's criterion.Reker and Wong (1984) tested this scale on 238 community and institutionalizedelderly people and demonstrated high internal consistency and stability:37psychological  well-being•^.82physical well-being^.78 (for factor scores)general well-being .91Test-retest reliability on psychological well-being = .79 (p < .001); physical well-being = .65(p < .001), and general well-being = .78 (p < .001). Reker and Wong (1984) report that thevalidity of the PWB is deemed sufficiently high to justify its use with the elderly. Samplesof community elderly (N=20) and institutionalized old people (N=24) were used to test forvalidity. In another study by Reker and Wong (1982), the PWB is reported to have held upextremely well in work with the elderly on perceived coping behaviour and well-being."Its ecological validity makes it a useful instrument in longitudinal and interventionstudies regardless of whether the elderly reside in the community or the institution"(p.30). A study investigating optimism, meaningfulness, and well-being reported equallyreliable and valid results (Reker and Wong, 1983). Pretesting of the PWB was conductedon 6 similar elderly subjects in the community with acceptable reliability levels of .76 forpsychological well-being, .64 for physical well-being, and .78 for general well-being.Quantitative ProcedureThe Perceived Well-Being Scale (Reker and Wong, 1984) was administered at bothvisits verbally by the writer. Each item from 1 to 16 was read out loud to the subjects by theresearcher. This was done because of hearing and visual impairments, poor dexterity ofmany subjects, and because of the concerns around interpretation of instructions on thePWB scale. Although this method takes longer to administer, the writer feels the informationis more reliable because it gives subjects time to understand the statements and thinkcarefully about their responses. Demographics about age, gender, income, education,living arrangements, marital status, and illness were taken as part of the first assessmentinterview for services.Each of the 16-item subjects' responses to the statements was circled on theresponse sheet by the researcher with a blue marking pen. One statement sheet was used38per subject. Subject names and phone numbers were listed on his/her statement sheetuntil the data was coded; names and numbers were then erased, to ensure subjectconfidentiality. Responses ranged from strongly agree, moderately agree, agree, undecided,disagree, moderately disagree, and strongly disagree. Only one response per statementwas allowed. The responses were tallied according to the score value for each response(Appendix F). A psychological and physical well-being score was recorded at the bottomof the scale, and these two scores added together to obtain the General Well-Being Score.The resulting general well-being score is a combination of psychological and physiologicalwell-being scores. The lowest score possible on the psychological and physiological well-being measures is 8, while a high score of 56 is possible. In the general well-beingcategory, the possible range of scores is from 16 to 112. Notes were made, if appropriate,about significant responses to statements to be considered in later analysis. For example, ifa statement elicited tears, apprehension, laughter, the response was noted and dated inblue marking pen.At Time 2 the same procedure was followed but responses this time were circled inred pen on the same sheet and subjects were also asked the 4 questions from the qualitativeformat illustrated in Appendix L. This enabled the researcher to note any significantchanges, between Time 1 and Time 2. Once again responses were tallied up and recordedat the bottom of the page. Notes were made about significant responses, to be consideredlater in analysis. When the test administrations from Time 1 and Time 2 were completedthe variables were codified on a Fortran sheet for data entry into the SPSS-PC+ system, fordata analysis, using the Wilcoxin Sign Test.Forty-five minutes was allotted to each interview at Time 1, and one and a quarterhours at Time 2. Average time was 1 hour for Time 1 and 1.5 hours for Time 2. Manyinterviews exceeded the allotment by up to one hour. This problem did show up duringpretesting of the instruments. The reason for the extra time was because I allowed subjectsto talk about circumstances in their lives that led to their present situations. Hessler (1992)maintains that " in order to effectively establish rapport, maintain control, and do all ofthe myriad other things necessary to conduct a successful interview, understanding the39respondent's perspective is critically important. .. . rather than trying to forge ahead withthe interview forsaking the respondent's perspective, you need to call a temporary halt tothe plan and spend some time learning about where the respondent is coming from"(p.139). It is extremely important in this phase to resist the desire to "do social work" withthese people, however. This is essential to the robustness of the study. Steps were taken totry to stay within the confines of time but these older respondents, had a tendency toelaborate, digress, and generally took more time to form their thoughts and responses.The writer was aware and carefully attempted to control for experimenter bias orexpectancy effects she might have been unintentionally exhibiting by attempting to displayconsistent behaviour with all subjects during the interviews, and by conducting theinterviews using a routine by asking the questions in the same order. However, this maynot be enough because bias can be unintentional - in other words, the experimenter maynot be aware of his or her influence. Another solution to this problem would have been torun all conditions simultaneously so that the experimenter's behaviour is the same for allsubjects, however this solution was not feasible in this study. When running simultaneousgroups is not possible, one might consider using interviewers who are unaware of theresearcher's hypothesis, or the blind technique (Grinnell, 1985). However, this was not afeasible solution for this study. In order to accomplish this the writer would have requiredadditional interviewers to help conduct her research, so she conducted all the interviewsherself at Time 1 and Time 2, and was as accurate and consistent in behaviour andinterviewing routine as possible. As well, use of standardized qualitative format helps tocontrol for the experimenter bias effect (Patton, 1990).TriangulationThe decision to triangulate the data by introducing a qualitative component to thequantitative methodology was based upon the premise that the subjects are the experts. Ifchanges did occur in established measures of perceived well-being, the writer felt that thesubjects themselves would be the most qualified to identify, illuminate, and elaborate as to40why changes may have occurred. Because this research is an exploratory descriptive studyof effects of homemaking services on client well-being, a decision was made to conductthese qualitative interviews by asking the four open-ended questions illustrated inAppendix L with a view to illuminating the quantitative data results. The subjects werenot given 'carte blanche' in offering information, however. In other words, they were notencouraged to elaborate about issues other than the question at hand. They were givenadequate time at the start of the interviewing to allow the researcher to gain a sense oftheir current health status and life circumstances. They were encouraged by the structureof the question to elaborate on one particular issue at a time with appropriate probing andre-direction, if needed, from the writer. This was important because of the writer's interestin their opinions about homemaking service. To reiterate, the 4-question interview wasused as an adjunct to this primarily quantitative study. The injection of the qualitativeelement is to enhance, strengthen, and aid in interpretation of the quantitative data bytapping into and interpreting the deeper meanings subjects' experience. Too often, itseems, elderly clients' assessments of homemaking services go unaddressed. Studies haveoften focused primarily on policy issues, quality of care, and cost effectiveness (Weissert etal., 1988; Weiler, 1974; Herdman and Kerr, 1975; Walton and McNairn, 1978). But clientsfrequently are "passive recipients" and from an exploratory point of view, it seemedappropriate to this researcher that first-hand information should be derived from theexperiences of clients who receive services.Unfortunately, time and resources were scarce. This could be viewed as a limitationwhen attempting the principle of triangulation. Many researchers would advocate for oneor the other with the strong advice that justice cannot be afforded both without adequatetime; however, for purposes of this project, the element has been injected.Qualitative ProcedureDuring the qualitative aspect of the data collection, 6 interviews were taped andtranscribed with permission of subjects, and the other 22 interviews were recorded by41note-taking. This method can be limiting because of the inability to make observations atthe same time, and the possibility of inaccurate recording.Ten subjects from the four categories of marital status and living arrangementswere selected by the researcher for recording because of the desire to have a representativesampling within the sample of the different categories of subjects: married, widowed,single, and separated. Names from each category were put into a box, then randomlychosen by the writer. The decision to choose 10 subjects was a consequence of the writer'stime and resource limitations. Four out of ten subjects approached the idea of beingrecorded somewhat reluctantly, and with varying degrees of apprehension. Although Iassured them of my commitment to their confidentiality, some said that they preferredtheir responses not be recorded on tape. Perhaps subjects felt that their homemakingservice would be in jeopardy, and perhaps because they took their participation in thisstudy seriously, they felt they could not answer the questions as candidly on tape.Studies on cautiousness of the aged suggest that the older adult is more cautiousthat the younger adult. Two explanations were given for this. First it was believed by JackBotwinick, a researcher in this area, that the older people were more conservative thanyoung adults, and were less likely to take chances. Secondly, it is also believed by somescholars that the self-image of the aged is more unstable that their younger counterparts. Itis believed for this reason that the older subjects prefer not to risk making a mistake thatmight further reduce their low self-image (Botwinick, 1966; 1977). Conversely, otherstudies on cautiousness suggest that the elderly are not as cautious as the young adults(Botwinick, 1973; Okun and Elias, 1977). Botwinick (1973) reports that the elderly simplychoose the 'no risk' items in tests more frequently than younger adults, and therefore givethe false impression that they are more cautious than younger adults. This researcher wasconcerned about the instruments used in cautiousness studies.As we know, in the measurement of older people, instruments must be eldercompatible, and this may not have been compensated for in past studies of cautiousness.However, in the present study the issue of recording by tape machine was not pursuedaggressively as I wanted to avoid all discomfort on the part of my valued participants.42Appendix D illustrates the initial qualitative format which was pretested on 4individuals and was subsequently restructured to the present format. The questions notonly were closed-ended but were too leading, and elicited many one or two-word answers.The writer was aware immediately that the structure was not conducive to elaborateaccounts and it was re-structured. The re-structured format in Appendix L included open-ended questions which elicited descriptive responses.Although the qualitative technique can be time-consuming for the researcher, itcan often yield very important information rich in detail. Personal interviews can alsoenable the researcher to make valuable observations about subjects and their environmentswhich have the potential, as a result, to add to the data interpretation and analysis. Idealresearch might interpret results from both quantitative and qualitative methods ofevaluation. In fact, researchers of today are looking more favourably upon this concept oftriangulating data (Patton, 1990; Norris, 1993).As with quantitative methods, there are advantages and disadvantages to qualitativeinterviewing. Following is a list of those which this researcher experienced while usingpersonal interviewing techniques. These were chosen as each interview progressed.Advantages of Personal Interviewingmore flexibility in asking questionsdata tends to be richer in informationa more effective way of enlisting the co-operation of respondents- advantageous interviewer administration - i.e. probing, answering respondentsquestions, clarifying instructions and meaningsrapport and confidence building more feasiblelonger interviews can be done in person- multi methods of data collection - i.e. visual cues, observation of subject in his/her own environment, body language43Disadvantages of Personal Interviewing- difficulty generalizing results to other populations- difficulty analyzing large masses of information while addressing issues ofefficiency and effectiveness- costly (travelling time, gas, car maintenance, time)- data collection period is longer than telephone procedure- subjects often difficult to access (hard-to-find areas of the city and buildings)- costly transcriptions (typing fees, equipment rental and failure)- interviewer effects unknownDESIGN LIMITATIONSAvailability sampling was one of the major limitations of this study and design.Uncontrolled sampling produces some obvious sample biases: the direction of availabilityand willingness to be interviewed. Normal assumptions for calculating sampling errorsdo not apply in this study. Further studies of this type drawing from a large randomsample might yield generalizable results.Demand characteristics, or the knowledge of the questionnaire subjects gainedafter test one, was another design limitation in this study. When the same subjectsparticipate in both groups they often can determine the true purpose of the experiment(demand characteristics). This researcher took precautions not to give away the mainreasons for interviewing the subjects, through subtle eye contact, body language, verbalintonations, and such.Social desirability is another problem of the design. It is very important to becognizant of respondents giving answers they think the interviewer wishes to hear44(Cozby, 1985). This might have been controlled for by the use of a separate social desirabilityscale in conjunction with the PWB, however, constraints and resources did not permit theapplication of such measures in this study.Mortality or the possibility of drop out, is a disadvantage of the repeated measuresdesign; that is to say, if an experiment or condition runs over an extended period of time,the subjects may be lost for various reasons. Mortality is a threat to internal validity whenthe mortality rate is related to the nature of the experimental manipulation (Rubin andBabbie, 1989). This writer was mainly concerned about 'drop out' due to severe illness,hospitalization and even death, because so many respondents were seriously ill. This wasone of the main criteria for setting the re-testing after only 6 homemaking visits, and notfour or 5 months. In fact, two of the initial 30 subjects were lost: one due to stroke andhospitalization and subsequent surgery, and the other had to be eliminated from thesurvey because of several suicide attempts and hospitalization. This left a total of 28subjects to complete the study.History can be a threat to the internal validity of a study. This term refers to anyoutside event that is not part of the manipulation that could be responsible for the results(Grinnell, 1985). In the repeated measures design it is almost impossible to control forhistory and during the second interview considerable effort and time were allotted tocareful inquiry about significant changes that may have occurred in subjects' lives whichmay have invalidated results. Significant events and/or changes have been documentedand will be taken into consideration during data analysis.Maturation refers to the possibility that any naturally occurring change within theindividual is responsible for the results (Cozby, 1985). This is a problem in this repeatedmeasures design because it has the potential to result in change from pretest to posttest.For example, people change over time; they become fatigued, bored, and wiser.45Testing can be a problem if simply taking the pretest changes participant'sbehaviour. Taking the test may enable the subject to become aware of the attitude beingtested, and make them more 'sophisticated' about the matter in question, or more adept atthe skill being tested - if this occurs, the experiment would not have internal validity(Rubin and Babbie, 1989).The above problems or pitfalls can be controlled by the use of a sufficiently largesample and appropriate control groups, however, because of resource and time limitationsa control group was not feasible for this research project.ADVANTAGES OF THE METHODOLOGYThe repeated measures design also has its strengths. When utilizing repeatedmeasures, one follows the same group over at least two points in time (Rubin and Babbie,1989). This design is predicated on the theories that the social system is dynamic and itseeks to explain change (Hessler, 1992). Since this study is investigating whether or notperceived well-being is affected by homemaking service, the researcher deemed it essentialto obtain a baseline reading of 'well-being' before the services started and several visitsafterward in an attempt to detect any changes in the measure.Biddle et al. (1985) argued that the repeated measures design is the only realalternative to the experiment which is viewed by some as flawed due to its artificiality. Anobvious advantage of the repeated measures design is that fewer subjects are neededbecause each subject participates in all conditions. This is useful when subjects are scarce,as was the case in attempts at recruiting applicants for homemaking services. Anotheradvantage to this repeated measures design as that it is extremely sensitive to findingdifferences between two groups (Cozby, 1985). Because subjects in the group are identical46in every respect (they are the same people), error variability due to subject differences wasminimized.To achieve internal validity in this study (results valid within the confines of theexperimental procedure used) was an unrealistic goal. Random sampling techniques werenot employed. The use of control groups or control of extraneous variables throughmatching or manipulating the research environment were not considered in this studyprimarily because of resource and time constraints. To match all subjects on all variableswould have been a very costly undertaking in terms of time and resources. The primarygoal of this exploratory descriptive study is to try to determine whether a relationshipbetween homemaking and perceived well-being of subjects exists. With generous timeand resource allotments, random sampling and control groups would certainly be aprimary objective, if this study is to be replicated and produce generalizable results.DATA ANALYSISQuantitative PWB ScaleEach of the 16 statements on the Perceived Well-Being Scale was administeredorally to subjects. Each item was rated on a 7-point Likert scale.Statement numbers 2, 5, 8, 12, and 16 are negative statements relating topsychological well-being. Scores ranged from 1=SA (strongly agree) to 7=SD (stronglydisagree). Item numbers 7, 10, and 15 are positive statements and scores ranged from7=SA (strongly agree) to 1=SD (strongly disagree).Statement numbers 1, 3 , 6, and 11 are negative physical well-being statements andscores range from 1=SA (strongly agree) to 7=SD (strongly disagree). Whereas, statementnumbers 4, 9, 13, and 14 are positive physical well-being statements and scores range from7=SA (strongly agree) to 1=SD (strongly disagree).47The lowest score in both psychological and physical well-being is 8, and thehighest achievable score is 56. The sum of psychological and physical well-being scoresequals the general well-being score. The lowest general well-being score is 16 and thehighest is 112Subjects were asked whether they strongly agree, agree, moderately agree, wereundecided, moderately disagree, disagree, or strongly disagree with each of the 16statements. A score of 7 on each item reflects a high level of well-being. Scoring instructionsfor the scale are illustrated in Appendix F.In order to try to detect a change in well-being scores, the scale is administeredtwice: before intervention and after, then the two scores are compared.Comments or reactions made by subjects about a particular statement were recordedon the statement sheet by the statement and dated. These comments were compared withcomments or reactions at Test 2 and incorporated with the qualitative data.Qualitative Analysis ProcedureThe six persons who agreed to taping represented the different marital statuscategories of the total sample (married, widowed, single, separated subjects). Data wastranscribed the same day it was recorded and read for meaning on that same day whenpossible; a typist was hired to do this work, and often it meant reading the transcriptionsthe next day.The data from the other 22 subjects whose thoughts and opinions were recordedby taking notes was collected daily until all subjects had been administered the PWB Scaleand qualitative questionnaire after 6 homemaking visits. The information was read forelaboration the same day it was collected, while the experience was still fresh in my mind.Due to limited time and resources, and because it was desirable to have the sameinformation from each individual interviewed, the standardized open-ended formatillustrated in Appendix L was used and each subject was asked exactly the same questionsin the same order at Time 2. The questions were composed in advance exactly the way48they were to be asked and careful consideration was given in the wording of each questionin order to increase data credibility and to prevent the kind of problem that occuredduring pretest when questions were not open-ended and/or were too leading, andsubjects answered questions in one and two words. The rationale behind the standardizedopen-ended interview according to Patton (1990) is to "minimize interviewer effects byasking the same question of each respondent" (p.285). As well, Patton (1990) recommendsthat standardized open-ended questions facilitate analysis and organization of data.The interview at Time 2 consisted of the administration of the Perceived Well-Being Scale, and then the subjects were asked the four questions from the qualitativeformat. Subjects were directed to answer the questions as thoroughly as they could andwere gently redirected if or when they digressed from the topic and kept focused so thatinterviewee time could be carefully utilized.The first question of the qualitative format: What, if any, significant changes havetaken place in your life over the past 6 (8 or 10) weeks, was asked with a view to obtainingbackground information about significant events which may have occured in the subjects'lives during the period that the homemaking services were being carried out. Thisquestion allowed the researcher to control for confounding variables which may havecontributed to the change in PWB scores (the first objective of this study). I was looking forhappy events such as gains, special occasions, good news, improved health, and sadoccasions, disappointments, deterioration in health, and losses which may affect one's life,or even uneventful periods.Question 2, What is your opinion of the homemaking service is an opinion or valuequestion aimed at understanding the thoughts subjects had about the service ofhomemaking. This question was asked with a view to obtaining the answer to the thirdobjective of this study: to determine subjects' feelings regarding the homemaker and service. Thisis an important question for the Continuing Care because it has the potential to speak totheir mandate.Question number 3 of the qualitative format, How do your view your homemaker, isanother opinion/value question which attempts to obtain and understand subjects' thoughts49and interpretations of their homemakers. This question was asked to gain an understandingof any changes in well-being scores which may or may not be associated with thehomemaker, and in an attempt to answer to the third objective of this study.The last question was, What would you like to see happen that might improve thehomemaking service for you and/or other elderly clients of Continuing Care? This question wasdesigned to be a knowledge question: one which attempts to elicit the subject's factualknowledge of the service he or she has received. I asked this question to determine whatrecommendations recipients of the homemaking service offered.The weakness of the standardized approach is that it does not permit the researcherto pursue subjects' issues or concerns that were not anticipated during the composition ofthe qualitative questions. The strength of this format is the reduction in interviewer effectsand bias, particularly if more than one interviewer is used; all subjects are asked the samequestions and the ability to compare responses is greater, and finally, this format facilitatesthe organization and analysis of data (Patton, 1990).The qualitative data was classified for content analysis in order to facilitate asearch for patterns in subject responses. Content analysis according to Patton (1990) "is theprocess of identifying, coding, and categorizing the primary patterns in the data" (p.381).Notes were made during the administration of the PWB scale at Times 1 and 2 in themargins of each subject's PWB test sheet. These notes were included in the data analysis ifthey had relevance to the study. For example, if a subject shed tears during his/herresponse to a particular statement I wrote "Client tearful" in the margin next to the itemnumber.After reading through all the transcribes and my own notes twice, and makingcomments in the margins about my own ideas of what I thought the subjects were saying,I went back to the first transcribe and began to give recurring ideas and concepts in thedata a label and coloured the idea or concept with a coloured felt pen and added the labelat the side of the paragraph in the same colour. Coding was done for each question.For example, the following excerpts are illustrated to clarify the coding process.These examples are from Time 2 interviews with subjects who were responding to50question 2: What is your opinion of the homemaking service?Oh, well, we were brought up that way ... you didn't get to go outuntil you did your part of the chores. I had to clean the bathroomand my sister did the steps, and cleaning day was on Friday andbaking was on Saturday, and my father liked everything in itsplace you know, and we had to get it done right . . .The codes I used for the above statement were learned behaviour and gender roles.This concept alludes to the way the subject was brought up in her family to carry out herduties as a young girl in the family. It also conveys the expectation of the male figure, andthe acknowledgment by the female of her role at this time. This coding procedure reflectsthe content, or embodies the meaning of the text in terms of a concept. Another examplefrom the data is the following:Oh yes, well you can imagine how it feels to sit here and look atthe dust pile up and not be able to do anything about it, I mean . .don't ever let anybody tell you about the golden years .The concepts which I formulated from the above comments made in answer toquestion 2 were loss of control and disappointment. Learned behaviour, gender roles, loss ofcontrol and disappointment were recurring ideas or concepts in other respondent'sresponses to this question. When all the data for each of the four questions was labelled orcoded, the researcher re-read the interview notes and transcribes with a view to searchingfor common themes within each question. Because the qualitative interview consisted offour questions the patterns or categories were in a sense imposed prior to data collection.Specifically, the writer was looking for answers to questions about the homemakingservice and the homemaker. So, for example, it was anticipated that when asking thequestion: What is your opinion of the homemaking service, an opinion answer would beforthcoming. Of course, the type of opinion is not known or anticipated and duringcoding, one looks for patterns, themes or categories which may emerge in the response tothis question.Following is a list of the four questions. Examples from the concepts derived fromthe data in those questions are listed in the left-hand column and those which relate tocommon themes are clustered. The right-hand column states the themes and the plus (+)51signs in front of a theme indicate additional information from notes during administrationof PWB at Time 1 and Time 2.1. What, if any, significant changes have taken place in your life over the past 6 (8 or10) weeks?Conceptssense of controlfeeling of normalcyfortunateimproved healthfearuncertaintydeteriorationhelplessdependenthumiliationfrustrationpeace of mindless isolatedless worryThemesimproved self-perceptionimproved health perception+ decreased sense of self+ vulnerability+ anxietydiminished function/mobility+ decreased anxiety2. What is your opinion of the homemaking service?Conceptsdecreased pressurefulfilled needsreassuredwonderful thingincreased confidencepleasingnot intrusivegood servicehelpfulintrusiveinadequate schedulingpoor quality workloss of independenceloss of autonomyuselessregained prideThemesfeelings of reliefsatisfactioncriticismsdisappointment+ decreased self-conceptloss of controlvalue of housekeepingregaining social contactsexpectations^gender rolesstandards learned behaviourrenewed confidence^+sense of identity3. How do you view your homemaker?Concepts^ Themes52the girl, my girlfriendgodsendreal gemthe workerthe homemakerthe maidyoung girlmy helpera real princessreliablesympatheticpleasantthoroughself-directedwillinghard-workingunderstandingattached to hermiss heraccustomed to herdesire to keep hersomeone to talk todislike herlabelshomemaker qualitiesclients' feelings4. What would you like to see happen that might improve the homemaking servicefor you and other Continuing Care clientsConcepts^ Themesschedule changesdifferent homemakersvariation on quality of workno controllack of client inputlack of continuitypassive recipient53This process of listing concepts and clustering into themes was less complicatedthan many processes of qualitative analysis, because of the pre-imposed question format,and the exploratory nature of the study. The researcher was looking for opinions tospecific questions and there was less need for 'interpretation' of responses. Rather, theintent was to record the answers to the 4 questions as subjects reported them and identifycommon responses or new patterns which may emerge. This information was used toenhance the quantitative data.Notes made during the administration of the PWB scale were coded and added or"fitted in" to the concepts of the qualitative data. For example, in statement # 2 of the PWB:No one really cares if I'm dead or alive, a note in the margin of one subject's sheet said: Clienttearful. Another response to statement 16: I'm afraid of many things, elicited comments suchas, Well I'm always afraid of ending up in one of those nursing homes, or I don't like being alone atnight, or I'm afraid for my grandchild's future. All of the "notes to myself" were gathered andlisted by subject number, and some of relevance were included by entering an "+" besidethe themes derived from the qualitative format on the previous pages to designate addedinformation from "notes to myself'.Other comments were frequently gesticulation about the wording of the items like# 7: It's exciting to be alive or # 9: I'm in good shape physically. Comments were directed at theauthor of the PWB Scale and not the researcher. These comments and gesticulations maybe forwarded to Reker and Wong with a view to improving the scale. However, I didreturn to these side notes consistently during the analyses to see if their significance wasappropriate to this study.Notes were compared with each subject's scores for discrepancies. For example, Iwas looking for differences in scores and data from the "notes to myself " - a high score inwell-being would be inconsistent with tearful comments of hopelessness and despair, andvice versa.54Chapter VRESULTSDESCRIPTION OF THE SAMPLEAgeThirty subjects agreed to participate after being asked by the researcher and/orshown a letter inviting their participation in the study (Appendix A), and twenty-eightrespondents completed the study. Ages of the twenty-eight subjects ranged from 65 to 87years, with a mean of 75 years and a standard deviation of 6.0948. The median is 74.5. Thedistribution is trimodal: mode 1=71 years, mode 2=73 years, and mode 3=84 years of age.Table 3 depicts the cumulative frequency distribution of ages. Age groupings of subjectsare illustrated in Figure 2.Table 3Cumulative Frequency Distribution: Ages of Respondents (N=28)Age Absolute Frequency Cumulative Frequency65 2 268 1 369 1 470 1 571 4 972 1 1073 4 1474 1 1576 1 1677 1 1778 1 1879 1 1980 3 2281 1 2384 4 2787 1 2865-69 70-74 75-79Age80-84 85-89cb^25cb40353020cbcbtx. 15105055Figure 2Age Groups of Subjects (N=28)Gender, Marital Status, and Living ArrangementsAs expected, the women (23) outnumbered the men (5), 80% and 20% respectively.Figure 3 reflects the marital status of the subjects. Forty percent of the sample werewidowed, 50% were married, and the remaining 10% were single and separated. Forty-four percent of subjects lived alone, and 56% lived with one or more family members.IncomeThe data on income level was collapsed for coding purposes. Figure 4 illustratesincome levels ranging from $5,000 to $30,000 per annum. One subject (3.6%) claimed lessthan $5,000 a year (lived with spouse), and one subject (3.6%) received more than $30,000in annual income. Four subjects (14.3%) had incomes of $5,000 to $7,499. Approximately40% of the sample (11) received $7,500 to $9,999 annually. Three people (10.71%) received$10,000 to $14,999 annually, while approximately 14.3% of subjects had annual incomes of$15,000 to $19,999. Four subjects (14.3%) reported $20,000 to $29,999 per year.cc7,500 - 9,9995,000 - 7,4990 - 4,99930,000 +20,000 - 29,999'47P15,000 - 19,99910,000 - 14,999Figure 3Marital Status of Subjects (N=28)Figure 4Income Level of Subjects (N=28)5610^15^20^25^30^35^40Percentage57EducationThe education levels of subjects ranged from Grade 5 to Postsecondary educationas Table 4 depicts, with frequency and percent. The histogram in Figure 5 illustratesrespondent education levels by grade and percentage.Table 4Highest Education Level Reported (N=28)Grade Level Frequency PercentGrade 5 3 10.7Grade 6 2 7.1Grade 7 1 3.6Grade 8 5 17.9Grade 9 2 7.1Grade 10 6 21.4Grade 11 — —Grade 12 7 25.1Postsecondary 2 7.1TOTAL 28 100%Figure 5Education Level of Subjects (N=28)Respiratory (3.6%)Cancer (10.7%)Cardio (17.9%)Osteoarthritis (14.2%)Osteoporosis (17.9%)Arthritis (35.7%)58RaceOne Filipino female, two Iranians (married couple), and 25 male and femaleCaucasians were interviewed. Eighty-nine percent of the sample (89%) were Caucasians.Chronic IllnessAll subjects suffered from one or more chronic illnesses. The pie chart in Figure 6illustrates the largest percentage (35.7%) of subjects (10) suffering from arthritis. Five ofthe respondents or 17.9% experienced cardiovascular conditions. Three subjects sufferedfrom cancer (10.7%). Almost eighteen percent (17.9%) or 5 subjects suffered fromosteoporosis, while 4 subjects (14.2%) experienced osteoarthritis. One of the subjects(3.6%) suffered from respiratory disease (emphysema). The largest portion of subjects,67.8% or 19 out of 28 subjects, suffered from bone and joint diseases which resulted inphysical and functional disabilities and the need for homemaking support. This largepercentage of bone and joint disease sufferers consisted solely of women.Figure 6Chronic Conditions of Subjects (N=28)59Care Levels of SubjectsReports of the levels of care by age, gender and marital status of respondents aredepicted in Table 5. Age range of males was between 65 and 89. Male subjects in this studywere married. Two subjects between ages 70 to 74 were levelled at PC (Personal Care), andone male was receiving care at the 1C2 level (Intermediate Care 2). One male subject in the75 to 79 year old age range was levelled at IC 1, and one male in the 80 to 84 year old rangewas also IC1.The females in this study varied in terms of marital status. Nine subjects weremarried: three in age groups 65 to 69 were levelled PC (Personal Care), and one widow atIC1. Age group 70 to 74 reveals two PC, one IC1, two IC2 in the married group, two PC inthe widowed group, and one IC2 in the single group. Age group 75 to 79 shows one PCmarried subject, one PC widowed subject, and one PC separated female. The 80 to 84 agegroup illustrates one widowed PC and 6 widowed females at the IC1 level. The 85 to 89age range reveals one widowed PC subject.Table 6 summarizes the personal characteristics, and percentages of suchcharacteristics, of the respondents in this study.Table 5Levels of Care by Age, Gender and Marital Status (N=28)Married Widowed^Single^SeparatedCare Levels PC IC1 IC2 PC IC1^IC2 PC^IC1^IC2 PC^IC1^IC2Age - Males65 - 6970 - 74 2 175 - 79 180 - 84 185 - 89Age - Females65 - 69 3 170 - 74 2 1 2 2 175 - 79 1 180 - 84 1 685 - 89 160Table 6Personal Characteristics of Respondents (N=28)Characteristics N %Female 23 80.0GenderMale 5 20.065 - 69 4 14.370 - 74 11 39.3Age 75 - 79 4 14.380 - 84 8 28.585 - 89 1 3.6Married 14 50.0Marital StatusWidowed 12 42.9Never Married 1 3.6Separated 1 3.5Living ArrangementsLive Alone 12 42.9Not Alone 16 57.1Less than $5,000 1 3.6$5,000 - $7,499 4 14.3$7,500 - $9,999 11 39.2Reported Income $10,000 - $14,999 3 10.7$15,000 - $19,999 4 14.3$20,000 - $29,999 4 14.3More than $30,000 1 3.6Grade 5 3 10.7Grade 6 2 7.1Grade 7 1 3.6Grade 8 5 17.9Education Grade 9 2 7.1Grade 10 6 21.4Grade 11 - -Grade 12 7 25.1Postsecondary 2 7.1Filipino 1 3.6Race Iranian 2 7.1Caucasian 25 89.3Arthritis 9 32.1Cardiovascular 7 25.0Chronic IllnessesCancer 10.73Osteoporosis 4 14.3Osteoarthritis 4 14.3Respiratory 1 3.6Total 28 10061FINDINGSPerceived Well-Being ScoresThe independent variable is homemaking services and the dependent variable isperceived well-being. A two-tailed probability evaluation with an alpha setting of 0.05was deemed appropriate for this study. The non-directional hypothesis states: homemakingaffects established measures of perceived well-being. The null hypothesis states:homemaking has no effect on established measures of perceived well-being. Data processingand statistical computations used the SPSS /PC+ software. Results were analyzed forstatistical significance using the non-parametric Wilcoxin Sign Test. Appendix E displaysa copy of the PWB Scale -Revised, while Appendix F illustrates the scoring instructions forthe Perceived Well-Being Scale - REVISED (PWB-R) (Reker and Wong, 19 84).Table 7 illustrates the final results of the repeated measures Perceived GeneralWell-Being test. A baseline score was recorded before subjects received homemakingservices, in the three categories of psychological, physical, and general well-being. Sixhomemaking visits later, subjects were administered the PWB Scale and scores wererecorded at Test 2, designated After in Table 7. Differences in scores are indicated betweenTable 7Differences Between Psychological, Physical, and General Well-BeingScores Before and After Homemaking Services (N=28)HomemakingServicesMean PsychScoreMean Physical^Mean GWBScore ScoreBefore 44.400 24.967 69.367After 47.571 29.464 77.035Psych 1 with Psych 2 Z = - 3.2826 2-tailed P = < .0010Phys 1 with Phys 2 Z = - 3.3738 2-tailed P = < .0004GWB1 with GWB2 Z = - 3.8320 2-tailed P = < .0001Conclusion: Using alpha p = < .05 2tail, since T obt < T crit, Ho rejected.62psychological, physical, and general well-being. Mean psychological well-being scorebefore homemaking was 44.400, and after homemaking the mean score was 47.571. Meanphysical well-being scores before homemaking were 24.967, and 6 homemaking visitsafter, the mean score was 29.464. The overall general well-being score (combination ofpsychological and physical well-being) was 69.367 before homemaking started, and 77.0356 visits later. Because the investigator chose alpha .05 (5 chances out of 100 the relationshipis the result of chance) as the cutoff point to separate findings that are not consideredsignificant from those that are, we must conclude from the 2-tailed probabilities listed inTable 6 that these results are statistically significant and the null hypothesis: homemakinghas no effect on established measures of perceived well-being, is rejected.Results are positively and statistically significant at the 5% level. Figure 7 representsthe before/after scores of respondents' psychological well-being. Figure 8 representsphysical well-being scores at Test 1 and Test 2. The combination of psychological andphysical well-being are represented in the overall general well-being scores of subjects,before and after 6 homemaking visits, in Figure 9.Figure 7Psychological Well-Being Scores Before and After Homemaking Services (N=28)...•.•..^Phys VVB Test 1^.—.• Phys VV13 Test 2^I1^3^5^7^9^11^13^15^17^19^21^23 25^27Subjects1009080706050403020100Figure 8Physical Well-Being Scores Before and After Homemaking Services (N=28)Figure 9General Well-Being Scores Before and After Homemaking Services (N=28)6364Highest General Well-being ScoresThe average difference in General Well-Being Score of all subjects between pre andposttest was 7.1 points. Three subjects had decreases in scores and one had no change. Allother scores have increases at posttest between 1 and 24 points, as Table 8 illustrates.The highest GWB score at both pre and posttest was obtained by a 70 year old,married, Caucasian female who lived with her spouse. Prior to Time 1 she suffered a heartTable 8Rank Order Changes in Pre/Posttest General Well-Being Scores (N=28)Subject # Pretest Score Posttest Score Change in Score2 54 78 2417 70 91 2118 57 73 1630 52 68 1629 64 78 1414 68 81 1316 73 86 137 51 64 136 67 77 1019 58 68 104 83 91 824 72 79 *726 59 66 712 88 95 73 71 77 623 78 83 525 93 98 520 67 71 45 61 64 38 87 90 311 72 75 322 84 86 215 81 83 227 73 74 121 73 73 01 79 77 -29 48 43 -528 76 68 -87.1 = Average Change in Score65attack, and her husband suffered several heart attacks, open-heart surgeries and a strokeprior to homemaking services. Combined family income was in the $20,000 to $29,999range. Her pretest GWB score was 93, and her posttest score was 98 out of a possible 112..Another married, white 65 year old female who lived with her spouse obtainedhigh GWB scores at pre and posttest (88 and 95 out of 112). This lady also suffered a heartattack and her spouse's health was very tenuous at best. Her income range was below$5,000, however combined family income was in the $10,000 to $14,999 range.The third highest GWB pre and posttest score was obtained by an 84 year oldmarried white male who lived alone, and he experienced a lot of emotional support froma large family, particularly from his eldest 60 year old daughter who brought him mealseach day. His wife had dementia and he visited her each day in the nursing home. Hisaverage income was in the $20,000 to $29,999 range. His illnesses included arthritis andblindness in one eye. His scores pre and posttest were 83 and 91 out of 112 respectively.Lowest General Well-being ScoresThe lowest pre and posttest GWB scores were obtained by an 81 year old Caucasianwidow with multiple health problems. Annual income was between $20,000 and $29,999and she lived alone. She had a daughter and family in Vancouver who kept in touch bytelephone daily. Table 8 illustrates her pretest score of 48, posttest score of 43 out of apossible 112; and decrease in score of 5 points. Possible reasons for this decrease inperceived well-being was her anxiety around the bad news she received about her health.She appeared to be very depressed and worried about some diagnostic tests she was toundergo. Her illnesses include cancer, asthma, kidney problems, and gallstones.The next lowest score in GWB was obtained by an 84 year old Caucasian widowwho suffered from a heart condition. She lived alone and had no family or friends to relyupon for support. She appeared to be depressed although was not diagnosed as clinicallydepressed by her physician. She was very anxious and afraid. Her income range was$20,000 to $29,999. Her pre test score was 51 out of a possible 112. Posttest was 64/112.66A white married 69 year old female who lived with her spouse had a score of 52 atpretest and 68 at posttest. Her spouse had recently suffered a CVA. Income range was$20,000 to $29,999 combined. She claimed to be in a "dysfunctional" marriage, and hadvery strained relationships with her two sons and their families. She appeared depressedalthough had never been diagnosed by a physician as such.For the total sample, lowest scores pre and posttest were obtained by widows, butnot necessarily those in lower income brackets, as much of the research reports (Aronson,1989; Harris, 1978; Herzog and Rodgers, 1981; Kasl and Berkman, 1981). Widows in thislow score bracket reported higher incomes than most in this category ($20,000 to $29,999).Greatest Decrease in Score at PosttestThe greatest decrease in posttest score of GWB was obtained by a married whitebed-ridden 73 year old female, who suffered from severe emphysema. She lived with hersupportive spouse, and had a very supportive family, but her health deteriorated in the 6weeks and her overall score of 76 decrease by 8 points (Table 8).A widowed white 68 year old female, living alone, who had terminal cancer,showed no change in score at posttest. (Test 1 and 2 = 73/112). Her cancer was causing herconsiderably more pain and difficulties in managing activities of daily living. Althoughshe expressed her appreciation of the homemaking, her spirits were being negativelyaffected by her deteriorating health. Her income range was $20,000 to $29,999.Greatest Improvement in GWB ScoreTwo widows achieved the greatest improvement in overall GWB scores. The firstwas an 80 year old in the $20,000 to $29,999 income range who lived alone. She hadsuffered a heart attack prior to homemaking and had no children or relatives to turn to forsupport. She was very anxious and frightened at the pretest assessment interview, and67item number 2 of the PWB Scale - "No one really cares whether I'm dead or alive",provoked tears, as she responded undecided. Further, statement number 8 - "Sometimes Iwish I never wake up" provoked a tearful episode, and she responded moderately agree tothis item. These responses suggest depression, according to Reker and Wong (1984). Herpretest score was 54 and her posttest score was 78 of a possible 112 points; an increase of 24points (Table 8). She enjoyed the homemaking and was thankful for it, and felt goodenough psychologically (less depression, less fear, less lonely) and physically (moreenergy) at posttest to cancel the service.The second subject with the greatest improvement in score was an 80 year oldwidow who lived with her only daughter and her family. She scored 70 at pre test and 91on the posttest: an increase of 21 points. This lady suffered from severe emphysema andosteoporosis, and was in the annual income range of $7,500 to $9,999. At pretest she hadrecently been discharged from the intensive care unit after having suffered from a severebout of pneumonia. This had been the ninth hospital admission and discharge in 3months. She had been very near death and her status at Test 1 was tenuous at best. She wasbored and spent her days and nights watching television, while her daughter slept all dayand worked nights. She was also discouraged about the lifestyles of her daughter andchildren and grandchildren. She agreed strongly to the statement "I am afraid of manythings" on both tests, qualifying her fear as that of death. She strongly agreed that she wasbored. However, the of particular interest was her response to item number 9 "I am ingood shape physically". At pretest she responded with a definite "disagree", and atposttest she responded with a definite "agree". She clearly felt better at Test 2 and this mayhave been because she was perceiving her health status to be improved. She had nohospital admission during the interval between Time 1 and Time 2.Outstanding Changes in ResponseResponses to item #15 (PWB Scale) "I have peace of mind" were particularlyinteresting in that the differences in responses between Time 1 and Time 2 were so great.Responses to Statement—From strongly agree to strongly disagree68Figure 10 illustrates the responses graphically. It appears that peace of mind of mostsubjects improved at Time 2 after the 6 homemaking visits. About 85% of respondentsagreed that they had peace of mind at Time 2, while during the baseline recording, onlyabout 17% agreed they had peace of mind.Figure 10Response to Statement: "I have peace of mind" (N=28)Figure 11 illustrates the graphic response to the statement, "I am in good shapephysically". Another dramatic difference between Time 1 and Time 2 occurred. At Time 2there were 19 positive responses to this statement (68%), as opposed to 9 positive responses(32%) at Time 1.Statement 7 on the PWB Scale - "It's exciting to be alive" provoked the consternationof many subjects. This statement was designed by Reker and Wong (1984) as measurementof psychological well-being, and the presence or absence of depression. Twenty-three(82%) respondents suggested to the writer that the word exciting was an inappropriateword to describe their lives at this time. They felt that life was no longer exciting for them,but agreed that the words satisfactory , adequate , or suitable might best describe life as theyknow it today. Seventy percent of the sample agreed that life was exciting, in spite of thewording, and at posttest , 78.6% of the sample agreed that life was exciting.El Frequency at Test I • Frequency at Test 2^IStrongly DisagreeDisagreeMildly DisagreeUndecidedMildly AgreeAgreeStrongly AgreeOcc0^1^2^3^4^5^6^7^8^9Frequency of Response69Figure 11Response to Statement: "I'm in good shape physically" (N=28)Only two subjects felt life was not exciting; one was a 72 year old male who tried to commitsuicide several times, and was deleted from the study, and an 80 year old widow whodisagreed at Time 1, but 6 weeks later, she strongly agreed that life was exciting.This lady made a remarkable recovery in her outlook on life, psychologically andphysically. She was very depressed, although not clinically so, at Time 1. She had nofamily or friends, and was completely isolated, partly because of her inability to ambulatewithout a walker as a consequence of severe arthritis. Her homemaker took her over toanother CCD client in the same building and introduced the two ladies when she saw howdepressed and lonely this subject was. When the researcher arrived at her apartment toadminister Time 2, she was greeted at the door by the subject, who was having a "teaparty" with six other ladies. These ladies had involved the subject in bowling, and churchactivities, and one might presume this to be a success story that we can attribute to thewise homemaker who introduced this lonely lady to others in the apartment complex.70EMERGING THEMES FROM QUALITATIVE DATAFollowing are the five themes which emerged from the 4 qualitative questions:1. perceptions of own health2. opinions about the homemaking service3. relationships between gender identity, roles, and housekeeping values4. perceptions of the homemakers5. lack of continuity in the servicePerceptions of Own HealthAlthough question number one: What if any significant changes have taken place inyour life over the past 6 (8 or 10) weeks? was asked with a view to obtaining informationabout significant changes in subjects' lives during the 6, 8 or 10 weeks of homemaking inorder to control for extraneous variables, the concepts and themes which emerged fromthis inquiry resulted in descriptions of perceived health both before and after homemaking.Direction and focusing of the question by the interviewer ascertained whether anysignificant life changes which may have confounded the results, but the direction ofresponses invariably ended up with the descriptions, seen below, of how the respondentsfelt physically before and after the homemaking services began. Therefore, in this primaryanalysis, "perceptions of own health" is taken as their key response to the first question.In terms of client need as a result of chronic conditions, ill health and decreasedfunctioning, the respondents in this study were at considerable functional, social, andeconomic disadvantage compared to seniors who do not qualify for homemaking. Fiftypercent had no immediate family, and few acquaintances with whom who they couldhave regular contact. Economically many of their annual incomes reflected the poverty71level, and objective health measures indicated a bleak future for many of these elderlypeople. At the time of the initial assessment they were clearly in need, having beenreferred by their physicians and/or hospital nurses and/or social workers. Health issuesseemed to be foremost in their minds. Fifteen subjects were aware of their failing health,had limited knowledge of their diagnosed illness and experienced diminished functionand mobility as is illustrated in the recorded posttest interview response to question 1:Before I started the homemaking my doctor said I was sick, I knewI wasn't feeling good, thought it was the flu. I couldn't move. Icouldn't get out of the bathtub. I didn't have a bath for threeweeks because I couldn't face getting in and out of the tub.An 84 year old male respondent when asked about significant changes in his life atTime 2 digressed and told me about his vulnerability and diminished function resulting fromhis failing health:Because of my health and I couldn't . . . I was . . . my wife wasgone, and she left me, and I couldn't see, my eyesight isn't thatgood anymore and I can't see very much. You see I can't getaround like I used to in the good old days (laughs). I guess myhealth is failing me. You know, my ... and that is the reason that Igot a homemaker.The theme of anxiety is depicted below. This 79 year old widow was unaware of theseverity of her problems. She was to be admitted into hospital shortly after this interviewtook place because her physician suspected lung cancer. She suffered from emphysemaand arthritis but did not seem to understand the implications or the extent of her poorhealth:Yeah, I was feeling not good, but I didn't know. I didn't know Iwas that sick, I was really sick, I guess and I didn't know that. Mydoctor just phoned me one day and tell me I'm gonna get somehelp because he say I need somebody to help me and come in andcheck up on me (laughs).Twenty-one percent of the sample met the criteria for high risk, or vulnerableelderly who are at risk for institutionalization: unmarried, female, living alone, on lowincomes. Their needs are a result of physical decline and chronic health conditions.Problems in ambulating and decreased mobility were particularly prevalent, however, it72frequently seemed that those who were most at risk were the ones who denied poor healthand claimed that they didn't really need any help (6 subjects). One 80 year old lady who,although she displayed enthusiasm for the research project and agreed to participate inthe study, appeared mildly agitated and resistant to the idea of receiving assistance fromhomemaking even though her health was clearly compromised.The following respondent had been assessed to receive service, because of theconcerns of her doctor and her son, and did, in fact accept the homemaking service, butshe expressed the need to impress upon the writer that she was still in control and founddifficulty in adapting to this new lifestyle which was thrust upon her. Although sheagreed to participate in the present study, and had completed phase 2, she still presentedin a defensive mood. The following excerpt of the transcript depicts the way she portrayedherself even after services. The themes vulnerability, and decreased sense of self-esteem seemto show through her anger in the excerpt below:I don't know why you're around bothering me. Are you writingsome kinda book about me or somethin'? I'm okay you know.Who said I was sick anyways? Some dumb doctor? What d'youexpect? What do they know? They know nothin'. A bunch ofquacks! I didn't ask for nobody to come around to bother me youknow, my son wanted all this, and now have to put up with somegirl I don't know coming in here every week and bothering me.Eleven (39.2%) subjects seemed to accept their deterioration and did not wish toburden others with their concerns. In the excerpt below I did sense a decrease in anxiety,which may have resulted from a reassurance from her physician:Well, you know I just thought I'm getting old and decrepit andthis is just one of these things I have to live with. This is old age,but then Mrs. J told me to go to me doctor because I could hardlymove, and I started to get scared and wondered is this really age?Turned out it wasn't just age but something else, but I feel betternow because he (the Doctor) put a name on it. I had the pain but Ididn't want to talk about it, but now I can talk about it because ithas a name and I'm not just crazy. By the way dearie, don't letanybody fool you about the golden years, what's so good aboutbeing old?The theme of diminished function/mobility is depicted in the following excerpt.Becoming sick frequently evoked feelings of humiliation as Mrs. ^, an 82 year old73spinster and former accountant, and Mr. , an 84 year old so painfully relate:Oh it's terrible, I just never thought I'd ever urn, well who wouldthink that an old lady like me would wet my bed? I sometimesthink, oh this just can't be happening to me, you know, I neverthought it would ever happen to me. You just never know, and it'sso embarrassing to have the girls have to wash my sheets when Iwet the bed.Well, I just find it embarrassing to ask for help ... you know I wasa businessman and ran my own meat outlet, and you just go byfrom day to day and never think it will ever happen to you, andbingo, you've been reduced to a crippled-up old crock like me andyour pride goes out the door!Perceptions of health, however, did take on a more positive light. Improved self-perception and improved health perception are illustrated by subjects, who appeared lessanxious after homemaking services:Well, I still have aches and my hands get bad at times, but it's sogood to feel I don't have to do it (work) when I'm feeling so bad.That little girl coming in here, just gives me extra energy and thepeace of mind knowing that my house is in order. You actually dofeel better, but it's probably all up here (points to her head).Yes, yes I do feel much better since C  has started to come in,I mean well, who's to say, maybe it's all in my head that I feelbetter, but I feel good when I know when she comes in, that for thenext two weeks the house is going to be clean and that makes mefeel better somehow.Although the objective health measures may not have changed, it appears that it isthe subjective assessment of one's health status (improved health perception) that enables theindividual to function more independently and effectively:Well, the help I get takes my mind off my problems, I mean that Ireally think it's your mind. Sure I know I have problems but whenS comes I know the work it getting done, and I feel morerested so it gives me a chance to do the other things that piled up.Your body works if your mind's willing and you can overcome alot of things if you're happy in here (points to her head), at least ifyou're feeling more at ease about things. I can walk to the storenow, and pick up things I need, and I know I don't have to go backto a pile of stuff I couldn't do, cause S does it all now.All respondents, except for one lady, felt they were feeling better physically afterthe homemaking service was in place. Twenty-one subjects (75%) acknowledged that they74were feeling better physically, and 24 (85%) acknowledged feeling better mentally; theseacknowledgments were confirmed by changes in PWB scores. The homemaking assistancemay have provided them with more peace of mind, an increased sense of control, a theperception of feeling better as a result.Opinions of the Homemaking ServiceThe homemaking service is part of the independent variable and opinions aboutthis service are crucial to the exploratory part of this research.It is important to understand the complexity of the homemaker/client relationship.Two people come in contact who have never met before, and the homemaker is expectedto work in a home she is not familiar with, for a person she doesn't know, with nosupervision, no co-workers to talk to, and no structure to adhere to. She arrives at thedoorstep of the client with a list of tasks she/he is to carry out, which have been dictatedby a Case Co-ordinator of Continuing Care.For the home care client, the sanctuary of home suddenly is subject to outside andunfamiliar forces. For the elderly lady, her home has been her domain for years; the oneplace where she experienced control, comfort, familiarity and self-worth. Suddenly astranger comes to her door and she is expected to allow her in to touch and clean herpersonal possessions, even her body. Two complete strangers suddenly become involvedin intimate activities.In response to question 2, What is your opinion of the homemaking service? the themeof criticism is illustrated in the following excerpt. Mrs.  , a 65 year old house-proudlady, was critical initially as she discussed the homemaking service:No, I didn't want her in here at first. One reason because shesmelled like smoke, but what can you do? That's who they sent. Ididn't like it because when she left, the house smelled like smoke,even my closets smelled like smoke. I don't even know her .... arethey bonded? I mean I don't want to sound like complaining, buthow do you feel if a stranger comes in your house?75Fifty-three percent of the sample became comfortable with the intrusion and wereglad to have the help. There were mixed reviews, however, about the quality service itself,and the themes of disappointment and criticism are revealed below:Well, she didn't do what I wanted her to do. I mean all I got was alick and a promise. She didn't even get up on a chair and clean thetop of the china cabinet. She said she wasn't allowed to . . . whatkind of maid service is this?The idea of strangers intruding and touching cherished, precious belongings wasdifficult for 25% of subjects to come to terms with, as is demonstrated by the followingcomments from an 80 year old apartment-bound widow, who suffered from severeosteoporosis. The theme of loss of control as a result of intrusion is depicted below:I hope they know not to touch some things in here. Are theytrained like that? I don't want anybody to touch my mother'svase. You know that vase (points to it) is over 200 years old, shegot it from her mother, and nobody touches it. (I walked towardsthe priceless article to have a better look at it and the subjectshouted at me) Don't you touch it either!Fifty-three percent (15) respondents expressed feelings of relief at having someonehelp them even if it was a stranger, especially subjects whose income levels were in thevery low ranges. These seemed to be the people who appreciated the service the most:I don't care who they send, as long as I get help. I can't stand to sitin here anymore it's such a mess and I'm too sick to anythingabout it. Anybody could come and I would be happy.Oh no it didn't bother me a bit when she came. I was glad to havesome help, any help would do. We're so lucky to have this whenwe get old and sick, oh no, I can't say I was worried about the girlcoming in, I was glad.It appeared that the larger the subject's income, the less satisfaction with theservice. Clients are asked to declare income at assessment, because services are pro-ratedon income. Perhaps because of this fee for service, the client's expectation was greater. Thetheme of disappointment emerged as a result. The number of hours clients were allocatedfor homemaking was of concern to some, particularly those with a fee. The followingsubject felt that "a proper cleaning" could not be performed in the amount of time given.76Also because she paid a portion of the cost of the service, she felt somewhat cheated that a2 hour cleaning period was reduced to 1 hour and 45 minutes because the homemakerrequired travelling time to get to the next appointment:I pay for two hours and she leaves here 15 minutes early everytime. And this last time I asked her to clean the chandelier and shesaid she wasn't allowed. She forgot to dust the baseboard too. Ipay $7.31 a week, I mean what am I paying her for if the workdoesn't get done?In spite of the fact that clients are told not to expect a professional cleaning serviceand that homemaking is part of a Continuing Care Program to maintain clients in thecommunity and provide a healthy safe environment by the provision of certain services,subject expectation was often high and criticism of the service was forthcoming:Well, she did everything but—she do it, but uh, you know, shereally did nothin', and the second time she came I laid downbecause I had just come from the doctor, and I fell asleep rightaway. She did almost nothin'! You know, do I have to go behindthe woman and say do this, do that? The problem is I need thehelp, and I'm glad of it, but I wish they could be more fussy.The unexpected theme of value of housekeeping in response to question 2: What isyour opinion of the homemaking service? is expressed by an 80 year old lady with severeosteoporosis illustrates this point:I like to have my kitchen floor done with hot soapy water first, andthen I usually dry it off with a cloth and then put the wax on witha clean cloth. But she doesn't do that, she just sort of pushesaround a damp BeeMop, here and there, she'd just push it aroundand then tell me she's finished. That's not what I'd call cleaning.You'd think they'd train them right. I mean what's the sense inpaying for it if you don't get it mopped right?Others perceived the service to be a "wonderful thing" and the theme of satisfactionemerges in the following excerpt of an 84 year old man whose wife was in a nursing home:Oh, it's great. Well, she .. .the homemaker comes in and does whatwork, I mean the kind of work that I would never think of. Awoman would I guess. You know, think of doing all this stuff thatshe is doing. You know, I would never think of it. I used to dust . .this half of it, of course, but when the homemaker comes in the . .well, when she goes out this place is spotless!77The responses generally were very positive, however, one angry deficit-conscioussubject's response is an example of the theme decrease in self concept. She felt the service wasa complete waste of government money. However, this statement may have been inresponse to her loss of independence and autonomy:No I don't want it (the service) anymore. It's a waste of governmentmoney. The young people have to pay for it, it just turns me sick! Imean what are we doing squandering money like this, whenwe're so much in debt? What about the young people today? Howcan they pay for all this? I've never asked for help before and I'mnot an abuser of the system like so many of them. You know youshould check it out. I know people in here who get a maid justbecause somebody told them to get their doctor to call you guys.Everybody rips off the system. I think it's disgusting!The declaration above comes from an 80 year old lady who was very ill and in needof service. This widow lost her husband 30 years previously, and she reportedly workedhard all her life (independent and autonomous). She is a proud lady who watchedtelevision all day, and read the newspapers, and exhibited remarkable knowledge andconcern about our economic condition in Canada. Her doctor phoned a referral for helpbecause of her multiple serious health problems, but during the posttest she informed meshe no longer wanted the service and would be cancelling it when she was finished withthe diagnostic tests at the hospital in the following week.An important consideration when considering perceptions of homemaking servicesis the feeling of loss of control and independence that occurs as a result of receiving suchassistance. Twenty respondents (71%) bemoaned such losses; even though they expressedand acknowledged the value of the homemaking service. It represented, at least in theirminds, one step closer to institutionalization. Having to relinquish independence can bean important issue in dealing with the service itself as Mrs. B relates:I find it degrading to ask for services, but what can I do? I canbarely get around anymore. I know I should be thankful for whatI get and I am thankful, I need the help, but I wonder what thenext step will be? What happens to me when this isn't enough?One female subject clearly required the assistance of homemaking, but unfortunatelydid not feel good about the homemaker being in her home. This 72 year old lady had been78a widow for 45 years and was extremely independent, proud, and meticulous about herhome and possessions. Diminished health had caused her to rely upon external help. Herstatement seems to exemplify her grief over lost independence and autonomy and resultingdecreased self concept, even though she acknowledged the usefulness of the service:You know, I probably shouldn't say this to you, especially, but Ijust wish I didn't have to have her (homemaker), I wish I didn'tneed anybody's help. I actually hate it when her day comes roundand I say to myself, oh, no, she's coming again tomorrow. I can'teven go out when she's here, so I have to go sit in another room.It's so humiliating to ask for help, especially if you're like me. Youknow I raised 3 kids and worked two full-time jobs all by myself,and I travelled later, and lived in a cute little house I boughtmyself in Kerrisdale. And now look at me!To summarize, 23 of the 28 (82%) subjects expressed satisfaction with the serviceitself, in spite of the negative comments illustrated in this chapter, which were mainlyrelated to subjects' fears and concerns about their status in life at this time. Between thetime span of this repeated measures design, it appeared that relationships emerged whichbecame quite significant to subjects, and possibly to the homemakers. The followingtheme, which came out of question 2: What is your opinion of the homemaking service?illustrates the importance of the role of housewife and housecleaning.Relationship between Gender, Identity, Roles and Housekeeping ValuesThe role of homemaker/housewife was of apparent importance to these elderlywomen. Comments about the importance of being a housekeeper, and the identity as aresult of women's roles in the home, emerged as subjects responded to question 2. All thewomen in the sample except three (one separated one widowed and one single woman)saw themselves as good housewives who take their role seriously:Listen, this is what I do, I cook, I clean, I bake. We were raised tolook after husbands, babies and the house, and I've always been agood homemaker to my family.I worked my fingers to the bone for that man, because I thought79that's what true love is, you serve your husband because youshould be thankful that you got one. Don't ever let your mandown my mother said, and that means keep him happy, keep hishouse clean and if you want to stay in his favour never let him gethungry.Even when women no longer have husbands to care for as a result of death, divorceand/or separation, the salience of the homemaker role and sense of identity still persists:Now that H is gone and I'm not a housewife anymore, I still dowhat I have to do around here, because that's what I do, I'm still ahomemaker .For this cohort of women, husbands were viewed as the "provider" while thewoman's identity was generally confined to the home. Women viewed themselves andwere often judged by others in terms of the kind of home they "kept", the whiteness of theclothes on the line, and whether they made their cakes from "scratch". To be seen by otherhousewives, friends and relatives as a good homemaker was to be highly valued, andmost women took great pride in how good others judged them to be. The followingexcerpts illustrate the themes of sense of identity and gender roles:Ah, I've always been a homemaker you know, I've always donemy own work, and I've never had any help even when I was sickwith my babies. I mean, I just did everything. I used to bake myown bread, I baked all the time, but of course, I can't do that now.It bothers me now, because I would like to be able to do all thestuff myself.Well, I just like to keep a clean place, and looked after my family.It's a pleasure to look back at all you have accomplished. It givesyou something to be proud of.Following are examples of the theme learned behaviour. Many women seemed tohave been conditioned in homemaking by their mothers:Mother was clean, and we were poor, but you know we alwayshad clean white clothes to wear on Sunday. She never believed indirty grimy clothes. She always believed on Sunday we had nice,well she always said your clothes could be old and patched, but atleast they're clean.Cleaning was what we were brought up with. On Saturday I hadto clean the stairs, and my sister had to clean the bathroom. Myfather wouldn't put up with anything less. He wanted his house80clean. We all had chores to do in the house, and my mother wouldgive the one that did the best job a special treat.An excellent example of the theme gender roles comes from this 80 year old ladywho shared with me a special little ditty with me that she remembered her grandmotherreciting to her:"G is her name, single is her station, Lord help the man thatmakes the alteration" (laughs).My mother and grandmother used to say that little ditty to meand told me "God help the poor man that gets you!" Anotherthing my mother always said to me is the way to a man's heartwas through his stomach, so you better learn how to cook now. Iwas cooking supper every night for my mother and father andsisters, when I was nine. My mother always told me that a man'shome is his castle and if I wanted to be a good wife, I had to keepit clean and make him proud. I always kept a nice house for myhusband, he could bring anybody from work home, my housewas so clean.For those who have friends and social support, the value of housekeeping, a themeemerging from the second question, seems paramount. Hostessing is not taken lightlybecause it is still seen as an opportunity to display housekeeping and homemaking skillsto peers:I don't have that many friends anymore, they all died, but I do seea few every other week and we have tea and sometimes playcards. I like the company and I like to have the place presentablewhen they come. I wish I could still bake, I was a great cook, myhusband used to tell me, but I can't stand for long periods of timeat the sink so I have to buy cookies and cakes when they come, andit's not the same.Most respondents valued women's work highly, even though it may still not behighly appraised by society as a whole. These elderly ladies derived such a great amountof pride and a sense of identity from knowing that others knew how competent they were:I always was a good cook, and all my friends knew it too.I won ribbons at the blueberry pie contest eight years in a row,there wasn't another woman around that could come close to mypies.The other women used to ask me the secret of my white sheets.Nobody knew how I got my sheets so white. I used to just love to81hang them out then wait for everybody to come around and askme how I got them so white. And I wouldn't give away that secretever.We never had money, or good clothes, but my kids always lookedgood when we took them out. People used to stop us on the streetand say what lovely kids they are, and oh my, how well-dressedthey always are. I could patch up old clothes like nobody andmake them look good. I can still do it today, I bought this materialfor $1.89, just a remnant, but look what I can do with it, (displaysher blouse for me) I can make anything look good. You had to inthose days, you had no money.Twenty women in this sample of twenty-eight (71%) extolled upon the virtues andvalue of housekeeping and homemaking. The five who did not were males, and of thethree remaining ladies who did not shout the praises of good housekeeping, two wereacutely ill and dying and possibly homemaking ceased to be of importance. The onlysubject who did not elaborate upon the virtues of housekeeping was the lady who seemedto be consumed by concern about Canada's deficit, and she was focused on her ownserious health concerns.Perceptions of the HomemakerWhen asked: How do you view your homemaker? at posttest (question 3) thehomemakers were labelled as "the girl", "the maid", "a good friend", "my girl", "theworker", and occasionally "an employee". Homemakers frequently were the only socialcontact five clients had from week to week. As previously mentioned, 50% of subjects hadno family or friends. All of these subjects became very attached to their workers. Mr. K_who is 84 years old, looked forward every week to his homemaker visit as is shown in theexample below. This statement clearly illustrates the themes client feelings and homemakerqualities which emerged from responses to question 3:How do I see her? Oh really great! She's so bright and cheery.She's somebody I can talk to. She's very good that way. She's areal friend. She tells me about her kids, and I feel like I'm part ofthe family.82A married couple in their 70's, who both suffered from complications ofcardiovascular disease, expressed their delight and their feelings about their "little girl":Oh, she's a real gem, a godsend! We see her as our friend, not assomebody we hired. Let's say we consider her as an aid, to help usin the support that we really need to have in the house. She's sucha cheery little girl, I don't know how I got along without her. Myhusband says, oh what a lovely job that little girl did last week, theplace just shines, and oh what a job P_ did doing this, anddoesn't she do that good .. .Social and emotional support from another human being and the theme of clientfeelings are reflected in the following comment from a 78 year old separated arthritic lady,who lives alone in a two-room basement suite in the house of an Asian family:Well, she's somebody who's really doing me a favour because Ihate housework (laughs). No really, I don't get to see people veryoften and when comes it's like a friend dropping over. Shemust really like old people, because she's always nice to me andshe tells me about her kids, and what she's doing on the weekend.She's more than just a help to me, she's like a friend. And she's notembarrassed to do anything. I had a thing here (points to herbuttocks) and I couldn't really see it, but it hurt, and E comesin and I tell her and she says well let me see it, maybe I can helpyou. So there I am, old flabby me, I pull down my pants and E_looks at it without even hesitating, like she's seen old ladies backends all her life! Only a good friend would do that, eh?A comment from an 87 year old lady who lives in a seniors complex, and seems tohave lost just about all her friends because she outlived them all illustrates her feelings andthe significance of someone to talk to:It's gotten so lonely and quiet around here now . . . Mr. diedlast week and it seems like everyone's gone now, so it's really nicewhen F comes to clean the house. I have someone to talk to, butshe works too, she just doesn't talk! Sometime if she finishes earlyI give her a glass of juice, and she sits and talks to me. She broughtme some flowers and a card on my birthday. . . the only flowers Igot. Sometimes she hugs me.A married couple, who are both 78 years of age, severely crippled with rheumatoidarthritis, and childless express their feelings about their homemaker:(Mr. S) There's nobody like her! C is a real princess. The otherone was real sloppy but C^, we just love her. She's alwayslaughing and joking. She makes me laugh too.83(Mrs. S) She's great. I wished we'd had her before. We worktogether and we talk all the time. She's a godsend. It's like havinga girlfriend. We just hope we can keep her. I've got so used to hernow.The theme of homemaker qualities emerged from other subjects in this study:I maybe shouldn't say this but the best thing with G_ is thecompanionship, I know you told me not to make her a coffee but Ido that anyway, and we sit down and have a chat. She's nice to meand listens. That's important, and she does what needs done,that's important too.She wears nice clothes, and she's always happy and she sayshow's this and how's that, and what can I do for you today, andhow do you feel? It's nice to have someone that cares about you.She must like old people.Not included in the task list is the emotional support provided by this homemaker:Well, being cheery is a big help for me, I only wish I felt betterwhen she was here, because I like her so much, and I feel badwhen I'm not up to snuff, because she's always so bright andoptimistic. She hugs me every time before she leaves.The following interview sample illustrates the kind of caring and sensitivitysubjects feel for their homemakers:She knows me and I know her, and you sort of uh, get sort ofattached to them you know. She was going to take my drapesdown last week but I said no, you're too small and you might hurtyourself, I'll get my grandson to do it. I don't want you to hurtyourself, or they might send somebody else.Twenty-six of the twenty-eight subjects (92%) in this study had positive remarks toshare about their homemakers, despite the disappointment of five subjects in the qualityof performance of housecleaning duties. One subject mentioned earlier felt the service wasa waste of taxes and did not acknowledge any positive feelings she may have had abouther worker. Another elderly subject just felt the worker was intrusive and although sheacknowledged the importance and her need for help, she admitted that she did not lookforward to her worker's weekly visits, and tried to make herself scarce each time.84Lack of Continuity in the ServiceThe most common themes to emerge in response to the question: Can you suggestways of improving the service? was the frequent lack of continuity and feeling of being thepassive recipient of services when homemakers' schedules were changed by agencies toaccommodate other clients or emergencies. Twenty of the respondents were faced withpermitting a different worker into his/her home and life often on different days thanthose scheduled. Following are two examples of the responses I received:I liked the girl they sent me and I had her three times and one daythey phone me and tell me they're sending somebody else 'causeshe (the homemaker) has been sent to another client. Why didthey do that to me, why couldn't they just send the other womansomebody else? I was just getting used to T It's frustrating, I just got to know C and she knew just how todo everything and where everything is, and then they stoppedsending her, and when I phoned and asked about it they said,well, we had to send her somewhere else. I liked her and now Ihave to try to get to know a stranger.None of the subjects mentioned race or the culture of their homemaker. Eighteensubjects felt that the quality of the cleaning should be uniform, because subjects discoveredthat different homemakers perform different tasks. For example, although shopping forclients is prohibited by homemakers as a result of Richmond Continuing Care policy,some homemakers continue to run shopping errands for their clients. Ironing, is anothertask which is prohibited however, I did receive some complaints from subjects whose"neighbour gets ironing, so why can't I?" Subjects felt that everyone should be treatedequally in this regard. With these exceptions, there were no other recommendations.85Chapter VIDISCUSSION AND CONCLUSIONThis study was undertaken to explore relationships between the formal support ofhomemaking services and measures of perceived well-being of twenty-eight community-dwelling senior recipients of such care.The findings of the present study support the hypothesis of this study: establishedmeasures of perceived well-being in community-dwelling seniors were changed after theintroduction of homemaking services. This has been supported by the objective measuresof perceived well-being and by the subjective comments made by elderly informantsabout their homemakers during posttest interviews.Elderly respondents perceive their homemakers as meeting many of their needsthrough the provision of emotional and social support. However, the instrumental support,that is to say, the support provided through the execution of the housekeeping chores thatsubjects can no longer carry out because of diminished function and deteriorating health,has proved to be significant, particularly to female subjects. The significance of thepresumed emotional support subjects might receive from their homemakers was notdirectly expressed. The themes: perceptions of health, opinions of the homemaker and thehomemaking service, gender identity and roles, values of housekeeping, and lack of continuity inservice were expressed directly.The sex ratio in this study is concurrent with current demographic trends whichshow an unequal distribution of aging males and females (McPherson, 1990). In otherwords females outnumber males as they age. Demographers suggest the current ratio is 75males for every 100 females for those 65 and over, and for those aged 80 and above, theratio decreases to 54:100 (Statistics Canada, 1985). The sex ratio of this study wasapproximately 30:100 which is much lower than the current figures. This most likely is areflection of the convenience sampling procedure. The sample also consisted of an almost8650/50 split between married and widowed people. These findings are consistent with thedemographic trends in Canada and North America today (Health and Welfare, Canada,1990).With regard to perceived well-being scores, the results of this study show little ifany support for gender differences. One of the problems of course, is the small representationof males in the study, however, those men who did participate obtained similar scores tofemales. These data are supported by evidence from other studies that indicate thatgender is a poor predictor of well-being (Medley, 1976; Diener, 1984; Wilson, 1967).Age seemed to have little or no relationship to perceived well-being of subjects.Some of the highest general well-being scores in this study were achieved by those in theireighties and those in their mid sixties. Conversely, some of the lower general well-beingscores were achieved by those in the same age groups previously mentioned. The authorconcurs with the literature that the age of an older adult is a poor predictor of general well-being. Research on age and well-being requires more longitudinal data before an accurateassessment of their relationship is possible. However, there have been suggestions thatindividuals' well-being remains stable over time, so if one is a happy-go-lucky youngperson, one will be a happy-go-lucky old person, and vice-versa, at least until the early70's (Kozma et al., 1991).Being married is related to measures of PWB in all age groups, according toresearchers such as Diener (1984) and Larson et al. (1978). The current study reveals thatthe one common denominator in subjects with the highest PWB scores both pre andposttest is marriage. These findings concur with other similar results in the literature.Perhaps this is because being married enables spouses to experience more activity andinteraction socially, than those who are unmarried, thus increasing perceptions ofpsychological and physical well-being. The married respondents in this study who livedtogether reported more social activity than the widowed respondents. A good maritalrelationship, not simply the status of being married, is thought to be an importantpredictor of well-being (Larson et al., 1986). The absence of marital harmony was reflectedin the general well-being scores of two couples of the five in this study. Other variables87were considered when analyzing the results from these individuals' lower PWB scores,and after having interviewed them twice, some degree of discord became apparent.Levels of perceived well-being in widowed people is thought to be lower than thoseof married people (Atchley, 1989). Similar results are evident in the present study usingthe PWB Scale (Reker and Wong, 1984). Widows had lower well-being scores. The lowestgeneral well-being scores were from widows in their 80's, who lived alone, and whoreported moderate incomes. This may have been a result of the poorer health and diminishedsocial contacts of the large proportion of widows (40%) in this study. Conversely, thegreatest improvements in perceived general well-being scores were achieved by twowidows: both 80 years of age; one lived alone, the other with her daughter and family; onein the $20,000 to $29,999 income range and the other at the poverty level. Becauseextraneous variables between tests were carefully considered and eliminated by thoroughinterviewing techniques, the author suggests that perhaps these differences in scores are aresult not only of the homemaking support, but also a sense of control and hardiness.Sense of control suggests that individuals feel that they can make decisions and "takeeffective action to produce desirable outcomes and avoid undesirable ones" (Sarafino,1990, p.113). This sense of control was displayed by a lady who lived alone and had nofamily or friends. She was a very responsible woman who although, her baseline well-being score was low, did manage to gain control over her life and lift herself out of hercircumstances. I mention this because those were the words she used when I saw her sixweeks later during the posttest interview. I believe she took steps to regain some of thecontrol she felt she lost during her illness, she succeeded and this reflected in her well-being score.The second lady with the greatest improvement was the stereotype of the strong-willed elderly woman we see in caricatures beating off would-be purse snatchers with herhandbag. She displayed a special determination and perseverance often referred to as'psychological hardiness' and assertiveness (Kobasa et al., 1982; Tobin, 1991). This hardiness,or bloody-mindedness as the British refer to it, is thought to diminish the impact of thevery stressful events in life. According to Kozma et al. (1991), "Hardiness has been found88to account for 12% of the variance in happiness and the elderly" (p.94). Tobin (1991) hassuggested that: "most critical to resisting the adverse effects of crisis is aggressiveness, thatis, assertiveness, even combativeness in interactions with the external world facilitatesadaptation to stress. Thus those who apparently can evade the developmental pushtowards increased passivity in advanced old age are better equipped to cope with stress"(p.19). A small number of respondents displayed this hardiness.Income level and perceived psychological well-being are reported as being small,but nevertheless statistically significant (Larson, 1978). General conclusions around incomesuggests it is perceived financial satisfaction rather the actual income which is a morepowerful predictor of well-being (Kozma et al., 1991; Lawton et al., 1984; Rodgers et al.,1988). That is to say, it is not the actual amount itself that predicts PWB but the satisfactionlevels from the income that are important. If an individual feels she can live her life quitesatisfactorily on $7,500 a year, the actual amount has no bearing on well-being; it is thesatisfaction this amount offers.The present study reveals a small but significant relationship between income andperceived well-being. While it is true that the highest perceived general well-being scoreswere achieved by elderly in the $20,000 to $29,999 income bracket, it is also true that thesecond highest score was achieved by a married woman whose combined income wasconsidered to be below the poverty line. Results also revealed that the lowest perceivedwell-being scores were achieved by elderly widows also in the $20,000 to $29,999 incomebrackets. It may be that the size of the income is irrelevant if the extent of satisfaction withit is acceptable. One subject may be satisfied with living on $8,000 a year if she knows thatshe has more income than her neighbour, or conversely if she is aware that all neighbourslive on $8,000 a year. Diener (1984) has referred to this phenomenon as the relativedeprivation theory, and he suggests that other scholars interested in this area of studyreport that relative deprivation is significantly related to financial satisfaction, whileincome is not.Education of subjects in the present study was not a predictor of well-being. Thehighest percentage of subjects (25%) reported a grade 12 education, followed by89approximately 22% reporting grade 10 levels. Those with the highest levels of perceivedwell-being reported education levels below grade 10.Researchers such as Larson (1978), and Palmore et al. (1973) report that educationhas been a better predictor of life satisfaction in males. It seems appropriate that educatedmales would have higher scores in life satisfaction because, as supporters of families, theyhad access to greater occupational opportunities. One must also consider that this cohort'seducation level was high if grade 10 was attained and/or completed, as compared withthe expectation today that high school is no longer considered sufficient or adequateenough to be competitive in today's work world.Because of reported effects of health deterioration and chronic conditions on well-being, the expectation of the writer that health has a major effect on perceived andobjective psychological and physical well-being is confirmed. Evidence of this is found inthe quantitative and the qualitative data from both the objective measures of PWB andfrom the responses of respondents to questions at posttest. In particular, the recurringtheme of self-health perceptions which became the primary theme to emerge from responsesto the first qualitative question, seems to speak to the importance of health perceptionsand perceived well-being. Sources of evidence are also provided by other researchers inthis area of interest such as (Stock et al., 1983; Stoller, 1984; Reker and Wong, 1983;Cousins, 1979; Sarafino, 1990; Kozma et al., 1991).It appears that as predictors of perceived general well-being respondents' self-health ratings are effective. Perceived physical health seems to exert a significant, directinfluence on perceived general well-being, whereas objective (physicians or diagnostic)measures are negative and indirect (Kasl and Berkman, 1981). Subjective health (self-health ratings) appears to involve the subjects' own cognitive comparisons of the objectiveconditions, to those of their peers. Purely objective (physicians' diagnoses) measures donot involve such comparisons, and subjects, especially older people, have a tendency tobelieve what the doctor tells them or does not tell them (Stoller, 1984). It often seems that"what they don't know doesn't hurt them". And so it has been shown in individuals, thatdespite medical advice, if a subject feels good and believes his/her health to be good then90the perception of the individual becomes his/her reality. As well I noted when subjectswere less aware of the severity of their health problems, their own subjective assessmentsreflected in a higher perceived well-being score. This finding is consistent with Kasl andBerkman's (1981) results.The author had access to respondents' health status as a result of conversationswith physicians before and/or after initial assessment of clients for homemaking services.Therefore, both objective (physicians') health measures and respondents' subjective (theirown) measures were known by the researcher. Except for cases in which subjects wereirretrievably ill, as in the cases of terminal cancer patients, or those with sudden acuteillness, subjects' own perceptions of health exerted a significant direct effect on perceivedgeneral well-being, whereas objective measures were often insignificant, and indirect.These findings concur with other studies and contribute to the empirical evidence of theinseparability of the mind/body (Cousins, 1979) and support the model of thebiopsychosocial model of health, which implies that health and illness outcome is aconsequence of the interplay of biological, psychological and social factors (Kleinman,1980; Chopra, 1993).Informants in this study expressed their approval and frequent satisfaction withthe homemaker who visited them each week, or bi-weekly. Their behaviour during theposttest and the scores reflected the way they felt about this new social contact. Changes inscores of the PWB Scale and information shared by subjects during qualitative interviewsadds to the research which reports strong correlations between social support, perceivedwell-being and perceived physical well-being (Blazer, 1982; Fillenbaum, 1984; Kart, 1990;Krause, 1990; Kane and Kane, 1981; Hogue and Gorton, 1981; Berkman and Kasl, 1981;Revicki and Mitchell, 1990; Connidis, 1989). Subjects receiving the social support ofhomemaking actually scored higher at Test 2 on both the physical well-being and thepsychological well-being categories. As Krause (1990) and Connidis (1989) purport, socialsupport serves as protection against adverse effects of stressful events through life.Further, social support is believed to facilitate adaptation to the crises and changes whichoccur during this period in life.91The most remarkable evidence for the significant effect of social support onperceived general well-being, but by no means the only one in this study, was the 84 yearold widow, with no family or friends, who was extremely depressed and confined to herapartment because of arthritis at Test 1. She used a walker to ambulate. Within six weeksof homemaking this lady was bowling three times a week with a group of ladies she met asa result of an introduction by her homemaker. Where she previously had no socialcontacts, she now has more lady friends than she can handle. In fact, when the writerarrived at the subject's apartment for the second interview, she was greeted at the door,not by the respondent, but by her friends, of which there were six. The subject was havingan 'after-bowling tea party'. Her change in PWB scores, as well as her comments to meabout her homemaker and the wonderful deed she had performed by introducing her toall these friends reflected a significant increase in this subject's well-being and perceivedhealth status, as a result. Examples from other respondents' interviews were also evidencefor the significance of social support. Phrases like: "it's so nice to know that someone willcome and see me next week", " I enjoy her visits so much", "when she's here I feel better","she gives me something to look forward to".The unanticipated results in this study reflected the significance of instrumentalsupport. The author has chosen to use the word, 'instrumental' by way of comparison tothe emotional or social support given to respondents by homemakers. Instrumentalsupport, for purposes of this research, is the actual tasks which were performed by paidhomemakers, in respondents' homes as dictated by assessors from Continuing Care. Thissupport included household tasks such as vacuuming, mopping, and dusting, bathroomand kitchen cleaning, assisting with bathing and hairwashing, and small meal preparationor assistance. The importance of such instrumental tasks to female respondents particularly,became very evident when themes of gender identity, social expectation, roles, and self-esteem began to emerge during the posttest response to question 2: What is your opinion ofthe homemaking service? of the qualitative interview. Not only were the housecleaning tasksimportant to subjects, but also the quality of such work took on an increased significanceas interviews progressed.92Women of this cohort appeared to have gained and/or maintained their identitythrough the role of homemaker and housewife. This identity has been maintained into oldage, even after spouses died. Mac Rae (1989) saw this role as "a very meaningful and focalcomponent of their self identities" (p.256). The homemaker role is a source of continuity inself-identity for the women in this study. These results concur with results from otherstudies in the area of female role and self-identity that report the importance of continuityin identity (Mac Rae, 1989; Matthews, 1979; Lopata, 1966).Subjects were not encouraged to disclose information about the values ofhousekeeping, but rather were asked to expand upon the information as it was related tothe researcher during posttest interviewing. Perhaps the surprise element should havebeen unwarranted because of the importance of maintaining a clean house myself. I hadnever really analyzed my feelings about my need to maintain my home at very highstandards, however, after hearing the stories of the twenty ladies, I came to see that theyechoed my sentiments exactly, and the stories about their childhood and their motherssounded much like stories of my own training and conditioning to be a good housewife.Issues of control, pride and independence served to exemplify the importance of theinstrumental help they received from homemaking agencies.If a woman's self-esteem is elevated because her self-identity is still in tact as aresult of being able to "keep house", even if it is with help from a homemaker, it followsthat her perceived well-being will be positively affected, and possibly her perceptions ofher health as a final outcome. The results of the data in this study provide evidence for theaforementioned effects and outcomes. If the provision of homemaking services impactupon the perceived well-being, and subjective health status' of clients in such a way , thenContinuing Care has met its mandate practically as well as theoretically.Although these results are not generalizable, they do provide the impetus to studythis area further. There are several issues and concerns around the research method whichprovide thought for future researchers.93Recommendations for improvement in Research Methods of the ElderlyBecause of time constraints and lack of economic resources, this research waslimited. Other researchers need to consider the importance and impact of the randomsampling method. The subjects of this study had to be recruited as they came into theContinuing Care Program because of time constraints, but if this writer were to attempt toreplicate this study a random sampling technique would be imperative. Also, the lack ofcontrol groups due to time and resource feasibility meant that it was impossible to make acausal relationship between homemaking and well-being. A control group could possiblyhave been recruited by using clients who refused homemaking services, even though thishappens infrequently and it could prove to be extremely time-consuming to wait for suchsubjects. The difficulty of obtaining a control group with the exact levels of chronicconditions is also an almost insurmountable undertaking, however future researchersmight consider advertising for elderly subjects with comparable chronic conditions andneeds as a means of control. There are older adults who require homemaking assistancebut are too proud to admit to the need or to or ask for help. As well, there are also elderlypeople in need who are unaware of the resources available. One might advertise forsubjects in the seniors community centres and through volunteer groups.Another method of collection which eliminates the need for longitudinal study isthe 'cohort analysis'. This method involves collecting the same information at differenttimes, with different respondents in the same age cohort being studied each time. The ideais that while respondents are different, they are usually representative of the same agecohort. Changes with age as well as differences between age cohorts may be inferred(Schaie et al., 1988).In a similar study to this one, I would recommend improving the longitudinalmethodology. There are very few studies that examine the same group over time. Thereason for this dearth of longitudinal data is because this type of study is expensive toconduct and time-consuming to complete. A more effective method of detecting changesover time might include taking measures over three or four different times instead of two,as was the case in the present study. I am suggesting that in this study, subjects' increases94in perceived well-being scores may have been influenced by changes in the season.Pretesting for this study was conducted shortly after a long, cold, and difficultwinter for older adults. Most subjects had been confined to their homes for many weekswhen they were first interviewed. It is conceivable that they suffered a form of seasonalaffective disorder (SADS) which is characterized by depression beginning each year in thefall and remitting or switching to mania in the spring when days start to lengthen(Rosenhan and Seligman, 1989). It affects women more than men (4 to 1), and the depressionseems to be governed by the amount of sunlight one receives. It is no accident that olderretired people "go South" in the winter months. Travel to sunnier climates causes aremission of depression within days according to Rosenhan and Seligman (1989).The category of SADS is a relatively new one in the DSM 111, and there has beenlittle research in the area of SADS and the elderly, although there have been some recentstudies on seniors and winter in Canada. For example, in the February 1989 report of theNational Advisory Council of Aging, monographs by researchers such as Michael Persinger,Professor of Psychology and Neuroscience; Dr. Charlotte Matthews, Gerontologist; Dr.Cyril Gryfe, Consultant in Geriatric Medicine; Josee Verdon, Fellow in Geriatric Medicine;and Harold A. Hanen, Faculty of Environmental Design, University of Calgary, reportmood fluctuations, loss of independence, increased health problems and infections, anddecreased mobility and activity in Canadian seniors as a result of winter life. This writerrecommends further repeated measures studies on the elderly be conducted with seasonalchanges in mind, and that measurements be recorded at each season of the year to controlfor the effects of seasonal affective disorder.Although recent interest in the elderly has produced a large amount of literature,the research itself can be inadequate in terms of basic research standards. Several problemsare worth considering in the study of elderly people.The first problem is the relatively few trained gerontological social workers andother scholars available to conduct gerontological research, and train others to work withthe aged. Although it appears that programs and courses in gerontology are on theincrease, there still are few gerontologists and social workers with specialized training at95this time in Canada to satisfy the need and demand.Secondly, future researchers of the aged might consider the importance of researchinstruments for the elderly. There have been relatively few research instruments designedspecifically for the aged. Many of those that have been designed for older adults havequestionable reliability and validity (Kane and Kane, 1981). It is absolutely essential todayto employ instruments that are appropriate for the problems and people studied. Elderlypeople fatigue easily, do not perform at their maximum capacity on timed tests, experiencevisual changes that create difficulty in reading small print, and have fewer educationyears than younger adults. All these add up to testing difficulty and unreliability if thetest is not developed with the older adult in mind.A third problem involves the knowledge of the aged that is required to conductadequate interviews. This researcher found interviewing subjects to be extremely time-consuming because very old people do not comprehend as readily; they take time to formtheir thoughts; they are unsure of themselves, and they like to talk about themselves andfrequently digress during interviewing. The often feeble state of an aged person may alterthe interview situation so that the interviewer may try to hurry through the statements orquestions, even though an interview with an old person should be slow-paced. Previousknowledge and training helped this investigator considerably, but it can be difficult forresearchers who lack knowledge of the aged. In trying to elicit information from very oldadults, researchers need to remember to be patient, enunciate clearly, and eliminate theuse of jargon.Recommendations for Future Social Work ResearchMy first recommendation is that more social work research be accomplished in thefield of gerontology. In the literature, there are sparse studies in this area, partly becausestudies of the elderly are relatively new, and also because there are also few trainedgerontological researchers. Study of the elderly is still in its infancy, but growing quicklyand now is our chance to make valuable contributions to this new and exciting field.96My second recommendation is directed at educational institutions. As students werequire more knowledge of our elderly population. Very few universities in Canada haveelectives in gerontology, and even fewer have full-time studies in the field. Simon FraserUniversity in British Columbia offers a Post Baccalaureate Diploma in Gerontology andmore recently has instituted a Masters Program to commence in the Fall of 1994. This willonly be the second program in Canada to offer such degrees. University of Victoria onVancouver Island offers a Masters and PhD program in the faculty of Psychology whichexamines the life span development in aging. Because of the changes taking place in ourhealth care system and the proposals to put health care into the community, it is imperativethat social workers be afforded more extensive training in the area of research, counsellingthe elderly, and understanding the problems of this growing population.In working with the elderly, it is not uncommon for concrete services to be offeredin combination with counselling services, as Case Managers of Continuing Care can attest.Counselling service provided through our Home Care Program is more likely to be short-term-oriented rather than ongoing. It is often task-centered rather thanpsychotherapeutically focused. Issues of concern revolve around the chronic conditions ofclients, death and dying, adjustment to functional limitations, grieving the losses ofhealthier days and friends and family, understanding disease processes, aging, love,marriage difficulties, and ethnicity.In my experience as a gerontological social worker, I have found when dealingwith the elderly one should be prepared to cope with resistance. Counselling in issues ofloss of health, family supports and finances are extremely difficult, and simple resolutionsare not likely to be forthcoming. Resistance may surface in the form of anger, frustration,disappointment, discouragement, manipulation, and ambivalence. Undue anger isfrequently directed at the social worker or case manager. There is much to learn about theelderly client if we are to work effectively with them. It is imperative to be sensitive to theirissues.It has also been my experience that there is a scarcity of evaluation in manygovernment programs. As social work researchers, we can offer our services and97contributions by researching these programs to test their effectiveness and efficiency. Iwould encourage my colleagues to become excited about this frustrating but thoroughlysatisfying process.More work needs to be done in the area of homemaking and client well-being. Thisstudy has only minimally scratched the surface. Studies in various levels of care, gender,age groups, ethnic groups, types of illness and disability, income levels, and educationallevels need to be considered; all these areas need to examined separately and together inlongitudinal studies. Qualitative studies of homemakers could yield rich data.The issue of dependency is an area which needs exploration. Are we helpingclients to maintain their independence, or are we creating dependency by supplying thiskind of service? Case Managers in Richmond Continuing Care are asking this question.Interviewer ImpressionsAs interviewer, I frequently felt anxious about my behaviour. It is imperative to tryto control for experimenter effects. I did this by attempting to keep my behaviour constant,and I designed the questioning format in a way that would allow for consistency inadministration. I found the rigidity of trying to keep control and constancy to be somewhatartificial and there were times when I would like to have been carried away by my subjects'stories and become more involved, but I realized I had a task to perform and conductedmyself accordingly. In a way, this action was probably to my advantage because it kept methinking about the experimenter's effects problems throughout the interviews. If I were toconduct this study again, I would hire interviewers to do the work I have done by myselfbecause of the enormous amount of time it takes to do a repeated measures quantitativeand qualitative study with 28 subjects. I found the process of interviewing elderly to bephysically, mentally, and emotionally draining.Because of the time involved, and the difficulties in listening to and recordingconversations which often were difficult to comprehend because of digressions, speechand hearing problems of some of the subjects, and the difficulty in distancing oneself from98the often painful reports of some subjects and trying not to "do social work", the processwas exhausting. I would suggest it might be wise to use interviewers in spite of problemsof control simply to see if the present results can be replicated.Recommendations for Homemaking ServicesMy impression is that many of the subjects' negative opinions in this study are theresult of not fully understanding the reason behind the service. As assessors we try toinform clients that the homemaking service is designed to help individuals maintain theirindependence in the home and community by assisting with tasks that the recipient orhis/her family cannot perform. Many subjects believed the service to be a "maid service"because of hearsay from other clients who have the service, or from friends, and complainedto the writer when certain housecleaning tasks were not done to their specifications. Thisproblem might be dealt with before the complaint arises by exemplifying the purpose ofthe homemaking service to clients; both homemaking agencies and Continuing Care casemanagers could emphasize the difference between what we are providing and a professionalcleaning service, and the purpose of providing the service.Another complaint from subjects was the variations in services provided by somehomemakers. Although there is a specified home support plan which is offered to clients,respondents claim that homemakers frequently stray from the home support plan, perhapswith good intentions, but because clients often communicate with each other the wordeventually gets out that " Mr. S.__ has his shirts ironed last week so why can't I?" Or," Mrs.C's homemaker takes her shopping, why can't my homemaker do the same?" This type ofinconsistency in service delivery might be rectified if all homemakers either performed thesame tasks or perhaps if the client were given more flexibility in the types of services ortasks we offered.Too often we dictate the services and the client is the passive recipient. Animportant pilot program is underway in Manitoba, where the client is not the passiverecipient of services. Instead he or she is given total control of the services they desire by99issuing them a monthly cheque to buy their own services. This study is being conductedby Eckhard Goerz, MSW, Manager of Continuing Care/Home Care Program in Manitoba.Mr. Goerz has initiated a two-year pilot project during which 30 clients of the Home CareProgram receive funds in lieu of service. The funds are provided directly to the individualswho then assume full responsibility for recruiting, employing and training their careproviders. This project is currently past the mid point of its two-year term and reports todate suggest a high level of client acceptance with minimal administrative difficulties.Moreover, the client no longer is a passive recipient and has an active voice and participationin his/her needs. The model could be useful to future planners of homecare for ourincreasing population of elderly.Another complaint from the subjects in this researcher's study was the difficulty inadjusting to new homemakers who are sent to client's homes because of schedulingdifficulties. Often when a client becomes accustomed to his/her homemaker a trust orconfidence grows. A change in homemakers requires that the client gather his or heremotional resources and physical energy to deal with someone "new". For clients who areparticularly weak, the task of showing a new homemaker where things are in the homecan be exhausting and frustrating. The changing of homemakers without consulting theclient is seen as another relinquishment of his/her independence, and the recipient of theservice is frequently put into the position of "having to accept whatever is given fromwhomever gives it" (Barer, 1992, p.140).Initially subjects experienced some discomfort when the homemakers wereintroduced into their homes. Not only was the service tangible evidence of their inabilityto function independently, but also it was seen as an intrusion - an invasion of privacy.For the homemaker, the task of working in a new home can be just as traumatic, and itwould appear that adjustments have to be made for both homemaker and client in order toproduce a workable relationship. According to Barer (1992), "primary relationshipsfrequently develop out of the secondary provider/client relationship. Rarely does theprovider of homecare services remain an anonymous entity" (p.138). And this was theresponse in 92% of subjects who reported a kind of bond forming between themselves and100their homemaker. This response hearkens back to my point about consistency in homemakerassignment. At a time when elderly people feel overwhelmed by changes in their lives, it isimportant to try and provide as much consistent care and attention as possible in order forthem to adjust to the multitude of inconsistencies that invade their lives in their later years.ConclusionThe obvious advantages of homecare is that most older people prefer it. Care athome offers better morale and security as long as proper services are given to providecomfort, support, and direct treatment of physical and emotional ills. The older personand the people in his/her life have a different perception of illness and treatment in theprocess of home care. Instead of being placed in a hospital or facility, people remain wheretheir care can be observed and where they can participate in that care. They are not passiverecipients of care. It becomes evident to family members and older people themselves thatmental or physical illness can be lived with as long as the stress on the caregivers does notbecome too onerous. Life does not have to stop or become totally disrupted, andrehabilitation and recovery can occur even in a proportion of the very old and the verysick.Through this study I have learned that home is significant to many older people. Itis a part of their identity. Home is where things are usually familiar and relativelyunchanging, and a place where they can maintain a sense of autonomy and control at atime when so many changes are taking place in their lives. Some insist upon remaining athome regardless of the cost to their emotional and physical health and personal security.Such tenaciousness may be attributable to the need for autonomy and independence; afear of loss of contact with familiar and loved people, places and things; a fear of dying,because of the reputation of hospitals and nursing homes as place "where old people go todie"; and a trepidation about change and the unknown, which frightens all of us no matterhow old we are. In Canada, the idea of home is highly valued and cherished andcommunal or institutional living is often viewed as a loss of personal liberty and dignity.101The notion of home can refer to many things, from the four walls surrounding aperson, to the neighbourhood in which one's residence is located, or to the possessionsthat make us feel at home. The meaning of the word home may include other individualsliving with a person, as well as neighbours, pets, and plants. Home is a place where manywomen gain and maintain a sense of identity because of the pride they take in making acomfortable place for their families to grow up in. Home is often one's castle, as the sayinggoes. It can be either a place where one has lived a good part of one's life or a new place, aswhen older people move into a retirement community. The concept of home is unique toeach individual.Home can also be a euphemism. In our eagerness to recognize the importance ofthe feeling of home, we should not overlook those elderly people who dislike their livingconditions, who have never 'felt at home' where they are, and who are eager to movesomewhere else - even to an institution.The identification of the effect of homemaking services on client well-being wasthe major objective of this study. The study has revealed a change in the standard measureof perceived well-being using Reker and Wong's 1984 Revised PWB Scale, after theintroduction of six homemaking visits. Quantitative methods were used primarily anddata was triangulated using a qualitative questionnaire with a view to enhancing andilluminating the results. Because homemaking has been viewed by some as a panacea forhealth care problems of the elderly in terms of a cost effective alternative to institutionalizedcare, it was important to this researcher to try to answer the question: Does it actually dothe client any good? Results from this study indicate that homemaking does help somecommunity-dwelling elderly people maintain a kind of independence in the community.For many subjects, perceptions of health status improved and general well-being scoreschanged significantly. However, many questions remain unanswered. Does the servicereduce the incidence of institutionalization and does it increases the amount of time aclient stays at home before being placed in a facility? There is much research to beconducted in this area.102BIBLIOGRAPHYAllen, R. E. (Ed.) (1985). 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(1991).New York: Springer. ••I/ • its^• it• -Tobin, Sheldon S. and Toseland R. (1983) Models of services for the elderly. In Monk, A.(Ed.) Handbook of Gerontological Services. New York: Van Nostrand.Tunstall, J. (1966). Old and Alone. Routledge: Kegan Paul.Turner, Francis J. (Ed). (1986). Social Work Treatment: Interlocking Theoretical Approaches.3rd Ed. New York: Free Press.Vincente, L., Wiley, J. A., and Carrington, R.A. (1979). The risk of institutionalizationbefore death. The Gerontologist. 19, 361-367.Walton, L. and McNairn, N. (1973). Long Term Home Care or Institutionalization? Canadian Family Physician, May, 459-460.Weiler, Philip G. (1974). Cost Effective Analysis: A Quandry for Geriatric Health CareSystems? The Gerontologist, 14/15, 414-417.Weissert, W. G., Cready, C. M., and Pawelak, J. E. (1988). The past and future of home- andcommunity-based long-term care. The Milibank Quarterly, 66 (2):309-369.Williams, E. Idris. (1980). Caring for Elderly People in the Community. 2nd Ed. London:Chapman and Hall.Wilson, W. W. (1967). The Correlates of Happiness. Psychological Bulletin, 76:294-306.Wingard, D. L. (1982). The sex differential in mortality rates. American Journal ofEpidemiology, 115, 205-216.Wong, P. T. P. and Reker, G. T. (1982). Coping behaviour and well-being in Caucasian andChinese elderly. Paper presented at the Canadian Association on Gerontology,Winnipeg.Woodruff, Diana S. and Birren, James E. (1975).Issues. New York: D. Van Nostrand.•^•Woodruff-Pak, Diana S. (1988). Psychology and Aging. New Jersey: Prentice Hall.World Health Organization Expert Committee. (1974). Planning and Organization ofGeriatric Services. Technical Report Series 548, Geneva Switzerland: World HealthOrganization.APPENDICES110Appendix ALetter Inviting Subject Participation111THE UNIVERSITY OF BRITISH COLUMBIA^112School of Soda! Work6201 Cecil Green Park RoadVancouver, B.C. Canada V6T 1Z1January, 1993Dear Continuing Care Client:As part of her master's thesis, Eileen Dougall Reilly, RSW, will be conducting astudy of elderly community-dwelling people who will be receiving homemaking servicesthrough the Continuing Care Division of the Richmond Health Department.This study is an investigation of the perceived "well-being" of elderly peopleboth before and after homemaking services have been provided. Your co-operation inthis project would be of significant value in the improvement of services to seniorcitizens .If you would like to participate in this research, please inform your CaseManager at the time of your assessment interview and she will give your telephonenumber and name to Eileen Dougall Reilly, who will contact you by telephone within 24hours to arrange a meeting with you in your home, at your convenience.Your participation is voluntary, protection of your identity is ensured, and anyinformation you choose to share will be completely confidential and will in no way affectyour application for homemaking services.We anticipate that the results of this study will serve to improve the quality ofservice(s) not only to yourself, but also to future nts of the Richmond ContinuingCare Division ."IEileen Dougall Reilly,Co-InvestigatorAppendix BLetter Explaining Study113THE UNIVERSITY OF BRITISH COLUMBIA 114THE IMPACT OF FORMAL HOMEMAKING SERVICES ON THE PERCEIVED WELL-BEING OF COMMUNITY-DWELUNG SENIORSSchool of Social Work2080 West MallVancouver, B.C. Canada V6T 1Z2Tel: (604) 822-2255^Fax: (604) 822-8656January 1993Eileen Dougall Reilly is conducting a study of community-dwelling seniors who haverecently been assessed by the Continuing Care Division of Richmond HealthDepartment to qualify for homemaking services. This study is an investigation of theperceived "well-being" of elderly people both before and after homemaking serviceshave been provided.Your voluntary participation in this study will enable Eileen Dougall Reilly to completeher master's thesis and provide valuable data which will serve to improve the qualityof service(s) not only to yourself, but also to others who utilize Continuing Care .You have the right to refuse to participate. You may withdraw at any time withoutaffecting your application for homemaking services. You are under no obligation tobecome involved in this study, however we shall view your participation in the firstinterview as constituting your consent. We assure complete confidentiality of anyinformation you choose to share.This study will consist of two private face-to-face confidential interviews. During thefirst interview you will be asked to respond to 16 short statements which may or maynot describe the way you feel at that time.The interview will take about 30 minutes ofyour time. Six to eight weeks later Ms. Reilly will contact you by telephone to arrangefor the second interview. All information will be codified to ensure your privacy. Allrecords will be stored in a locked file cabinet and any reference to names andphone numbers will be purged from the data and destroyed by shredder as soon asthe information has been processed.It is our sincere hope that your contribution to behavioural science research will bea rewarding experience .If you have any questions regarding this study please phone:Eileen Dougall Reilly, RSW^272-4169Dr. Sharon Manson Singer^822-3251Appendix CLetter Requesting Agency Permission115THE UNIVERSITY OF BRITISH COLUMBIA116School of Social Work6201 Cecil Green Park RoadVancouver, B.C. Canada V6T 1Z1Nov. 27,1992Ms. Bev Latrace,Director, Continuing Care Division,Health Department,300 - 8120 Granville Avenue,Richmond, B.C., V6Y 1P3Dear Ms. Latrace:Please accept this letter as confirmation of our verbal agreement that RichmondContinuing Care Division will permit me to conduct research for my masters thesiscontingent upon approval from University of British Columbia Ethics Committee earlyin the new year (1993).I look forward to a successful and mutually rewarding experience in ContinuingCare Division.Thank you for your kind consideration of my request.Yours truly,-C• 132f2s.Eileen Dougall Reilly, RSWAppendix DPretest Format for Qualitative Interview117Ct  THE UNIVERSITY OF BRITISH COLUMBIA^118Appendix DSchool of Social Work6201 Cecil Green Park RoadVancouver, B.C. Canada V6T 1Z1HOMEMAKIM SURVEY & DEMOGRAPHICS Jan. 1993What do you like most about the homemaking service?^What do you like least about the homemaking service?^What would make the service better?^L-17\_,p c-osv How did the homemaker make you feel?^Appendix EPerceived Well-Being Scale119120PERCEIVED WELL—BEING SCALE — REVISED (g) Gary T. RekerThis questionnaire contains a number of statements related to yourmental and physical well—being. Read each statement carefully,then indicate the extent to which you agree or disagree bycircling one of the alternatives provided. For example, if youSTRONGLY AGREE, circle SA following the statement. If youMODERATELY DISAGREE, circle MD. If you are UNDECIDED, circle U.However, try to use the UNDECIDED category sparingly.^SA^A^. MA^U^MD^D^SDSTRONGLY AGREE MODERATELY UNDECIDED MODERATELY DISAGREE STRONGLYAGREE AGREE DISAGREE DISAGREESA A MA U MD D SDSA A MA U MD D SDSA A MA U MD D SDSA A MA U MD D SDSA A MA U MD D SD SA A MA U MD D SDSA A MA U MD D SDSA A MA U MD D SDSA A MA U MD D SDSA A MA U MD D SDSA A MA U MD D SDSA A MA U MD D SDSA A MA U MD D SD- SA A MA U MD D SDSA A MA U MD D SDSA A MA U MD D SD1. I have many physical complaints.2. No one really cares whether I amdead or alive.3. I think that I have a heartcondition.4. I have plenty of physical energy.5. I am often bored.6. I have aches and pains.7. It is exciting to be alive.8. Sometimes I wish that I neverwake up.9. I am In good shape physically.10. I feel that life is worth living.11. I think my health is deteriorating.12. I don't seem to care about whathappens to me.13. I don't get tired very easily.14. I can stand a fair amount ofphysical strain.15. I have peace of mind.16. I am afraid of many things.Appendix FScoring Instructions for Perceived Well-being Scale121122SCORING INSTRUCTIONS FOR THE PERCEIVED WELL-BEING SCALE - REVISED (PWB-R) Appendix F^Gary T. Reker1. Psychological Well-Being (Items 2:5,7,8,10,12,15, and 16)- For Items 2,5,8,12, and 16SA = 1 ... SD = 7- For Items 7,10, and 15SA = 7 ... SD = 1Lowest score = 8; highest score = 562. Physical Well-Bein; (Items 1,3,4,6,9,11,13, and 14)- For Items 1,3,6, and 11SA = 1 ... SD = 7- For Items 4,9,13, and 14SA = 7 ... SD = 1Lowest score = 8; highest score^563. General Well-Being: Sum of psychological and physical well-being.Lowest. score = 16; highest score = 112Appendix GLetter of Permission to Use Perceived Well-Being Scale123C.j)No/NW.14 orTRENT UNIVERSITY PETERBOROUGH ONTARIO CANADAK9J 788Department of Psychology124January 5, 1993.Ms. Eileen D. Reilly66-6600 Lucas RoadRichmond, BCV7C 4T1Dear Eileen:The enclosed material may not reach you in time. In anyevent, you have my permission to use the Perceived Well-BeingScale-Revised for your Masters thesis.The scoring key is enclosed. Three measures can beobtained: psychological well-being, physical well-being, andgeneral well-being. The statistical analysis will depend on yourresearch design. I assume that a control group will be used in apre-post experimental design. Treat the pre-scores on eachmeasure as a covariate and compare adjusted post scores forsubjects receiving homemaking services with those not receivingsuch services.All the best with your research.Sincerely,Gary T. Reker, Ph.D.ProfessorAppendix HAgency Consent Letter125126Appendix H^The Corporation of theTownship of RICHMOND300 - 8120 GRANVELLE AVENUE, RICHMOND, B.C. WY 1P3(604) 278-3361 FAX 660-1113HEALTH DEPARTNIENT - CONTINUING CARE DIVISIONNovember 27, 1992Dr. Sharon Manson SingerSchool of Social WorkUniversity of British Columbia2080 West MallVANCOUVER, B.C.V6T 1Z2Dear Dr. Singer,This letter is to acknowledge that Eileen Dougall Reilly has beenapproved to conduct her research for her Masters Thesis in theContinuing Care Division of the Richmond Health Department in thenew year (1993), contingent upon approval from the University ofBritish Columbia Ethical Review Committee.Yours truly,Beverley Latrace,Director, Continuing Care Division,Richmond Health Department.BL/aaAppendix IEthics Approval Letter (UBC)127The University of British ColumbiaOffice of Research ServicesBehavioural Sciences Screening Committeefor Research Involving Human SubjectsDEPARTMENTSocial WorkINEMTL/TION(S) WHERE RESEARCH WILL BE CARRIED OUTSimon Fraser UniversitySimon Fraser University, St. Paul's Hospital, BC Children's Hospital FdnPRACIPAL INVESTPDATORManson, S.12811 February, 1993 •Notice of Ethical ReviewThe Committee has reviewed the protocol for your proposed study, and has issued a Certificate ofApproval on the condition that evidence that the following requirements have been satisfied will besupplied to the Office of Research Services before commencement of the research :In addition to Dr. Manson Singer's recommended changes in Appendix 1, the followingadditional points must be addressed:1) McLaughlin: Put the consent form on UBC letterhead.2) Anderson: Put all letters and forms on UBC letterhead.3) Mackinnon: Explain how the 27 participants in the second survey will be identified.If you have any questions regarding these requirements, please call:Dr. Barbara McGillivray, Chair, 875-2157Dr: Allan Hannam, Associate Chair, 822-3416Ms. Shirley Thompson, Manager Ethical Reviews (ORS), 822-8584PLEASE SEND ALL CORRESPONDENCE TO:THE OFFICE OF RESEARCH SERVICES, 323 WOODWARD-IRCUBC CAMPUS ZONE 3Appendix JRichmond and Lower Mainland Continuing Care Stats129STATS - EFFECTIVE FEBRUARY 28, 1993CCD Homemaker Services Richmond L.M.(Ex. Rmd) Province (All Units)No. Clients 1,320 16,492 44,019No. Hrs. Srv./Mos. 15,969 222,205 580,603Average Hrs.Per Client/Mos. 12.09 13.47 13.19(L.M.) Lower Mainland =^BoundaryNorth ShoreVancouverBurnabySimon Fraser130KAppendix KTelephone Follow-Up Conversation131132Example of telephone conversation used at initial recruitment after LTCassessors asked clients if they would be interested in participating in the study:Hello Mr/Mrs^This is Eileen Dougall Reilly calling. ^ has just called me to tell meyou might be interested in participating in my research project through theUniversity of British Columbia and Continuing Care. As  (Assessor) hasprobably mentioned to you, although I work as an assessor for Continuing Care,myself, I am also a graduate student in the faculty of Social Work and I amstudying community-dwelling senior citizens like yourself who have beenreferred for homemaking services. Do you think you might still be interested inparticipating in my study?(If answer is yes) - Thank you very much. I would like to come to see you at yourhome at your convenience to have you respond to some statements about howyou're feeling. What time and day do you think would be convenient for you?Thank you for agreeing to be part of my study. I'm sure you will find itinteresting.(If answer is no) - Well, thankyou, I understand. I certainly don't want you to feelobligated to participate. Your acceptance or refusal will certainly not affect theprovision of your homemaking service. Thank you for considering it, however,Good bye.Appendix LQualitative Questionnaire133134Qualitiative Questionnaire^ March 1993(Restructured format)1. What, if any significant changes have taken place in your life overthe past 6 (8 or 1.0) weeks?2. What is your opinion of the homemaking service?3. How do you view your homemaker? (Or what is your opinion ofthe homemaker, if the wording is not understood properly bysubject)4. What would you like to see happen that might improve thehomemaking service for you and other Continuing Care clients?Appendix MThank You Letter to Respondents135THE UNIVERSITY OF BRITISH COLUMBIA 136School of Social Work2080 West MallVancouver, B.C. Canada V6T 1Z2Tel: (604) 822-2255^Fax: (604) 822-8656June 16, 1993DearI am writing you to thank you for your valued participation in myresearch. As you recall, I asked you a number of questions about the way youwere feeling, before we started homemaking for you and then several weeksafter. I was interested in measuring your perceived psychological and physicalwell-being before and after services to see if there were any changes in yourscores after six homemaking visits.The results of the study show that most of your well-being scores did, infact, improve after you received homemaking services from Continuing Care. Italso appears that homemaking services and the homemaker may have beeninstrumental in enhancing your sense of well-being. At this time I am unable toinfer causation, but hopefully this study will provide the impetus for furtherevaluation and studies in this important area.As well, you shared with me some of your concerns and praises aboutthe service, and this information was valuable. It is our plan at the HealthDepartment to take your comments seriously so that we may improve ourservice to you.I would like to thank you for sharing your valuable time and thoughtswith me, and allowing me into your lives for a short time. It was a great privilegeto know you. I hope your contribution to social sciences research and my mastersthesis was as enjoyable as it was for me. I hope to see you all this summer as Iwill be working again for the Continuing Care Department as an assessor.Sincerely,• Eileen Dougall Reilly, BA, BSW, RSW.

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