ROSALIE A. CAFFREY

C A R E G I V I N G TO THE ELDERLY IN N O R T H E A S T T H A I L A N D

ABSTRACt. Caregiving has been extensively explored in developed countries, but less so in developing regions. In Thailand, a rapidly expanding elderly population and a declining birthrate have important implications for future care of the elderly. This report is based on further exploration of data obtained from a larger study in rural Northeast Thailand of 89 households with elderly age 65 and over. Four levels of caregiving and methods for caregiver selection were identified from this data. In addition, a subgroup of 39 caregivers were interviewed for their perspectives on the activities of caregiving, the impact of caregiving on caregivers' lives, support of kin and the meaning of caregiving to the involved caregivers. Poverty was the most common problem identified by these caregivers, but caring for men and difficulty in pleasing the elders were seen as contributing to the non-enjoyment of caregiving. Affective rewards and a strong norm of filial obligation may be the motivating forces for children to continue to care for parents in the context of cultural change.

Key Words: caregiving, culture change, elderly, exchange theory, Thailand, women

INTRODUCTION The ability of the family to continue to provide support for its elderly members in the context of demographic and social changes that have accompanied modemization has been a critical concern for many researchers. While the number of elderly continues to rise and lifespans continue to increase, decreasing fertility is resulting in fewer children to care for these elderly. In addition, the increase of children's mobility, the participation of women in the work force, and the loss of economic power of the elderly has resulted in major changes in the status of the elderly (Treas 1977). As governments attempt to develop appropriate policies to care for this vulnerable population, the focus of much of the research in the developed countries has been how much support the family is able to provide to its elderly members without assistance from the public sector. Research in developed countries has found that, contrary to popular stereotypes, families do continue to function as a key support for the elderly (Shanas 1979a, 1979b; Stone, Cafferata and Sangl 1987), but to caregivers of increasingly older and more debilitated elders, the physical, social, emotional, and financial burdens may be extreme. Little research has been done in developing countries to examine caregiving and to determine its impact on caregivers and their families. An understanding of this phenomenon will be essential for policy-makers confronted with a rapidly expanding elderly population. In general, these aging populations will involve the following unique characteristics making policy-planning an even more difficult process than it has been in the developed countries: 1. The very large population sizes are resulting in large numbers of elderly in a much shorter period of time than was experienced in the more developed Journal of Cross-Cultural Gerontology 7:117-134, 1992. © 1992 Kluwer Academic Publishers. Printed in the Netherlands.

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regions, even though increasing proportions of the elderly in the overall population structure will likely come after the year 2000. 2. Larger numbers of the very old, the majority of whom will be women, have potential for creating special problems, since most have little in the way of resources to exchange for care from others. 3. In most developing countries, poverty is a critical problem and families often must make choices about whether to provide food, health care, and education for their own children (as an investment for the future) or to provide for their aging parents. At present there is minimal expectation that governments will step in and assist as they do in Western countries. As a result, policy planning will be especially difficult for countries with limited resources and experience. CAREGIVING IN THAILAND Thailand, as a developing country, has some unique cultural features that make the study of caregiving especially intriguing. Since 1970, Thailand has implemented a very successful family planning program which is rapidly resulting in a higher percentage of elderly in the total population as well as a decreasing number of caregivers for these elderly (Knodel, Chamratrithirong, and Debavalya 1987). The actual numbers of elderly have been nearly doubling every 20 years, from 709,000 (Ministry of Public Health 1985) in 1960 to a projected estimate of 6,800,000 by the year 2020 (Kinsella 1988). These numbers will no doubt have a powerful impact on public policy decisions influencing how resources will be distributed to care for this vulnerable population. The role of the family must be clearly understood in order to make appropriate decisions. Northeast Thailand was selected as a research site for three reasons: 1. This area, being the poorest region in Thailand due primarily to its poor soil, is in a period of economic transition from a kin-based to a cash-based economy. Thus, it is possible to examine changes associated with the early stages of modernization as a baseline for further study as this process continues. 2. The Thai have traditionally had a strong Buddhist-based ideological system, which emphasizes care and respect for the elderly. It is based on the cultural ideology of "parent repayment" in which children are expected to repay their parents for having borne and raised them (Klausner 1987; Mulder 1985). Whether this cultural value will survive the value changes involved with modemization is uncertain. 3. Northeastern Thai family structure had traditionally incorporated means to care for the elderly. The matrilocal postmarital residence pattern as well as the custom of giving the house to the youngest daughter (or son) through inheritance have functioned to encourage her (or his) continued residence in the home and the provision of care to the elderly parents (Cowgill 1986; deYoung 1955; Foster 1975; Lux 1969; Mizuno 1968, 1978). Traditionally,

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care has been assured for these parents during their lack of economic opportunities associated with agricultural economy along with the attractions lifestyle are resulting in the increasing migration of homes of their parents in search of work.

old age. More recently, a primarily kin-based of the modern urban children away from the

METHODOLOGY Specific objectives of this research were to: 1. Identify the Thai caregivers' definition of caregiving. 2. Identify factors which influenced family or caregiver decisions about caregiving (such as who, where, and when). 3. Evaluate how changes associated with modernization were affecting caregiving of the elderly. 4. Identify support resources available to caregivers. 5. Evaluate the impact of caregiving on caregivers and their families. This report is a further exploration of data obtained from a larger study of the impact of modemization on family care of the elderly conducted in Soongnem District, Nakom Rajisima Province in Northeast Thailand. The larger study collected data from 89 households in six rural villages containing elderly age 65 and over. Research methodologies included the collection of both qualitative and quantitative data over a nine month period, 1988 to 1989. A Thai translator, skilled in the three dialects spoken by villagers in the region assisted in the data collection. Findings from the larger study found that change from a kin-based to a cash-based economic system is resulting in changes in how families provide care to their elderly parents (Caffrey 1992). This report further examines family caregiving based on relevant findings from the sample of 89 households and additionally from the perspectives of a subgroup of 39 caregivers selected from these 89 households. In the larger study of the 89 households, one-fifth (N=18) of the elders had identified themselves as primary caregiver. The subgroup of 39 caregivers in this study were selected from the remaining group of 71 identified caregivers based on the following criteria: 1. They must have been identified as a caregiver either by the elder themselves, or if any elder was not mentally competent, by someone else who would have this knowledge (including the caregiver him or herself); 2. They must have been able to be present for the interviews. We did not request that those identified caregivers, who also worked, take time off from their work to interview. Usually, in these cases, the elder was still primarily responsible for him or herself and, perhaps, also for the grandchildren. All but three of the 39 caregivers were female with an average age of 40. The youngest was 13 and the oldest was 74 years of age. The average age of the elders who were receiving care was 76.5 years, and the average length of time they had been receiving care was 11.6 years with a range of from one to 40 years and a standard deviation of 10, indicating wide variability in this data.

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In accordance with Thai tradition, it is typically the youngest daughter who assumes the primary caregiver role. If there are no daughters, the daughter-inlaw (wife of youngest son) is expected to assume this responsibility. Among these 39 caregivers one-third (33.3%, N=13) were the youngest or only daughter. One-fifth (20%, N=8) were another daughter and about 13% (N=5) were a daughter-in-law. Six were granddaughters (15%), three were spouses and three were nieces. Only one son was identified as primary caregiver and that was because his wife had just given birth; therefore he was serving in this capacity only temporarily. Approximately 80% (N=13) of these caregivers were married, 10% (N=4) single, 5% (N=2) widowed and 5% (N=2) divorced. The average number of children of these caregivers was 2.1 with a range of 0 to 8 children. FINDINGS

Relevant Findings From Sample of 89 Elders Health Status In developed countries, others assume the role of caregiver to elderly whose declining health and decreased physical stamina does not allow them to perform activities of daily living. Therefore, assessment of health status and seven activities of daily living was done to determine the need for caregiving. Threequarters of the 89 elderly assessed their health as fair to poor. Pain (especially in hip, knee joints, and the lumbar area) was the most common problem. Years of hard labor in the fields and poor nutrition may be viewed as precipitating factors, enhanced by lack of exercise as these elders retire from active participation in daily activities. On the other hand, a surprising finding was the fact that 95% of the 89 elders were able to perform unassisted most of seven basic daily activities including: (1) eating; (2) putting down and taking up their sleeping mat; (3) getting up and down stairs; (4) walking 300 meters; (5) toileting; (6) bathing; (7) dressing. Only two elderly required almost total care. (See case studies) It seems likely that only those elderly who are relatively healthy are survivors in this rural area of Thailand. Death, when it comes, comes quickly to most elders leaving very few who are totally dependent on their families for physical care.

Levels of Caregiving While the original intent of this research was to study how families provide care to elders who are functionally disabled in performing the activities of daily living, the fact that few elderly are in need of this type of care required a reassessment and re-definition of the phenomenon of caregiving from the Thai perspective. Based on data obtained from the 89 elders, it would appear that there are three levels of caregiving to the elderly. The fourth level emerged in

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discussions with village monks. Level I involves taking on the head of household responsibilities when the elderly parents consciously turn over these responsibilities to the identified caregiver. While the average age of retirement for these rural agricultural workers is age 65, the average age at which these elders withdraw from head of household responsibilities is age 67. The range of ages was from age 50 to 98 thus indicating that while 67 is an average age, the actual process may be extremely variable. In fact, the median age was 64.5 years. Retirement from agricultural activities signals the imminent retirement from household management activities as well. Elders continue to contribute to the household through childcare, cooking and cleaning, and also become more involved with religious activities at the local w a r (temple). Level II occurs when the elders cease assisting with common household activities and also withdraw from religious activities associated with the w a t usually after they have reached an average age of 75 (the age of the "old-old" according to Neugarten as cited in Sankar 1984). Finalizing inheritance arrangements may also take place at this time. Level IlI occurs when the elder is ill and the caregiver must then take on additional responsibilities associated with caring for an ill person. This stage may occur at any age and may be only temporary with a return to one of the other levels of caregiving after the elder's recovery. Or it may be an ongoing stage until the elder's death. Level IV activities include arranging an appropriate funeral and making offerings at the w a r on behalf of the deceased relative on religious days. Interviews with village monks revealed that carcgiving does not end with death, but may very well extend indefinitely into the future. Having a proper funeral is very important to Thai elderly, but the expenses involved may make this difficult for the children, especially if they are poor. Traditionally, after three days of mourning, during which time monks pray and neighbors visit, the body is cremated. If family must travel a long distance, or if there is not enough money, the body may be buried temporally and then when the family is present or the money has been raised, the body will be disinterred for the cremation ceremony. Expenses include payment for the monks services, rental of the w a t , flowers, and food for the guests. A few elderly or their families have purchased death insurance from the government to eliminate concerns about this problem. In addition, according to a monk, for those people who die without sufficient merit and must remain on the temple grounds as ghosts, the family's offerings of food to the temple on religious days is thought to not only provide food for the monks, but to also benefit the elders by making merit on their behalf. Usually it is the female members of the family who take on the responsibilities for these activities.

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Decision-making Process The decision-making process regarding selection of the 71 identified caregivers in the 89 households studied generally took one of the following four forms: 1. The result of following cultural custom in which the last child (or last grandchild in some cases) married and automatically assumed the responsibilities as the older siblings moved out of the elder's home. 2. A request (or sometimes a decision) made by the elder's family regarding a caregiver (usually when someone other than youngest daughter or wife of youngest son was to be the caregiver). For example, when the caregiver was a grandchild or a daughter-in-law (but not wife of youngest son), the caregiver may be asked (or told) to assume this role. This situation also may involve the elder moving out of his/her own home into the caregiver's home. 3. A decision made by the caregiver him/herself. Examples included situations when the caregiver was someone other than the youngest daughter who felt he/she needed to assume the caregiving responsibility. For example, spouses may assume the responsibility when children are not willing or able; or when youngest daughters had left the family home to work or raise a family elsewhere and then made a decision to retum to care for the parents; or when the youngest daughter asked the parents to join her in her own home. 4. A decision made by the elders themselves occurred in situations such as when the elders had no children and selected another relative, often a niece, as their caregiver. In general, when caregiving decisions that were made by cultural custom (as with youngest child), the caregiving activities assumed were those associated with Level I. In these situations the caregiving daughter would indicate that she had been caring for her parents since she had been a young girl or at least from the time of her marriage. Indeed, daughters are trained from an early age to take on household responsibilities, and the transition into the final phase of her parent's family life cycle as caregiver does not necessarily involve an assumption of an unexpected role. By the time a conscious discussion and decision by children and other kin is required to select a caregiver, caregiving needs were often of Level 11 or III, indicating increasing debility on the part of the elder or an illness that required family support beyond that currently being received by the elder. Customarily, children did not wish to leave their parents alone and would make every effort to provide care. According to monks, village puyaibaans (headmen), and other villagers a common and acceptable replacement solution when children needed to leave home to seek work elsewhere, was to select one sibling to remain in the home and care for the parents. Often this was the last child married, but sometimes it was a daughter who had divorced or was widowed. One daughter told us it was because she was the least educated. An eider daughter who had reached the stage of retirement from farming often took

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her parent(s) into her own home. In other cases, one of the daughters would return home to care for her aging parent(s) after her own children were grown and she was better able to leave her own family. This was especially true when the elder required either Level II or IN caregiving. Elders in the "young-old" stage (ages 65 to 74) were more able to care for themselves, and, therefore, it was easier for children to leave them unattended. As elders became increasingly older and more debilitated, four possible changes in living arrangements could be made which enabled them to maintain their independence: 1. Moving to the front living area or porch in order to "get more air" and be closer to the stairs. 2. Moving to the downstairs area (under the main house) if the area had been enclosed in order to enable elders who had difficulty with stair climbing to maintain their mobility. 3. Building a small house near the main house that was close to the ground in order to provide easy access for the elderly as well as to provide more room in the main house for an expanding household. Choice of one of these three options was almost equally divided among the elderly who had made these changes. 4. Moving in with a child or relative after retirement or during an experience with an illness (usually occurring if the elder was not getting along with the child he or she was currently living with, if the child was unable to provide the care needed because of daily employment, or if the elder had no children and another relative was assuming care).

Findingsfrom Subsample of 39 Caregivers Caregiving Activities Caregiving activities engaged in by the 39 caregivers primarily included common household activities. Most common was cooking with 100% of caregivers performing this activity. Second was doing the laundry (85%) and third, giving money to the elders (80%). Cleaning was performed by 77% and 54% took care of the elder's bedding. Over one-third emptied the elder's chamber pot. These activities were performed for elders at all three levels of care. Although the mean age of eiders who were receiving assistance in the above activities was older than the mean age of those who were not, only two of the above activities showed significant differences for age. Average age of those elders who required assistance putting down and taking up their sleeping mat was age 80 (versus age 73). Emptying the chamber pot was done by caregivers for elders whose mean age was 81 (versus 74). As indicated previously, only two elders needed intensive Level II care. These elders were quite confused, and the care involved not only the above activities, but intensive personal care as well, including bathing, dressing, assisting with eating, and careful monitoring to guard against wandering off.

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Fifty-nine percent (N=23) of the 39 caregivers had been involved in caring for the elderly during at least one episode of illness within the past year. Sick-care activities they identified included: 1. Obtaining medical care for the elder. This was more difficult in the more isolated villages because of transportation costs involved in getting to the distant subdistrict clinic or hospital and loss of potential work time and wages. 2. Buying medicines, either from the hospital, local pharmacy cooperative or market, and then administering them to the elder on a regular basis. 3. Providing personal care such as bathing, staying up at night with them or sleeping nearby, cooking special foods (such as rice soup), helping them dress, making their bedding, helping them to the bathroom or emptying the chamber pot, and/or special medical treatments such as dressing surgical wounds. 4. Arranging for an appropriate Buddhist healing ritual, particularly the sutra khwan luang (calling the spirit essence of the person who is ill) when the elder is very sick and appears to be dying (Tambiah 1970). The Thai referred to this ritual as the "long life ceremony."

Support Resources Ninety percent (N=35) of these caregivers feel they receive enough help from others, and 95% (N=37) think that if they need help in the future, they will get it. For the few who do not receive enough help, the help needed is usually financial. In fact, not enough money was identified as the major area of difficulty in relation to caregiving by 51% (N=20) of caregivers. This problem became particularly acute if the elder required medical care, and some families worded about how they could afford to obtain medical care if needed. Kin usually live nearby and can be counted on to help when needed. Most help is provided by sisters and sisters-in-law as well as the caregivers' own children. Male kin provide transportation and financial help as needed. Neighbors usually visit, and may help with money and with consultation about health care.

Definition of Caregiving A primary interest in this research was to determine the meaning of caregiving to caregivers. The purpose was to understand caregiving as a cultural phenomenon and occurring within the context of shared norms, values and beliefs. The Buddhist teaching regarding filial obligation stresses the concept of "parent repayment." Children "owe" a debt of obligation to their parents who gave birth and provided care to them. Exchange theory has been proposed as a useful model to examine relationships between elders and caregivers. According to Dowd (1980), problems associated with the declining status of the aged are essentially due to a loss of valued resources thereby causing decreased power to gain respect and care from others. From this perspective, care is dependent on reciprocal exchanges of

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perceived equitable value between elder and caregiver. However, other researchers have proposed that another norm may be operating in exchanges between kin. Sahlins (1965) proposed three types of exchanges. One of these, "generalized reciprocity," is characterized as more altruistic and is based on what the receiver needs and when he needs it. The expectation of a retum is indefinite and failure to reciprocate does not stop the giving. This concept of generalized reciprocity in which payment is deferred until parents need the services and children are able to repay it is exemplified in the expressed Thai cultural norm regarding "parent repayment." More recently, researchers have proposed that there are two kinds of relationships in which members give and receive benefits. Clark and others (Clark and Mills 1979, Clark, Powell, and Mills 1986) have conducted experiments designed to determine distinctions between what they identify as "exchange" versus "communal relationships." Exchange relationships involve a concern "with how much he or she receives in exchange for benefiting the other and how much is owed the other for the benefits received" (Clark and Mills 1979:12). However, in communal relationships (such as between friends, lovers and family members), the motivation is not the expectation of a benefit so much as it is a concern for the needs of others. In fact, keeping track of benefits given and received would be viewed as inappropriate in a communal relationship focused on keeping track of the needs of the other (Clark, Powell, and Mills 1986). George (1986:68) has described these two types of relationships as governed by two different norms: 1. The norm of reciprocity, which holds that members of a relationship should experience equitable levels of profit and loss. 2. The norm of solidarity, which suggests that family members should be given as much help as they need, without concern for a return on one's investment in the relationship. Exchange theory provides a useful model for examining factors influencing caregiver motivations and satisfactions. Any relationship must involve some type of reciprocity in order to be satisfying and the norm of solidarity may be viewed as based on an "affective" reward system. Expressions of appreciation may be at least as effective an exchange resource as the potential for inheritance or assistance with household activities. "Caregiver burden" may be seen as occurring when the caregiver perceives they are giving more to a relationship than is being received, and when this situation results in a depletion of personal resources including one's physical health, financial resources, or emotional wellbeing. Since questioning these Thai caregivers as to why children take care of their parents usually illicited the common cultural norm of filial obligation cited above, attempts were made to be more circuitous in attempting to get at the specific meaning of the caregiving experience for caregivers. Thus, caregivers were asked if they found the caregiving experience to be personally enjoyable, and over one-third said they did not. While most did not elaborate further, a few said they did it from a sense of obligation, thus fulfilling the culturally expected behavior but with limited personal rewards.

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Those who did gain personal satisfaction from their caregiving cited reasons that fell into two primary areas: the reciprocity involved and affection for the elder. Caregivers who responded according to the norm of reciprocity did so from two perspectives. Some were repaying their parents for care formerly received, thus reflecting an orientation to repayment for past services. Others saw the norm of reciprocity from a future orientation which involved collecting merit which would hopefully result in receiving care from others when they needed it. This later view was reinforced by the Buddhist doctrine of making merit (tamboon). While the focus of merit-making is purportedly on ensuring a prosperous rebirth, it is also often thought to enhance the possibilities to better one's position in this life as well (Tambiah 1970). The ideology of merit is based on the concept of generalized reciprocity and, therefore, consistent with the cultural norm regarding appropriate filial behavior. One not only collects merit for one's own future, but is also obligated to pay others who have accumulated merit and to whom one owes a debt for having been cared for. The accumulation of merit thus acts as a resource available to the elderly in exchange for care from others. The second reason expressed by some caregivers was that they did it out of love or affection for their parents and they felt happy and proud to be able to care for them. These responses may be viewed as characteristic of communal relationships (Clark et al. 1985) or the norm of solidarity (George 1986) in which the giving of benefits are not based on an expectation of a return, but rather on a genuine concern for the needs of the other. These caregivers often described their relationships with their parents in very positive terms indicating that affective rewards were ongoing. When caregivers were asked to describe what was personally most difficult for them in relation to caregiving, 41% (N=16) responded that difficulties in pleasing the elder was their primary problem, specifically being unable to please the eider with food or unable to do things right or as fast as the elder wanted it done. Caregivers who found the experience to be more positive were able to fulfill cultural expectations for their behavior, and their caregiving was personally rewarding as well. Those caregivers who did not find the caregiving experience to be personally enjoyable indicated that the societal norm was a powerful motivator and strongly enforced by kin and neighbors in these rural villages. Guilt, as well as loss of face or shame, was likely to be the price paid if they did not perform the expected filial roles in relation to their elderly parents. Further analysis of variables related to non-enjoyment of the caregiving experience found only two situations that were statistically significant. The first was that caring for males was less enjoyable than caring for females. Secondly, elders who were described as difficult to please were considered less enjoyable to care for. (See Table I) The fact that caregivers from this sample experience less enjoyment in caring for males may be understood in the context of the matrilocal society in which mother-daughter relationships are fostered through

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TABLE I Factors related to personal enjoyment of caregiving in rural Thailand Factors

Enjoy

Not enjoy

Total

7 (21.9%) 14 (43.8%)

9 (28.1%) 2 (6.2%)

16 (50.0%) 16 (50.0%)

6 (15.4%) 19 (48.7%)

9 (23.1%) 5 (12.8%)

15 (38.5%) 24 (61.5%)

Difficult to please*

Yes No Care-receiver's sex** Male Female

* p < 0.01 (Chi-square, df= 2). ** p < 0.025 (Chi-square, df= 2). the traditional Thai family life-cycle. The role played by men is primarily focused on relationships between the family and outside society (Goolsby 1990; Potter 1977). Thus men may not experience the close emotional relationships within the family that women do. Economic factors had little to do with the variable of personal enjoyment with caregiving. It is clear that while economic factors provide an important context for caregiving, there are other factors that must be considered such as the quality of personal relationships between parents and their children as well aswith the community.

Impact on Caregivers A concern that had been evident in studies done on caregiver burden in Western countries was that since caregiving is primarily a woman's role and most caregivers are middle-aged women (who must combine their caregiving with traditional household activities while remaining employed outside the home), this combination of roles may potentially be highly stressful (Brody 1981). Modemization in Thailand has resulted in a number of social changes which affect women associated with the move from a kin-based to a cash-based economy. These changes include a breakdown in traditional extended family systems as children move to urban settings in search of work and women also move into the labor market. Women now have equal access to education, thus opening up career opportunities. Furthermore, the emphasis on birth control is resulting in fewer children who will be able to assume the role of caregiver to their parents in the future. All of these factors combined would be expected to have a major impact on the availability of women to provide caregiving to their elderly parents. On the other hand, strong traditional cultural values still emphasize the role of women in traditional household maintenance as well as financial management of the extended family (Goolsby 1990; Potter 1977). Since most of the caregivers interviewed were involved with fanning, the full impact of modernization had not resulted in major changes in their roles. Therefore, for the most part, they were still involved in providing care to the elderly according to the traditional Thai rural caregiving model.

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To assess other responsibilities these women had and the extent to which they affected their caregiving role, caregivers were asked about the amount of time they spent working and caring for the home, and whether they had enough time for both of these activities. Most caregivers spent about three hours a day doing housework and about six hours a day working outside the home in the fields. Three questions were asked to determine whether or not time was a problem. When asked if they had enough time to do everything they needed to do, 23% (N=9) said they did not. Asked whether or not they had enough time for themselves, 21% (N=8) of the caregivers said they did not. When asked about whether they were able to work as much as they needed, again 23% (N=9) of caregivers felt they could not. While nearly one-fourth of these caregivers were experiencing time problems associated with caregiving, over three-quarters found that caregiving was not a major burden. They were able to fit in their caregiving with their other activities without difficulty. In addition, most received support from their families, kin, and neighbors. For the most part, their elderly parents did not require intensive care. And more than 60% saw their own health as being good to excellent. However, this was a fairly select group of caregivers since no caregivers who would have had to take time off from their work activities were interviewed, thus eliminating a potentially more burdened group. Therefore, some sample bias has affected the results.

Future Caregiving The projected impact of the decreased birthrate resulting in smaller family size is expected to affect caregiving of the elderly after the year 2010 (based on the decrease in the birthrate which began in 1970 and on the caregivers' average age of about 40). These current caregivers are going to be entering the stage of life when they themselves will be needing care at a time when potential caregivers are beginning to decrease. Additionally, the average number of children these caregivers had was only 2.1, less than one-half of the number of their parents' living children. Therefore, it seemed important to ask these caregivers if they thought there might be a problem in the future for some people to get help when they became old from their families. Only about 13% said, "yes" and 5% said they didn't know. Most think the traditional pattern of caregiving will continue with no changes. TWO CASE STUDIES OF INTENSIVE LEVEL II CAREGIVING Only two senile elders requiring complete assistance with the activities of daily living were encountered in this research. They lived in two of the more developed villages located on Friendship Highway (the highway connecting Bangkok with the Lao border). The first eider was an 88 year old lady who was being cared for by her youngest daughter, age 48. The daughter's husband was kamnan (district head) of the district. The daughter ran a small store on the first floor of their house. Her elder sister, age 65, also participated in some of the

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interviews. According to the caregiver daughter, her mother had quit working at age 55 to care for the grandchildren. She was widowed eighteen years ago (age 70) and at age 81 had quit working in the house. She became senile only three years ago. There had been ten children, but one son was dead and the location of another son was unknown. The mother had owned 65 rai. Each living child had received seven rai each as their inheritance twenty years ago, and this caregiving daughter had received 16 rai in addition to the house. (One rai is equivalent to 0.4 acres.) According to the daughter, the remaining children had stayed near their mother because their mother had given them land to farm and to build their homes. The caregiver daughter had three children, but one son had been killed two years ago in a motorcycle accident. Her daughter, age 21, lived at home and worked as a receptionist at the health department in Soongnern and the youngest son was in the third year of school (this was the caregiver's second marriage). She identified these two children as her own future caregivers. At the time of our first interview, the caregiver daughter had bought an additional 81 rai (from her husband's earnings from the American Air Force during the Vietnam War and then from employment in Sandi Arabia). In addition, she was renting 200 rai for growing cassava. Six months later, the store had been expanded and seemed to be doing very well, so they were no longer renting land. In addition, her husband also rented out his tractor and repaired tires; therefore, this was quite a wealthy family in Thai rural terms. They earned about 150,000 baht ($6000 per year) with about equal amounts earned by the store as from farming. They owned two color televisions, two radios, a video player, refrigerator and motorcycle. The toilet was an indoor waterseal, and water was piped in from the village well. The house had originally been the caregiver's parents' home, but the daughter and her husband had recently added a new modem brick addition. A telephone had been installed by our second visit, although the daughter was finding that it was more of a nuisance since villagers were calling out and not paying for their calls. It was the only telephone found in any of the villages studied. When the mother stopped working in the house at the age of 81, the daughter took on the responsibilities of cooking and washing her clothes, etc. Care became more intense as her mother became more senile. She described the following typical day: She began caring for her mother at 6 am by taking her to the bathroom, helping her shower and dress, cleaning her room, fixing and feeding her breakfast. The caregiver's sister (age 65 who is a widow and lives next door) then took over and watched her mother during the day while the caregiver worked in her store. At noon, the caregiver fixed lunch and fed her mother again. In the aftemoon, the sister stayed with her mother again while the caregiver worked in the store. In the evening, the caregiver fixed and fed supper to her mother, made her bed, and undressed her for sleep. Her sister also helped when her mother was sick by staying overnight, however her mother was

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seldom sick. Usually her mother had no problems sleeping at night when the lights were off. This daughter would have liked more help from her kin, but she understood they are busy. Some sisters and brothers helped when they could, but some had to work outside the home and could not help. But the fact that they came and asked her if they could help made her feel good in her heart because it meant they loved their mother. The most difficult aspects of caring for her mother was having to clean up the incontinence and seeing her mother sick. However, she said that when she was a child, her mother did the same for her and it is her duty. The second situation involved a youngest daughter, age 61, from Bangkok. She had recently retired from the army (which she had joined following the death of her husband over 30 years ago) and retumed home to care for her 104 year old (according to the daughter) senile mother. Her mother had a total of fifteen children, but only six were still alive. Four lived nearby, two in the compound with the mother (but in separate houses) and two in the village. She said that when she first came, no one had cleaned up her mother or her house. They were just sleeping there at night. She felt it was her duty as youngest daughter to remain and care for her mother, although her own daughter had asked her to live with her in Bangkok. Her mother's house was a typical Thai wooden structure requiring a ladder to enter the house. The bedding had all been moved to the front room so that the daughter could better watch her mother at night. The caregiver described her caregiving activities as follows: At the time she first moved in, her mother had been senile for a year, but was still using a chamber pot - throwing the contents out through the floor boards. One month prior to our first interview, her mother had become incontinent, and the daughter was spending much of her time cleaning up after her, washing her mother's clothes and the floor. During the daytime her mother talked to people she imagined were there, but in reality, they were all dead. When her mother ate, the daughter had to watch her closely because she played with her food. At night, her mother played with the mosquito netting, talked with dead people, and sometimes even played with matches. This caregiver saw herself as providing around-the-clock care. When the daughter left the house to get food, she had to put everything away and lock the door leaving her mother alone. She felt as if she left her mother in prison, and then worried all the while she was gone. If she wanted to go to Bangkok to visit her own daughter, she told us her kin would stay with her mother at night. But during the time of the research, she never went to Bangkok. Instead, her daughter, who is a teacher at a college in Bangkok, came to see her. When this caregiver was asked if she could expect help in the future, she said, "I don't know who. Some of my brothers and sisters don't even say 'hello' when they pass by to get rice [from the rice storage shed]. Some children are not good." She went on to describe how they didn't even give money for their own father's cremation, nor were they giving money for the cremation of a sister who

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died recently. She wouldn't even ask them to help her with her mother given this past history. She said, "They know their duty. I don't want to teach them their duty." She went on to say that even when she is working hard to keep her mother clean, they never asked how she is doing or if they can help. When asked if she got tired from taking care of her mother, she said, "When I am cleaning her, I remember that I was in her stomach for nine months and then I was born early and she had to clean and change me, so now I do the same for her. It is my duty because she cared for me." She couldn't understand why the other children didn't feel the same. Each of the elder's children had received two rai each, but most of the income for the households came from working as laborers on the farms nearby or from the grandchildren who worked at the jute factory in Soongnern. This caregiver was currently living off the army pension which she had received in one lump sum and obtained her daily rice supply from her own two rai which she rented out. She expected to move in with her daughter in Bangkok after her mother died as her daughter had requested. Although these two situations are similar in the intensity of care required by the elder, they are quite different in four ways. In the first, the youngest daughter continued to provide care to her mother according to accepted traditional cultural practices. In addition, she was receiving good support from her kin, especially her sister. Third, this family was quite well-off financially (in Thai terms). And finally, the children of this elder ranged in age from 48 (caregiver) to 65 (eldest daughter). In the second situation, the daughter made a conscious decision to care for her mother, but only after her work responsibilities in Bangkok were completed. In addition, support from kin was minimal. Even expressions of concern were not forthcoming. Third, the financial status of this family was more limited than that of the first. The small amounts of land (2 rai) distributed to the children by the mother gave them enough rice to feed themselves, but meant that they had to earn money as laborers elsewhere. And finally, the children of this eider ranged in age from 61 (caregiver) to the 80s, considerably older than the first case situation. Both of these caregivers saw their caregiving in terms of generalized reciprocity. Because of the mental status of the mothers, little emotional exchange occurred. Thus expressions of concern and appreciation from others as well as their assistance in care are clearly important in preventing "burnout." But regardless of support and appreciation, the norm of "parent repayment" plays an important role in both of these daughters continued care of their senile mothers. Economics also clearly plays a role. Those households with little land and dependent on daily labor to eam enough money to support their families, have little time, energy or money to help kin, including parents. Caregivers who must give daily intensive care must either be relatively wealthy themselves in order to be released from work responsibilities or have access to kin who are able to be released from work responsibilities to assist in the care of these difficult parents.

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Finally, children of parents who live to extreme old age may have more difficulty providing care due to their own advanced age, and younger grandchildren may be less willing or able to assume the role of caregiver. CONCLUSIONS AND DISCUSSION The change from a kin-based to a cash-based economy associated with modernization is changing how families provide care to their elderly. Loss of productive land is forcing the breakdown of the traditional extended family system and lifecycle. Support is changing from the direct care provided by children to cash support sent by distant employed children (Caffrey 1992). However, this study, for the most part, examined caregivers who were still providing care within the context of the traditional Thai family structure and lifecycle. In general, these caregivers were able to accommodate their caregiving with their other responsibilities of household and agricultural work. In addition, the fact that few of the elders required intensive care made the caregiving job much easier. The primary motivations for caregiving were identified as: (1) fulfilling the expected cultural norm of filial obligation; (2) love or affection for the elder; (3) a desire to reciprocate for past services and to build up future merit for themselves. The difference between the first and third was an attitude of obligation versus an attitude of gratitude. Factors which made caregiving least enjoyable was difficulty in pleasing the elder and caring for males. However poverty was also identified as a major problem by the caregivers. One may anticipate that as children become less economically dependent on their parents, a breakdown of the traditional Thai family system will occur. Affective bonding may be the most important motivator for children to continue caring for their parents. Those elders who do not cultivate close emotional relationships with their children may be at special risk of abandonment when their more independent children are making decisions about their own family's welfare. It may be anticipated that in the future, rural elderly in the age group of 65 to 74, the young-old who traditionally would be receiving Level I care (assumption of the traditional household management activities by their youngest child), may find themselves increasingly alone during this phase of the aging life cycle as children leave home to enter the labor market. This may be especially true for elderly who have little land or whose land has limited productivity, since farming may not provide enough economic incentive for children to remain in the household to care for their parents. Whether women will be at special risk for neglect due not only to the fact that they live longer than men, but are also generally poorer than men, is a concern. It may be that the affection variable may counteract the economic variables as an exchange resource and enhance the potential for family support. On the other hand, men may be at special risk due to the fact that less affection may be involved. A critical issue with implications for future policy development in Thailand

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will be the increasing number of very old and debilitated (frail) elders who will put additional stress on families with already limited resources. In general, however, one may anticipate that children will attempt to fulfill their caregiving responsibilities when their parents require caregiving at the more intensive stages of Level II and Level HI. For most children, the problem is not that they don't want to care for their parents, but their resources for doing so are limited because of the economic pressures of raising their own families. Meanwhile, the cultural norm of filial obligation with its powerful enforcement through community sanctions will continue to play a major role in motivating sometimes reluctant children to care for their parents. ACKNOWLEDGEMENTS This study was supported by a grant from the National Science Foundation, the Center for the Study of Women in Society at the University of Oregon, a Carpenter Grant through Southern Oregon State College and Sigma Xi. The National Research Council of Thailand gave permission to conduct the study. Special thanks go to Dr. Geraldine Moreno-Black, University of Oregon, Dr. Prabha Leeprasert at Mahidol University, Bangkok, the staff of the Soongnern Health Research and Training Center and to my husband, Paul, for their support during this research. REFERENCES Brody, E.M. 1981 "Women in the Middle" and Family Help to Older People. The Gerontologist 21 (5):471-480. Caffrey, R.A. 1992 Family Care of the Elderly in Northeast Thailand: Changing Patterns. Journal of Cross-Cultural Gerontology 7(2): 105-116. Clark, M.S. and J. Mills 1979 Interpersonal Attraction in Exchange and Communal Relationships. Journal of Personality and Social Psychology 37(1): 12-24. Clark, M.S., M.C. Powell and J. Mills 1986 Keeping Track of Needs in Communal and Exchange Relationships. Journal of Personality and Social Psychology 51(2):333-338. Cowgill, D.O. 1986 Aging Around the World. Belmont, CA: Wadsworth Publishing Co. deYoung, J. 1955 Village Life in Modern Thailand. Berkeley: University of California Press. Dowd, J.J. 1980 Exchange Rates and Old People. Journal of Gerontology 35:596--602. Foster, B.L. 1975 Continuity and Change in Rural Thai Family Structure. Journal of Anthropological Research 31:34-50. George, L.K. 1986 Caregiver Burden: Conflict Between Norms of Reciprocity and Solidarity. In Elder Abuse: Conflict in the Family. K.A. Pillemer and R.S. Wolf, eds. Pp. 67-92. Dover, Mass: Auburn House Publishing Co. Goolsby, R.L. 1990 Women, Work and Family in Northeastern Thailand: Issues of Gender, Household and Power. Paper presented at Third Conference of Northwest Regional Consortium for Southeast Asian Studies, Seattle, WA. Kinsella, K. 1988 Aging in the Third World. Bureau of the Census, International Population Reports, Series P-95, No. 79. Washington, DC: U.S. Government Printing Office. Klausner, W.J. 1987 Reflections on Thai Culture. Bangkok: Amarin Printing Group Co.,

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School of Nursing and Health Southern Oregon State College Ashland, OR 97520, USA