Old age and caregiving in a Black community

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Old age and caregiving in a Black community
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Lawson, Sylvia Cicily Claire, 1936-
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Older African Americans -- Florida -- Eatonville   ( lcsh )
Older people -- Care   ( lcsh )
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Thesis:
Thesis (Ph. D.)--University of Florida, 1990.
Bibliography:
Includes bibliographical references (leaves 252-268).
Statement of Responsibility:
by Sylvia Cicily Claire Lawson.
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Typescript.
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Vita.

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OLD AGE AND CAREGIVING IN A BLACK COMMUNITY


By

SYLVIA CICILY CLAIRE LAWSON


















A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE
UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE
REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY


UNIVERSITY OF FLORIDA


UNIVERSITY OF FLOI:A LIDlMJES


1990



































Copyright 1990

by

Sylvia Cicily Claire Lawson

















In Memory Of My Parents

Eunice E. Earle
(1899 1983)

Stanford A. Earle
(1884 1959)

and My Sister

Rowena E. Earle Mitchell
(1920 1980)















ACKNOWLEDGEMENTS


I would like to express my appreciation to the many

persons who provided me with their help, time, and moral

support in the production of this dissertation. These

persons include friends, family members, faculty members at

the University of Florida, and the government and people of

the Town of Eatonville, Florida.

Special thanks are extended to my chairperson, Dr. Lee

Crandall, whose patience and support were above and beyond

the call of duty. Without his guidance, critical comments,

and constant encouragement this dissertation would have taken

much longer to complete.

I am also very grateful to all the other members of my

committee. Dr. Akers has been a special tutor, mentor and

friend who has encouraged me throughout my graduate career.

His critical comments and helpful suggestions ensured that

the dissertation was satisfactorily completed. Dr. Vera has

been a special friend, teacher and mentor throughout my

graduate career. Dr. Paul Duncan steered me on the original

path to Medical Sociology. Dr. Kelso has given me support

and many ideas throughout my graduate career, and Dr. Gubrium

sowed the seeds of caregiving for the elderly. I owe a








special debt of gratitude to Dr. Faye Gary Harris for her

encouragement and for willingly stepping in at the last

minute as a substitute committee member. Thanks also to Drs.

Felix Berardo and Joseph Vandiver for their support and

encouragement, and to Dr. Michael Radelet for supervising the

pilot study and encouraging me to proceed with the research

project.

Collecting the data for this dissertation would not have

been possible without the assistance of the people of the

Town of Eatonville, who, without reservation, opened their

doors and their hearts to me. To them all I say thank you.

Some support for this research was provided by the

Office of Affirmative Action, University of Florida. I am

especially grateful to Dr. Jacqueline Hart for her assistance

and encouragement.

Thanks to the American Sociological Association for

providing me with a Fellowship, and to the University of

Florida for providing me with a Fellowship. Several other

persons at the University of Florida including Dr. Madeline

Lockhart, Dean of the graduate school, and Dr. Art Sandeen,

Vice President for Student Affairs, have been very supportive

and encouraging.

Thanks to Ms. Connie Sadler for her assistance in

transcribing the taped interviews and to Ms. Nadine Gillis

for the final product. To my dear friend Barbara Cohen I

will always be grateful for her love, caring, and support.








Special thanks to Revd. Dr. Gary Crawford and my church

family at the Westside Baptist Church for their love and

caring over the years. I could not have survived without

them.

The support and encouragement of my close-knit family

sustained me daily. I am grateful for the support of my

sisters and brothers-in-law, Mary and Vernal Dyce, Agnes and

Augustus Wright, and Monica and Clive McKenzie; my brothers

and sisters-in-law, Joseph and Pearl Earle and Jonathan and

Yvonne Earle; and my brothers John and James Earle. Special

thanks to my brother Jonathan who was always there for me

with his daily words of encouragement and for all his

assistance. Thanks also to my cousin Iretta for her support

and encouragement.

My two children Deirdre and Peter took on the

responsibility of parenting their mother during the long

arduous years of graduate school. I can only hope that they

will be proud of and benefit from my accomplishments.















TABLE OF CONTENTS



ACKNOWLEDGEMENTS........................................ iv

LIST OF TABLES.......................................... xi

LIST OF FIGURES......................................... xii

ABSTRACT................................................ xiii

CHAPTERS


INTRODUCTION..................................


America's Elderly: An Overview....
Marital Status ....................
Health Status .....................
Living Arrangements...............
Housing Alternatives............
State of Health .................
Visitation by Family and Friends
Racial Constraints...............
Geographic Distribution...........
Standards of Housing..............
Income of the Elderly.............
Plan of Research...................


BLACK FAMILIES--BLACK ELDERLY PERSONS.........

Definition of Family...........................
Black Families.................................
Socio-Demographic Profile of Black Families...
Education...................................
Economics...................................
Marriage and Divorce.........................
Living Arrangements of Children.............
Young Adults Leaving Home...................
Conceptualization of Black Families...........
Kinship and the Extended Family...............
Black Elderly Persons..........................
Marital and Living Arrangements.............
Housing.....................................


vii


ONE


TWO









Health Status ............................... 58
Economic Status ............................. 60
Religion.................................... 63
Kinship Relations and Family Support........... 66
Summary ....................................... 67

THREE CAREGIVING.................................... 69

A Review of the Literature..................... 69
Caregivers and Caregiving..................... 71
The Formal Support System..................... 73
The Informal Support System................... 75
Impairments of the Elderly..................... 77
Visual Impairment ............................. 79
Mental Impairment ........................... 80
Activities of Daily Living.................... 88
Instrumental Activities of Daily Living........ 89
Support Systems for Elderly Black Persons..... 90
Caregiver Stress and Burden................... 93
Caregiver Stress.............................. 93
Felt Burden.................................. 94
Caregiving and the Black Elderly ............ 96
Summary........................................ 99

FOUR METHODOLOGY AND RESEARCH SETTING............. 100

Methodology.................................... 100
The Research Setting........................... 105
Demographic Profile ........................... 109
Education.................................... 111
Economics................................... .112
Politics ...................................... 115
Housing. ...................................... 115
Religion. ..................................... 115
Recreation. ................................... 116
Caregiving in Eatonville ...................... 119
Sample for Interviews and Quantitative
Analysis ................ ................... 120
Measurement of Variables...................... 123
Operationalizing the Major Variables.......... 124
Age of Respondent............................ 124
Gender of Respondent... ..................... 124
Marital Status .............................. 124
Residential Status .......................... 125
Living Arrangements......................... 125
Disability.................................. 125
Health Status ............................... 125
Number of ADL Tasks.......................... 126
Number of IADL Tasks......................... 127
Socio-Economic Status....................... 127


viii









Family ..................................... 129
Care Receiver................................ 129
Caregiver.................................... 129
Formal Support............................... 129
Informal Support ............................ 132
Agency Awareness............................. 133
Indication for the Need for More Help........ 134
Summary....................................... 134

FIVE FINDINGS AND DISCUSSIONS...................... 136

Vignette #1.................................... 139
Vignette #2.................................... 145
Vignette #3................................... 147
Vignette #4 ................................... 154
Vignette #5.................................... 156
Vignette #6.................................... 163
Quantitative Descriptive Analysis............. 170
Family....................................... 173
Children, grandchildren and siblings...... 173
Migration.................................. 176
Occupation and work........................ 178
Income source.............................. 180
Marital and living arrangements............ 183
Home and land ownership.................... 183
Household composition ..................... 186
Impairments................................. .191
Activities of Daily Living-ADLs........... 191
Instrumental Activities of Daily
Living (IADLs) .......................... 193
Caregiving. ................................ 196
Cross Tabulations of Quantitative Data...... 198
Need help by caregiver.................... 201
Formal support by informal support......... 202
Agency awareness by formal support......... 203
More help needed by age.................... 204
More help needed by sex................... 204
More help needed by disabled status....... 204
More help needed by formal support......... 209
More help needed by number of health
problems. ................................ 210
More help needed by informal support ..... 214
More help needed by other agency
awareness. ............................... 217
Discussion. ................................... 218
Summary .................................... 220









SIX CONCLUSIONS AND IMPLICATIONS.................. 221

Implications for Future Research.............. 222
Policy Implications............................ 223


APPENDICES

A CODING........................................ 237

B SURVEY OF CAREGIVING RESPONSIBILITIES......... 239

C INFORMATION SHEET. ............................ 247

D CHARACTERISTICS OF EATONVILLE'S ELDERLY
ACCORDING TO AGE COHORT....................... 249

E POSITION OF ORANGE COUNTY IN THE STATE
OF FLORIDA. ................................... 250

F POSITION OF THE TOWN OF EATONVILLE............ 251

REFERENCES............................................. 252

BIOGRAPHICAL SKETCH. .................................. 269















LIST OF TABLES


Table Page

4-1 Population Figures--Eatonville--1980........... 110

4-2 Age Distribution--Eatonville--1980............ 110

4-3 Number of Households--Eatonville--1980........ 110

4-4 Average Number of Persons per Household--1980. 111

5-1 Characteristics of Eatonville's Black
Elderly Sample................................. 171

5-2 Summary Table of Elderly Sample by Offspring
and Siblings ................................ 174

5-3 Current and/or Previous Occupation............ 179

5-4 Summary Table of Marital, Residence and
Household Status .............................. 184

5-5 Summary Table of Activities of Daily Living... 193

5-6 Summary Table of Instrumental Activities of
Daily Living................................. 195

5-7 Summary Table of Caregiving Characteristics
of Eatonville's Elderly Sample ................ 197

5-8 Means, Standard Deviations and Other Values
of Major Variables............................. 199

5-9 Results of Tests of Significance and Measures
of Association................................ 200

5-10 Degree of Help Needed Based on the Number
of Health Problems............................. 213

5-11 The Need for More Help Based on Type of
Informal Support Received..................... 215

5-12 The Need for More Help Based on Type of
Community Support Received.................... 216















LIST OF FIGURES


4-1 Schematic Representation of the Place
of the town of Eatonville in the East
Orlando Community .............................. 118

5-1 Diagram showing the combinations of level of
dependence and type of support described in
each of the six vignettes of elderly persons
in the community ................................ 169


xii














Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy

OLD AGE AND CAREGIVING IN A BLACK COMMUNITY

By

Sylvia Cicily Claire Lawson

August, 1990

Chairman: Lee A. Crandall
Cochairman: Jaber F. Gubrium
Major Department: Sociology

Currently existing formal and informal support systems

necessary for providing a better quality of life for

noninstitutionalized elderly persons, especially those who are

poor and Black, may be inadequate. This research employs a

conceptual framework and methodology designed to examine

knowledgeability, accessibility, and use of services among

noninstitutionalized elderly Black persons. The social and

cultural situations of Black elderly persons are examined to

assess whether these elements determine and or contribute to

their participation in, and knowledge about, available formal

sources of assistance for instrumental activities of daily

living (IADLs). The analytical model differentiates elderly

persons who are users from non users of formal services and

assesses their knowledgeability regarding formal and informal


xiii








services which are in place to assist them with various IADL

functions.

Information was gathered, over a period of approximately

twelve months, on a convenience sample of 71 elderly persons in

an all black community in central Florida, using in-depth

interviews and participant observation. This approach provides

process data rather than the typical snapshot supplied through

one-shot survey interviews. The nature of the design of the

study allowed for the cross-checking and rechecking of what

people say and do, increasing the reliability and accuracy of

the data.

The data gathered by this research do not support

assumptions about kinship patterns of informal caregiving that

place great emphasis on the role of the black extended family.

A large proportion of the elderly studied were living alone.

The findings suggest that black elderly persons have limited

awareness of the various services available through government

agencies to assist them with their IADL functions. They

instead utilize informal agency sources of help or do without

needed services. The informal system of caregiving in this

community also appears to fall short of providing the

assistance needed by black elderly persons.


xiv














CHAPTER ONE
INTRODUCTION


Caregiving in its simplest form refers to care provided

to someone who, because of physical or other limitations, is

unable to perform certain functions unassisted. The concept

of caregiving to the elderly is well defined by Horowitz

(1985), as care provided to persons over the age of 65 with

some degree of physical, mental, or emotional impairment

which limits independence and necessitates ongoing

assistance. This is the concept of caregiving used in the

present research.

Insufficient caregiving for functionally disabled

elderly persons in the community has become a serious social

problem in American society. The responsibility of caring

for persons 65 years of age and over, which has been for

centuries primarily the responsibility of the family, one

segment of the informal support system, has now become a

joint venture between the state (the formal system) and the

family. The informal support system consists of all unpaid

help provided by family, friends, neighbors, or others who

are not part of a group formally organized to provide long-

term care assistance (Branch and Jette, 1983). Formal

support on the other hand, refers to organized care provided









by government or voluntary organizations or agencies that

exist to provide long-term care services to the

noninstitutionalized impaired elderly (Branch and Jette,

1983). Once responsibility shifts to or involves the state,

there are social as well as moral obligations to be

addressed. The question becomes: are those who are in need

receiving the care needed to lead a reasonably satisfactory

level of daily living? Where the formal system of caregiving

falls short, the burden shifts to the informal system to give

needed support. Where the informal system falls short,

governmental assistance is needed.

This research focuses on the informal system of

caregiving to elderly black persons in need. The literature

on black families has continued to expound on the primary

role played by these families in taking care of their elderly

relatives in the extended family setting. The general

consensus is that the informal system is especially strong in

the black community. The question is: to what extent is this

image of elderly care in the black community accurate? That

is: are black families still playing the role of caregivers

to their elderly relatives in these final decades of the

twentieth century? In spite of the consensus in the

literature, there has been very little empirical research on

the role of the extended family and other informal caregiving

for black elderly persons. Although the gerontological

literature is replete with studies concerned with caregiving









for the elderly, there is very little research on caregiving

for black elderly persons. This research takes a careful, in-

depth, qualitative approach to locating and describing the

state of care, informal and formal, provided for elderly

persons in one black community. To the knowledge of the

researcher this is the first study to do so. The purpose is

to contribute to our knowledge of how needy elderly persons

are cared for in the black community.

This study, then, is an attempt to help fill some of the

gaps in research on elderly black persons. The problem is

mainly one of supports for this population of persons. Black

elderly persons in need of assistance are more likely than

white elderly persons to be in residence in the community

than in institutions. The general question that needs to be

answered is: what are the systems in the community that do or

do not provide care for black elderly persons who are in

need? The systems that are available for providing care to

elderly black people fall into two distinct but interrelated

categories of the formal and the informal caregiving systems.

The major part of the study was conducted through visits,

observations and interviews concentrated on the informal

system mainly during the year the researcher spent in

residence in Eatonville, historically, an all black

community in Florida. Data were also gathered on the formal

system through interviews with government officials,

published data, and record archives.









As noted, the central reason for embarking on a study

such as this is to see to what extent black family

traditions, and community traditions have an impact on

caregiving to elderly persons. Is the traditional view of

the importance of the extended black family myth or reality?

It is possible to obtain answers to this question in a

variety of ways, but the researcher opted to conduct the

study in Eatonville for several reasons. It was felt that a

predominantly black community would present a more

homogeneous group of elderly persons. Also, it was believed

that black traditions and social support systems would be

most viable and visible in a community which had a long-

standing identity as an autonomous community rather than

being just a semblage of neighborhoods. Eatonville was

selected because it closely fit the model of a community

which was nearly all black with some historical identity as a

separate community of black citizens.

Answers to the above questions have implications for

policy makers. A study such as this should also have

implications for the discipline of sociology, especially to

the fields of social gerontology and medical sociology, since

black elderly persons and their need for health and other

care as a group represents a source of potential research

interest and constitutes a segment that has received very

little study. However, the focus is primarily applied and

descriptive social research addressing the physical, social,









mental, and financial welfare of noninstitutionalized black

elderly persons, (aged 65 years and over). There is little

theoretical development in the literature on which to build,

and neither testing nor construction of theory is a goal of

this research. Rather, the goal of this research is to

provide a description of the informal and formal care given

to black elderly persons based on their perceptions and

descriptions and on the researcher's own observations. The

notion of caregiving having been introduced, an overview of

the elderly in America will be presented.

America's Elderly: An Overview

There are today approximately twenty-seven million

persons aged 65 and over in the United States, comprising 12

percent of our population (U.S. Bureau of the Census, 1984).

This translates into approximately one in nine Americans who

are aged 65 years and over. Older persons today are

categorized as falling into three groups: the young-old, 65

to 74; the old-old, 75 to 84; and the oldest-old who are

those aged 85 years and over. Demographic shifts are evident

due to the rapid graying of America in the decades of the

1970s and the 1980s as well as projections for the 1990s and

well into the twenty-first century. The trend is toward a

progressively older society. By the year 2030, when the core

of the baby boom generation reaches retirement age, the

projection is that over one in five Americans will be aged 65

or older (U.S. Bureau of the Census, 1984). It is also









estimated by the Census Bureau that the very old, those 85

and older, will increase from 2.7 million today to 8.6

million in 2030 and 16 million in 2050. These shifts have

forced the polity into the realization that there is need for

the creation of more support systems to care for these

elderly persons.

The proportion of people who are elderly varies by race,

ethnicity, and sex. People aged 65 and over make up 12

percent of all whites, 8 percent of blacks, 6 percent of

Asians, and 5 percent each of the Hispanic and American

Indian populations (Hess, 1986). Despite the goal of the

1965 Older Americans Act to enable the aged to maintain

independence and to improve the quality of their 1ives, the

practice of institutionalizing functionally impaired older

people continues unabated (Olson, 1982). The problem is not

so much with current numbers of persons institutionalized,

but with the rate of institutionalization. This is, a 2

percent rate of institutionalization in 1910 amounted to

80,000 persons, whereas the 1980 rate (at 5.0 percent

institutionalized) translates to over one million elderly

persons living in institutions, a better than tenfold

increase (Olson, 1982). If the rate of institutionalization

continues to increase as the population ages, then by the

early twenty-first century the numbers of persons in such

care will grow still further. Despite increases in the rate

of institutionalization, there still remains a large









percentage of elderly persons (95 percent to 98 percent) who

are not institutionalized at any given time. Blacks make up

11.69 percent of the United States (US) population. That is

26,488,218 persons (U.S. Bureau of the Census 1980). Of the

population of black persons in the United States,

approximately 2.2 million are over the age of 65 years.

Elderly black people have many problems that elderly white

people do not have. This situation is referred to by some as

double and triple jeopardy (Jackson, Kolody, and Wood, 1982;

Kart, 1985). That is, they have the problem not only of

being elderly, but complicating this are the features of

being black and, for the majority, of being poor. Black

females have quadruple jeopardy, that is, of being old,

black, poor, and female.

Because of the uniqueness of their situation, blacks

should be studied separately as a subgroup of the elderly

population who have special needs and who need special

attention from researchers. As early as 1968, Billingsley

pointed out that, even though the black family system is one

institution in a complex of various American institutions,

the black family cannot be totally understood or interpreted

from a general (white) analytical framework. The limits of

using a general analytical framework have been evidenced

through various studies. Areas such as poverty and kinship

patterns are very important in any study relating to black









families. The same does not hold for the general U.S.

population.

Poverty is suffered by large numbers of elderly black

people today; in 1981, 39 percent of elderly blacks lived

below the poverty level (U.S. Bureau of the Census, 1981).

The systematic racial discrimination tolerated in the United

States during the early decades of this century resulted in a

lack of education for this cohort of individuals leading to

lack of professional qualifications for the majority and

hence the impossibility of procuring high-paying jobs. This

led to marginal occupations and dependence on social services

agencies throughout the life of many blacks, and gave them

little access to private pensions. In the case of black

elderly people, this helps to explain the fact that few of

them are found in retirement villages, retirement

condominiums or such. Institutionalized racism exacerbates

the economic situation. Most blacks still feel uncomfortable

in white dominated communities.

Kinship patterns among blacks also contribute to the

preference that blacks have for remaining at home to the end

of their days. It has been claimed and it is generally

acknowledged that the black kinship network is more extensive

and cohesive than kinship bonds among the white population

(Staples, 1981). Research shows that for blacks the kinship

network serves its members most effectively as a functional

mutual aid system (Mindel, 1986). Numerous studies have









shown the positive effects of kinship networks among blacks,

but there are others that have found relatively few

differences by race among elderly people in participation

with family and kin (Heiss, 1975).

Most black elderly people have experienced extended

family arrangements. The offspring of black elderly persons

have traditionally felt responsible for their care and

welfare, whether they be parents, grandparents, or other

blood relatives. Even close family friends are ofttimes

afforded the same treatment as family in black communities;

sometimes such persons are termed "fictive kin."

Blacks have always been known to be religious. Churches

and friendly societies all cater to elderly black persons,

filling the gaps left void by government. Out of these

informal institutions have sprung such organizations as

Dorcas Societies and similar groups which have taken care of

clothing the poor. Black elderly women especially, while

benefiting from these organizations, also contribute a great

deal to them in terms of service. They voluntarily do sewing

and craft as means of helping each other.

The survival pattern for whites has always been better

than that of non-whites. However, the difference in life

expectancy at birth for whites which was 15.9 years higher in

1900-1902 than it was for blacks had, by 1982, decreased to a

4.9 year difference for females, and a 6.6 year difference

for males (U.S. Department of Health and Human Sciences,









National Center for Health Statistics, Monthly Vital

Statistics Report, 1983). In 1983 life expectancy at birth

for white males and white females in America was 72 years and

79 years respectively, while for black males and black

females it was 65 years and 74 years, respectively (U.S.

Department of Health and Human Services: Report of the

Secretary's Task Force on Black and Minority Health, 1985).

The lower life expectancy of blacks has been attributed to

their generally lower socio-economic status in the United

States (Butler and Lewis, 1983).

It has, however, been found that reversal occurs at a

certain age. At that age which has been termed the

"crossover point," blacks begin to show a greater survival

rate than whites (Cornely, 1970; Heiss, 1975; U.S. Dept. of

Health and Human Services, 1985). In 1976 the crossover was

found to occur at age 65 for men and 72 for women. This

"crossover" was first reported in 1968 (Heiss, 1975), but the

explanation for it was unclear and it was attributed to the

"survival of the strongest." This is still used to explain

this phenomenon (Manton, 1982; Markides, 1983). Although

blacks comprise about 11.69 percent of the total population

in the United States, black people make up only 8 percent of

the older age group. Black older women outlive black older

men. The.ratio of black women per 100 black men increased

from 115 in 1960 to 131 in 1970 and black females make up









56.7 percent of the total black aged population (Butler and

Lewis, 1983).

Marital Status

The majority of men over 65 years in the United states,

even those aged 75 and older, are married (79.8 percent in

1983), and living with their wife. In contrast, the majority

of women over 65 are not currently married (U.S.Bureau of the

Census, 1984a). Several factors contribute to the

probability that an older man will have a wife with whom he

will be living. One well known factor is that men typically

marry women who are younger than themselves while society

still discourages women from marrying men who are younger

than they are. This difference is exacerbated by the lower

life expectancy of males. Another factor is that the

remarriage rates of older men are higher compared to women

(U.S. Department of Health and Human Services Survey

1983b:7). In 1980, among nonmarried persons aged 65 and

over, men remarried at nine times the rate of women. The

result of this situation is that most older women are widows.

There are at least three times as many widows as widowers to

be found in the U.S. (Hess, 1986).

Among black elderly persons whether male or female, a

lower percentage are married both in the young-old period and

in the old-old period when compared to white elderly persons.

Substantially more black elderly persons are widowed and

divorced than are white elderly persons (Mindel, 1986). For









black women, aged 75 years and over, 78 percent are reported

as widowed in 1983 (U.S.Bureau of the Census, 1984). The

shorter life expectancy of black men is an important

contributory factor, leaving a black woman widowed much

earlier than a white woman.

Health Status

As people get older their resistance to new diseases

declines. Verbrugge (1986) states that chronic diseases

developed earlier in life tend to deteriorate, and although

acute conditions are less frequent in older persons, the

recovery period for them is longer. "Health status refers to

measures of illness, injury, and symptoms, including people's

own evaluations of their health, interview reports of health

problems, and data from medical examinations" (Verbrugge,

1986:182). Closely associated with, or linked to, health

status is "health behaviors." It is common knowledge among

health care professionals that health behaviors impact very

strongly on health status. "Health behaviors refer to all

curative and preventive actions, relating to short-term

disability ('restricted activity'), long-term disability

('functional limitations'), use of health services, and use

of medications" (Verbrugge, 1986:182). Culture plays a major

role in any analysis of health behaviors in that "cultural

patterns and typical ways of life give substance to the

manner in which illness is perceived, expressed, and reacted

to" (Mechanic, 1978:55).










There are some health problems which are common

companions to old age. These are heart disease, cancer,

cerebrovascular disease and hypertension. Heart disease has

been identified as the principal cause of death among the

elderly and accounts for a great deal of morbidity,

disablement, and inactivity in older people (Kart, 1985).

The incidence of cancer increases with age; hence, older

people should be encouraged to have periodic preventive

medical examinations. Cerebrovascular disease which

manifests itself as a stroke is the result of impaired brain

tissue. Cerebral thrombosis is a main cause of stroke in the

elderly. Kart (1985) notes that as many as one in four older

people have hypertension, or high blood pressure. Other

prevalent elderly-related health problems, which are

bothersome though less life-threatening, are arthritis,

digestive disorders, foot and skin problems, and chronic

respiratory symptoms (Verbrugge, 1986). Other health

problems associated with aging are the decline of sensory

(vision, hearing, balance) and mental faculties and the

weakening of bones and muscles. A popular manifestation of

bone weakening is osteoporosis especially in elderly females.

Elderly black persons demonstrate different

configurations regarding certain chronic diseases. There is

a higher incidence of hypertension among elderly black

persons. The incidence of diabetes is also reported to be

higher in elderly black persons. The same is true for









certain types of cancers (lung, esophagus, prostate, stomach,

cervix, uterus, multiple myeloma, pancreas and larynx). In

fact, it is reported that blacks have the highest overall age-

adjusted cancer rates (for both incidence and mortality) of

any U. S. population group (Report of the Secretary's Task

Force on Black and Minority Health,1986a. 1986b).

Health data confirm that older men are more seriously

ill than older women, but the data also indicate that older

women are more frequently ill than men. "Data on subjective

perceptions of health status, acute and chronic conditions,

and disability for acute and chronic conditions support this

conclusion" (Verbrugge, 1986:185).

When the health problems of elderly persons are analyzed

according to gender, older women are found to have more acute

and more chronic conditions; they are bothered more by their

chronic conditions, but these diseases are seldom life-

threatening. Older men have higher rates of life-threatening

conditions, which lead to employment restrictions and earlier

death. Attitudes and behavior toward illness may be very

important in explaining sex differentials in short-term

disability, limitations and death among older people

(Verbrugge, 1986).

The overall level of health of America's aged has not

changed greatly since 1970: "while there are proportionately

more chronically ill very old people, the younger aged are

reported to be in better health than in the past" (Hess,









1986:17). Nine-tenths of the elderly describe their health

as fair or better compared with other people their age

(U.S.Bureau of the Census, 1983), and over half report no

limits on any major activity because of health

considerations. By age 85 years and over these figures

shift, with half reporting themselves unable to carry out a

major activity because of poor health. In 1980, as in 1965,

four of five older people reported having at least one

chronic condition, although in most cases this did not

interfere with major activities (Hess, 1986).

Health status plays a major role in caregiving for

elderly persons. It is a key determinant in their living

arrangements.

Living Arrangements

The 95 to 98 percent of America's older people who are

not institutionalized live in the community, and most live in

their own households. Seventy-one percent of all persons

over 65 own their own home (Woodward, 1986). Those who do

not live in their own homes have a variety of housing

arrangements available to them depending on their health and

economic status.

Living arrangements of older people has been classified

as living alone (complete independent living), living with

non-relatives, living with a spouse, living with other

relatives, and not living in a household (Shanas, 1962;

Wilson, 1977). A variety of factors impinge upon and









determine which of the five arrangements will be selected by

or for individual elderly persons. These factors include

marital status, sex, functional impairments, race, income,

health status (both mental and physical), and attitudes.

The vast majority, approximately 95 percent, of all aged

persons, live independently in the community, either by

themselves or, more often, with a spouse, family, or friends.

Butler and Lewis (1983) report that of every ten older

Americans, seven live in families. Approximately one fourth

live alone or with nonrelatives. This situation differs for

men and women. Women are three times more likely to live

alone or with nonrelatives.

The frequent statement that most older black people live

in extended families is only a myth. Studies have shown that

"50.2 percent of black persons over the age of 60 years lived

alone or with only one other person, relative or nonrelative,

while 16 percent were found to live entirely alone" (Butler

and Lewis, 1983:27). There is also evidence that 11 of every

100 older blacks have no living relatives, compared to 6 of

100 whites (Butler and Lewis, 1983). Data contrasting men

and women show that half of all black older men live with

their wives. But again, because of a longer life span, only

one fifth of black older women live with their husbands

(Butler and Lewis, 1983).










Housing Alternatives

In the United States, residences available to the

elderly are Adult Foster Homes, Adult Congregate Living

Facilities (ACLFs) or Congregate Housing, Senior Citizens

Lodge and Home Care, and Granny Flats. There are also

personal care boarding homes, commercial boarding homes,

congregate care homes, congregate care, life care or

continuous care, retirement villages, and shared living.

The old are anything but homogeneous. These people lead

vastly different lives depending upon their situation.

Living arrangements of men over 65 differ markedly from those

of women. Similarly, the living arrangements of people with

children differ from those of persons without children.

Grouping together all older people would therefore only

obscure these important differences. Differences in marital

status are responsible for many of the differences in the

living arrangements of men and women, black and white.

The most recent data on marital status of elderly women

reflect a most striking change in living arrangements of any

age or sex group over the past two decades: the decline in

older women who live with other relatives (from 19 to 10

percent between 1965 and 1981) and the commensurate rise in

the proportion living alone (from 31 to 40 percent during the

same period). The major contributory factor to this shift is

economics, giving older women more independence today than

they had two decades ago. More older women are now able to









afford independent residences and maintain their own

automobiles. In some cases this is due to the liberalization

of Social Security benefits and the introduction of Medicare

in 1965 (Hess, 1986).

With the concept of shared housing (not only intra- but

also intergender) becoming more popular, in the future we

might expect to see more widows and widowers who are not

married living together in the same household. In 1983 there

were about 120,000 households in which a nonmarried couple,

one of whom was 65 and over, lived together (U.S. Bureau of

the Census, 1983d).

State of Health

The state of health of the elderly plays a major role in

deciding their living arrangements. The greater the number

of chronic ailments that older persons have, the less the

likelihood of their living alone. This situation is

compounded if the impairments result from severe impairments

of vision or mobility. Increased frailty and incapacity can

necessitate that an older person not living with a spouse,

and who has grown children, change his or her living

arrangements. That is, he or she may move in with one of his

or her children. The physical condition of the very sick

older person forces him or her to be much more dependent upon

family members not only for physical care but for

companionship and social activities.










In the absence of children, an older person may move in

with a relative, or have a relative move in with him or her.

In situations such as these, they mutually decide who should

be head of the household.

Sometimes elderly dependent parents move from one

section of the country to another to share a child's home,

paying something towards the rent. If their health is fairly

good, some are able to help with babysitting while their

children go to work. Some are also able to help with

housework.

Visitation by Family and Friends

One important aspect of an older person's life is

receiving visits from relatives and friends; older people

therefore prefer to live near at least one child. This

allows them to see their children often. Visiting their

children or receiving visits from them contributes to the

life satisfaction of older persons. This is further enhanced

if there are grandchildren present. Some may see their

children as often as once per week while others receive

visits only on special holidays such as Christmas, Easter and

Thanksgiving. Family anniversaries may also merit visits

especially from those who live far away.

Most older people are long-time residents in the areas

in which they live and are able either to visit or receive

visits from neighbors. However, an older person may

sometimes find that he or she has outlived most of those who









once were visiting neighbors. Visits from relatives, other

than children, also play a major role especially for those

older persons who do not have children. Other people such as

clergymen, church visitation groups, and welfare workers may

form a part of the visiting group. A survey carried out

about three decades ago demonstrated that in general, persons

without living children appear to be the most isolated group

in the aged population (Shanas, 1962).

Today there is expected to be less isolation as we find

that elderly persons can choose the type of living

arrangement which best contributes to a reduction in

isolation and hence enhances their life satisfaction. The

myth of the isolated elderly no longer has strong support

(Aldous, 1987). The Older Americans Council plans various

activities, and provides meals-on-wheels delivered by

volunteers. These volunteers play a double role. As they

deliver meals they also use this time to visit. To reduce

loneliness experienced by some elderly persons, there is day

care designed especially for the elderly and there is low

cost congregate living which moves the older person from

living alone to living with others. Those who are more

affluent may move into retirement villages where activities

are designed to keep them from being lonely and bored.

Racial Constraints

Living arrangements may differ according to race. More

older blacks than whites do not live with their spouses.










This has been attributed to the greater economic pressures on

black families, including unemployment and public welfare

laws that encourage black men to leave home early in life.

The lower socioeconomic status of the majority of black

elderly persons also militates against them living in

expensive retirement facilities.

It has often been posited that black elderly persons

live in extended families. Thus, isolation has never been

seen to be a problem with black elderly people. Shifts have

been seen however, in the living arrangements of elderly

blacks. An examination of multigenerational households in

the U.S. population found that a major change had occurred

suggesting that elderly people who might have lived with

their kin have gradually shifted to living alone (Mindel,

1979). This is an indication that black elderly persons are

more similar to whites than previously supposed in that among

the black elderly there is almost as great a tendency for

them to live alone as there is among whites (Mindel, 1986).

Cantor et al. (1979) found that a larger number of black

elderly women were likely to report themselves as heads of

households than was the case among white families. They

contend that this sharing of limited resources suggests a

positively adaptive method of meeting the pressures of

poverty and unemployment within a functional family system.

Mindel (1986) observes that among black Americans there is a










greater likelihood that an elderly female will be a head of

household.

Older people want to continue to live in their own homes

as long as possible irrespective of their race and whether or

not they have children. The common belief that older people

in the United States are isolated either physically or

socially has not been proven. On the contrary Shanas (1962)

concluded from a survey that when older people had children

they generally lived close to at least one of them.

Furthermore, older people see their children often. Even

children who live at a distance apparently try to see their

parents on major holidays and other special occasions. While

marital status, health status and gender play a major role in

determining the living arrangements of older people today,

because of the available social supports, most older persons

can fit into one form or another of living arrangement and

avoid institutionalization.

Geographic Distribution

Older people, both black and white, live most frequently

in central parts of cities and in rural locations. The

residence patterns of older black persons show a somewhat

different configuration than that of older people as a whole.

Three-fifths still reside in the South, many in rural areas,

but because of the large numbers that moved to urban areas in

the black rural-to-urban migrations of the early 1900s, older

black persons are now also concentrated in central cities,










primarily in those areas with the worst housing. By 1970,

one of two older blacks lived in central city locations. In

1980 black elderly remained heavily concentrated (68 percent)

in the central core of older cities (Hess, 1986). Many are

trapped there under the dual influence of economic hardship

and a continuing racism that tends to preserve the suburban

areas for whites.

Standards of Housing

It has been estimated that up to 30 percent of older

persons in the U.S live in substandard housing largely as a

result of outright poverty or marginal income. Many of these

have become substandard as the costs of maintenance,

utilities, and property taxes have so skyrocketed that upkeep

and needed improvements have become impossible for many

elderly homeowners. Government subsidies for maintenance

have been a great help recently because most elderly people

live on fixed incomes. Those who do not live in their own

homes either live alone, with relatives or friends or in

retirement facilities. Some older people live in public

housing, "often seen by them as a highly desirable resource

in view of the wretched alternatives available. Many are so

poor that they cannot even afford public housing and some of

these are forced to reside in single room occupancy (SROs)

hotels embedded in a fierce environment peopled by petty

thieves, pimps, prostitutes, addicts, and hustlers"

(Stephens, 1976).









Income of the Elderly

Poverty, like substandard housing, is typically

associated with old age. People who are poor all their lives

can expect to become poorer in their old age and elderly

blacks are especially plagued by poverty. In fact, it is

reported that the rate of poverty among older blacks is twice

that of older whites. "In 1984 the median income for black

males over the age of 65 was $6,163 compared to $10,890 for

white males. For black females the 1984 median income was

$4,345, while for white females the figure was $6,309"

(Johnson, 1988:101). Blacks have often been employed in the

service industry and in seasonal jobs. In the competitive

sphere of job situations one could say that they are at the

bottom of the heap. Many blacks have few work skills, and

discriminatory hiring practices common throughout the society

render some virtually unemployable. Jobs generate only

sporadic and minimal income. Carp's (1972) study of the

occupational characteristics of the aged slum dweller show

that

retirement--usually from menial jobs that provided
no security, tenure, or fringe benefits--has not
been an event that occurred on a given day, but was
rather the culmination of increasingly frequent and
lengthy periods of time during which these
individuals were unable to obtain employment.
(Carp, 1972:57)

These observations fittingly describe many blacks. It has

been noted that some find more or less steady conventional

jobs in low-paying, low-skill services, working as waiters,









dishwashers and cleanup helpers. These are jobs with

abysmally low pay scales, little security, and poor working

conditions. All of these contribute to their dependency on

Social Security and Welfare. The economic status of elderly

persons dictates their living arrangements to a great degree.

It is also a determinant of caregiving and plays a major role

in health status, health beliefs and education.

Plan of Research

To reiterate, the purpose of the study is to examine the

level and type of caregiving of elderly persons in a black

community. It was assumed that by going into the community

and studying it through interviews and observations, other

questions and issues that affect black elderly people would

surface. The intention was to explore the use of formal and

informal networks in order to test whether friends, kin,

church, and neighbors provide a pivotal resource for

responding to the needs of elderly persons in the community.

In order to examine caregiving of black elderly persons,

this research concentrates on the age group 65 years and

older taking care in some instances to compare and contrast

the care-giving network as it affects the young-old, those 65

to 74 years of age; the old-old, those 75 to 84 years; and

the oldest-old, those who are 85 years and over. The

research methodology employed is based on the view that data

needed to understand caregiving at this stage of our









knowledge are best gathered through qualitative research.

Certain information can only be garnered from field

research.

Chapter Two addresses black families and black elderly

persons in the United States. An analysis of black families

is germane to the study of black elderly persons and a review

of previous research on black elderly persons is in turn

necessary for studying a group of black elderly persons in a

particular community. It is necessary to have as clear as

possible an understanding of this racial group before

attempting an assessment of its elderly subgroup. This

chapter also analyzes the demographic characteristics of

black families and black elderly persons. The aim is to

bring into focus changes concerning the diversity of black

family patterns and the theories that are used to study

today's black Americans. The major demographic areas

addressed are (1) family composition, (2) marriage and

divorce and (3) education, employment and income. Black

elderly persons are analyzed in terms of health problems

and kinship in addition to the general demographic

patterns.

Chapter Three presents a review of caregiving by formal

and informal support systems. The chapter begins with a

brief introduction which is followed by an overview of

caregivers and caregiving including the literature, the

formal support system, the informal support system,










impairments of elderly persons, activities of daily living

(ADLs), instrumental activities of daily living (IADLs),

support systems for elderly black persons, and caregiver

stress and burden. The chapter ends with an analysis of

caregiving and black elderly persons followed by a brief

summary.

Chapter Four contains a description of the methodology

used and the setting in which the field research took place.

Data were gathered from a convenience sample of 71 elderly

persons and/or their primary caregiver where this was

necessary.

The findings from the field research are presented in

descriptive form in Chapter Five supported by a quantitative

analysis of forty independent variables. A description of

the elderly people of Eatonville as well as their caregiving

networks is included. Family, impairments and caregiving are

addressed. Vignettes are utilized to demonstrate the various

ways in which the elderly persons of Eatonville access and

utilize formal and informal support systems either separately

or combined.

Chapter Six contains conclusions and implications. The

potential impact of this study lies in its assessment of how

factors relating to caregiving affect the well being of black

elderly persons. It is hoped that local, state, and national

programs designed for older persons will eventually shift an

emphasis from support for the institutionalized to support







28

for the elderly person living at home, paying special

attention to black elderly people. Such a shift will

influence the life satisfaction and wellbeing of older black

persons in positive ways.














CHAPTER TWO
BLACK FAMILIES--BLACK ELDERLY PERSONS


Of all social institutions, the family is perhaps the

most basic (Tischler et al., 1983). Sociologists view

institutions as systems of social norms and norms are

society's rules of conduct for its members (Leslie, 1979).

The family can be studied either as an institution or as a

social group. Leslie (1979:22) points out that

when the family is viewed as a social institution,
the norms governing family forms and functions are
emphasized. [However], when one focuses upon the
family as a social group, attention is directed
more toward its internal functioning than toward
its relationships with other aspects of the
society.

Definition of Family

It is difficult to find a definition of family general

enough to cover the family as it exists in all societies, but

a generally accepted typology of families includes the

concepts of nuclear family and extended family. A family has

traditionally been defined as a married couple or group of

adult kin who cooperate and divide labor along sex lines,

rear children, and share a common dwelling place. A variety

of family forms have emerged to challenge this definition.

Examples of these are single-parent families, cohabiting

families, blended families, families without children, and









gay and lesbian families (Strong and DeVault, 1989). Strong

and DeVault (1989) propose a contemporary definition which,

in order to include these diverse forms, would define the

family as one or more adults related by blood, marriage, or

affiliation who cooperate economically, share a common

dwelling place, and may rear children.

The classical definition of family, of which we now see

variations is that given by Peter Murdock (1965) in his book

Social Structure. Murdock's definition states that

the family is a social group characterized by
common residence, economic cooperation, and
reproduction, and consists of a male and female
adult and their offspring or adopted children.
(Murdock,1965:1).

Murdock used husband/wife and therefore implied legal

marriage. He later distinguished marriage and the family.

Murdock's definition really speaks about the structure of the

family, and implies the makeup of a family. He refers to a

nucleus of individuals. His nuclear family is approximately

the same as Levi Strauss's conjugal relationships. While

nuclear stresses the husband-wife relationship,, extended

family is used to imply parent-child relationship applying to

a type of family which usually comprises three generations,

that is, man, spouse, their children, their children's

spouses (especially sons), and their children living either

in the same household or very near to each other with some

cooperative domestic arrangement. Extended family is the

same as consanguine, implying blood relatives. The nuclear









family tends to be a small unit, whereas the extended family

is a larger unit. The nuclear family, because of its size,

is more applicable to living in modern societies and the

extended family to living in more traditional societies.

Authority structure differs in the different family systems.

The nuclear unit tends to be patriarchal, implying that

authority is vested in the male. It is, however, sometimes

matriarchal.

Functions of the family are central to life, culture,

and society. Functions of the family were long seen as

providing a source of intimate relationships, acting as a

unit of economic cooperation, producing and socializing

children, and assigning status and social roles to

individuals. It is contended, however, that while these

are the basic functions that families are "supposed" to

fulfill, families do not necessarily have to fulfill them

all. Strong and DeVault (1989) suggest that technology,

industrialization, mobility, and other factors are altering

the way the family performs its functions today. The

question as to whether every family performs these basic

functions leads to the debate over the universality of the

family. The United States with its numerous ethnic and

racial groups supplies various family forms which could be

studied cross-culturally. To this end, the present review of

black families in the United States addresses black people as

a sub-group of the society and discusses family forms of









blacks, that is, residence, forms of marriage, authority

structure, and functions of black families. The area of kin

relationship will also be addressed since kinship is germane

to any study of black families and black elderly persons in

particular.

Black Families

Knowledge of black families must form the basis for

studying any segment of black communities since the family is

intricately tied to the society. A diversity of black family

patterns exists in the United States and it is maintained

that different family forms prevail at different class and

income levels throughout the American society. This has led

to the conclusion that the black family is itself a fiction

(Glick, 1988). Hence, this study will analyze 'black

families' rather than 'the black family.'

Family forms of blacks can be analyzed in terms of

residence, forms of marriage, authority structure, functions

of black families and kin. In this analysis of black

families three major demographic areas are addressed. These

are family composition; marriage and divorce; and education,

employment, and income. The strengths of black families is

also addressed.

Studies of black families date as far back as the early

1900s and can be found in the works of W. E. DuBois (1969),

Franklyn Frazier (1932), Melville Herskovits (1930, 1941),

and Drake and Cayton (1962). Others such as John Dollard









(1937) conducted community studies in the South in the 1930s,

focusing on the prevailing caste system and its effect on

social life. Hylan Lewis (1955) carried out a community

study among blacks in a North Carolina town. Virginia Young

(1970) conducted research among southern black populations.

Molly Dougherty (1978) carried out research among black girls

and described how they developed into women in a rural black

community in North Central Florida. Very little research on

blacks was carried out in the 1940s and the 1950s.

Research among black populations and black families in

the United States has been influenced by the sociological

tradition and contributions of both Frazier (1932, 1939) and

Herskovits (1930, 1941). Frazier (1939) referred to the

instability of marital unions among "New World" blacks, as

well as the lack of social support for the man to operate

effectively in the male or father role. He emphasized a

structural explanation, to replace an explanation based on

African cultural survival in vogue then. He also formulated

some significant generalizations about the effects of slavery

upon the family life of American blacks. With respect to New

World blacks, he observed that black Americans were trying to

build a stable life after the almost total social

disorganization of slavery and in a society which continued

to be hostile and discriminatory. Frazier argued that the

effects of emancipation on black families resulted in









problems affecting today's black family. Frazier (1939:81-

85) wrote

mobility of the black population after emancipation
was bound to create disorder and produce
widespread demoralization. Promiscuity, and
confusion in marital relations would be evident
while marriage as a formal and legal relation was
not a part of the mores of the freedmen. The
severe hardship on Negro "families" after
emancipation left them without any means of
subsistence. Where families had developed a fair
degree of organization during slavery, the male
head assumed responsibility for their support.

Frazier noted that this severe hardship became a test of

the strength of family ties. Two general tendencies are

manifest in the fortunes of the Negro family dating the

period of its adjustment to the state of freedom. For those

families that had achieved a fair degree of organization

during slavery, transition was easy. Authority of the father

was firmly established in these families, and the woman in

the role of mother and wife fit into the pattern of a

patriarchal household. Roles were fairly clearcut, and the

father became the chief, if not the sole breadwinner thus

demonstrating that he had assumed the responsibilities of his

new status. Sometimes he acquired land of his own and

thereby further consolidated the common interests of the

family group (Frazier, 1939). The second tendency is that

the loose ties that held men and women together in
a nominal marriage relation during slavery broke
easily during the crisis of emancipation. When
this happened, the men cut themselves loose from
all family ties and followed the great body of
homeless men wandering about the country in search
of work and new experience. Sometimes women,









primarily those without children, did the same.
(Frazier, 1939:88)

Historically emancipation locked black families into two

groups, in which many today still find themselves. Most

studies would have us feel that the latter group is the most

dominant and some scholars' descriptions of black families

have implied that their members are shiftless and uneducated.

Herskovits (1930), in his study of New World black

families, noted that a close bond existed between mother and

child. He also noted the peripheral status of the man or

father, implying matrilocality and marginality. His

conclusion was that these patterns were vestiges of African

systems. Herskovits has been acclaimed as one of the first

scholars to recognize similarities in African cultural

patterns and those of African descendants living in the

United States, the West Indies, and Brazil. It is said that

one of his major contributions was a more realistic

conceptualization of family life in traditional African

societies, which are characterized by unity, stability, and

security (Dodson, 1988).

Negative assumptions have been made about blacks in

general and about black men in particular. The main ones are

that they do not want to work and are disinterested in their

children. Such pathological and dysfunctional views of black

families, associated with the work of authors such as Daniel

Patrick Moynihan (1965) in the "Moynihan Report," have

elicited responses in defense of black families. One such









response comes from the writer and sociologist William Ryan.

Ryan's (1976) work, Blaming the Victim, serves as an

excellent rebuke to all those who place all the blame for the

black person's ills on the black person himself. In

pondering the thought processes of victim-blaming, Ryan

analyzes a new ideology which he sees as very different from

the open prejudice and reactionary tactics of the old days.

Its adherents include what he calls "sympathetic social

scientists with social consciences in good working order and

liberal politicians with a genuine commitment to reform"

(Ryan, 1976:7). Continuing his chastisement of this group of

victim blamers, Ryan (1976:6-7) states that

they are very careful to dissociate themselves from
vulgar Calvinism or crude racism and indignantly
condemn any notions of innate wickedness or genetic
effect. The Negro is not born inferior they shout
apoplectically. Force of circumstance, they
explain in reasonable tones, has made him inferior.
They dismiss with self-righteous contempt any
claims that the poor man in America is plainly
unworthy or shiftless or enamored of idleness.
They say that he is caught in the cycle of poverty.
He is trained to be poor by his culture or family
life, endowed by his environment.

The culture of poverty theory has also been used to

analyze black families and became a part of the

infrastructure of black ills. Oscar Lewis (1966) carried out

studies in Puerto Rico and referred to unstable family forms,

mating patterns and poverty. It was Lewis who used the term

"Culture of Poverty" to imply that the poor "in time" come to

represent a certain sub-culture of poverty. This "culture of

poverty" syndrome has been assigned to black persons in the









United States because they are usually seen as having

unstable family forms and mating patterns and as being

necessarily poor. Lewis' "culture of poverty" theory as

applied to black people in the United States, has, however,

been rejected. Ryan (1976) draws our attention to "those who

would want us to believe the myth regarding the culture of

poverty, that it produces persons fated to be poor, in order

to blind us to the fault of a corporation dominated economy"

(Ryan, 1976:120). Ryan also addresses the myth that black

families produce young men incapable of achieving equality

which he observes is "designed to blind us to the pervasive

racism that informs and shapes and distorts every social

institution" (Ryan, 1976:120).

Attempts at demythologizing black families are to be

found in the works of several other researchers including

Joyce Ladner (1988), John McAdoo (1988), Harriet Pipes McAdoo

(1988), and Robert Staples (1971, 1981, 1985). Staples

(1985) blames the inability of black aspirations for a

traditional family life and roles on structural conditions.

These structural conditions are said to have the greatest

impact on the black male and force him to abdicate his role

as husband and father. This has had far reaching effects

resulting in what Staples sees as the most significant change

in black families during the last 30 years: the proliferative

growth of female-headed households. He notes that "when the

Moynihan report was first issued in 1965 more than three-










fourths of all black families with children were headed by a

husband and wife. In 1982, however, barely one-half of all

such families included parents of both sexes" (Staples,

1985:1006). This had severe consequences for black families

because of disparities in family income. Households headed

by black women had a median income of $7,458 in comparison

with the median income of $20,586 for black married couples

and $26,443 for white married couples (U.S. Bureau of the

Census, 1983).

An examination of the situation of black families 20

years after the publication of the Moynihan report forces

Staples to ask questions such as: "How is it that a group

that regards family life as its most important source of

satisfaction finds a majority of its women unmarried?," "Why

does a group with more traditional sexual values than its

white peers have a majority of its children born out-of-

wedlock?," and "How is it that a group that places such

importance on the traditional nuclear family finds a near

majority of its members living in single-parent households?"

(Staples, 1985:1006).

Staples sees the structural conditions of the black

population as being responsible for the problems experienced

by today's black families. "These conditions not only

denigrate the black male but reduce the quantity and quality

of black males and hence rob black females of satisfactory

potential mates" (Staples, 1985:1006). Studies have shown









that 46.6 percent of the 8.8 million black men of working age

were not in the labor force. Some were unemployed, some had

dropped out of the labor force, some were in prison and

almost 1 million were classified as "missing" because the

Census Bureau said it could not locate them (Staples, 1985).

The situation is further exacerbated by the number of

black males serving in the Armed Forces. Census figures

(1983) report that in 1982 a significant number (415,000) of

blacks were under arms. This figure represented 20 percent

of all United States military personnel. It is estimated

that 90 percent of these were male (Staples, 1985).

The job situation of black males in the civilian labor

force contributes to enlistment as a choice. Instead of

being a means to an end, the Armed Forces become an end in

themselves for a large number of black males. "This results

in a rate of re-enlistments for black males which is much

higher than their white counterparts" (Staples, 1985:1009).

Socio-Demographic Profile of Black Families

Black families include a variety of family types. The

majority are either families which are maintained by a

married couple or those which are maintained by one parent

and one or more of the parent's own young children. In 1985,

81 percent of black Families were of one or the other of

these types, and the corresponding proportion for all

families without regard for race was 91 percent (U.S. Bureau

of the Census, 1986). Families which were not of either of









these types consist of such groups of relatives as

grandparents and their grandchildren, brothers and sisters,

and other relatives. A large percentage of black families

have young children among their members. In 1985 this figure

was 57 percent. This is a reflection of the higher birth

rate of black women coupled with the shorter survival of

black marriages (Glick, 1988).

Single parent families are another common form of black

families. In 1985 these families represented 30 percent of

all black families while the corresponding proportion for all

families without regard for race was 11 percent (U.S. Bureau

of the Census, 1986). Factors such as the vast increase in

the divorce rate and a decline in mortality rate for young

mothers have resulted in four times as many young children

living with a divorced parent versus a widowed parent in 1985

as did so in 1960 (Glick, 1988). Glick (1988) also notes a

continual increase since the 1960s and up until the present

time, in the number of young adults who are living in the

parental home.

Education

Blacks are still more likely to attend racially

imbalanced schools representing 44 percent of black children

in the North and 20 percent in the South. They have less

education on the whole than their white counterparts, and the

education they receive may be inferior due to the fact that

the schools they attend lie mainly in poor school districts.









Only 8 percent of blacks compared to 18 percent of whites

have college degrees. However, blacks today have much better

prospects than their parents did. Blacks have made strong

gains in education. From 1968 to 1878, for example, the

proportion of black children in the South attending mostly

black schools dropped from 79 percent to 59 percent (Stevens,

1980). From 1970 to 1980 the proportion of black

undergraduates at American colleges jumped from 7 percent to

11 percent, while black enrollment in graduate and

professional schools increased from 4 percent to 6 percent

(Stevens, 1980).

These educational gains have led to better-paying jobs

for many blacks. For example, about 6 percent of the

nation's managers and administrators are black. Today blacks

hold about 10 percent of the positions in finance, real-

estate, and insurance. And between 1968 and 1980 the number

of blacks elected to public office in the 11 states of the

deep South increased from 156 to 1813 (Henslin and Light,

1983; Rowan, 1981).

Despite such gains, however, black persons remain

underrepresented in American politics; Wright (1979) notes

that less than 2 percent of elected officials are black.

Although black people today have better education and

increased opportunities, ethnic discrimination still

underlies their relative impoverishment. At all levels,

whether among factory workers, managers, or supervisors,










income gaps still separate blacks and whites, and the gap

always puts whites on top (Wright, 1979).

Economics

Although nearly one third (30.9 percent) of all black

families lived in poverty in 1984, nearly the same number

(29.4 percent) of black families had earnings above $25,000

(white median family income was $27,000 that year). Income

varies widely among black families by family composition.

While median income for all black families totaled $15,432 in

1984, it totaled $28,775 in married couple families with the

wife in the labor force, but just $8,648 for female headed

households (Malveaux, 1988). Whether black families

experience poverty, receive public assistance, or maintain

relatively high earnings, disparities between black and white

families at every income level are important (U.S. Department

of Commerce, 1985). It is important to emphasize the

diverse composition of black families, in that black families

range from single mothers who receive public assistance and

raise their children against all odds, to upwardly mobile,

dual-earner families with incomes above $50,000 per year

(Malveaux, 1988).

Marriage and Divorce

"Young adult black persons have a consistent pattern of

postponing marriage longer than persons of other races"

(Glick, 1988:119). Statistics show that there was a sharply

increasing delay of marriage between 1970 and 1985 in the









form of a rising percentage of persons in their twenties who

had never married (Glick, 1988). The phenomenon called a

"marriage squeeze" is held as one of the prime reasons for

this delay. The marriage squeeze as experienced today makes

it more difficult for women of marriageable age to find

husbands in their range. Back women are reported to be

especially affected by this phenomenon (Strong and DeVault,

1989).

Staples (1985) explains that the reason why a near

majority of black Americans, especially women, are not

married and living in traditional nuclear family units

is not a result of any devaluation of marriage qua
institution but rather a function of limited
chances to find individuals in a restricted and
small pool of potential partners who can
successfully fulfill the normatively prescribed
familial roles. (Staples, 1985:1005)

The divorce rate in black families is said to be the

highest of all racial groups in the United States of America.

One in every two black marriages is said to end in divorce.

Combined data from several national surveys taken between

1973 and 1980 indicate that 37.2 percent of black males and

42.2 percent of black females who have ever been married have

divorced. This is not surprising since a large percentage of

blacks fall in the lower socioeconomic group and because of

the strong negative correlation between socioeconomic status

and divorce rates. As income levels for blacks increase,

divorce rates also decrease (Raschke, 1987). It is reported

that in 1985 there were 25 percent as many black divorced









persons as black married persons in the United States.

Findings suggest that the proportion of divorced persons who

remarry is lower among blacks than whites at each interval

since divorce (U.S.Bureau of the Census, 1980; Glick, 1988).

Based on findings from an earlier study conducted in 1980,

Glick (1988) notes that remarriage is more likely to be

followed by redivorce among black women 35 to 44 years old

than among women of other races of the same age.

Both cultural and structural explanations have been used

to explain black family forms. However, neither cultural nor

structural explanations by themselves can adequately account

for existing black family forms; both are needed. For

example, cultural explanations require knowledge of the

African family system, and the American plantation system,

and its patterns of mating. It was in the plantation system

that the weakening of the male role began as well as the

attempt to de-emphasize any form of family unit. Economic

production was the prime objective of the American plantation

system, but it was not encouraged within the context of the

"family life." This led to unstable relations between

managers and workers and among workers. This instability

could contribute to the claim that black marriages are less

stable (Heiss, 1975). It was only after emancipation that

the ex-slaves attempted to introduce some stability into

their family units.









Living Arrangements of Children

Some of the sharpest differences between the family life

of blacks and other races can be found in the living

arrangements of young children. For example, of all children

under 18 in 1985, 15 percent were black but 35 percent of

those living with a lone mother were black. The most extreme

contrast is found among children living with a mother who had

never been married--two of every three (67 percent) of these

children in 1985 had a black mother. In fact, as many black

children were living with a never-married parent as with a

divorced or separated parent (26 percent and 24 percent,

respectively).

Nearly all of the racial differences that can be

demonstrated from data present a picture of much greater

family disorganization in the living arrangements of black

children than of other young children. Even though there was

about a one-third downturn between 1980 and 1985 in the

proportion of black children living with a separated or

widowed mother, there was a doubling of the proportion with a

never-married mother (from 13 percent to 25 percent).

The rapid growth in the number of young children
living with a never-married mother is closely
related to the sharp upturn in the proportion of
births occurring to unmarried mothers. Vital
statistics reveal that the proportion of births to
unmarried mothers rose from 35 percent in 1970 to
59 percent in 1984 for black births and from "only"
6 percent to 21 percent for all races. Although
the rate of increase for black births to unmarried
mothers was not as great as that for all races, the
level is still close to three times as high as that
for all races (59 percent versus 21 percent). As









recently as 1960, there were more young children
living with a widowed parent than with a divorced
parent, but now four times as many live with a
divorced parent as with a widowed parent. This
shift resulted from both a declining mortality rate
for young mothers and a vast increase in the
divorce rate. (Glick, 1988:114)

Glick observes that a continuing larger proportion of

black than other children under 18 live apart from either

parent. According to the 1980 census, these children

represented 4.5 percent of the children of all races and 11

percent of black children. A significant proportion of those

children who were living apart from their parents were

residing with relatives, and the rest were living with foster

parents or in institutions. Living with their grandparents

was the most frequent form of living arrangement for those

children who were living with relatives (about two-thirds).

It is hypothesized that in these circumstances, many of the

mothers being younger, better educated, and more employable

must have left their children in the care of older relatives

while they moved elsewhere to increase their opportunities to

earn a living (Glick, 1988).

Young Adults Leaving Home

The departure of young adults from their parental home

generally occurs during their late teens or their twenties

and is a critical period for all concerned. Glick and Lin

(1986) report that up until 1970 approximately 32 percent of

the black population 18 to 29 years old were still living in

their parental homes or had returned to live there. By 1970,










however, the trend had turned upward and has continued to

rise. In that year, the authors note that the figure had

risen to 40 percent, and by 1984 it stood at 46 percent, well

above the 36 percent for those of all races in 1984. This

recent phenomenon of late departure from (or return to) the

parental home has also been characteristic of young adults of

all races. Factors which are said to contribute to this

include relatively high rates of unemployment, divorce, and

unmarried parenthood, as well as to more young adults

delaying marriage while they attend tertiary institutions to

further their education (Glick and Lin, 1986).

Conceptualization of Black Families

Early research among black populations and black

families in the United States has been influenced by the

sociological tradition and contributions of both Frazier and

Herskovits. Earlier works such as those of Frazier have,

however, been criticized because of their cultural

ethnocentric approach. Dodson (1988) looks at contrasting

approaches to the study of black families and compares the

cultural ethnocentric approach to the cultural relativity

approach. She notes that the pathological and dysfunctional

view of black families has been primarily related to the

cultural ethnocentric approach associated with the work of E.

Franklin Frazier (1939) and Daniel P. Moynihan (1965).

Dodson (1988) sees the works of these scholars as having

culminated in the implementation of social policies










predicated on the assumption that the black family is

unstable, disorganized, and unable to provide its members

with the social and psychological support and development

needed to assimilate fully into American society. Dodson

observes that studies which concentrated on the dysfunctional

and disorganized aspects of black family life have deduced

that the typical black family is fatherless, on welfare,

thriftless, and overpopulated with illegitimate children.

Inevitably they have recommended economic reforms for

"saving" black families from their own pathology (Dodson,

1988).

Opposing the cultural ethnocentric approach are those

scholars who tend to focus on the strengths of black families

rather than their weaknesses, having in most instances traced

the origins of these cultural differences back to black

Americans' African cultural heritage. The cultural

relativity school begins with the assumption that black

American culture and family patterns possess a degree of

cultural integrity that is neither related to nor modeled on

white American norms (Dodson, 1988). Dodson sees the

cultural relativistic view as having been developed primarily

as a reaction to the deficit view. Proponents of this view

maintain that the black family is a functional entity.

Dodson observes that this conceptualization is designed to

challenge the theories and social policies emanating from the

ethnocentric approach. However, she is aware of the common









assumptions underlying the theoretical and empirical

arguments of the two schools. That is, that black and white

families are qualitatively different culturally. She notes,

however, that this assumption is not shared by all students

of black family life. Proponents of the cultural relativity

view include Andrew Billingsley (1968), Robert Hill (1972),

Wade Nobles (1974), and Virginia Young (1970). The consensus

among these scholars is that black Americans' cultural

orientation encourages family patterns that are instrumental

in combating the oppressive racial conditions of American

society. There is, however, a variation in their individual

assessment of the degree to which African culture influenced

the culture of black Americans (Dodson, 1988). In examining

the American black family, proponents of cultural relativism

in North America point out that slavery did not totally

destroy the traditional African base of black family

functioning (Dodson, 1988). Dodson cites the works of

Blassingame (1972), Nobles (1974), and Turnbull (1976).

Research has also found that black families are not

disorganized or dysfunctional. Young (1970) observed

patterns of high illegitimacy rates and frequent marital

dissolutions usually associated with disorganization.

However, these patterns were interpreted by the researcher as

natural to the emotional underpinnings of the family system

and thus, functional. The central position of the female in

the domestic organization is thought to be related to the









restrictions on black male participation in the economic and

political institutions of the wider society throughout the

Western Hemisphere (Dougherty, 1978; Scanzoni, 1971).

Historically, family theorists have argued that family

structure and achievement interact with one another (Parsons

and Bales, 1955). While that may have some validity for

certain ethnic groups in America, none of those groups share

the history and current social conditions of the black

population in the United States (Staples, 1985). According

to Staples (1985) "the peculiar history of black Americans,

combined with structural conditions inimical to family

formation and maintenance, have precipitated a crisis in the

black family." Staples' observations have been supported by

others (Coner-Edwards and Spurlock, 1988).

Kinship and the Extended Family

Strong kinship bonds is one of five characteristics

which have been isolated as being functional for the survival

of black families and is identified as one of the strengths

of black families (Hill, 1972). Nobles (1974, 1988) has

indicated that the black community is oriented primarily

toward extended families, in that most black family

structures involve a system of kinship ties. This idea has

been supported by Billingsley (1968), Hayes and Mendel

(1973), Hill (1972), and Stack (1974). Blacks are known to

have higher fertility rates and larger families than whites.










This renders them more likely to live in multigenerational

households.

At this point it may be useful to define the extended

family. The most famous definition is that given by George

Murdock (1965:2):

An extended family consists of two or more nuclear
families affiliated through an extension of the
parent-child relationship rather than of the
husband-wife relationship; that is, by joining the
nuclear family of a married adult to that of his
parents. It embraces, typically, an older man, his
wife or wives, his unmarried children, his married
sons, and the wives and children of the latter.
Three generations, including the nuclear families
of father and sons, live under a single roof or in
a cluster of adjacent dwellings.

The extended family system is assumed to provide support

for family members, either as assistance for protection or

for mobility. It is argued that the extended family in the

black community consists not only of conjugal and blood

relatives, but of nonrelatives as well. Additionally, the

prevalence of extended families, as compared with nuclear

families, is held as another cultural pattern which

distinguishes whites and blacks. Dodson (1988) argues,

however, that the extent to which such families are

characteristic of the black community has not been adequately

substantiated.

Numerous studies have shown the positive effects of

kinship networks among blacks, but there are others that have

found relatively few differences by race among elderly people

in participation with family and kin (Heiss, 1975). In









addition, some maintain that black people have fewer

relatives to call on in an emergency (Heiss, 1975). Kinship

patterns among blacks are much debated and kinship is linked

to the extended family. Cowgill (1972) in his earlier work

went to great lengths to show how the elderly in developing

countries were not as dependent on their governments as those

in developed countries because of kinship patterns. This

theory has been extended to apply to black elderly persons in

the United States. Some have charged that patterns of kin

relations sometimes produce frustration and unhappiness, but

Heiss (1975), addressing this charge states that there is

little evidence to support this. Heiss concludes that people

who live in extended households are not significantly less

satisfied than those who live in nuclear homes (Heiss, 1975).

Heiss observes that this holds for several different kinds of

multigenerational homes.

Harriette Pipes McAdoo (1988) in an empirical

examination of upward mobility and extended-family

interactions in black families, examined whether involvement

within the extended-family support network was a help or a

hindrance to upward mobility. Theories related to the value

of support networks as a coping strategy of poverty and not

of culture were directly addressed. The findings indicated

that the education and achievement of the individuals were

often impossible without the support of the extended family,

and that the reciprocal extended family-help patterns









transcended economic groups and continued to be practiced

even when families had moved from poverty to the middle-

income level. McAdoo concluded that the continuation of the

extended-family support system reflects continued cultural

patterns and is a factor in countering the vulnerability of

the black middle class. Both factors are operational within

all of the mobility patterns.

The kin support network because it involves
cultural patterns created and retained from earlier
times that are still functional and supportive of
black family life is as essential now as it was in
earlier generations. (McAdoo, 1988:166)

Hayes and Mendel (1973) demonstrated that the extended

family is a more prominent structure for black families and

that blacks differ from whites in intensity and extent of

family interaction. Based on their study of midwestern urban

families they concluded that, with the exception of parents,

blacks interact with more of their kin than do whites. Black

families also receive more help from kin and have a greater

number and more diversified types of relatives living with

them than do whites.

Dubey (1971) examined the relationship between self-

alienation and extended family. He concluded that subjects

with a high degree of powerlessness were significantly more

oriented toward the extended family. Dubey's study has been

credited with raising the question of whether the extended

family is used as a buffer between oppression of the dominant

society and the unmet needs of the family (Dodson, 1988).









Stack (1974) proposed that the extended family is, in

part, a strategy for meeting physical, emotional, and

economic needs of black families, and involves a reciprocal

network of sharing to counter the lack of economic resources.

Kinship and the extended family are said to play important

roles in the lives of black elderly persons.

Black Elderly Persons

The number of elderly Americans who are black continues

to increase at a faster rate than the other segments of the

black population. In 1980, elderly black persons age 65

years and over constituted almost 8 percent of the black

population, that is about 2.1 million. Moreover, 7.5 percent

of the elderly or 157,000, were 85 years and older. The

"cross-over" phenomenon experienced by blacks who manage to

survive to 75 years of age has been used to explain the

tendency for this group of black people to disproportionately

outnumber others 75 years and older (Cornely, 1970). Elderly

black people were the fastest growing segment of their

population group in the decade of the seventies, increasing

34 percent. During this period the increase for the total

black population was only 16 percent (Johnson, 1988).

Because black Americans have had limited access to

supportive social services, elderly black persons have relied

a great deal on the supportive resources of their families,

and families in turn have relied on elderly relatives (Dancy,

1977). Research has shown that the larger black extended









family is highly integrated, is not based on female

dominance, and provides important resources for the survival

and social mobility of its members (Mindel, 1986).

In recent years, considerable new work has been done

examining the nature of the black extended kin support system

and its ability to care for its members (Aschenbrenner, 1973;

Hill, 1971; Martin and Martin, 1978; Mindel, 1980; Stack,

1974; Staples, 1981). With respect to black elderly persons,

this support system often becomes crucial, considering that

in many cases formal governmental support systems are not

always sufficient. A common theme which runs through much of

the discussion of the black family is the important function

of the black family as a social and psychological refuge for

individual members (Mindel, 1986).

Elderly persons tend to be an important element in the

structure of black family systems. In fact Wylie (1971)

argued that the elderly are more apt to be included in the

black family structure than in white families. Cantor,

Rosenthal, and Wilker (1979) found that elderly black women

continued to carry out instrumental and effective familial

roles far beyond the period customary among whites. They

argue that elderly black women were more highly involved in a

mutual assistance system among and between family members.

It was mentioned earlier that elderly black persons

experienced what has been described as triple-jeopardy and

elderly black women quadruple-jeopardy because of their










position in the American social arrangement. Black elderly

persons experience great hardships because they are subject

to racist stereotypes, and the often impoverished quality of

their lives reflects this (Dancy, 1977). The socioeconomic

status and position of blacks within the United States must

be addressed in considering issues affecting the care of

elderly black Americans (Bennett, 1982; Johnson, 1988).

Johnson (1988) makes reference to the covert and overt

aspects of various forms of racism which have been

instrumental in determining both the status and position of

the black elderly. "The engineered human degradation and

oppression of racism have taken their toll on the current

population of black elderly, and will influence the well-

being and quality of life of all black Americans for the

foreseeable future" (Johnson, 1988). Any study of black

elderly persons in the United States must demonstrate an

understanding of the difference in demographic facts,

history, culture, and life style as against the majority

group.

Marital and Living Arrangements

Among black elderly persons, a lower percentage are

married both in the young-old, and in the old-old period than

are white elderly. This holds for both male and female

(Johnson, 1988). There is also statistical evidence that

substantially more black elderly are widowed and divorced

than are white elderly. The marital status of black elderly










persons in 1980 was as follows: 56.9 percent of the men were

married, 22.1 percent were widowed, 14.7 percent were

divorced or separated, and 6.5 percent were single, never

married; for the women 25.0 percent were married, 57.7

percent were widowed, 11.6 percent were divorced or

separated, and 5.6 percent were single, never married

(Johnson, 1988). Since women outlive men, they also tend to

be without a mate.

Many elderly black persons live alone. It has been

noted that this tendency is almost as great among elderly

black persons as it is among whites. Black elderly persons

often take other relatives into their homes. It has been

noted (Hill, 1972) that four times as many families headed by

black elderly couples take younger relatives into their

households than do white elderly couples. Hill also reports

that families headed by black elderly females take in the

highest proportion (48 percent) of children. Another

important observation is that "a higher proportion of white

than black female headed families had elderly members living

with them" (Hill, 1972:6).

Housing

Stokesberry (1985) argues that in the area of economic

issues, and other issues, there is not a great deal of

difference in the need for services for all elderly persons

in terms of quality, quantity, and accessibility. However,

being a minority member exacerbates the problem all elderly









have in reference to their need for appropriate, affordable,

and adequate housing. Black elderly persons like their white

counterparts experience housing problems. Those who do not

own their own home, must resort to renting (sometimes

subsidized by government) or living in elderly hotels (SROs).

Although there are Adult Congregate Living Facilities

(ACLF's), not too many black elderly persons reside in them.

The literature supports the claim that most black elderly

persons reside at home.

Health Status

"The health status of elderly black people is poorer

than that of elderly white people" (Aiken, 1982:179).

Elderly black persons demonstrate different configurations

regarding certain chronic diseases. A Report of the

Secretary's Task Force on Black and Minority Health reports a

higher incidence of hypertension among elderly black persons.

The incidence of diabetes is also reported to be higher in

elderly black persons, and the same is true for certain types

of cancers (U.S.Department of Health and Human Services,

1985). It is reported that major chronic diseases which are

aggravated by dietary excesses are said to be in excess

prevalence among minority groups. For example, hypertension

and diabetes are prevalent among black Americans

(U.S.Departmentof Health and Human Services, 1985). Dietary

intake is influenced by socioeconomic status. Nutrient

intakes are higher at higher levels of disposable income (in









the low to middle income range), with the exception of

carbohydrate intake, which decreases with decreasing income.

Black elderly persons continue to suffer from the lack

of adequate health care services. The majority receive

health care through Medicaid funding. It has been and

continues to be a problem for black elderly persons to find

physicians who will agree to accept the Medicaid

reimbursement. Neighborhoods and geographic location play a

major role in this situation (Stokesberry, 1985). The cost

of medical care and the availability and accessibility of

such care place difficulties in the paths of black elderly

persons. Studies have implicated structural, social, and

psychological factors in health utilization behavior.

In terms of availability and accessibility, the

conceptual framework generated by Andersen and Newman (1973)

and Aday and Andersen (1978) with regard to health services

finds application in, and contributes greatly to,

understanding these phenomena. Three groups of variables are

identified in this conceptual framework: (1) predisposing

factors which are social-structural variables (for example,

race, religion, ethnicity) as well as family attitudes and

health beliefs that may affect the recognition that health

services are needed; (2) enabling factors which include

individual characteristics or circumstances, such as

available family income and accessibility of service, that

might hinder or accelerate use of a health service; and









finally (3) need factors which include subjective perceptions

and judgments about the seriousness of symptoms, the level of

physical disability or psychological impairment, and an

individual's response to illness. With regard to black

elderly persons their educational level (a predisposing

factor) and their income and insurance coverage as well as

accessibility of health services (enabling factors) are

important predictors of their use of health services. This

model finds easy application to the availability,

accessibility, and use of formal services by elderly black

persons.

Economic Status

Black elderly persons have generally earned less than

their white counterparts throughout their lifespan. The

types of income that those over 65 have available to them are

significantly different for the black and the white

population. The three major sources of income for elderly

black persons, whether they were living alone or in a family

situation, were, in order, Social Security, earnings from

employment, and Supplemental Security Income (SSI). For the

white elderly who were living alone, the three sources of

income were Social Security, dividends, and pension incomes;

and for white elderly who were living in a family situation

the three main sources of income were Social Security,

dividends, and earnings from outside the home (Stokesberry,

1985).









Separating the men and the women, Stokesberry (1985)

points out that 39 percent of black women receive SSI in

addition to Social Security and income from continued

employment after age 60 or 65. Among the black males, 27

percent were receiving SSI, indicating that their Social

Security payments obviously were so low that they were also

entitled to the SSI. For white males, only 12 percent were

receiving SSI and only 11 percent of white female elderly

were receiving SSI.

At the end of the decade of the 1970s, approximately one

out of three black elderly persons lived below the poverty

level (Stokesberry, 1985). Drawing from the data of Hill

(1978), Stokesberry observes that "even with a dramatic

reduction in the proportion of black elderly persons living

in poverty during the seventies (50 to 36 percent), at the

end of that decade the numbers of black elderly persons below

the poverty level was still three times that of the white

elderly" (Stokesberry, 1985:32). The disparity in the

poverty level of black elderly persons continued to be an

area of concern in the 1980s. Johnson (1988) reports the

number of black elderly persons living below the poverty

level as being two times that of whites in the 1980s.

Johnson (1988) reports a decline from 39.1 percent in 1983 to

33 percent in 1986 representing a figure of well over 700,000

black elderly persons aged 65 and over. Although this shows

some improvement in the economic situation of black elderly









persons from the 1970s to the 1980s, such a disparate

situation is still an indictment on a country which is one of

the richest in the world.

Stokesberry (1985) refers to the existence of blacks

whose income from Social Security, SSI and private pensions

may not meet the basic needs for food, shelter, and health

care. This is compounded by the fact that the lack of

training and skills to continue employment after retirement,

if that is a financial necessity, or to re-enter the

workforce is a special problem for these persons

(Stokesberry, 1985).

Elderly black persons largely represent that pool of

elderly persons who, in the days when they had membership in

the labor force, were saddled with the lowest paying and

dirtiest jobs. Their numbers include a few retired school

teachers, retired owners of small businesses, or former

government employees, but these represent only a very small

proportion of today's elderly black persons. The majority

worked in manual labor, and domestic service jobs. These

jobs did not offer benefits and were not covered by Social

Security. As a result, many black elderly persons now

receive minimum Social Security which cannot cover everyday

living expenses. Black elderly persons are thus likely to

remain employed after retirement age due to inadequate or

nonexistent retirement income.










Although there does not seem to be a difference in the

proportion of elderly blacks and whites who re-enter the work-

force after they reach 65, elderly black males in this

situation have a much higher unemployment rate than do

elderly white males (Stokesberry, 1985). Of note, too, is

the fact that the unemployment level for black females is

lower than it is for white females.

The economic disparity in the black American community

can be seen at all levels and in all types of families.

Black family median income was 56 percent of white family

income in 1984. This difference in income was also found

among the elderly who have generally earned less throughout

their life span. In 1984 the median income for black males

over the age of 65 was $6,163 compared to $10,890 for white

males. For black females the 1984 median income was $4,345.

For white females the figure was $6,309 (Johnson, 1988).

Religion

In considering the unique aspects of the black cultural

experience it is imperative that one be attuned to the

religious experience of black elderly persons. Hill (1972)

lists strong religious orientation as one of the strengths of

black families, which function for their survival,

development, and stability.

A strong orientation toward religion and the black

church is a cultural attribute which holds a great deal of

importance in the lives of black elderly persons. Dancy









(1977) states that "the black elderly have needed a frame of

reference to enable them to cope with the oppressive forces

of racial discrimination, and for many this frame of

reference is religion." "Historically," he states,

religion and the black church have played a vital
role in the survival and advancement of blacks.
The black church is an independent institution
which blacks control in their communities. It is
the one black institution which has remained
relatively free from white authority. (Dancy,
1977: 22-24)

Black churches include such traditional black Protestant

denominations as the Baptists and Methodists, as well as

varied Pentecostal or fundamentalist religious groups.

In the black church there are points of uniqueness
(culturally and experientially) that differ from
the mainline churches of the dominant society. An
example is worship through celebration. The black
elderly have within the black church the freedom to
express themselves as the Spirit dictates. The
black church is a place of affirmation, rejoicing,
and recognition. Historically, these churches have
provided for the elderly a place where they can
feel like somebody and be somebody. The church's
role as the provider of opportunities for many poor
black elderly persons to gain an understanding of
the world beyond their city and state through
missionary groups and church related trips has been
observed. (Dancy, 1977:23)

Dancy sees the religious experience of the black elderly

especially those from the low-income group, as contributing

to the value they place on life.

In the face of life's many trials--ageism, racism,
the normal changes of sixty and more years, the
uprooting from the rural South to the urban North
or West--the black elderly have often found solace,
strength and assurance in the black church. In
society at large they have experienced rejection,
but in the church they have found acceptance and
freedom. The black church has provided them an









avenue of release-"that soon we'll be done with the
troubles of the world," as the spiritual puts it-
and an avenue of rejoicing and renewal. Self-
understanding is shaped by many factors. American
society has not helped to instill racial pride in
black people. Such pride and affirmation have had
to come from within, and from the supportive
encouragement of other black persons and of the
black church which refused to accept the idea that
black people were inferior. Through the church,
black elderly persons were reminded that they
possessed dignity and that such dignity would
endure in spite of all that men could do to them.
(Dancy, 1977:23)

Many black elderly persons would not have much to keep

them going if they did not have the black church. It is

important therefore, that anyone embarking on a study of

black elderly persons and black communities have an

understanding of the dynamics of the black church and the

influence that religion has on black elderly persons. The

church is described as a channel through which a large

segment of the black elderly can be reached, and the black

church continues to be a source of communication with the

outside world for many black people in the United States.

Historically, the black church has been a strong social

force among black elderly persons. Dancy (1977) observes

that "when vital social services were not available to its

parishioners, the black church provided the needed counsel,

the services, and the framework of meaning. The black church

has always been an organizing force" he notes and "a service

center for its members" (Dancy, 1977:24). A challenge facing

those who are interested in the problems of black elderly

persons in terms of social supports, as advocates, is to









change the societal system which fails to meet the clients'

needs. In this effort, the cooperation and support of black

pastors and congregations can be enlisted. By mobilizing in

this fashion, these persons and the church can move beyond

their daily piecemeal supportive efforts (Dancy, 1977).

Whatever the task, there is powerful potential for reform

when the black church is considered a part of the informal

network system as it affects black elderly persons. The role

of the church in an aging society is becoming more visible.

This does not only apply to the black church, but other

churches and synagogues are being called on to develop a wide

range of activities to enhance the spiritual, emotional, and

physical well-being of older persons (Sheehan, Wilson and

Marella, 1988). It is obvious then, that something which

black churches have been doing for their elderly persons for

a very long time is now being recognized and courted for the

rest of the elderly population.

Kinship Relations and Family Support

No analysis of black elderly persons would be effective

or complete without some observations about the kinship

system and the role it plays in the lives of black people.

There is a growing body of literature on black families

describing the components of the kinship system. Literature

on the kinship interaction among black families as well as

the system of mutual aid and support that persists and exists

within black families is also on the increase (Mindel, 1986).









Discussions of kinship in the United States usually cover

three areas, affectional attachments, interaction, and mutual

assistance (Mindel, 1986).

It appears from the research that for blacks the kinship

network serves its members most effectively as a functional

mutual aid system. Numerous studies have shown that black

relatives help each other with financial aid, child care,

advice, and other supports to a rather extensive degree

(Aschenbrenner, 1975; Hill, 1971; Martin and Martin, 1978;

Shimkin et al., 1978; Stack, 1974). Strong kinship bonds is

one of the attributes of black families. A sense of

cohesiveness is a strength of black families and elderly

persons are often the focal point of that cohesiveness.

(Dancy, 1977).

One consequence of discrimination is that it has
caused black people to depend on each other and to
distrust the dominant society which would not
accord them respect. The desire for dignity and
freedom from oppression helps account for the black
elderly person's reliance on the strong family
bond. Family members recognize and value black
elderly persons, because they have survived and
surmounted many obstacles which the dominant
culture has strewn in their path. In turn, the
family frequently provides needed emotional support
and understanding. (Dancy, 1977:20-22)

Summary

In this chapter black families have been examined in

terms of social, economic, and demographic factors. Various

theoretical approaches used to study black families in

America have been analyzed. The strengths and weaknesses of

black families have been discussed and a profile of black









elderly persons has been presented. Of importance is how

black elderly persons have coped considering their position

in the society. The role of the black church as it continues

to respond to the needs of its elderly members has been

examined. Caregiving as it relates to black elderly persons

continues to be dependent on the informal support system

which includes, family, church and kinship networks. It has

been shown that studying black families from the cultural

relativistic approach can have positive effects by dispelling

some of the myths long held about these families. It could

also reduce the tendency of stereotyping these families and

so prove effective in countering the cultural ethnocentric

school which has for years underpinned some of the wrongs

that have been meted out to black Americans by some

researchers. The caring nature that is inherent in black

families has enabled them over the years to take care of and

nurture their elderly relatives. This characteristic is also

responsible to some extent for the manner in which elderly

relatives of black families have also always supported the

younger members of their families.














CHAPTER THREE
CAREGIVING

A Review of the Literature

Although there may be no theory of caregiving for the

elderly, there is, within the literature, information on the

concept of caregiving and since this is such a central part

of this study it is important that we inform ourselves

regarding its meaning. In the literature there is no clear

cut or agreed upon general concept of caregiving. Although

there is a rapidly growing body of literature on caregiving

wherein reference is made repeatedly to the aspects of

caregiving tasks, the stress and burden of caregiving

(Cantor, 1983; Gubrium and Lynott, 1987), the economics

associated with caregiving (Arling and McAuley, 1983),

caregiver selection (Ikels, 1986), as well as the demands,

risks, and costs of caregiving, family responsibility and

caregiving (Gubrium, 1988; Soldo and Myllyluoma, 1983) the

difficulty still lies in finding any concise conception of

the term. Indeed what we have is all very much an intuitive

and common sense understanding of the meaning of caregiving,

and the above are examples of the common sense ordinary way

in which the term caregiving is used in the literature. The

concept of "caregiving" is used when older people need care









of any sort because they are chronically impaired and hence

unable to perform certain functions without assistance. This

care may be administered in the home or in an institution.

This study is concerned with care which is administered in

the home, and that is the conception of caregiving that is

used. That is, a consensual, intuitive, common sense meaning

of caregiving. But in order to go beyond what is in the

literature I define caregiving using the following questions:

First, is there a need for care? Is there impairment? Is

there helplessness? and is there a need for assistance? The

search for answers to these questions directs the researcher

into looking at programs such as Social Security, Medicare

and Medicaid and other such features (these constitute the

formal system), and family members and friends (these

constitute the informal system).

Why are findings on such things as Social Security,

hospitals, food stamps, family members, friends and

neighbors, important to such an investigation? The answer

lies in the fact that the concept can be subdivided into two

types of caregiving: formal and informal. Both systems

together make, up one caregiving network.

The term caregiving has been used in the gerontological

literature as an umbrella term to cover a wide variety of

support services for elderly persons. The concept will be

defined here in terms of its application and utility. A

caregiving equation could be defined as follows: Formal +









Informal Assistance = Caregiving. Why is there a need for

formal and informal assistance? There is a time in the lives

of many human beings when they are unable to do things for

themselves and unable to supply all the support they need to

manage effectively. For example a person who is impaired

mentally, physically, and/or economically needs assistance

from one or both systems. Hence, we can logically say that

caregiving is taking place if the needed assistance is

forthcoming and does not cause a strain for the care

receiver, or causes very little strain, while taking place.

The concept of Caregiving usually connotes a care equation

and caregiving can take place when the care receiver is in an

institutionalized or noninstitutionalized setting.

Caregivers and Caregiving

Many older people are able to cope by themselves, but a

large number get to the point where they need care. This

places them in the category of care receivers. Those who

administer the care are known as caregivers and the product

administered is known in the gerontological literature as

caregiving.

Older people not only have to cope with the physical

problems indigenous to their population, but they also have

to cope with stressful life events such as death of a spouse,

loss of financial benefits when they are no longer able to

work, and loneliness (Shivers and Fait, 1980). Shivers and

Fait (1980) also note that "if any generalization can be made









about the aging process, it is the increasing vulnerability

of the organism to environmental stress, disease, and

continuing loss of functional ability of organs and systems"

(Shivers and Fait, 1980:19).

In a survey conducted by the American Association of

Retired Persons, the major events causing the need for care

were found to include major illness, hospitalization, death

of a spouse, retirement, and being laid off or fired

(American Association of Retired Persons, 1986). This survey

also found that the kinds of help provided by caregivers

range from financial support and managing finances to

household chores, personal care, ambulation, transportation,

administration of medication, companionship, making or

receiving phone calls, and arranging outside help ((American

Association of Retired Persons, 1986). Caregiving, then,

refers to care provided to an elderly person with some degree

of physical, mental, or emotional impairment which limits

independence and necessitates ongoing assistance (Horowitz,

1985).

The organization of society today determines that people

receive support from agencies of government (the formal

system) or from family, kin, and neighbors (the informal

system). The elderly recipient of care may benefit from both

formal and informal support systems.

Care receivers are often plagued by various chronic

illnesses that limit their abilities to care for themselves.









Care receivers, on average, suffer from four medical problems

from among a list of over 20. These include high blood

pressure, arthritis, vision problems, heart problems,

depression, circulatory problems, hearing problems, memory

loss, sleep disorders, dizziness, respiratory problems,

diabetes, stroke, constipation, bone fracture (especially of

the femur), cancer, elimination problems, diarrhea,

drug/alcohol problems and Alzheimer's disease (American

Association of Retired Persons, 1986). The AARP study also

reports that the health conditions most frequently

experienced by older care receivers were high blood pressure,

arthritis, vision problems, heart problems, depression, and

circulation problems (American Association of Retired

Persons, 1986).

The Formal Support System

Government, through bureaucracies at local, state and

federal levels, is committed to providing financial support

in the form of Social Security to the elderly. Through

Medicare and Medicaid, government also provides a portion of

the payment for the health care for the elderly. In a series

of reports compiled by the Social Security Administration,

public social-welfare expenditures are defined as cash

benefits, services, and administrative costs of all programs

operating under public laws that are of direct benefit to

individuals and families. The programs included are those

for income maintenance (social insurance and public aid) and






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Missing
or
Unavailable









The Informal Support System

Caregiving needs to be assessed in the same way as any

other social organization. Once the formal segment has

carried out its role, everything that remains is expected to

be undertaken by the informal system.

Informal caregivers are usually spouses, children, and

relatives in that order. The process of caretaker selection

appears to follow rules that transcend cultural differences.

Certain demographic groups have a greater likelihood of being

care givers than others. Results of the survey conducted by

the American Association of Retired Persons (1986) indicated

that the probability or likelihood of being a care giver is

greater for females than it is for males, and the likelihood

of having caregiving responsibilities is greater for females

who are older, and widowed (American Association of Retired

Persons, 1986). This finds support in the caregiving

literature where many researchers note that filial caregiving

connotes daughters and that this has implications for the

role of women in our society.

Researchers have been able to detect the underlying

dynamic that leads to caretaker selection (Ikels, 1986). The

factors found to be involved in the selection of caretakers

fall under three headings: Demographic Imperatives,

Antecedent Events, and Situational Factors. Demographic

Imperatives listed the caretaker as being the only child, the

only child of preferred sex, and the only proximate child.









Antecedent Events incorporate those such as gradual

emergence, explained by the dependent child or children who

were still at home when widowhood occurred. These children

are said to be slated early on for the caretaking role and

gradually assume it. Situational Factors such as least

inconvenience and greatest motivation are also used in the

selection of a candidate for the role of caretaker (Ikels,

1986). All things being equal, in most cultures the child

with the least obligations and the greatest motivation will

undertake the role of caretaker.

Most caregivers provide several different supports

simultaneously. The average caregiver provides approximately

four supports to the person being cared for (American

Association of Retired Persons, 1986). This places heavy

burdens on them, since a large proportion also hold full time

jobs. The majority of employee caregivers care for aged

relatives who live in their own home, some near the caregiver

and some quite far away. Some caregivers share housing with

the older person, while some of the care receivers may live

in a nursing home near or far from the caregiver (American

Association of Retired Persons, 1986).

Some subgroups of the elderly population are known to

place more faith in the informal support system and hence

receive most of their support from this system. Black

elderly persons are among those who, for reasons that have









been given some support in the literature, place heavy

dependence on the informal support system.

Impairments of the Elderly

The process of aging begins with conception and

continues until death. Unless some catastrophic event causes

early death, most people tend to follow an aging cycle that

terminates at or about the beginning or the middle of the

seventh decade. Only a few people live into their nineties,

and a tiny proportion go on to be centenarians. According to

the 1980 Census there were 32,000 persons aged 100 or older

in the United States, two-thirds of whom were women. Many

factors contribute to longevity. This can be the result of

genetic foundation, nutrition, environment, physical

capacity, lack of stress, or a combination of these. Many of

those attaining long life can expect to be plagued by some

kind of impairment either mental or physical. Some elderly

experience minimum impairment while others suffer terribly.

To impair is generally defined as "to make worse, to

lessen in quality, quantity, value, excellence or strength;

to deteriorate" (New Webster Dictionary of the English

Language-Deluxe Encyclopedia Edition, 1984). Melloni's

Illustrated Medical Dictionary (1985:218), defines impairment

as "damage resulting from injury or disease," and mental

impairment as "intellectual defect as manifested by

psychologic tests and diminished effectiveness (social and

vocational)."









When considering impairments in the elderly one should

concentrate on those that cause the greatest handicaps, since

certain impairments of elderly persons are more devastating

than others. Hearing, visual, and mental impairment are of

particular concern and demand special emphasis. When we are

dealing with areas such as living arrangements for the

elderly, we are faced with an even greater problem; that of

functional impairment. Those who are functionally impaired

are those who have trouble in mobility or transportation,

personal care, basic housekeeping activities, and self-

management, i.e., taking medication, using the telephone

(Verbrugge, 1986).

"Hearing loss is more common than visual loss among

elderly persons, although both are found to increase with

age" (Butler and Lewis, 1983:108). Although most persons

past 60 years of age retain hearing sufficient for normal

living, the elderly individual is three times more likely to

display a significant loss of hearing than is a younger

person, and older males have greater hearing loss than do

older females (Shivers and Fait, 1980). Statistics from the

National Health and Nutrition Examination Survey (HANES I) of

1971 indicate that the ratio of hearing loss for persons less

than 17 years of age as opposed to that for persons of 65

years and over increases from 3.5 per 1,000 persons to 133

per 1,000. About 19 percent of individuals age 45 to 54 as

compared to 75 percent in the 70- to 79-year-old age group









report a hearing loss. It has also been reported that 23

percent of elderly persons 65 to 70 years of age and 40

percent of those age 75 and above reported that they had

hearing impairments that were somewhat handicapping (The

National Health and Nutrition Examination Survey, 1971).

Hearing is crucial to mental health in old age; hence

hearing loss has been known to contribute to depression among

the elderly. Butler and Lewis (1983:109) note that "hearing

impaired persons receive much less empathy than visually

impaired persons and are more subject to depression,

demoralization, and psychotic symptoms." It is estimated

that in the United States there are 5.5 million elderly

persons (over the age of 65) with hearing defects (Butler and

Lewis, 1983).

Visual Impairment

Visual impairment presents its own problems for the

elderly. Nearly half of the legally blind population in the

United States is 65 years of age or older (Butler and Lewis,

1983). Macular degeneration, cataracts, glaucoma, and

diabetic retinopathy are the four most common causes of

visual impairment in the older age group (Butler and Lewis,

1983). Visual impairment can be devastating in terms of both

psychological isolation and physical immobilization. Visual

impairment can result in accidents in old age. By affecting

driving, the outcome can be loss of one's drivers license,

thus increasing dependency on others for transportation.









Visual impairment can also be responsible for accidents in

the home such as physical injury and the misreading of labels

on medications and on household products. All of this

impedes the visually impaired person from living alone.

Mental Impairment

Chronic conditions among elderly persons include those

of a psychopathological nature. The elderly are more likely

than younger persons to develop mental manifestations of

their physical problems. According to Pfeiffer (1977),

approximately 15 percent of the elderly population in the

United States suffer from significant, substantial, or at

least moderate psychopathological conditions. It is also

estimated that between 70 and 80 percent of elderly nursing

home patients suffer from moderately severe mental disorders

(Whanger, 1973). Kart (1985) reports that organic brain

syndromes, depressive disorders, schizophrenia, and alcohol

disorders are listed among the specified diagnoses accounting

for the highest rates of patient-care episodes in outpatient

psychiatric services for old people in the United States in

1971. He cautions however, that for many reasons these

figures may not be as authentic as we could be led to

believe. Kart (1985) cites several factors that are

conceptual and methodological in nature which contribute to

this probable incorrect documentation. He notes that

the epidemiology of psychopathological conditions
is beset by conceptual and methodological problems.
Diagnosing schizophrenia or depression is often
difficult even under careful conditions of









assessment. Diagnoses are not made under strict
experimental conditions. There is a substantial
degree of subjectivity involved, complicated by the
fact that different doctors use different
definitions and criteria and vary widely in their
competence and in their understanding of aging
processes. (Kart, 1985:182)

Changes in the environment have also been said to be a causal

factor in the early mental change shown by elderly persons

(Libow, 1973). Research shows that many cognitive problems

in old people may result from adverse drug reactions (Lipton

and Lee, 1978). Iatrogenic brain disorders are not uncommon.

Doctors unwittingly produce reversible and often unrecognized

irreversible brain disorders. Tranquilizers and hypnotics

are said to be the most likely causes of such conditions, but

steroids used for arthritis can cause organic brain disorders

as well as hypomania or depression or both (Butler and Lewis,

1983). Despite the difficulties involved in determining the

degree and extent to which psychopathological conditions are

distributed among the elderly, there is no doubt that some

elderly people are mentally impaired, hence requiring care

that is usually very demanding on the caregiver.

The mental health evaluation in its simplest sense is a

method of looking at the problems of older people, arriving

at decisions as to what is wrong, and concluding what can be

done to try to alleviate or eliminate these problems.

Evaluators use historical data from the person's past;

current medical, psychiatric, and social examinations; and

their own personal interactions with the individual to get a










many sided and, one hopes, coherent picture of what is

happening (Butler and Lewis, 1983). Knowledge of the racial,

cultural, and ethnic backgrounds of these elderly persons

during the process of evaluation is germane to the evaluation

process.

Decisions made on the basis of the mental health

evaluation should be aimed at the well-being of the older

person, not only via medical and professional treatment, but

through social supports. Knowledge of the resources

available for treatment purposes should be uppermost in the

mind of the therapist; also it is important to know of the

older person's own emotional and physical capabilities, the

assets in his or her family and social structure, and the

kind of services and support available in the community

(Butler and Lewis, 1983:165). Treatment goals should be

reasonable and reachable and when decisions are made not only

must the margin of error be small and aimed at the well-being

of the elderly person, but care should be taken that

presentation of the decision should be in language which can

be understood by the older person's family and friends as

well as by the older person (Butler and Lewis, 1983). This

will provide them with a basis for assessing the mental

health care offered them and will know what to expect and how

to best participate actively in evaluation and treatment

(Butler and Lewis, 1983).









Depression appears to be the most common functional

psychiatric disorder in the later years. Depression can vary

in duration and degree; it may be triggered by loss of a

loved one or by the onset of a physical disease (Impallomeni

and Antonini, 1980; Kart, 1985). Depression often results

from adjustment reactions. It can be triggered by fear. The

fears of elderly persons are many and justified. Elderly

persons fear being alone, they fear being attacked, and they

fear the loss of loved ones. Kart (1985) observes that the

complexity of their emotionality can result in increased

blood pressure (increased heart rate) stemming from their

physical problems and these in turn can result in depression.

Today's elderly person grew up in the 1920s, a period when

people were termed mad, crazy, and so on if they acted even

slightly strange; hence their fears are justified. A

depressed individual may show any combination of

psychological and physiological manifestations. Diagnosis is

difficult and treatment is problematic. Drug therapies are

popular for the elderly since they are viewed by many

professionals as poor candidates for the psychotherapies

(Kart, 1985:183).

Suicidal thoughts often accompany depression. Suicide

rates are very high among the elderly. According to the U.S.

Public Health Service, in 1975 these were between 43 percent

and 62 percent higher than they were for the total

population. The elderly accounted for 16.3 percent of all









the suicides in the United States in 1975 (U.S.Department of

Health, Education, and Welfare, 1977). An examination of

suicide rates by sex and race for 1979 revealed that aged

white males show the highest suicide rate of any group, 39.2

per 100,000 population. Their rate is three times that of

aged black males (12.9), more than five times that of aged

white females (7.3 per 100,000 population), and about

sixteen times that of aged black females (2.5 per 100,000

population) (U.S. Bureau of the Census, 1982-83). Elderly

females in the United States have among the lowest suicide

rates in the world.

Paranoia and hypochondriasis are two additional

functional disorders common to elderly persons. Paranoia is

a delusional state, usually persecutory in nature. It often

involves attributing motivations to other people that they

simply do not have (Kart, 1985:184). Paranoia is reported to

be more common in individuals who suffer from sensory defects

such as hearing loss (Eisdorfer, 1960; Houston and Royse,

1954). Some paranoia may result from changes in life

situation. Paranoid reactions of the elderly person are

usually directed at the spouse or adult children or persons

working in the home (home help). There is a lot of

misinterpretation and misunderstanding in such situations.

Paranoia could contribute to the degree of stress which

caregivers and others experience. The older person usually

accuses others (Pfeiffer, 1977), and isolation can result by









virtue of their behavior, this in turn can lead to

depression.

Hypochondriasis is an overconcern for one's health,

usually accompanied by delusions about physical dysfunction

and/or disease. The disorder presents problems in treatment

since hypochondriacs are not predisposed to psychological

explanations of their condition. Telling the patient that

nothing is really wrong is rarely effective (Kart, 1985).

Elderly people and their relatives fear Alzheimer's disease.

They also fear cancer, especially cancer of the colon, and so

they use laxatives to prevent constipation. Butler and Lewis

(1983:298) note that bowel complaints, especially

constipation, in both mental disorders (for example,

depression) and physical conditions, are frequent and provoke

anxiety in older people.

The distinction is made between organic brain syndromes

(OBS) and organic mental disorders (OMD) (American

Psychiatric Association, 1980). Organic brain syndrome

refers to a group of psychological or behavioral signs and

symptoms without reference to etiology. Organic mental

disorder designates a particular OBS in which the etiology is

known or presumed (American Psychiatric Association, 1980).

OBS can be grouped into six categories, the most common of

which are delirium, dementia, and intoxication and

withdrawal. It is believed that as many as half of those

elderly persons with mental disorders have OBS (Redick et









al., 1973); the prevalence rate of OBS appears to increase

with age (Redick et al., 1973), although onset usually occurs

in the seventh to ninth decades and is more common in women

than in men (Fann et al., 1976).

Kart (1985) observes that primary degenerative dementia

of the Alzheimer type may be the single most common OBS.

According to the DSM-111, between 2 and 4 percent of the

entire population over the age of 65 may have this dementia.

Alzheimer's disease has an "insidious onset and gradually

progressive course" (American Psychiatric Association, 1980).

"It brings a multifaceted loss of intellectual abilities,

including memory, judgement, and abstract thought, as well as

changes in personality and behavior. The clinical picture may

be clouded by the presence of depression, delusions, or (more

rarely) delirium" (Kart, 1985:184). Some conditions may

manifest themselves as something else, leading to

misdiagnosis, for example, senility. There are times when

there is misdiagnosis of this condition and some use the term

pseudosenility to refer to such conditions (Libow, 1973).

Causes of pseudosenility, Libow notes, include drug reactions

(and the elderly are usually taking more than four types of

drugs at any single time), malnutrition (another problem of

older people), and fever. When these conditions are treated,

the senility often vanishes (Libow, 1973).

Older persons need a lot of support to help them

overcome the feelings of worthlessness and depression that