Growing numbers of young Japanese laborers moved from the countryside to large cities during the period of high economic growth between 1955 and 1970. As a result, 30 years after that period, the number of families in the countryside consisting only of elderly parents had increased compared with the number in large cities (Uchino, 1987). Elderly individuals are not likely to move from their homesteads, but increasing numbers of elderly individuals are currently moving to large cities. In Tokyo and its suburban cities, for example, the elderly population has increased between 12% and 16% (Miura, Otomo, & Saga, 1995). Elderly parents who become too old to manage their daily lives and have to be relocated to their children's home to be cared for are called Yobiyose-rojin (Hìgashigawa, 1994).
The issue of Yobiyose-rojin, a phenomenon frequently seen in Japan, has received much attention since approximately 1985 (Sakai, 1989). Both bang relocated from their own homes, often against their wishes, and adapting themselves to their new environments are very difficult for Yobiyose-rojin. As a result, they are likely to suffer from loneliness and be at a higher risk of becoming demented or bedridden (Ando, 1994; Mizuno & Takasaki, 1998; Saito & Yoshida, 1997; Smider, Essex, &Ryff, 1996).
In Japan, children have traditionally been expected to take care of elderly parents. However, the number of children considered capable of caring for elderly individuals has decreased because female workers and households consisting of just the nuclear family have been increasing. Relocation has a major impact on not only Yobiyoserojin, but also their caregiving children. Caregiving children are very likely to find the conditions stressful because they are required to help their parents adapt to a new environment in addition to the burdens of elder care.
There have been few studies about relocated Japanese elderly individuals. As a beginning project to examine the impact of relocation, the authors analyzed characteristics and factors that might contribute to the caregivers' burden, specifically comparing the burden on daughters and daughters-in law who care for an elderly parent. The amount of positive assistance required for these caregivers will be determined based on this comparison.
The percentage of elderly parents living with their children has declined in Japan, but the rate of 47% in 2002 was still higher than that in the United States or Germany (Ministry of Health, Labour and Welfare, 2005). The number of households with elderly residents, whether married or single, has increased year by year. Of the total number of households with elderly residents in 2003, 28.1% were married-couple households and 19.7% were single-member households (Ministry of Health, Labour and Welfare, 2005). This increase in the number of "elderly households" in Japan is because of the decrease in the number of farmers, the metropolitanization of cities, the shift of population into large cities accompanying structural changes of industries, and the limited space in small houses in large cities (Ishikawa, 1997).
The discipline and rules of the old patriarchal family system in Japan were effective, and many elderly parents previously had lived with their eldest son (Adachi, 1997). According to "National Life Survey, 1996" (Ministry of Health and Welfare, 2000), the largest groups among all caregivers taking care of elderly parents were daughtersin-law (33.4%), spouse (27.9%), and daughters (20.6%). This recent survey result demonstrated that Japanese people still follow the old custom in some degree, although over the years they have mostly departed from the old customs and many parents have come to prefer an independent life away from their children's households (Ministry of Health and Welfare, 2000).
In Japan, there is a shortage of facilities where frail elderly individuals are accepted. As such, elder care by family members is required to meet the social need. Few reports revealed the factors that defined the caregivers' burden to illustrate what caregivers, their family members, and their community should do. Studies have been conducted on caregivers' burden (Archbold, 1983; Cantor, 1983; Deimling, Bass, Townsend, & Noelker, 1989; Fitting, Rabins, Lucas, & Eastham, 1986; Kosberg, Cairi, & Keller, 1990; Montgomery, Gonyea, & Hooyman, 1985; Scharlach & Boyd, 1989; Zarit, Reever, & Bach, 1980; Zarit & Zarit, 1983) although most of them were conducted in the United States. These studies failed to present clear definitions and did not critically examine the causal association of the issue where many factors interact with each other (Fujisaki, 1990).
Recently, several investigators (Lawton, Moss, Kleban, Glicksman, & Rovine, 1991; Nana, 1991; Perlin, Mullan, Semple, & Skaff, 1990; Stephens & Zarit, 1989) used the stress recognition theory introduced by Lazarus and Folkman (1984) as a theoretical model to explain the burdens caregiving families faced. This study employed the framework designed by Nana (1991) using Lazarus's cognitive theory of stress. The framework was modified by adding items related to "relocated elderly individuals" to develop the framework for this study (Figure).
Any of the events that a caregiver may face during relocation or elder care are potential Stressors. If caregivers appraise the Stressor as a burden, the caregivers would present psychological and physical manifestations, which eventually lead them to cope with the Stressor or the stressor-induced symptoms. Demographic characteristics and internal and external resources (e.g., knowledge, physical fitness, financial strength, social supports, social networks) are likely to influence caregivers' burden.
Figure. Factors contributing to caregivers' burden with elder care.
This study's design was descriptive, exploratory, and cross-sectional. Structured interviews were used to collect data.
The participants were caregivers who lived in seven suburban cities around Tokyo with a large population of Yobiyose-Rojin and met the following criteria:
* Primary caregivers.
* Daughters or daughters-in-law of Yobiyose-rojin.
* Caring for a parent older than 65 when he or she had moved.
* Caring for a parent who had moved into or nearby the household of their families.
Of the caregivers introduced by the public health care facilities in the seven cities, 133 caregivers met these criteria.
Caregiver candidates were chosen from the public health care facilities in the seven cities and a public health nurse requested they participate. The authors called each of the primary caregivers who agreed to participate and arranged the interview date and place after confirming they were willing to cooperate. The interview length was from 50 to 120 minutes. The survey started in April 1997 and continued for 1 year.
To evaluate the appropriateness of interview questions, a pilot study was conducted. The sample of the pilot study included 10 pairs of relocated elderly parents and their primary caregivers. The sample participants of the pilot had a similar profile to that of the actual study. Through the pilot study, it was found that two additional alternatives for reasons for relocation would be needed - "illness and hospitalization" and "living alone."
Information of the potential areas of stress was collected from participants. These topic areas included:
* Mental status of elderly individuals.
* Activities of daily living (ADLs) of elderly individuals.
* Reasons for relocation.
* Caregiver s intention of relocating.
* Parent-child relationship.
* Companionship with elderly parent.
* Hours of caregiving.
The questionnaire included two observational scales to evaluate the elderly individual's mental status and level of ADLs.
Mental status was assessed using Nishimura's Scale for Rating Mental States of Elderly (NM scale) (Kobayashi et al., 1988). The NM scale consists of five items related to housekeeping, communication, registration memory, and orientation. Each item is scored 0, 1, 3, 5, 7, 9, or 10, and the summed score indicates the degree of dementia - adequately function (48 to 50), borderline function (43 to 47), slight dysfunction (42 to 31), moderate dysfunction (30 to 17), and severe dysfunction (O to 16).
COMPARISON OF CAREGIVER CONDITIONS BETWEEN DAUGHTER AND DAUGHTER-IN-LAW
Level of ADLs was assessed by Nishimura's Scale for Rating Activities of Daily Living of Elderly (N-ADL scale) (Kobayashi et al., 1988). The N-ADL scale has five Ítems related to abilities of "Walking and sitting," "Mobility," "Dressing and bathing," "Eating," and "Toileting." Each item is scored from O to 10 and the summed score indicates the degree of function or dysfunction. The maximum score of 50 indicates independence in all items.
Resource availability was evaluated by determining
* The caregiver's employment (yes or no).
* Perceived sleep (good or not good).
* Perceived health (good or not good).
* Leisure time (yes or no).
* Support of family members (good or not good).
* Availability of any person to consult on an formal and/or informal basis (yes or no).
* Frequency using daycare services (less than twice a week, more than three times a week, or every day).
* Financial status of the elderly individuals.
The caregiver's burden was measured by the Japanese burden scale developed by Nakatani and Tojo (1989) for Japanese population. The burden scale is a 12-Ìtem scale measuring caregiver's perceived anxiety, fatigue, parent-child relationship, social activities, and willingness to provide care on a continuous basis. The caregivers respond on a 4-poìnt scale describing the degree to which each statement applies to them. The responses range from "never applicable" to "very applicable" with higher score indicating higher burden. This instrument has been employed in many studies which have demonstrated the adequate reliability and validity of this instrument (Nakatani &Tojo, 1989; Simìzu, 1991). Cronbach's alpha of the instrument in this sample was .87.
To compare characteristics between the daughter group and the daughter-in-law group, the chi-square test was performed on discrete demographic variables, Stressors, and resources. Analysis continued with i tests on continuous valuables. T test and analysis of variance (ANOVA) were used to examine differences in caregivers' burden by conditions of elder care, Stressors, and resources. Pearson's correlation coefficients were used to determine the relationships between caregivers* burden and Stressors. The Statistical Package for the Social Sciences software Version 8.0 (SPSS Inc., Chicago, IL) was used for the analysis. A significance level of. 10 was adopted in this study to better understand the risk factors associated with caregivers' burden (Munro, Jacobsen, Duffy, & Braitman, 2001).
MEAN ± 5DOF FACTORS CONTRIBUTING CAREGIVERS' BURDEN SCORE IN THE DAUGHTER AND THE DAUGHTER-IN-LAW GROUP
Eighty-nine of the 133 caregivers were daughters and 44 were daughtersin-law. Thirty (68.2%) of 44 daughtersin-law were the wives of eldest sons.
Comparison of Caregiving Conditions (Table 1)
The mean ages of caregivers were 52.4 ± 7.7 years in the daughter group and 51.1 ± 7.2 years in the daughterin-law group. The mean hours of elder care per day in the daughter group were higher than the daughter-in-law group (p < .05). The mean scores of N-ADL (After) and NM (After) for the daughter group were lower than for the daughter-in-law group, indicating that daughters were taking care of elderly parents with poorer ADLs (p < .1) and mental status (p < .1) on average.
When asked about their agreement to the relocation of their parent and willingness to take care of them, 53.9% of the daughters indicated agreement to their parent's relocation and willingness to act as caregivers and no daughters refused the proposal of the relocation. On the other hand, the most frequent answer in the daughter-in-law group was "I had no choice but to accept the proposal," and 11.4% of the daughters-in-law opposed the proposal.
Caregivers' Burden (Table 2)
The mean scores of caregivers' burden were 27.3 ± 6.4 for the daughter group and 30.4 ± 6.7 for the daughter-in-law group, indicating that daughters-in-law had greater burden than daughters (p < .05). In the daughter group, caregivers who had problems with their own health (p < .05) or sleep (p < .1), who received no support from other family members (p < .01), and who had no one to consult with on an informal basis (such as a close relative or friend) (p < .1) had greater burden than those who did not. Also, those who frequently used daycare service had greater burden than those who did not (p < .01). NM (After) (r = -.36 ? < .01) and the hours of elder care per day (r = .36 p < .01) were correlated with caregivers' burden. In other words, daughters who perceived greater burden were caring for elderly parents with more impaired mental status and spending more hours for elder care.
In the daughter-in-law group, those who did not have a good relationship with their elderly parent before relocation perceived greater burden than those who had a good relationship (p < .01). Daughters-inlaw who answered "I had no choice but to accept the proposal" related to their agreement on parent's relocation perceived greater burden than those who agreed to the proposal (p < .01). Those who had bad sleep perceived greater burden than those who did not (p < .01). NM (Before) (r = -.34p < .05),NM(After)(r = -.37/><.05), N-ADL (Before) (r = -.31 p < .05), and N-ADL (After) (r = -.36 ? < .05) were correlated with the caregiver's burden. That is, daughters-in-law who were caring for elderly parents with more impaired mental or physical status perceived greater burden.
Profile of the Caregiver Families
Although daughters-in-law dominate the elder caregiver population in Japan (Ministry of Health and Welfare, 2000), the daughter group was larger than the daughters-in-law group in this study. One of the possible reasons for this is that daughters' families in Metropolitan Tokyo have come to be less restricted by the old patriarchal family system. Most husbands of caregiving daughters were cooperative, which represents a characteristic of a new type of Japanese family. However, 68% of the husbands of the daughtersin-law were the eldest son, which demonstrates that the old patriarchal family system remains in some families.
When asked about their intentions to take care of their elderly parents, more than half of the caregìvers in the daughter group expressed their willingness to do so, while only a few did in the daughter-in-law group. The decision to relocate a parent was typically made by a husband who did not actually engage in elder care, and reinforces the decision-making process in the old family system. These findings indicate that the decision-making process greatly influences the choice of provider of care.
Characteristics of Caregivers' Burden by Daughters and Daughters-in-law
The number of caregiving hours per day is a factor known to affect caregiver's burden (Mizuno, Murashima, & IkIa, 1992; Nakatani, 1992). Although the daughters-in-law spent fewer caregiving hours than the daughters, daughters-in-law perceived a greater burden. In America, the daughters-inlaw's affection for her parent-in-law is positively related to their feelings of caring (Archbold, 1986; Finley, Diane, & Banahan, 1988). In this study, the daughters-in-law who had initially opposed the proposal to take care of the elderly parent especially perceived a greater burden. The daughters-in-law who had bad relationships with their parent before relocation also perceived a greater burden. In Japan, the eldest son's families have no choice but to care for their elderly parent This "victim" mentality of caregivers may increase their burden (McGrew, 1998).
For daughters-in-law, the unfavorable parent-child relationship and their unwillingness to participate in parent care appear to be important factors on caregivers' burden. In contrast, for the daughter group, poor physical and sleeping status, inadequate support from other family members, and lack of a person to consult with on an informal basis were significant factors on their burden. Also, the mental and physical status of the elderly parent and hours of elder care per day were related to perceived burden for daughters. These findings suggested that different approaches are needed depending on the kinship relationship between the elderly individual and the caregiver.
Favorable Assistance Required for the Caregivers
The findings of this study suggest that appropriate support is necessary before relocating elderly individuals. Archbold, Stewart, Greenlick, and Harvath (1990) stated that caregivers perceived less burden when they could anticipate the conditions of elder care in advance. Nurses, who have broad knowledge and information on caregiving, should play a role as a coordinator to provide realistic information on anticipated situations and make sure that the caregivers' opinion is reflected in the decision-making process for relocating elderly individuals. It is necessary to furnish instrumental support and emotional support to allow a caregiving daughter-in-law to express her feelings.
Many daughters made the decision to take care of their elderly parents more positively than daughters-in-law. The daughters also perceived fewer burdens although their parents usually had more severely impaired mental or physical status. Caregiving daughters have a high risk of burning out because they tend to do too much with elder care (Nakatani, 1992). Using daycare services for an elderly parent with dementia, having occasional family parties, and going out once in a while are recommended outlets for caregiving daughters to help them evaluate the elder care conditions objectively.
Through this study, a picture of care burden related to Yobiyose-rojin was described. These findings suggest that different forms of support may need to be chosen based on the identity of the primary caregiver. When a daughter-in-law is the primary caregiver, her intention must be reflected in the decision whether her parent-inlaw should be relocated. When a daughter is the caregiver, the present support system must be modified to meet her needs.
There were some restrictions in conducting epidemiological investigations - the privacy protection act and the participants' tendency to conceal family matters, especially related to elderly individuals. Because participants in this study were provided with public services, they already had some support and might have solved or relieved the most serious problems. Further studies should examine how the conditions of relocated elderly individuals and caregivers would change over time and what assistance would be needed in the process.
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COMPARISON OF CAREGIVER CONDITIONS BETWEEN DAUGHTER AND DAUGHTER-IN-LAW
MEAN ± 5DOF FACTORS CONTRIBUTING CAREGIVERS' BURDEN SCORE IN THE DAUGHTER AND THE DAUGHTER-IN-LAW GROUP