Problems Faced by Family Caregivers: New challenges Japanese society faces as a result of the changing profiles of family caregivers Mao SAITO (Presenter), Ryozo MATSUDA, and Masatoshi TSUDOME (Institute of Human Science, Ritsumeikan University) Introduction The main subject of this paper is Japanese male caregivers who are caring for their wives or parents at home. As a result of the aging of society and the decrease in family size, the proportion of male caregivers has gradually been increasing in Japan. The main purpose of this paper is to analyze the situation and problems of male caregivers and discuss their future support and government policy. Aging of society in Japan First, I will provide a brief overview of changes in composition of households and family caregivers in Japan. After the World War II, the proportion of three-generation households decreased, families became more nuclear and smaller. Now, Japan has the highest ratio of elderly people in the world. In particular, the number of people over 75 years old is increasing dramatically. Recently, the number of households composed of elderly people, including single elderly, is increasing. Many elderly people live alone or with their partner. In the future, the problem of establishing a public care system and providing higher quality care will become one of the most important social issues in Japan. The change in profiles of family caregivers In prewar days, the patriarchal system meant that the head of a household had absolute authority to decide everything, including choosing his children s spouse. In that family system, women were supposed to take the role of carer. Despite an amendment to the Civil Code in 1947, in which women were given equal legal rights to men, including the right to choose a spouse, the norms of the old family system have remained. Accordingly, women are still expected to take the role of carer of their husbands and parents-in-law. Chart 1 shows the relationship between the main carer and care recipient. In 1968, the 1
main carers were still women; daughters-in-law being the majority (Figure 1). This is the typical attitude to the care of elderly parents in Japan. From the mid-1970s, the profile of carers has gradually been changing in response to demographic, social, and economic trends. The most important factor has been the increase in women entering part-time employment. Furthermore, married children are more likely to live separately from their parents due to the rise of mobility. As a result, family size has become smaller. As the number of daughters-in-law who took the role of carer decreased by approximately 50% between 1968 and 2004, the number of male caregivers increased by 28.2% in the same period. In fact, as a result of changes in attitudes to the care of spouses or parents, the relationship between caregiver and care recipient has also changed. In the past, wives traditionally took care of their sick husbands. But husbands rarely took care of their sick wives or parents. That was the duty of women: daughters-in-law or biological daughters. Today however, the number of men who are taking care of their sick wives or parents is gradually increasing. Figure 1 The change of the relationship between main carer and care recipient Source: the Japan National Council of Social welfare (1968, 1977), the Health, Labor and Welfare Ministry (1998, 2001, 2004) 2
The gradual appearance of male caregiver In the 1980 s, the burdens of family caregivers became a social issue, and the socialization of elderly care became a government policy issue in the early 1990 s. In December 1997, the Long Term Care Insurance System was established. The system assumed that caring was not a family responsibility but a social responsibility. It aimed to reduce the burden faced by family caregivers by providing with more professional care and support. It was put into force in April 2000. The introduction of care support made it easy for men to become involved in nursing-care at home. The appearance of male caregivers has helped to deconstruct the breadwinner-caregiver dichotomy, and to construct a new balance of responsibilities between genders in the family. As stated above, traditional responsibilities for family care was thought of as only a female role, so the burden of family care was considered a woman s problem. From this standpoint, the existence and increase of male caregivers has been largely neglected or overlooked. Male caregivers have often been portrayed as valiant or deviant (Thompson, 2002) when compared to women, even though male caregivers make an important contribution. Only the quantitative increase of male caregivers and the inverse decrease of daughters-in-law caregivers does not mean an improvement of gender equality. Gender inequalities in the provision of care by family members still remain. Furthermore, the abuse of the elderly, murders or double suicides all resulting from the burden of care giving, have not declined in Japan (Table 1). We should also note that the majority of the abusers and murderers are men. Table 1 Profiles of batterer in elderly abuse in April 2006- March 2007 Source: the Health, Labor and Welfare Ministry (2008) In Japan, the conditions and problems of male caregivers had not been pointed out by prevalent discourses on elderly care regardless of their increase. To focus on male caregivers may clarify the issue of long-term care policy in Japan. In particular, it could be important to reveal unique challenges faced by male caregivers, in order to reconsider the relationship between informal and formal support systems. It could also 3
lead to the improvement of the balance in caring responsibilities between men and women. Method In 2006, we conducted a national questionnaire survey for male caregivers (Tsudome and Saito, 2007). It was the first survey at a national level. We collected samples from 295 male caregivers who had used care services from the Health Co-operative Association of the Japanese Consumers Co-operative Union. The survey items are as follows: profiles of carers and care recipients, family relationship and support from other family members, difficulties in daily life and caring, the use of support services and needs for services (care attendant, nursing home etc), feelings and burden of caring, and free response questions(main difficulties in caring life, personal coping tactics, and future hopes). Findings (1)Demographic Profile The average age of respondents was 69.3 years old (range from 36 to 93). The largest age group was those aged 70 to 79, and the second largest age group those aged 60 to 69. The average age of care recipients was 79.1 years old (range from 50 to 102). 58.3 % of the respondents took care of their wives, 24.7% for their own mothers, and 7.8% for their own fathers (Table 2). The relationship between the respondents in their 60s and care recipients divided in two; spouse and parent. This indicates a possibility of double care-giving (Table 3). 4
Table2 The relationship between male caregivers and care recipients Table 3 The age of male-caregivers by relationship with care recipients Source: Tsudome and Saito, 2007. Source: Tsudome and Saito, 2007. 65.1% of all respondents were in poor physical condition, and 57.3% actually got medical treatments regularly. In fact, many male caregivers faced the double burden caused from caring itself and their own health problems. 73.9% of respondents did not have any job. The largest reason for unemployment was compulsory retirement; the second, retirement because of caring responsibilities (21.6%); and the third, unemployment or bankruptcy (6.9%). The respondents who were full-time workers made up only 5.8%. In addition, users of the Family Care Leave System were a mere 0.01% 1. This shows that in Japan, a traditionally patriarchal society, it is even difficult for men to return to paid work after taking on the role of caregivers. It is even more challenging for men to maintain their job and their care giving responsibilities simultaneously. Therefore, it is necessary to fundamentally improve the terms and conditions of compatibility between work and care. (2) Everyday life The period of caring has become longer. The average periods of caring was 62.3 months. Time of caring involvement in a day was likely to be remarkable too. Almost half the respondents (47.8%) spent more than half a day on caring. For most of them, it was difficult to enjoy any free time, and they were restricted in their relationships with friends, and their participation in social activities. They lived isolated lives. The degree of long-term care need has become higher and the amount of care task 1 The national use of the Family Care Leave System was only 0.04 % of those entitled to take it in 2005. (women 0.08%; men 0.02%). (Health, Labor and Welfare Ministry, 2006) 5
involvement bigger, while the size of households has become smaller. The majority of households contained two-people (58.3%), 39% consisted of a couple, and 17.6% consisted of a parent and child. Most two-people households are expected to be the family type that consists of just caregiver and care recipient. In this situation, the male caregiver is more likely to be isolated. Only 29% of respondents could get support from other family members who were living in the same household. With respect to the types of support, the most usual type was interchangeable support (helping with housework or physical caring) on behalf of the respondents. On the other hand, emotional support given to the carers by other family members was relatively low. This was probably because male caregivers were less likely to complain or express other negative feelings. It does not mean they were experiencing little distress. The most common difficulties that the respondents faced in daily life were cooking (43.4%), sewing (40.3%), and cleaning (23.7%) (Figure 2). For example, a respondent in his 70s who was caring his wife gave a symbolic answer as follows: I had never made coffee for my family before I started caring. Figure 2 Difficulties with doing housework (multiple answers) Source: Tsudome and Saito, 2007. 6
At the same time, the most common difficulties in physical caring were bathing (33.6%), toileting (32.5%), and washing hair (17.6%)(Figure 3). After the introduction of the Long-Term Care Insurance System, physical care (bathing, washing hair, feeding) that was previously done only by family members, can now be carried out by the private sector. However, hands-on care (toileting, dressing, 24 hours monitoring) is still usually carried out within the family. The difficulties faced by male carers can be interpreted as a result of their life course. The typical male life course in Japan is primarily focused on paid work. Work experience for men is central in maintaining their sense of identity. In fact, these difficulties could lead to specific strain placed on men who are ill-prepared for their new roles. Figure 3 Difficulties with physical caring (multiple answers) Source: Tsudome and Saito, 2007. (3) Support services and relationships Almost every respondent has been using various care services (95.6%), including home-visit nursing care services (42%) or day care services (regular visits to a nursing care facility) (30.5%). And many respondents depend on professionals including nursing care managers, primary care doctors, or care attendants (home care workers). 7
While the socialization of nursing care has extended and enhanced the credibility of professionals, the relationship between the respondents and their neighbors has the tendency to be poor. 40.7% of male caregivers who were previously working full-time said that they rarely greeted or associated with their neighbors. This tendency is unconnected to the length of time they had inhabited their house. Respondents whose relationship with neighbors had changed after they started caring were 22%. Specifically there was a tendency for sole male caregivers to become even more isolated from their neighbors than they were before they became caregivers. (4) Feelings and burden of caring In regard to abusive behavior, the percentage of respondents who actually had hit care recipients was only 10.5%. The proportion of angry or negligent caregivers was relatively higher (angry, 38%; negligent, 22.7%). The incidence of abusive behavior and its potential risk could be partly accounted for by the burden of the family caregivers. In this survey, many respondents felt distress (80.6%). However, most of them simultaneously felt satisfaction during caring. It is necessary to recognize that caring behavior towards family members inevitably brings ambivalent and complicated feelings, especially feelings based on love. Discussion We could find several common issues throughout this survey. (1)The change of the family relationships through caring First, we should take into account the change of the family relationships through caring when we design the elderly care systems in the future. As already mentioned, carers who take care of their spouse or biological parents have become the majority. Also, the number of elderly men and women who take care of their spouses, is likely to increase when those born in the post-world War II baby-boom period reach their seventies and beyond. As elderly couples do not often live with their children, their lives are possibly isolated and they are unlikely to get any support from other family members. Furthermore, the carers who take care of their biological parents are expected to increase, too. One reason is related to the trend toward later marriages. It is difficult for unmarried single carers to find potential partners. The increase in unmarried carers could lead to the additional tendency to marry later or not to marry. Secondly, the number of couples separating in order to care for their respective parents is expected to 8
increase. Some separated carers will possibly divorce as a result. The reduction of gendered family support obligations causes an increase in male caregivers in different ways. (2)Problems with male caregivers Many male caregivers in this survey had health problems. When men take care of their family members, they are likely to face economic difficulties too. It is an urgent issue to construct a system that creates a balance between work and nursing-care. Furthermore, it is of critical importance for male caregivers to overcome domestic skills difficulties caused by caring. As many male caregivers have centered their everyday lives upon paid work outside the family, taking care of someone in the family could be seen as an unexpected career (Pearlin, et al., 1994). Male caregivers are likely to take the role of carer as a job, and not to seek any help or support including that of neighbors and family members. We should reconsider the current long-term care system that assumes caregivers have house-keeping skills as a matter of course. In fact, welfare policies to address the limitation of domestic skills of family caregivers should be developed in addition to the provision of formal long-term care. (3)Support for family caregivers The Long-Term Care Insurance System was originally intended to provide with professional support to long-term care of the elderly and to enable them to maintain their human dignity through to the end of their lives. This system was initially planed to be a user (care recipient) -oriented system in which necessary services are received through a unified comprehensive procedure regardless of the types of household composition. But recently, the system has increasingly become dependent on the care provided by the family due to the country s poor economic situation. For example, when there is someone who lives with the user and takes care of him/her, the user can not always receive home help services regardless of the domestic skills of the caregiver. These home help services are extremely inefficient, because the services are provided only to the user, not to the family caregivers. As noted above, many male caregivers face acute domestic skills difficulties. Of course female carers may face the same problems too. The long-term care system should involve the support of carers lives as well as the users. It is particularly necessary to identify heavily involved family caregivers, assess their needs, and support them in their caring activities. 9
Conclusion What should the socialization of long-term care be? It should not be just the outsourcing of care. It should also be the support of the relationship between family caregiver and care recipient, even though they lack domestic skills, while at the same time reduce the burden of the carer. This survey was just the first step to highlight the role of male caregivers in Japan. To focus on male caregivers will lead us to clarify the situation and problems of family care giving and to reveal the issues of future long-term care services. This survey should also encourage community-based care services to reorient support towards family caregivers. Finally, it should lead to the development of programs to prevent abuse of and murder of the elderly. Male caregivers are not a homogenous group. It is important to avoid the tendency to reinforce a stereotype of the image of male caregivers experience as compared to women. We should understand the various experiences of male caregivers in all its diversity. Now, we are conducting qualitative research on male caregivers, to carefully listen to their voices. This research will help to reflect their various experiences on the practices of professionals as well as long-term caring policy of the government. Since the end of 1990s, peer support programs for male caregivers in Japan have started to emerge. In these programs, male caregivers have shared information and their own feelings. I conclude that future research should focus on the development of the support for family caregivers, in public, private and community initiatives, in order to develop higher quality care. Reference 2007 (Masatoshi Tsudome, Mao Saito, 2007, Japanese Male Caregivers. Proposal of Support for Family Caregivers, Kamogawa Books). Pearlin, Leonard I., Carol S. Aneschensel, 1994, Caregiving: The Unexpected Career, in: Social Justice Research, 7[4]: 373-390. The Health, Labor and Welfare Ministry, 1998. 2001, 2004, The National Livelihood Survey. Thompson Jr., E. H., 2002, What s unique about men s caregiving? In: Kramer, B. J., Thompson Jr., E. H.,(eds.), Men as Caregivers, Prometheus Books, 20-47. 10