Introduction

An examination of the provision of in-home health and social support services to elderly clients with the home as the site of care are here viewed through the lens of gender. The focus surrounds issues of gender in the relationship between elderly clients and home support workers and the dichotomy between a senior, their family member(s), and home support workers. The use of and access to space within the household as influenced by the gendered nature of care work are carefully explored. This article discusses the impact of my own perspective, as a daughter in a family receiving home care, on the framing of my analysis.

Background

In recent decades, Canada’s health care system, like that of much of the world, has embraced the concept of community and home care (Shapiro, 2002, 2003). The transition from hospital and institution-based care for both post-acute and chronic health conditions has involved “sending care closer to home”(Armstrong and Armstrong, 2004: 21–3), making relatively routine the proffering of a public service in a private place. It is estimated that 1 million people in Canada use home care services annually (Shapiro,2002).Several distinct groups of workers are included under the heading of home care workers. Many have professional training and qualifications as nurses, care managers, physiotherapists, occupational therapists and social workers. However, most home care workers are “unregulated workers” who provide non-professional services in the form of personal assistance with daily activities, such as bathing, dressing, grooming, and light household tasks that help to maintain a safe and supportive home. They are variously known across Canada as home support workers, personal careworkers, home helps, and, until recently, “homemakers.” These workers are the focus of this article, and are referred to as home support workers throughout.

The estimated 32,000 home support workers in Canada in 2001 provided approximately 70–80 percent of home care needs, including both personal care (bathing, toileting) and instrumental needs (food preparation, laundry).Despite ongoing problems with low pay, little or no job progression, lack of pay for travel time between clients, and often unpredictable hours of work, home support workers in Canada average eight to nine years of employment in this sector (The Home Care Sector Study Corporation, 2003). Home care has been prominent in current national policy discussions of the relative priority of community-based services in the continuum of care. While much research considers the funding of home care and its cost-effectiveness, little is known about the relational aspects of home-based care as experienced by elderly persons and home care workers (exceptions are Aronson, 2004; Karner, 1998;Martin-Matthews and Phillips, 2003; Martin-Matthews and Wakefield,1993).

Summary of findings

Home care workers are positioned at the centre of a web of contacts bridging the private world of family providing care to a senior and the public world of services (care, health, welfare benefits). Working at the “unregulated” end of the home care continuum, these women are often times poorly paid with little training, and their labours are largely invisible in the context of public discourse about home care. The qualitative data for the study was derived from verbatim accounts of home support workers, elderly clients, and family members of clients as they describe the context of “home” as the site of care. In the case of the elderly clients, three broad themes were identified in the research: issues of territory and boundary; control and cooperation; and the symbolic significance of home. The key issue was the negotiation of relationships with successive“ strangers” entering the private sphere of their home. For the home support workers, the issue of the territory of the home arose in the accounts; “It’s their space and their things, and it’s my job to try to respect that.” (Woman, age 53, employed in home care nine years).

In the instance of family members, only adult sons pointed out the relationship between gendered filial care and territoriality of certain spaces. Daughters and daughter’s in-law did not feel that any space was “off-limits” to them. This research underscores the importance of considering the “other players” in the home care dynamic. Conceptual approaches to the study of care giving and policy statements pertaining to community care remain firmly fixed on the dyadic nature of care work. This article highlights the role of spouses or others who co-reside with the elderly recipient of home care in the provision and receipt of that care. Their relationship to the care being provided in the home can be quite complex: as the primary carer or supporter to the recipient of home care, the home care services may complement their role and provide respite. These individuals may themselves benefit from the provision of care to another in a home they share, through having household services provided to them in an “adjunct” capacity (e.g. food preparation). At other times, the co-resider in the household may be more ancillary, not directly benefiting from the services but nevertheless affected by their provision.

Gender both implicitly and explicitly contributes to this framing in differing contexts. The accounts of workers, clients and family members indicate the particular relevance of gender to the meaning of home, to issues of territory and control, to the relationship between care work (especially body work) and space, and to issues of security and isolation. In situating home at the nexus of the private and the public spheres, this article has also considered what Giddens (1991) has called the distanciated relations that shape the contingent nature of home support work and of the provider–client interaction within the private sphere of the home. Framed within the context of governmental home care policies and agency guidelines, for elderly clients “the worker embodies both what the system can and cannot do for them” (Bowdie and Turwoski, 1986: 44).

For workers, employer policies and regulations often challenge their ability to address the unmet needs of clients—and may contribute to a blurring of the boundaries between paid and unpaid care work. Although feminist geographers Katz and Monk (1993: 272) speak of “the organization of space at the scale of the household,”it is curious that books on the sociology of family and aging rarely examine the concept of “home” (Rowles and Chaudury, 2005 is an exception). Given the prevalence of narratives of home in the accounts of elderly recipients of home care services, this is a particular omission in the language and focus of the sociology of aging and in conceptual approaches to the study of later life. Caught in the midst of policy debates about the future and funding of home care are elders and those who care for them, often struggling to respond to the immediacy of needs in the context of a system downsizing or in flux. The challenges at the heart of these debates unwittingly enter their lives in the form of “strangers,” or people outside of their realm of comfort. They are case managers, home care professionals, and, most typically women employed as home support workers, but not necessarily those who would normally be befriended (Da Roit 2007,pp. 251–269). The practices and procedures, and rules and regulations forged by governments and implemented by agencies in response to these policy debates enter the most intimate and private spheres of their personal spaces, when community-based care is, in the words of Armstrong and Armstrong (2004),brought “closer to home.”

References available in the original source document:

Current Sociology 2007; 55:229. Adapted with permission from the International Sociological Association. The full article can be found at http://csi.sagepub.com/cgi/content/abstract/ 55/2/229.

Anne Martin-Matthews is the Scientific Director of the Institute of Aging of the Canadian Institute of Health Research, and a Professor in the School of Social Work and Family Studies, University of British Columbia, Vancouver, Canada.

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