Utilization of Formal and Informal Home Care: How Do Older Canadians’ Experiences Vary by Care Arrangements?

Abstract

This study investigates how the receipt of formal, informal, and/or a combination of both types of care at home relates to older adults’ perceived loneliness, life satisfaction, and day-to-day lives. Quantitative analyses using the Canadian Community Health Survey (n = 3,928) reveal that older adults who only received formal care reported lower levels of loneliness and higher levels of life satisfaction when compared with respondents who received informal or a blend of home care. Qualitative analyses of persons aged 65+ years receiving formal and informal home care in Ontario (n = 34) suggest that formal care bolstered care recipients’ autonomy and reduced their sense of being a burden on family. In turn, receiving formal care served to improve these older adults’ social connectedness and well-being. Findings underscore older adults’ symbolic, functional, and emotional attachment to formal care services, as well as the limitations of a reliance on informal support.

Keywords

formal home care informal support loneliness life satisfaction

Introduction

Research describes the receipt of home care as an experience of discontinuity, dependence, and loss (Janlöv, Rahm Hallberg, & Petersson, 2005), as well as a resource that fosters independence and well-being (Hale, Barrett, & Gauld, 2010; Holmberg, Valmari, & Lundgren, 2012). In the home setting, older adults with chronic health conditions and disabilities receive support from both informal (i.e., family/friend) and formal (i.e., paid) care providers. While researchers have long been interested in the relationship between formal and informal care (e.g., Kemp, Ball, & Perkins, 2013; Penning, 2002) as well as the health consequences of receiving care in later life (Albert, Simone, Brassard, Stern, & Mayeux, 2005; Kadowaki, Wister, & Chappell, 2015), the relationships between diverse home care arrangements, social connectedness, and everyday life are under examined. Moreover, population-level data are rarely linked to interpretive analyses in ways that allow for multiple perspectives on later life care arrangements. How do older people’s social and health outcomes vary by the receipt of formal or informal care, or a combination of the two? What are the subjective meanings and experiences attached to these forms of support? This investigation explores how formal and informal care arrangements at home influence older adults’ perceptions of loneliness and life satisfaction, as well as their day-to-day lives. First, we analyzed population-based data from the Canadian Community Health Survey (CCHS)–Healthy Aging. Second, we drew on a qualitative study to interpret statistical findings and to give voice to older Canadians receiving care at home.

Formal and Informal Home Care

The home is increasingly the site of care for older people with chronic health conditions and impairments in Canada and internationally (Colombo, Llena-Nozal, Mercier, & Tjadens, 2011). While policymakers often consider it more cost-effective to provide care at home rather than in hospitals or long-term care facilities (Keefe, 2011), it is also the preference of many older adults. Although some older people may feel insecure in their homes (Cristoforetti, Gennai, & Rodeschini, 2011), or dislike their home environments and wish to move elsewhere (Hillcoat-Nalletamby & Ogg, 2014), many indicate a preference to make home modifications and to access support that will help them to age in place (Mahmood & Martin-Matthews, 2008; Wiles, Leibing, Guberman, Reeve, & Allen, 2012). Furthermore, relocating residences in later life can compromise mental and physical health (Bradley & Van Willigen, 2010; Walker, Curry, & Hogstel, 2007).

In 2009, an estimated one million older people, constituting 25% of the Canadian population aged 65 and older, received informal and/or formal care at home (Hoover & Rotermann, 2012). Informal caregivers give the majority of support to older people (Hollander, Liu, & Chappell, 2009; Keefe, 2011). In 2012, 5.4 million Canadians cared for an older family member or friend, and 78% of these caregivers supported someone living in a home setting (Turcotte & Sawaya, 2015). Informal caregivers are often responsible for direct, hands-on care as well as for managing care and assisting formal care providers (Rosenthal, Martin-Matthews, & Keefe, 2007; Sims-Gould & Martin-Matthews, 2010).

Some older adults also receive formal home care for assistance with personal care, homemaking, and clinical care (Canadian Home Care Association, 2013). These services are intended to complement, but not to replace, the support that older adults receive from family and friends (Funk, 2013). With population aging and higher rates of chronic health conditions and disabilities, the demand for home care services is increasing. Yet, within the Canada Health Act that guarantees equitable access to some forms of health care, home care is considered an “extended” rather than a “medically necessary” service, and is provided at the discretion of each province or territory (Lanoix, 2017). Older and disabled people are typically eligible for some publicly funded home care, but there is wide variation in the availability and quality of services between jurisdictions. Individuals who meet certain eligibility criteria can receive formal assistance from a personal support worker with activities such as bathing or dressing and, in some cases, with household tasks (e.g., laundry, cleaning), as well as nursing (e.g., wound care). In some jurisdictions, older people may also have access to more comprehensive home care from occupational therapists, physiotherapists, pharmacists, nurse practitioners, social workers, dietitians, and physicians (Health Council of Canada, 2012). Individuals with the financial means to pay for care, private insurance plans, and some government programs such as respite cover the costs of services that extend beyond publicly funded home care (Ontario Home Care Association, 2013).

Many researchers have explored the relationship between formal and informal care in the home setting (Litwin & Attias-Donfut, 2009; Suanet, Van Groenou, & Van Tilburg, 2012; van Groenou, Glaser, Tomassini, & Jacobs, 2006). Previous studies support the complementary model, which suggests that formal care supplements informal support, and that recipients typically use formal services when their needs exceed their families’ and friends’ caring capacities (Litwin & Attias-Donfut, 2009; Penning, 2002). Despite the high prevalence of informal care, some older people do not necessarily wish to receive support from their families and close friends. Research conducted in the United States and Germany (Pinquart & Sörensen, 2002) and in the Netherlands (Wielink, Huijsman, & McDonnell, 1997) finds that older adults prefer informal or mixed formal/informal support for short-term needs and household tasks, but would rather have formal care, either in home or institutional settings, for long-term assistance. Canadian research also suggests that individuals do not necessarily expect or want family members to provide care beyond emotional support (Kemp & Denton, 2003).

Home Care and Health Outcomes

Research on home care use has mostly focused on clinical outcomes or impacts on cost and health utilization, and less on psychosocial factors (Kadowaki et al., 2015). Studies typically suggest that home care services improve physical and psychological health such as reduced mortality risks (Albert et al., 2005) and lower rates of hospitalization (Xu et al., 2010). Individuals whose home care needs are met report lower levels of loneliness and perceived life stress, along with improved life satisfaction when compared with people with unmet needs (Kadowaki et al., 2015). King, Parsons, Robinson, and Jörgensen (2012) assessed the effectiveness of a restorative home care program and found that it improved clients’ health-rated quality of life. Another study found that even receiving minimal levels of formal home care (i.e., less than 1 hr per week) led to improved quality of life (Markle-Reid et al., 2008).

While there are some benefits to receiving formal home care, little research investigates how the combination or single form of formal and informal care relates to older adults’ perceived loneliness, life satisfaction, and day-to-day lives. Hellström and Hallberg (2004) did not find a significant relationship between receiving formal and/or informal care and quality of life. While studies have addressed the outcomes of home care by comparing between home care users and nonusers or those who are receiving home care and those who have unmet needs, there remains a gap in knowledge pertaining to the experiences of home care depending on who the care providers are. Given the heavy involvement of informal caregivers in the current Canadian context, more research is needed to explore the nature of care arrangements and its influence on older adults’ lives. This study examines the association between receiving formal and/or informal home care and older adults’ perceived loneliness, life satisfaction, and day-to-day lives. Receiving home care likely provides older adults with greater opportunities for social interaction and for maintaining social relationships. We therefore pose the research hypothesis:

Hypothesis 1: Older adults who receive care from both formal and informal care providers have lower levels of loneliness and higher levels of life satisfaction than older adults receiving only informal or only formal care.

We used a complementary approach to examine both population-level outcomes and subjective interpretations of home care use. Qualitative findings help to “tell the story” behind the quantitative findings, which are limited by the cross-sectional design, thus elucidating antecedence and outcomes as well as offering some insights into the temporal order of events. This approach allows for more nuanced explorations of aging in place and health than either quantitative data or qualitative data provide on their own.

Method

Quantitative Design

Data and sample

We used the public use microdata file (PUMF) from the CCHS–Healthy Aging. The CCHS involved interviews with individuals aged 45+ years in private dwellings in the 10 Canadian provinces. Residents of the three territories, persons living in Aboriginal reserves or Crown lands, persons living in institutions, full-time members of the Canadian Forces, and residents of some remote regions were excluded from the sampling frame (Statistics Canada, 2010). Data were collected between December 2008 and November 2009 and a total of 30,865 valid interviews were conducted using computer assisted personal interviewing with a response rate of 74%. Additional information on methodology and sampling strategies of the CCHS are described in detail elsewhere (Statistics Canada, 2010). We selected respondents aged 65 years and older who had provided information to the interviewers on receiving care at home, resulting in an analytic sample of 3,928. Missing values for the receipt of home care (n = 13) were excluded.

Measures

Home care

Home care use was identified with three categories: (a) formal, (b) informal, and (c) both formal and informal care. We measured whether respondents received professional care including health care, homemaking or other support from paid workers or volunteer organizations (=formal care), or support from family, friends, and/or neighbors (=informal care) during the past 12 months because of a health condition or limitation that affects their daily activities.

Loneliness

Loneliness was measured using the three-item Revised UCLA Loneliness Scale. These three items include the following: “How often do you feel that you lack companionship?” “How often do you feel left out?” and “How often do you feel isolated from others?” Responses were hardly ever, some of the time, or often and the scale is represented as a summation of these three options, with higher scores indicating higher levels of loneliness (range = 3-9; Cronbach’s α = .80).

Life satisfaction

Life satisfaction was measured with a five-item scale (Diener, Emmons, Larsen, & Griffins, 1985). We used two subitems to reflect current perception rather than entire life satisfaction given that the experiences of home care services pertain to the past 12 months of respondents’ lives. These questions included “in most ways, my life is close to my ideal” and “the conditions of my life are excellent,” with responses ranging from extremely dissatisfied to extremely satisfied. Higher scores indicated higher levels of life satisfaction (range = 1-7). We kept these two items separate because the single-item life satisfaction measure performs similarly compared with the multiple-item measures (Cheung & Lucas, 2014). Other items such as “If I could live my life over, I would change almost nothing,” “I am satisfied with my life,” and “So far, I have gotten the important things I want in life” were excluded because they likely reflect how respondents feel about their entire life rather than capturing the current circumstances in which they receive home care services.

Demographic variables

Gender was measured as female (=1) or male. As only categorized data are available from the PUMF, age was segmented into two categories: younger (65-74 years old) and older (75 and older = 1). Race was categorized as non-White (=1) or White. Living arrangement was measured as living alone (=1) or living with someone else.

Socioeconomic variables

Level of education was categorized as 1 = less than secondary school completion (reference category); 2 = secondary school completion but no postsecondary education; and 3 = some postsecondary education and postsecondary degree or diploma. Household income was categorized into five groups: 1 = less than CAN$20,000 (reference category); 2 = CAN$20,000 to CAN$39,999; 3 = CAN$40,000 to CAN$59,999; 4 = CAN$60,000 to CAN$79,999; and 5 = CAN$80,000 and over.

Health status

Self-rated physical and mental health were measured as dichotomous variables due to skewness based on responses to a 5-point scale (0 = fair and poor; 1 = excellent, very good, and good). Functional limitations were created as a summary measure of ratings of the activities of daily living (ADL) capacity-instrumental and physical dimensions in accordance with the manual in the multidimensional functional assessment of older adults (Fillenbaum, 1988). Functional limitation in the PUMF is a 5-point scale indicating higher values as greater impairment (1 = no limitation, 2 = mild, 3 = moderate, 4 = severe, 5 = total impairment).

Social support

The Medical Outcomes Study (MOS) Social Support Survey (Sherbourne & Stewart, 1991) is a 19-item self-administered scale, which assesses perceived availability of general functional social support in four domains: tangible, affectionate, emotional/informational, and positive social interaction. Each item asked how often each type of support was available (1 = none of the time, 2 = a little of the time, 3 = some of the time, 4 = most of the time, and 5 = all of the time). Higher values indicate more support or a higher level of positive social interaction in the four social support MOS subscales. Correlations among four social support variables were high (.66-.82) and we combined social support in four domains as a measure (0-76).

Data analysis

Model 1 accounted for the individuals’ demographic characteristics, socioeconomic status, health-related factors, and social support. The effect of home care use was added to Model 2. Two sets of multivariate analyses were conducted while adding home care use: one is formal care and the other is informal care as the reference groups. As no significant association was found between informal and both types of care, the results that use formal care as the reference group are reported. As the CCHS–Healthy Aging recommended, all statistical estimates were conducted on weighted data. To handle missing data on the covariates, pairwise deletion was used. All assumptions were checked and a diagnostics suggested no concern with multicollinearity.

Qualitative Design

Qualitative data were gathered using an interpretive framework that privileges an understanding of research participants’ perspectives; views data as situated, social constructions that emerge throughout the research process; and acknowledges the existence of multiple realities (Charmaz, 2006; Corbin & Strauss, 2008). This framework was apt for gathering data on the subjective meanings of receiving formal and informal care.

Interview process

As part of a separate study, in-depth interviews were conducted with 34 older persons receiving formal home care as well as informal support from family and friends in the province of Ontario. A semistructured interview guide (Kelly, 2010) was used to collect detailed information on the types of formal and informal support that participants received and the impacts of this support on their day-to-day lives and sense of well-being (see the appendix). Interviews were conversational, allowing participants to share information they felt was relevant (Holstein & Gubrium, 1995). Participants often discussed their experiences of receiving formal and informal care within a broader life context, relating it to what else it enabled them to accomplish, their social and familial relationships, and experiences of growing older. Information was also gathered about place of birth, race, education, housing, marital status, and use of public/private home care (see Table 1).

Table 1.

Profile of Qualitative Interview Participants (N = 34).

Characteristic	N (34)
Gender
Women	26
Men	8
Race
White	34
Birthplace
Canada	21
Europe (various countries)	11
The United States	2
Education
University/college	20
High school	6
Less than high school	8
Housing
Owned home	19
Rental apartment	4
Assisted living/retirement community	4
Subsidized housing	6
Attendant care building for disabled people	1
Living arrangement
Alone	21
With spouse/partner	7
With children/relatives/care provider	6
Home care
Public	26
Private	3
Mixed public/private	5

Following institutional approval from McMaster University, 34 participants aged 65 to 100 years (M = 81) were recruited through multiple sources between February and September 2014: seniors’ groups and day programs (n = 12), a home care client registry (n = 7), home care case managers and supervisors who distributed brochures (n = 4), seniors’ ministries at religious institutions (n = 3), distribution of information to potential participants at a caregiver exhibition (n = 3), brochures left by Meals on Wheels drivers (n = 2), flyers in seniors’ housing and community centers (n = 1), email through an lesbian, gay, bisexual, and transgender (LGBT) seniors’ list (n = 1), and word of mouth (n = 1). These various means of recruitment were used with the aim of interviewing participants with diversity in terms of gender, class, race/ethnicity, sexual orientation, living environment, and health status or level of physical impairment. It should be noted, however, that this small sample does not reflect the demographic characteristics of the larger quantitative study.

All participants received formal home care due to chronic health conditions or physical disabilities, and many also received some support from family and friends. Most interviews were conducted in participants’ homes, except for two cases where respondents preferred to speak on the telephone. In three cases, family members were involved in interviews at participants’ request. While the presence of family members may have influenced participants’ responses, the data gathered nonetheless provide insights into diverse formal/informal care arrangements. The interviews averaged 1 hr in length, were audio-recorded with consent, and professionally transcribed verbatim. Pseudonyms are used throughout this article to protect participants’ confidentiality.

Data analysis

Data analysis involved the iterative stages of open, axial, and selective coding (Barken, 2017). To conduct open coding, the second author read and re-read transcriptions and identified key concepts; to conduct axial coding, concepts were related to one another; and finally, to conduct selective coding, the concepts and underlying themes most central to the overall interpretation of the data were identified (Corbin & Strauss, 2008). Procedures taken to ensure the trustworthiness of the analysis included negative case analysis and member checking (Corbin & Strauss, 2008). QSR International’s NVivo 10 (http://www.qsrinternational.com/product) was used to facilitate data storage and retrieval.

Results

Quantitative Findings

Table 2 provides descriptive statistics of the home care users in the quantitative study. More than half (53%) received informal home care, while a third (29%) received both informal and formal services, and less than a fifth (17%) received formal care only. Most home care users were women (57%-73%) and White regardless of the care arrangements (88%-93%). The frequency of respondents aged 75 years and older was highest in the order of combined (72%), formal (69%), and informal home care (61%). The frequency of respondents living alone was slightly higher in formal (48%) than in combined care (45%), and lowest in informal care (34%). Levels of social support were strongest in the order of informal, combined, and formal home care. The mean score of loneliness was higher in combined home care compared with informal or formal home care. Respondents receiving informal or formal home care only reported higher life satisfaction and the score was lowest among people receiving combined home care.

Table 2.

Descriptive Statistics of Home Care Users (Quantitative Study), n (%).

	Total	Formal care692 (17.6)	Informal care2,091 (53.2)	Both1,145 (29.1)	p value
Female	2,536 (67.1)	400 (57.7)	1,401 (67.0)	835 (73.0)	<.001
White	3,514 (90.6)	636 (92.8)	1,832 (88.6)	1,046 (93.0)	<.001
Age					<.001
65-74	1,333 (33.9)	212 (30.6)	808 (38.6)	313 (27.4)
75 and older	2,595 (66.1)	480 (69.4)	1,283 (61.4)	832 (72.6)
Living alone	1,561 (39.8)	335 (48.5)	709 (34.0)	517 (45.1)	<.001
Education					.017
Less than secondary	1,925 (49.8)	305 (45.3)	1,057 (51.3)	563 (49.9)
Secondary graduation	577 (14.9)	99 (14.8)	291 (14.1)	186 (16.5)
Postsecondary	1,361 (35.2)	270 (40.0)	713 (34.6)	379 (33.6)
Household income (CAN$)					.019
<20,000	775 (25.3)	145 (26.4)	381 (23.3)	314 (24.4)
20K-39,999	1,135 (37.0)	193 (35.3)	616 (37.7)	452 (35.2)
40K-59,999	558 (18.2)	107 (19.6)	316 (19.3)	199 (15.5)
60K-79,999	255 (8.3)	52 (9.4)	123 (7.5)	140 (10.9)
80K or more	342 (11.2)	51 (9.3)	198 (12.1)	180 (14.0)
Fair and poor physical health	1,705 (43.5)	262 (37.9)	870 (41.6)	573 (50.3)	<.001
Fair and poor mental health	371 (10.2)	52 (7.7)	204 (10.5)	116 (11.2)	.046
Functional limitations					<.001
No	1,511 (38.8)	312 (45.3)	964 (46.5)	234 (20.7)
Mild	1,377 (35.4)	275 (40.0)	650 (31.3)	451 (40.0)
Moderate	619 (15.9)	67 (9.7)	313 (15.1)	239 (21.2)
Severe	209 (5.4)	21 (3.1)	92 (4.4)	97 (8.6)
Total	177 (4.6)	13 (2.0)	56 (2.7)	108 (9.6)
Social support (M/SD)	61.2 (16.0)	56.2 (19.9)	63.3 (14.2)	60.4 (15.6)	<.001
Condition of life (M/SD)	4.9 (1.7)	5.1 (1.6)	5.0 (1.7)	4.7 (1.8)	<.001
Life close to ideal (M/SD)	5.1 (1.6)	5.1 (1.7)	5.2 (1.6)	4.8 (1.7)	<.001
Loneliness (M/SD)	4.1 (1.6)	4.1 (1.6)	4.1 (1.5)	4.3 (1.7)	<.001

Note. N = 3,928. Descriptives are weighted.

Table 3 displays the linear regression results on loneliness. Model 1 included demographic and socioeconomic status, health factors, and social support (R² = .221) and Model 2 added home care use (R² = .223). Older adults who relied solely on informal support or on blended care arrangements reported higher levels of loneliness when compared with individuals who relied entirely on formal services (Table 3, Model 2), p < .05, b = .195, and p < .05, b = .208, respectively. These findings show that the variances explained by home care use might be small but nonetheless contribute significantly to loneliness. Respondents who were women, lived alone, or had severe functional limitations reported higher levels of loneliness when compared with their counterparts, p < .01, b = .194; p < .001, b = .441; p < .001, b = .627, respectively. Lower levels of loneliness were reported among respondents who were older (p < .001, b = –.217), had better physical (p < .001, b = –.348) and mental health (p < .001, b = –.372), and had more social support (p < .001, b = –.035). There were no statistically significant differences by race, education, or household income.

Table 3.

Association of Home Care Arrangement With Loneliness.

	Model 1		Model 2
	b	SE	b	SE
Female
(Male)	.213	.061**	.194	.061**
Non-White
(White)	.008	.096	.005	.096
Age
(65-74)
75 and older	−.224	.060***	−.217	.060***
Living alone	.436	.071***	.441	.071***
Education
(Less than secondary)
Secondary graduation	.035	.082	.036	.082
Postsecondary	.027	.065	.031	.065
Household income (CAN$)
(<20,000)
20K-39,999	.033	.078	.032	.078
40K-59,999	.108	.096	.114	.096
60K-79,999	−.001	.120	.007	.120
80K or more	.007	.113	.006	.113
Physical health
(Poor and fair)	−.353	.059***	−.348	.059***
Mental health
(Poor and fair)	−.375	.095***	−.372	.095***
Functional limitations
(No limit)
Mild	.012	.067	.011	.067
Moderate	.406	.086***	.387	.087***
Severe	.648	.129***	.627	.130***
Total	.549	.142***	.526	.145***
Social support	−.034	.002***	−.035	.002***
Home care
(Formal care)
Informal home care			.195	.077*
Both			.208	.085*
R ²	.221		.223
R² change			.002

Note. Higher scores of loneliness indicate higher level of loneliness. In parenthesis is the reference category.

p < .05. **p < .01. ***p < .001 (two-tailed tests).

Regarding life satisfaction (Table 4), older adults who received both informal and formal services (p < .05, b = –.195) reported lower levels of life satisfaction when compared with people who only received formal care (Table 4, Model 2). These findings similarly show that the variances explained by home care use might be small but contribute significantly to life satisfaction. Similar patterns emerged with respect to the other covariates. Being older (p < .001, b = .373), having better physical (p < .001, b = .926) and mental health (p < .001, b = .626), and having more social support (p < .001, b = .019) were associated with higher levels of life satisfaction. Again, there were no significant differences in life satisfaction by race, education, or household income. There were no significant associations between type of home care services and life satisfaction when measured with the query “my life is close to my ideal” (results not shown but available on request).

Table 4.

Association of Home Care Arrangement With Life Satisfaction–Conditions of Life Are Excellent.

	Model 1		Model 2
	b	SE	b	SE
Female
(Male)	.026	.067	.038	.067
Non-White
(White)	.153	.105	.147	.105
Age
(65-74)
75 and older	.375	.066***	.373	.066***
Living alone	−.150	.078	−.148	.078
Education
(Less than secondary)
Secondary graduation	−.188	.090*	−.183	.090*
Postsecondary	−.041	.071	−.042	.071
Household income (CAN$)
(<20,000)
20K-39,999	−.127	.085	−.127	.085
40K-59,999	−.113	.105	−.118	.105
60K-79,999	−.107	.131	−.107	.131
80K or more	.025	.123	.025	.123
Physical health
(Poor and fair)	.931	.065***	.926	.065***
Mental health
(Poor and fair)	.624	.104***	.626	.104***
Functional limitations
(No limit)
Mild	−.271	.073***	−.259	.074***
Moderate	−.607	.094***	−.578	.096***
Severe	−.878	.141***	−.841	.143***
Total	−.749	.155***	−.699	.158***
Social support	.019	.002***	.019	.002***
Home care
(Formal care)
Informal home care			−.114	.084
Both			−.195	.093*
R ²	.2		.201
R² change			.001

Note. Higher scores of life satisfaction indicate higher level of satisfaction. In parenthesis is the reference category.

p < .05. **p < .01. ***p < .001 (two-tailed tests).

Qualitative Findings

The subjective value of home care in later life

The qualitative data provide insights into the subjective meanings and experiences of receiving formal and informal care. Participants had complex health problems and disabilities, including heart conditions, chronic pain, arthritis, diabetes, and visual impairments, among others. They also had varying formal and informal care arrangements. For example, those who lived near family members and/or close friends and had positive relationships with them more often affirmed the importance of informal support in their day-to-day lives. At the same time, participants’ use of formal support depended on their eligibility for publicly funded services, their capacity to pay for additional services themselves, and their knowledge of community resources and how to access them. Despite this variation, formal home care very often served to bolster participants’ life satisfaction and reduce their feelings of loneliness. They often developed strong interpersonal connections with formal care providers that were built upon reciprocity and allowed for meaningful social interaction. In addition, they highly valued home care because it allowed them to remain living in their own homes without placing what they perceived to be undue demands on family members.

Meaningful social interaction

While home care providers were primarily responsible for personal and clinically related tasks as well as some assistance with household chores, participants often described how their social interactions with care workers supported their social connectedness and day-to-day well-being. Celia, who at 71 years lived in near-constant pain from rheumatoid arthritis and osteoarthritis, described the importance of formal home care for mental health: “It’s good for me, like, emotional and psychological it’s good to have this person [home care provider].”

Participants highly valued home care that made them “feel known” and that recognized their personal needs and preferences. Louisa, age 74, had several health complications related to atrial fibrillation and was struggling to accept formal assistance. Louisa’s son, who participated in the interview, described the importance of formal care providers knowing her personal preferences:

One of the things that both my mom and I noticed and I think we both really appreciated was that the workers from the Caribbean would always call my mom by her name so, they would say, “Oh, good morning, Louisa.” I think at the beginning, they were a little more formal and, I mean, our last name is Mancuso so they would say, “Good morning, Mrs. Mancuso,” and my mom would say, “Oh, you don’t have to do that, just say Louisa.” And they would, every time they would come, they would say, “Good morning, Louisa,” or “Have a nice day, Louisa,” or “Have a nice weekend, Louisa.” That’s one of those little things of just using a person’s name . . .

So, it strengthens the relationship in a way and I think it . . . it showed there was a genuine concern where, it’s not that, oh, they’re coming to give someone a bath, they’re coming to help a person and the person has a name and it was always that they were coming to see Louisa.

Participants often developed close interpersonal relationships with formal care providers. Philip, who at age 84 not only received some publicly funded home care but also paid for care privately to assist himself and his wife Kathryn who had dementia, considered care workers to be “like family”:

But this girl is right at home. She’s like my daughter. You know, they get so used to being here, you know, and they know Kathryn so well . . . And these girls are all like daughters to me so I have lots of fun with them. They are part of my social life.

Perceived reciprocity

Participants’ strong interpersonal connections with home care providers were not simply premised on workers doing things for clients. Rather, positive relationships often involved a degree of perceived reciprocity (Lewinter, 2003), with care recipients and providers “caring about” one another. Participants highly valued the opportunity to contribute to meaningful reciprocal relationships. Maggie, age 89, received help with a shower and some cleaning 3 times a week and emphasized the mutual concern and caring involved in her relationship with a care provider:

She’s just exceptional because she’ll come in and “Well, how are you today?” And I say “I’m okay. How are you?” “Well, I’m okay too, but now let’s think about it. Do you really feel pretty good today?” And kind of gets you talking and then she’ll tell me something about her little boy or whatever. We just have a little friendly chat while I get in the tub and . . . It’s just a lovely start to the day . . .

Kate, who at age 77 had limited mobility due to stenosis and received formal assistance with cleaning, described conversations where she empathized with the challenges her care provider faced in her personal life:

If she whizzes round, as we found out last week, if she whizzes round fast, she can do it in two hours but if she comes for three, then she can, you know, take her time and talk to me about her grandma . . . she has a very sick grandmother and so I usually ask her how she’s going on and things are going really downhill for her grandma.

Protecting autonomy and reducing demands on family

In line with previous research, participants often viewed the home as a locus of security, privacy, and autonomy (Mahmood & Martin-Matthews, 2008; Wiles et al., 2012). Although Martha, age 67, suffered from several health conditions that limited her mobility, including chronic obstructive pulmonary disorder and cellulitis, she highly valued the privacy of her own apartment: “I feel that the good Lord has taken my independence away from me so I’m not going to let Him take my privacy away from me.”

Although participants wanted to remain in their own homes, they shared profound concerns about the perceived burdens their care needs placed on family—especially younger working generations. Many participants indicated that they enjoyed close and supportive relationships with their families. Yet, they did not necessarily want kin to be heavily involved in direct care provision. Participants often discussed the challenges that adult children and other relatives faced as they balanced careers, child care, and sometimes health problems of their own, and did not want to add to their responsibilities:

Don’t rely on your children too much. You know, they have their own lives and they’re busy . . . I don’t want to be a burden. (Yolande, 72)

Because I know my children aren’t going to be around forever. They’ve got their own life to live, too, you know, and thank God Wayne’s divorced; he’s not married. He does have two daughters . . . So in time, yeah, he’s going to want to spend time with them, so I don’t want to be a burden to him. (Judy, 75)

The receipt of formal home care often supported participants’ well-being because it allowed them to remain living at home without placing too many demands on family. At age 66, Ray was HIV positive, was visually impaired, and suffered from kidney disease, arthritis, and diabetes. Ray did not expect his long-term partner to take responsibility for all his needs. Rather, he stated that formal home care allowed him to maintain a sense of independence and well-being:

And with the help you get, you know, from [home care agency], how important is that in your life?

Ray:

Oh, ultimately important.

If that wasn’t available, what would the alternative be?

Ray:

Probably suicide. Truthfully. I couldn’t look after myself. And who would want to live if you can’t live like you’re used to living?

Discussion

Our findings have implications for understanding the perception of home care among older adults and for long-term care policy. Previous literature identifies the medical and social benefits of formal home care services to people with chronic and multiple health conditions. The quantitative findings suggest that older adults who only received formal care reported lower levels of loneliness and higher levels of life satisfaction when compared with respondents who received just informal or a blend of home care services. While qualitative data do not explore which specific care arrangements led to better psychological health, they do shed light on the importance of formal home care for older adults’ day-to-day well-being, thus helping to interpret quantitative results.

Quantitative findings show the contradictory results to our hypothesis. Even though care recipients interact with more people when they receive both types of care, they might still feel lonely because they are concerned about burdening family and unwilling to ask for too much in socioemotional support. One can feel “lonely in a crowd”—it is less about the amount of time spent with family and friends, and more about the quality of these relationships. Qualitative findings complement the perspective that in the face of loss, formal home care services contribute to the social fabric of vulnerable older adults and add a protective layer of social connectedness. Subsequently, older adults with formal home care services could rely less heavily on their family, friends, and neighbors for health and social needs. This, in turn, served to reinforce their independence.

Although it is not the main focus of the current study, the quantitative findings provide additional information on loneliness and life satisfaction among older adults receiving home care services. Contrary to assumptions that loneliness increases with age, being older was associated with higher levels of life satisfaction and lower levels of loneliness. In addition, the findings suggest that social support is a critical role to reducing loneliness and increasing life satisfaction.

These findings have implications for the development of person-centered and relationship-centered care—approaches that increasingly guide the delivery of home care services across Canada. Key aspects of person-centered include sharing power among individuals involved in care relationships; respecting clients’ needs, perspectives, and interests; and including them in decision making. Relationship-centered care, moreover, hinges on strong, mutually beneficial relationships between and among clients, family members, and care providers (Brookman, Holyoke, Toscan, Bender, & Tapping, 2011). Research findings may contribute to practice guidelines that are person- and relationship-centered insofar as they recognize older people’s perceptions of formal support. While home care practice often focuses on the tasks that care providers do for clients, creating guidelines for working with clients in ways that support their needs and preferences would represent an important step in the continued implementation of person-centered care. Indeed, as Byrne, Frazee, Sims-Gould, and Martin-Matthews (2012) suggested, older people value care that supports their autonomy, control, and dignity. To preserve autonomy, care providers can collaborate with clients in the performance and scheduling of activities, responding to their shifting needs and preferences rather than simply performing mandated tasks. Such an approach requires flexibility in service delivery so that care providers can give the kinds of assistance that diverse older people need. The further development of person- and relationship-centered approaches could help to recognize older people’s contributions to care, and to foster strong relationships between care providers and recipients. This, in turn, can bolster home care clients’ quality of life, and potentially reduce their feelings of loneliness.

From a socioemotional perspective, the qualitative findings underscore trust, reciprocity, and social bonding between persons receiving and providing formal care, and speak to formal care providers’ capacity to access training and resources that promote high quality care. Trust is an important component of care worker–client relationships (Holmberg et al., 2012) because trusting relationships contribute to emotional security (Soodeen, Gregory, & Bond, 2007). While older people appreciate care providers who are reliable and have time to listen and to interact with them on a personal level, official descriptions and recording practices typically emphasize the physical, rather than emotional, aspects of care (Byrne et al., 2012). Training and working conditions that recognize the interpersonal dimensions of care can allow workers to meet older adults’ socioemotional needs. Training standards that focus on relationship-building, in line with ideals such as person-centered care, are integral to comprehensive home care services (Brookman et al., 2011). Working conditions including a lack of time with each client and little continuity in care provision (Martin-Matthews, Sims-Gould, & Tong, 2013), however, can sometimes constrain the implementation of person-centered approaches. Improved working conditions can help to ensure that all home care users benefit from the social dimensions of home care identified in this study.

The quantitative findings show that individuals who solely relied on formal care reported better quality of life compared with respondents who had blended care or who relied entirely on informal care. It could be that individuals who only use informal care may not be able to share their social or psychological needs with family or friends, for fear of being perceived as a burden—a feeling that is common among older adults (Peters, Hooker, & Zvonkovic, 2006). From a functional perspective, qualitative findings show that relying on formal services to fulfill obligations with cleaning, bathing, and administering medication reduced the feeling of being a burden. Consequently, this may have facilitated older adults’ capacity to maintain their relationships with family, while still being able to access much needed support in the home setting.

The findings provide evidence to ensure an effective interplay between formal and informal care for older adults. Although participants in the qualitative study did not want to place too many demands on family, the quantitative results show that informal caregivers still provide the majority of care at home. Less than a fifth of respondents relied solely on formal care—a finding that is consistent with previous Canadian and international research (Blomgren, Martikainen, Martelin, & Koskinen, 2008; Davey et al., 2005). Decision makers need to consider the consequences of different care arrangements, and the benefits of formal support to older people. To achieve care arrangements that reflect older adults’ needs and perceptions, resources should be allocated to ensure equitable access to high quality of formal home, and in turn to improve care recipients’ quality of life. Public policy should further recognize formal care providers’ important roles in meeting older adults’ needs (e.g., through enhanced recognition and remuneration for care workers).

Limitations

There are some limitations that could be addressed through future research. Qualitative data explored the experiences of people currently receiving formal home care as well as varying levels support from family and friends; older people who receive only informal or formal support may express different opinions. Further research is necessary to better understand the viewpoints and experiences of individuals with diverse care arrangements and with varied health conditions and impairments.

In addition, the findings of this cross-sectional analysis raise issues of endogeneity and make it difficult to untangle directionality. We included several covariates known to be associated with the dependent variables but were unable to control for additional factors and self-selection that may have a causal effect on loneliness and life satisfaction. Future longitudinal research could adopt experimental or quasi-experimental approaches to address this limitation. In addition, though home care was a significant predictor to explain the life satisfaction and loneliness among the older adults, given that it was only a small amount of variance, we are cautious to interpret this in terms of causal association.

Finally, it is notable that our qualitative results were not drawn from the quantitative sample. The quantitative survey, undertaken in 2008-2009, looked at Canadians across 10 provinces, while data for the qualitative study were gathered in the province of Ontario in 2014. Despite these discrepancies, the qualitative data still help to interpret why respondents who relied solely on formal care reported higher levels of life satisfaction and lower levels of loneliness. To further explore these findings, future research could nest a qualitative sample within a larger quantitative study to ensure consistency among respondents across analyses.

Conclusion

Through an analysis of formal and informal home care and its association to the outcomes of loneliness, life satisfaction, and day-to-day lives, this study expands our understanding of the social and functional attachments to aging in place. We find that each type of care, as well as the combination, has a differential association with loneliness and life satisfaction. At the same time, strong relationships with formal care providers served to bolster older adults’ sense of well-being while allowing them to mitigate the perceived demands their care needs placed on family.

Footnotes

Appendix

Authors’ Note

IRB protocol number/human subjects approval numbers: #2013235 (McMaster University).

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Funding support for this study was partially provided by University Research Grants Committee’s Seed Grant at the University of Calgary.

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