Health Care for Women International, 35:1367–1379, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 0739-9332 print / 1096-4665 online DOI: 10.1080/07399332.2014.972408
The Importance of Reciprocity for Female Caregivers in a Super-Aged Society: A Qualitative Journalistic Approach ´ ¨ STEPHANIE PAILLARD-BORG and LARS STROMBERG The Red Cross University College, Stockholm, Sweden
As Japan is facing a super-aged society, Japanese women find themselves on the front line as traditional family caregivers. Our aim was to describe the observations and thoughts of one Japanese woman’s experience of living with her elderly parents in the suburbs of Tokyo. One open-ended interview was performed and analyzed using content analysis with a methodological departure in qualitative journalistic interviewing. The case was a single woman in her late 40s living with her aged parents. Reciprocity was identified as the glue holding the joy and burdens of the role of caregiving for elderly parents. Moreover, gender was identified as a motivator for reciprocity from a macro to a micro level in a super-aged society. Japan is facing in the near future an accelerated decline in birthrate simultaneously with an especially long life expectancy, resulting in a very old population for which the planning of elderly care is essential and urgent. Indeed people in Japan have the longest life expectancy in the world. Life expectancy at birth was 83 years in 2009 (male 79.6 and female 86.4 years, respectively; Organisation for Economic Co-operation and Development [OECD], 2013). This was achieved in a fairly short time through a rapid reduction in mortality rates secondary to communicable diseases from the 1950s to the early 1960s, followed by a large reduction in stroke mortality rates after the mid-1960s (Ikeda, 2011). Japan has a unique demographic profile labeled a super-aged society (Kumagai, 1996). In Japan, traditional norms and beliefs encourage familial integration of older people in the family life, which is most obviously manifest in the Received 7 January 2014; accepted 30 September 2014. Address correspondence to St´ephanie Paillard-Borg, The Red Cross University College, P.O. Box 55676, Teknikringen 1, SE-102 15 Stockholm, Sweden. E-mail: [email protected] 1367
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relatively high rate of intergenerational coresidence involving elderly parents and their adult children (Kumagai, 1996). Nevertheless, the prevalence of multigenerational households has declined in Japan over the past three decades, suggesting that the traditional living arrangement has become increasingly optional as filial responsibility has lost some of its historical powerful force (Tagaki & Silverstein, 2011). In 2000, the Japanese government started the long-term care insurance (LTCI) program with the purpose of responding to the society’s major concern about aging, specifically the care problem, whereby citizens can be assured that they will receive care and be supported by society as a whole. Nonetheless, the LTCI Act was revised in 2011, adding to the law aspects of quality, a focus on promoting comprehensive support throughout LTCI (OECD, 2013). Japan’s LTCI system helps family caregivers not by paying them but by taking on a portion of their responsibilities. Monetary compensation was proposed before the program was ratified, but women’s associations argued that boosting household income would not relieve the burdens on caregivers, who are mostly female. Only direct provision of formal services, they contended, would make a real difference in the burden on families (Campbell, 2002). Such approach also facilitates the integration of women in the job market outside the home and allows women to gain some sort of independence. Undeniably, researchers have shown that over the last 10 years rising female labor force participation and changing life’s expectation and declining marriage and fertility rates have combined to produce unprecedented strains on Japanese traditional multigenerational households where caregiving to elders traditionally takes place (Horlacher, 2002; Retherford, Ogawa, & Matsukura, 2001; Takeda, Yamagata, Matsumura, & Okayama, 2004). In Japan, however, still over half of the women are not in paid employment and a quarter work in unstable and low-paid jobs, mostly due to the scarcity of permanent positions for married women and strong social expectations relating to the role of Japanese women (Shimono, 2007). Even if an increasing number of women are interested in developing a career, the situation stays complex in regards to occupation, family responsibility, and gender expectation. On this issue of empowerment through economic independence, one of the most notorious feminist journalists of the twentieth century in Japan, Matsui Yayori, made an interesting remark in the 1990s. She claimed that Japanese women, especially the younger generation, are disempowered in spite of any appearances to the contrary, because “any interest they might have had in social issues has been destroyed by a conformist educational system, material affluence, and a culture of mass consumption” (Loftus, 1997, p. 32). This generation that she described is the same age group that will soon be of an age to attend to elderly relatives. A recent national survey reported: “More than half of the public supports the idea that husbands should be the breadwinners, while
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wives should stay home and do housework.” More accurately the results of a survey on gender equality performed by the Gender Equality Bureau, a division of the Japanese Cabinet Office, showed that the share of Japanese who thought wives should stay at home jumped 10 percentage points to 52% between 2009 and 2012. The dramatic reversal in gender equality appears to be related to the weak economy (Gender Equality, Bureau Cabinet Office, 2013). One of the roots of this complex situation has its origins in the tenets of Confucianism where reciprocity is one of its major principles together with consideration, support, dependency, and privacy (Hashizume, 2000). Japanese people value reciprocity and understand it as a way of meeting debt and obligation. Caring for elderly parents arises from a sense of gratitude for childhood nurturing (Hashizume, 2000). In the midst of major sociological transformations, traditional gender expectations, and limited public resources, modern Japanese women often experience a struggle between their traditional roles and their current opportunities and values. At the same time, long-standing sociocultural attitudes and norms make it difficult for them to discuss it openly (Hashizume, 2000). The major demographic transition of Japan, therefore, and the distinctive role of women in that context make it of main importance to be investigated.
AIM Our aim in this case study was to describe the observations and thoughts of one Japanese woman on her experience of living with her elderly parents in the suburbs of Tokyo in the midst of a country facing a super-aged society and massive sociological changes. The particularly unique feature of the woman interviewed was her dual exposure to the Western and Eastern cultures. This profile gave her the ability to critically analyze the context in which she lived.
METHOD A single case study with one open-ended interview was performed and analyzed by content analysis with a methodological departure in journalistic interviewing. Under this particular type of interview, the research questions/issues are expected to be refined continuously as new and previously unexpected aspects of the phenomenon come to light, a process that Partlett and Hamilton (1976) called progressive focusing. Indeed, qualitative research in journalism allows one to start out the investigation of a given topic with a preliminary idea, and then to reveal more significant issues than originally thought (Hartin Iorio, 2004). The product of this type of interview permits
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then the qualitative case-study research to capture the complexity of a phenomenon within its real-life context.
The Case The Japanese female caregiver, called Miho for the purpose of this study, was in her late forties at the time of the interview and was educated as a teacher. She spoke English well and had lived in the United States for a couple of years. She resided in a house in the suburbs of Tokyo with her parents. At the time of the interview, Miho’s father and mother were 84 and 78 years of age, respectively. According to Miho, her parents were in reasonably good physical health, with increasing cognitive decline.
Data Collection In January 2013, the main author (SPB) was visiting Tokyo for the purpose of scientific research and had the opportunity to meet Miho. The data were collected, through an open-ended interview after informed consent was obtained. The interview lasted approximately 60 minutes in a private space in a hotel in central Tokyo. It was recorded, transcribed verbatim, checked against the original recording, and edited for accuracy. The interview was conducted by the main author (S. P-B.). The recorded interview session began by asking Miho about her living condition and arrangement with her parents, her perception about this situation, and, finally, about her views regarding the overall elderly living arrangement situation in Japan, more specifically, Tokyo. Additional questions were asked about her own observation and opinion regarding women’s roles, economic hardship at the national and family level, and traditions as well as the future of these traditions in regards to the younger generations. The focus was held in the Japanese capital city, Tokyo, in order to mark a clear differentiation with rural Japan. Supplementary questions were asked with the purpose of clarifying some answers, such as, “Can you give me example,” “What do you mean,” “Interesting, please could you develop,” “You are telling me that . . . is it right or would you like to add something that I missed?” and so on, that aimed to cover various aspects of her own experience, perception, and opinion about the care of elderly people in Tokyo from a woman’s perspective.
Data Analysis The data were analyzed by the content analysis method (Lundman & H¨allgren-Graneheim, 2008; see Table 1). The authors present the experience, observations, and thoughts of a woman living with her elderly parents
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TABLE 1 Examples of Data Analysis Process: Meaning Units, Condensed Meaning Units, Codes, Subcategories, and Categories Meaning units
Condensed meaning units
Code
Subcategory
When I am not home, I I can count on my Support from the Belonging can call my neighbors neighbors and surrounding and they take care of we take care of community my parents. We look one another. after one another. Yes, usually women Women are often Expecting Traditional take care of the caretakers, but responsibility Role elderly family it is not a role of women members, but some that is always are not happy about it contentedly but they do it. accepted.
Category Reciprocity
Gender
to connect her views and experiences in a super-aged society with what seems to reflect the tacit knowledge of the caregiver for the elderly. Using our analysis we reveal two categories and eight subcategories (Table 2). The accuracy of the subcategories and categories were verified against the original interview text to make sure that the meaning had not been changed during the analysis process and that the categories were grounded in the data (Lundman & H¨allgren-Graneheim, 2008).
Ethical Considerations The data collection and presentation of the findings are subject to the principles of international ethical standards for conducting interviews with an informant capable of giving informed consent to voluntarily participate in a study with a descriptive design. Guidelines from Swedish Law (The Swedish Code of Statutes, 2003) were followed. The relevant ethical guidelines were applied such as autonomy, integrity, and anonymity of the informant and her
TABLE 2 The Categories and Subcategories That Emerged From the Data Categories Gender Reciprocity
Subcategories Anticipated acceptance Traditional role Historical adjustment Belonging “We and I” Family resources Intergenerationality Adaptive creativity
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surroundings when describing the result in accordance with the World Medical Association Declaration of Helsinki (World Medical Association, 2013).
FINDINGS In this single case study with a qualitative journalistic approach, two main categories, gender and reciprocity, and eight subcategories presented below, were identified.
Gender Anticipated acceptance. Miho expressed several times during the interview that it had been implied “automatically” between the family members that she would be the one taking care of her elderly parents and taking over the whole responsibility for the task. She remembered that she began to endorse this role spontaneously because it seemed expected from her naturally. Miho found that the situation was relatively normal and she even confirmed that many of her female friends were doing the same. She described that it was expected of her family but also her community that she would take over this role. She did not share during the interview that there was possibility for discussion or refusal. Traditional role. According to Miho, the responsibility for taking care of elderly family members was almost at all times assigned to the women when the time came. It was described during the interview that the responsibility was not only toward one’s own parents but also to parents-in-law and other elderly family members. Miho expressed openly the gender specificity of this caregiving role as well as the frustration around it for some women. As low-paid and part-time jobs were rather common among married women, it became increasingly difficult and complex when a woman became a mother and wished to have a career. Miho added that if the situation could be difficult and unfair for some women, it was also challenging for men. She specified that the role of responsibility was not discussed enough from a man’s perspective. She shared that she knew of many men who perceived the almost sole responsibility for the family’s finances as very stressful. She added that the issue of salary and gender was deeply rooted in the tradition, but it was changing very slowly. Miho explained during the interview that men’s salaries were usually much higher than women’s; therefore, it was economically damaging for the family if a son, a man, quit his job and wished to take care of his parents. Historical adjustment. It was a recurrent topic during the interview that the younger generation did not have the same respectful attitude toward elderly persons as their own parents probably had. She emphasized that the difference in behavior was even more obvious among young females
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who had been expected during their upbringing to be gentle and kind. She expressed also that the multigenerational closeness was not as common as earlier in Tokyo, and the old traditional ways were being forgotten. Miho emphasized that it was specific to the urban environment such as Tokyo. Miho explained that because there were so many elderly people living in the community that they did not appear to the young people as “special anymore” but rather “common” citizens not deserving a specific respectful behavior due to their status.
Reciprocity Belonging. The important role of informal support that took place in a neighborhood where the elderly lived was also a frequent subject matter during the interview. Miho described life in the suburbs and the closeness between these inhabitants who had known one another for decades. It seemed to be very important for Miho to know that help was available from her neighbors and that they understood one another because they had the same values. They could share the same worries, tips, but also joyful moments. “We” and “I”. Miho used “we” quite often and repetitively. “We” and “I” were used at about the same frequency, respectively, 45 and 48 times. It was observed that the use of “I” was immediately changed to “we” when a general opinion was expressed. At some point during the interview, it was communicated to Miho that her own opinions were also appreciated, suggesting that not only were the “group” thinking, norms, and expectations of interest, but Miho continued to use “we” frequently. Family resources. Concerns and worries related to finances were often expressed by Miho. Apprehensions regarding financial expenses, amount of services available to the elderly for their home care, and changes about guidelines leading to increased expenses and decreased services were recurrent during the interview. Miho communicated her understanding and acceptance for the tradition as described above, but she still admitted repetitively that she was worried about the financial cost and suggested that in many families the financial burden for the working adult children was “multigenerational” because it involved the care of parents and grandparents. According to her, the support provided by the LTCI was satisfactory but not sufficient. She emphasized that the will of the caregivers to “give back” was progressively being challenged and accompanied with a feeling of shame. She had observed that the heavy financial and caregiving burden was increasing for the caregivers as three-generation households were common because the life expectancy was the highest in the world. Miho described that the aspiration to take care of the elderly family members was a way to repay for love and care earlier in life, and this attitude was one of the most fundamental pillars of the Japanese society.
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Intergenerationality. Miho expressed frequently during the interview the importance of intergenerational contact. She stated that it was her observation that grandchildren were not spending as much time with their grandparents in Tokyo compared with the more traditional countryside. Nevertheless, she believed that the social interaction and the traditional intergenerational coresidences were still relatively common in the capital city compared with other cultures. According to Miho, the intergenerational contacts were adapting to the modern lifestyle because mothers were more frequently employed outside the home as part-timers than in the past. She viewed the contact between the elderly people and the younger generation as a “gift” for the members of society. Adaptive creativity. Miho voiced confidence when discussing the concrete opportunities of intergenerational relations. She commented that she perceived the Japanese society as creative and able to maintain traditions in the midst of drastic societal changes. As an example, she described facilities combining nursing homes and nursery schools. She commented that this type of arrangement was still experimental and not widespread, but it was becoming increasingly popular. She added that, in her opinion, this kind of facility would not only stimulate the elderly by the presence of the children, but also the children would get experienced attention from the elderly people.
DISCUSSION The main findings of this study, gender and reciprocity, can contribute to understand the experience of a caregiver of elderly parents from a woman’s perspective in a super-aged society in the midst of a major societal mutation. Our results, based on one single woman’s interview, reveal the complexity surrounding the caregiving role. Campbell (2002) described the envisioned purpose of the LTCI more than 10 years ago as an insurance that would help family caregivers, largely female, by not by paying them but by taking on a portion of their responsibilities. We find that the recommended LTCI options were decent and rather satisfactory, but they were still insufficient, in many cases, to relieve the burden. According to Miho, the responsibility of caring was still largely taken on by women who often had low-paid part-time jobs. It suggests a double-burden of duties and therefore more stress on women. Researchers recently investigated the burden reduction of caregivers for users of care services provided by the LTCI. The majority of the caregivers are women. In that study, a total of 68.8% of the caregivers reported that the care burden is reduced by the introduction of the LTCI care services, and 86.8% of the caregivers are satisfied with the LTCI care services (Umegaki et al., 2014). These results confirm to some extent our findings by showing general satisfaction
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for the LTCI care services but also some dissatisfaction for one-third of the participants regarding the insufficient relief provided by LTCI. Another related issue, mentioned by Miho and confirmed by Shimono (2007), is the strong social expectation on the role of married Japanese women in the society and the limited career opportunities available to them. Apparently many companies choose to ignore the dilemma that some female employees are facing: getting time off to take care of elderly family members and the fear of losing their job. Miho said that the government was not facilitating the change or encouraging the corporate world to fully integrate women into the work force. Ambiguously, with the public insurance system in place, dependents (married women are treated as dependents) do not need to pay social security contributions or tax, in order to receive a pension and be covered by health insurance. Hirao (2007) confirms these allegations by stating that protection to the “dependents,” in some ways, sustains women outside the career path and in a dependent role that in turn maintains them as available caregivers. As described in the narrative, Japanese men are also facing difficulties based on gender. The high expectation on women as caregivers in turn contributes a high expectation on men as breadwinners. Traditionally, the Japanese masculinity is represented by the salaryman (Japanese expression for the white-collar businessman). Salarymen are expected to dedicate their lives to their jobs, while offering the material necessities for their families (Hidaka, 2011). Miho acknowledged that many men felt pressure. Most of the time, men have much higher salaries than women, which implies the economical responsibility for the family yet the impossibility for them to quit their job and take care of their parents, even if desired. Data from a new study by Japan’s Institute for Research on Household Economics, however, indicate that this trend is changing slowly (Lise, Sudo, Suzuki, Yamada, & Yamada, in press). In fact, an increasing number of middle-aged Japanese men are resigning from their jobs to take care of elderly parents. According to the study, 13% of men and 28% of women aged between 40 and 64 had quit their jobs and were living with parents who required nursing care (Hofilena, 2013). Nevertheless, Hofilena goes further and reveals that more men than women are remaining unmarried in that situation, as married men would have difficulty quitting their paying jobs to care for their elderly parents if they had their own family to support. The matter is then not the same for most women who are often already in a dependent economic position. It is related to the severe demographic issues that are facing Japan with not only a super-aged society but also with a very low birth rate due partly to men and women choosing, not to or being unable to get married. In 1996, Kumagai reported that intergenerational coresidency in both urban and nonurban settings was a common living arrangement. More than one decade later, Tagaki and Silverstein (2011) describe this living arrangement as slowly disappearing. Our study finds that despite the decline in
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coresidency, this situation was still prevalent, especially in the suburbs. Miho’s views are supported by Kato (2013), who stated in his recent study that there is a persistence of intergenerational coresidency in Japan, implying a strong sense of reciprocity, and that the Japanese family is still based on the stem family system. Throughout the narrative, the implication of Confucianism, strongly based on exchange and mutual benefit or reciprocity, on familial expectations is present (Hashizume, 2000). Miho did not use the term “reciprocity” directly, but she described it with her own words repeatedly. In family research, reciprocity is described in different ways. Starrels, Ingersoll-Dayton, Neal, and Yamada (1995), for instance, see reciprocity as a dimension of caregiving and functional solidarity. The concept of sekentei is defined as social appearance that causes an individual to worry about others’ observations and evaluations of his or her behavior. For instance, it is believed that sekentei prevents Japanese family caregivers of elders from utilizing needed social services, which in turn reinforces the familial reciprocity (Koyano, 1996; Ohta & Kai, 2010). Therefore, it also becomes a gender issue because mostly women are caregivers. Reciprocity was identified as the glue holding the joy and burdens of the role of caregiving for elderly parents and gender as a motivator for reciprocity from a macro to a micro level in a super-aged society. It means that men and women take gender-specific accountability and responsibility at all levels of the society, up from the national and community level and down to the intimate family sphere, in order to maintain this intergenerational mutual benefit. It appears that without this gender-specific role structure endorsed at all levels of the society, reciprocity could not be achieved.
Method Discussion A case study with a qualitative journalistic approach is an appropriate study design for describing social aspects and reasons for people involving and interacting in the world and with others. The journalistic approach focuses onhuman values and the lived experience without making any claims of generalizability. It is advisable for later similar studies to use a similar strategy and develop this method because readers are becoming increasingly more versed in multiple fields of expertise. A single case study is suitable when the case represents something unique worth documenting and analyzing (Yin, 2003). The unique profile of Miho, being a Japanese woman exposed to both the Western and Eastern cultures simultaneously and living with her parents, led to the methodological choice of this study. Indeed a qualitative single case study with journalistic interviewing highlighted in a unique manner the complexity and specific nature of Miho’s thoughts and observations (Bryman, 2011).
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CONCLUSIONS We report the results from this study to show that caring for elderly parents is a complex phenomenon, and this experience is unique to each caregiver, usually a woman. Currently intergenerational reciprocity is still frequently sustained in urban areas. It is still possible for many families because of the structured gender-specific responsibility accepted tacitly by family members. In the near future, however, the extreme demographic demand as well as the family members’ willingness to carry on this intergenerational reciprocity might have a drastic impact on the ancestral family order. In conclusion, we encourage a multidisciplinary approach in order to develop innovative solutions facing the societal demands of this super-aged society. Health professionals, policymakers, sociologists, economists, city planners, journalists, and more can play a central role in this complex transition and make it possibile to create a sustainable super-aged society. Despite the challenges, the maintenance of specific familial expectations associated with gender and intergenerational reciprocity could be foreseen as a societal strength in Japan if it is mitigated with pioneering solutions, possible compromises, and flexibility.
ACKNOWLEDGMENTS We thank “Miho” for her time and trust in us during the interview.
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The Importance of Reciprocity for Female Caregivers in a Super-Aged Society: A Qualitative Journalistic Approach ´ ¨ STEPHANIE PAILLARD-BORG and LARS STROMBERG The Red Cross University College, Stockholm, Sweden
As Japan is facing a super-aged society, Japanese women find themselves on the front line as traditional family caregivers. Our aim was to describe the observations and thoughts of one Japanese woman’s experience of living with her elderly parents in the suburbs of Tokyo. One open-ended interview was performed and analyzed using content analysis with a methodological departure in qualitative journalistic interviewing. The case was a single woman in her late 40s living with her aged parents. Reciprocity was identified as the glue holding the joy and burdens of the role of caregiving for elderly parents. Moreover, gender was identified as a motivator for reciprocity from a macro to a micro level in a super-aged society. Japan is facing in the near future an accelerated decline in birthrate simultaneously with an especially long life expectancy, resulting in a very old population for which the planning of elderly care is essential and urgent. Indeed people in Japan have the longest life expectancy in the world. Life expectancy at birth was 83 years in 2009 (male 79.6 and female 86.4 years, respectively; Organisation for Economic Co-operation and Development [OECD], 2013). This was achieved in a fairly short time through a rapid reduction in mortality rates secondary to communicable diseases from the 1950s to the early 1960s, followed by a large reduction in stroke mortality rates after the mid-1960s (Ikeda, 2011). Japan has a unique demographic profile labeled a super-aged society (Kumagai, 1996). In Japan, traditional norms and beliefs encourage familial integration of older people in the family life, which is most obviously manifest in the Received 7 January 2014; accepted 30 September 2014. Address correspondence to St´ephanie Paillard-Borg, The Red Cross University College, P.O. Box 55676, Teknikringen 1, SE-102 15 Stockholm, Sweden. E-mail: [email protected] 1367
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relatively high rate of intergenerational coresidence involving elderly parents and their adult children (Kumagai, 1996). Nevertheless, the prevalence of multigenerational households has declined in Japan over the past three decades, suggesting that the traditional living arrangement has become increasingly optional as filial responsibility has lost some of its historical powerful force (Tagaki & Silverstein, 2011). In 2000, the Japanese government started the long-term care insurance (LTCI) program with the purpose of responding to the society’s major concern about aging, specifically the care problem, whereby citizens can be assured that they will receive care and be supported by society as a whole. Nonetheless, the LTCI Act was revised in 2011, adding to the law aspects of quality, a focus on promoting comprehensive support throughout LTCI (OECD, 2013). Japan’s LTCI system helps family caregivers not by paying them but by taking on a portion of their responsibilities. Monetary compensation was proposed before the program was ratified, but women’s associations argued that boosting household income would not relieve the burdens on caregivers, who are mostly female. Only direct provision of formal services, they contended, would make a real difference in the burden on families (Campbell, 2002). Such approach also facilitates the integration of women in the job market outside the home and allows women to gain some sort of independence. Undeniably, researchers have shown that over the last 10 years rising female labor force participation and changing life’s expectation and declining marriage and fertility rates have combined to produce unprecedented strains on Japanese traditional multigenerational households where caregiving to elders traditionally takes place (Horlacher, 2002; Retherford, Ogawa, & Matsukura, 2001; Takeda, Yamagata, Matsumura, & Okayama, 2004). In Japan, however, still over half of the women are not in paid employment and a quarter work in unstable and low-paid jobs, mostly due to the scarcity of permanent positions for married women and strong social expectations relating to the role of Japanese women (Shimono, 2007). Even if an increasing number of women are interested in developing a career, the situation stays complex in regards to occupation, family responsibility, and gender expectation. On this issue of empowerment through economic independence, one of the most notorious feminist journalists of the twentieth century in Japan, Matsui Yayori, made an interesting remark in the 1990s. She claimed that Japanese women, especially the younger generation, are disempowered in spite of any appearances to the contrary, because “any interest they might have had in social issues has been destroyed by a conformist educational system, material affluence, and a culture of mass consumption” (Loftus, 1997, p. 32). This generation that she described is the same age group that will soon be of an age to attend to elderly relatives. A recent national survey reported: “More than half of the public supports the idea that husbands should be the breadwinners, while
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wives should stay home and do housework.” More accurately the results of a survey on gender equality performed by the Gender Equality Bureau, a division of the Japanese Cabinet Office, showed that the share of Japanese who thought wives should stay at home jumped 10 percentage points to 52% between 2009 and 2012. The dramatic reversal in gender equality appears to be related to the weak economy (Gender Equality, Bureau Cabinet Office, 2013). One of the roots of this complex situation has its origins in the tenets of Confucianism where reciprocity is one of its major principles together with consideration, support, dependency, and privacy (Hashizume, 2000). Japanese people value reciprocity and understand it as a way of meeting debt and obligation. Caring for elderly parents arises from a sense of gratitude for childhood nurturing (Hashizume, 2000). In the midst of major sociological transformations, traditional gender expectations, and limited public resources, modern Japanese women often experience a struggle between their traditional roles and their current opportunities and values. At the same time, long-standing sociocultural attitudes and norms make it difficult for them to discuss it openly (Hashizume, 2000). The major demographic transition of Japan, therefore, and the distinctive role of women in that context make it of main importance to be investigated.
AIM Our aim in this case study was to describe the observations and thoughts of one Japanese woman on her experience of living with her elderly parents in the suburbs of Tokyo in the midst of a country facing a super-aged society and massive sociological changes. The particularly unique feature of the woman interviewed was her dual exposure to the Western and Eastern cultures. This profile gave her the ability to critically analyze the context in which she lived.
METHOD A single case study with one open-ended interview was performed and analyzed by content analysis with a methodological departure in journalistic interviewing. Under this particular type of interview, the research questions/issues are expected to be refined continuously as new and previously unexpected aspects of the phenomenon come to light, a process that Partlett and Hamilton (1976) called progressive focusing. Indeed, qualitative research in journalism allows one to start out the investigation of a given topic with a preliminary idea, and then to reveal more significant issues than originally thought (Hartin Iorio, 2004). The product of this type of interview permits
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then the qualitative case-study research to capture the complexity of a phenomenon within its real-life context.
The Case The Japanese female caregiver, called Miho for the purpose of this study, was in her late forties at the time of the interview and was educated as a teacher. She spoke English well and had lived in the United States for a couple of years. She resided in a house in the suburbs of Tokyo with her parents. At the time of the interview, Miho’s father and mother were 84 and 78 years of age, respectively. According to Miho, her parents were in reasonably good physical health, with increasing cognitive decline.
Data Collection In January 2013, the main author (SPB) was visiting Tokyo for the purpose of scientific research and had the opportunity to meet Miho. The data were collected, through an open-ended interview after informed consent was obtained. The interview lasted approximately 60 minutes in a private space in a hotel in central Tokyo. It was recorded, transcribed verbatim, checked against the original recording, and edited for accuracy. The interview was conducted by the main author (S. P-B.). The recorded interview session began by asking Miho about her living condition and arrangement with her parents, her perception about this situation, and, finally, about her views regarding the overall elderly living arrangement situation in Japan, more specifically, Tokyo. Additional questions were asked about her own observation and opinion regarding women’s roles, economic hardship at the national and family level, and traditions as well as the future of these traditions in regards to the younger generations. The focus was held in the Japanese capital city, Tokyo, in order to mark a clear differentiation with rural Japan. Supplementary questions were asked with the purpose of clarifying some answers, such as, “Can you give me example,” “What do you mean,” “Interesting, please could you develop,” “You are telling me that . . . is it right or would you like to add something that I missed?” and so on, that aimed to cover various aspects of her own experience, perception, and opinion about the care of elderly people in Tokyo from a woman’s perspective.
Data Analysis The data were analyzed by the content analysis method (Lundman & H¨allgren-Graneheim, 2008; see Table 1). The authors present the experience, observations, and thoughts of a woman living with her elderly parents
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TABLE 1 Examples of Data Analysis Process: Meaning Units, Condensed Meaning Units, Codes, Subcategories, and Categories Meaning units
Condensed meaning units
Code
Subcategory
When I am not home, I I can count on my Support from the Belonging can call my neighbors neighbors and surrounding and they take care of we take care of community my parents. We look one another. after one another. Yes, usually women Women are often Expecting Traditional take care of the caretakers, but responsibility Role elderly family it is not a role of women members, but some that is always are not happy about it contentedly but they do it. accepted.
Category Reciprocity
Gender
to connect her views and experiences in a super-aged society with what seems to reflect the tacit knowledge of the caregiver for the elderly. Using our analysis we reveal two categories and eight subcategories (Table 2). The accuracy of the subcategories and categories were verified against the original interview text to make sure that the meaning had not been changed during the analysis process and that the categories were grounded in the data (Lundman & H¨allgren-Graneheim, 2008).
Ethical Considerations The data collection and presentation of the findings are subject to the principles of international ethical standards for conducting interviews with an informant capable of giving informed consent to voluntarily participate in a study with a descriptive design. Guidelines from Swedish Law (The Swedish Code of Statutes, 2003) were followed. The relevant ethical guidelines were applied such as autonomy, integrity, and anonymity of the informant and her
TABLE 2 The Categories and Subcategories That Emerged From the Data Categories Gender Reciprocity
Subcategories Anticipated acceptance Traditional role Historical adjustment Belonging “We and I” Family resources Intergenerationality Adaptive creativity
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surroundings when describing the result in accordance with the World Medical Association Declaration of Helsinki (World Medical Association, 2013).
FINDINGS In this single case study with a qualitative journalistic approach, two main categories, gender and reciprocity, and eight subcategories presented below, were identified.
Gender Anticipated acceptance. Miho expressed several times during the interview that it had been implied “automatically” between the family members that she would be the one taking care of her elderly parents and taking over the whole responsibility for the task. She remembered that she began to endorse this role spontaneously because it seemed expected from her naturally. Miho found that the situation was relatively normal and she even confirmed that many of her female friends were doing the same. She described that it was expected of her family but also her community that she would take over this role. She did not share during the interview that there was possibility for discussion or refusal. Traditional role. According to Miho, the responsibility for taking care of elderly family members was almost at all times assigned to the women when the time came. It was described during the interview that the responsibility was not only toward one’s own parents but also to parents-in-law and other elderly family members. Miho expressed openly the gender specificity of this caregiving role as well as the frustration around it for some women. As low-paid and part-time jobs were rather common among married women, it became increasingly difficult and complex when a woman became a mother and wished to have a career. Miho added that if the situation could be difficult and unfair for some women, it was also challenging for men. She specified that the role of responsibility was not discussed enough from a man’s perspective. She shared that she knew of many men who perceived the almost sole responsibility for the family’s finances as very stressful. She added that the issue of salary and gender was deeply rooted in the tradition, but it was changing very slowly. Miho explained during the interview that men’s salaries were usually much higher than women’s; therefore, it was economically damaging for the family if a son, a man, quit his job and wished to take care of his parents. Historical adjustment. It was a recurrent topic during the interview that the younger generation did not have the same respectful attitude toward elderly persons as their own parents probably had. She emphasized that the difference in behavior was even more obvious among young females
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who had been expected during their upbringing to be gentle and kind. She expressed also that the multigenerational closeness was not as common as earlier in Tokyo, and the old traditional ways were being forgotten. Miho emphasized that it was specific to the urban environment such as Tokyo. Miho explained that because there were so many elderly people living in the community that they did not appear to the young people as “special anymore” but rather “common” citizens not deserving a specific respectful behavior due to their status.
Reciprocity Belonging. The important role of informal support that took place in a neighborhood where the elderly lived was also a frequent subject matter during the interview. Miho described life in the suburbs and the closeness between these inhabitants who had known one another for decades. It seemed to be very important for Miho to know that help was available from her neighbors and that they understood one another because they had the same values. They could share the same worries, tips, but also joyful moments. “We” and “I”. Miho used “we” quite often and repetitively. “We” and “I” were used at about the same frequency, respectively, 45 and 48 times. It was observed that the use of “I” was immediately changed to “we” when a general opinion was expressed. At some point during the interview, it was communicated to Miho that her own opinions were also appreciated, suggesting that not only were the “group” thinking, norms, and expectations of interest, but Miho continued to use “we” frequently. Family resources. Concerns and worries related to finances were often expressed by Miho. Apprehensions regarding financial expenses, amount of services available to the elderly for their home care, and changes about guidelines leading to increased expenses and decreased services were recurrent during the interview. Miho communicated her understanding and acceptance for the tradition as described above, but she still admitted repetitively that she was worried about the financial cost and suggested that in many families the financial burden for the working adult children was “multigenerational” because it involved the care of parents and grandparents. According to her, the support provided by the LTCI was satisfactory but not sufficient. She emphasized that the will of the caregivers to “give back” was progressively being challenged and accompanied with a feeling of shame. She had observed that the heavy financial and caregiving burden was increasing for the caregivers as three-generation households were common because the life expectancy was the highest in the world. Miho described that the aspiration to take care of the elderly family members was a way to repay for love and care earlier in life, and this attitude was one of the most fundamental pillars of the Japanese society.
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Intergenerationality. Miho expressed frequently during the interview the importance of intergenerational contact. She stated that it was her observation that grandchildren were not spending as much time with their grandparents in Tokyo compared with the more traditional countryside. Nevertheless, she believed that the social interaction and the traditional intergenerational coresidences were still relatively common in the capital city compared with other cultures. According to Miho, the intergenerational contacts were adapting to the modern lifestyle because mothers were more frequently employed outside the home as part-timers than in the past. She viewed the contact between the elderly people and the younger generation as a “gift” for the members of society. Adaptive creativity. Miho voiced confidence when discussing the concrete opportunities of intergenerational relations. She commented that she perceived the Japanese society as creative and able to maintain traditions in the midst of drastic societal changes. As an example, she described facilities combining nursing homes and nursery schools. She commented that this type of arrangement was still experimental and not widespread, but it was becoming increasingly popular. She added that, in her opinion, this kind of facility would not only stimulate the elderly by the presence of the children, but also the children would get experienced attention from the elderly people.
DISCUSSION The main findings of this study, gender and reciprocity, can contribute to understand the experience of a caregiver of elderly parents from a woman’s perspective in a super-aged society in the midst of a major societal mutation. Our results, based on one single woman’s interview, reveal the complexity surrounding the caregiving role. Campbell (2002) described the envisioned purpose of the LTCI more than 10 years ago as an insurance that would help family caregivers, largely female, by not by paying them but by taking on a portion of their responsibilities. We find that the recommended LTCI options were decent and rather satisfactory, but they were still insufficient, in many cases, to relieve the burden. According to Miho, the responsibility of caring was still largely taken on by women who often had low-paid part-time jobs. It suggests a double-burden of duties and therefore more stress on women. Researchers recently investigated the burden reduction of caregivers for users of care services provided by the LTCI. The majority of the caregivers are women. In that study, a total of 68.8% of the caregivers reported that the care burden is reduced by the introduction of the LTCI care services, and 86.8% of the caregivers are satisfied with the LTCI care services (Umegaki et al., 2014). These results confirm to some extent our findings by showing general satisfaction
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for the LTCI care services but also some dissatisfaction for one-third of the participants regarding the insufficient relief provided by LTCI. Another related issue, mentioned by Miho and confirmed by Shimono (2007), is the strong social expectation on the role of married Japanese women in the society and the limited career opportunities available to them. Apparently many companies choose to ignore the dilemma that some female employees are facing: getting time off to take care of elderly family members and the fear of losing their job. Miho said that the government was not facilitating the change or encouraging the corporate world to fully integrate women into the work force. Ambiguously, with the public insurance system in place, dependents (married women are treated as dependents) do not need to pay social security contributions or tax, in order to receive a pension and be covered by health insurance. Hirao (2007) confirms these allegations by stating that protection to the “dependents,” in some ways, sustains women outside the career path and in a dependent role that in turn maintains them as available caregivers. As described in the narrative, Japanese men are also facing difficulties based on gender. The high expectation on women as caregivers in turn contributes a high expectation on men as breadwinners. Traditionally, the Japanese masculinity is represented by the salaryman (Japanese expression for the white-collar businessman). Salarymen are expected to dedicate their lives to their jobs, while offering the material necessities for their families (Hidaka, 2011). Miho acknowledged that many men felt pressure. Most of the time, men have much higher salaries than women, which implies the economical responsibility for the family yet the impossibility for them to quit their job and take care of their parents, even if desired. Data from a new study by Japan’s Institute for Research on Household Economics, however, indicate that this trend is changing slowly (Lise, Sudo, Suzuki, Yamada, & Yamada, in press). In fact, an increasing number of middle-aged Japanese men are resigning from their jobs to take care of elderly parents. According to the study, 13% of men and 28% of women aged between 40 and 64 had quit their jobs and were living with parents who required nursing care (Hofilena, 2013). Nevertheless, Hofilena goes further and reveals that more men than women are remaining unmarried in that situation, as married men would have difficulty quitting their paying jobs to care for their elderly parents if they had their own family to support. The matter is then not the same for most women who are often already in a dependent economic position. It is related to the severe demographic issues that are facing Japan with not only a super-aged society but also with a very low birth rate due partly to men and women choosing, not to or being unable to get married. In 1996, Kumagai reported that intergenerational coresidency in both urban and nonurban settings was a common living arrangement. More than one decade later, Tagaki and Silverstein (2011) describe this living arrangement as slowly disappearing. Our study finds that despite the decline in
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coresidency, this situation was still prevalent, especially in the suburbs. Miho’s views are supported by Kato (2013), who stated in his recent study that there is a persistence of intergenerational coresidency in Japan, implying a strong sense of reciprocity, and that the Japanese family is still based on the stem family system. Throughout the narrative, the implication of Confucianism, strongly based on exchange and mutual benefit or reciprocity, on familial expectations is present (Hashizume, 2000). Miho did not use the term “reciprocity” directly, but she described it with her own words repeatedly. In family research, reciprocity is described in different ways. Starrels, Ingersoll-Dayton, Neal, and Yamada (1995), for instance, see reciprocity as a dimension of caregiving and functional solidarity. The concept of sekentei is defined as social appearance that causes an individual to worry about others’ observations and evaluations of his or her behavior. For instance, it is believed that sekentei prevents Japanese family caregivers of elders from utilizing needed social services, which in turn reinforces the familial reciprocity (Koyano, 1996; Ohta & Kai, 2010). Therefore, it also becomes a gender issue because mostly women are caregivers. Reciprocity was identified as the glue holding the joy and burdens of the role of caregiving for elderly parents and gender as a motivator for reciprocity from a macro to a micro level in a super-aged society. It means that men and women take gender-specific accountability and responsibility at all levels of the society, up from the national and community level and down to the intimate family sphere, in order to maintain this intergenerational mutual benefit. It appears that without this gender-specific role structure endorsed at all levels of the society, reciprocity could not be achieved.
Method Discussion A case study with a qualitative journalistic approach is an appropriate study design for describing social aspects and reasons for people involving and interacting in the world and with others. The journalistic approach focuses onhuman values and the lived experience without making any claims of generalizability. It is advisable for later similar studies to use a similar strategy and develop this method because readers are becoming increasingly more versed in multiple fields of expertise. A single case study is suitable when the case represents something unique worth documenting and analyzing (Yin, 2003). The unique profile of Miho, being a Japanese woman exposed to both the Western and Eastern cultures simultaneously and living with her parents, led to the methodological choice of this study. Indeed a qualitative single case study with journalistic interviewing highlighted in a unique manner the complexity and specific nature of Miho’s thoughts and observations (Bryman, 2011).
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CONCLUSIONS We report the results from this study to show that caring for elderly parents is a complex phenomenon, and this experience is unique to each caregiver, usually a woman. Currently intergenerational reciprocity is still frequently sustained in urban areas. It is still possible for many families because of the structured gender-specific responsibility accepted tacitly by family members. In the near future, however, the extreme demographic demand as well as the family members’ willingness to carry on this intergenerational reciprocity might have a drastic impact on the ancestral family order. In conclusion, we encourage a multidisciplinary approach in order to develop innovative solutions facing the societal demands of this super-aged society. Health professionals, policymakers, sociologists, economists, city planners, journalists, and more can play a central role in this complex transition and make it possibile to create a sustainable super-aged society. Despite the challenges, the maintenance of specific familial expectations associated with gender and intergenerational reciprocity could be foreseen as a societal strength in Japan if it is mitigated with pioneering solutions, possible compromises, and flexibility.
ACKNOWLEDGMENTS We thank “Miho” for her time and trust in us during the interview.
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