Wages or Legitimacy? A Qualitative Analysis of Home Care Worker Perspectives in Choosing Work Settings.

Directly-Funded (DF) home care allows users to organize and purchase their own care services and is expanding globally. Little is known about the career pathways of home care workers. Our study asks, what experiences and factors do home care workers consider when choosing a work setting? And, specifically, what influences their decisions to work directly for their clients? Framed with Cranford's (2020) flexibility-security matrix for analyzing home care dynamics, we remotely interviewed 20 home care workers in two Canadian provinces. Three team members conducted axial coding and thematic analysis using Dedoose software. We identified personal and material factors at the intimate and labor market level that workers weigh when choosing whether to work for an agency or directly for a client. At the intimate level, workers value the flexibility, autonomy, and respect facilitated in care relations when working directly for a client. At the labor market level, agencies provide better job security and the benefit of supervisory support but lower wages. Additionally, as care work often serves as a stepping stone for immigration and citizenship agency positions are considered a more "legitimate" option than working directly for a client. Our study shows that workers directly employed by their clients enjoy more flexibility but lack security, whereas agency employed workers risk immediate reductions in working conditions in exchange for limited improvements in safety and supervision and, like other frontline care work, DF home care represents a key career pathway for immigrants with previous experience in health and social care settings.

Inequities in access to directly-funded home care in Canada: a privilege only afforded to some.

BACKGROUND: Directly-funded home care (DF) provides government funds to people who need assistance with the activities of daily living, allowing them to arrange their own services. As programs expand globally, many allow DF clients to hire home care agencies to organize their services rather than finding their own workers. In Canada, half of the DF home care programs allow users to purchase agency services. The goal of this research is to describe the role of agency providers in DF home care in Canada and consider potential equity implications for service access from the perspectives of clients and families. METHODS: Framed with intersectionality, the study included online focus groups with families and clients (n = 56) in the two Canadian provinces of Alberta and Manitoba between June 2021-April 2022. All transcripts underwent qualitative thematic analysis using open and axial coding techniques. Each transcript was analyzed by two of three possible independent coders using Dedoose qualitative analysis software. RESULTS: The article presents five thematic findings. First, the focus groups document high rates of satisfaction with the care regardless of whether the client uses agency providers. Second, agency providers mediate some of the administrative barriers and emotional strain of using DF home care, and this is especially important for family caregivers who are working or have additional care responsibilities. Third, there are out-of-pocket expenses reported by most participants, with agency clients describing administrative fees despite lower pay for the frontline care workers. Fourth, agencies are not generally effective for linguistic and/or cultural matching between workers and families. Finally, we find that DF care programs cannot compensate for a limited informal support network. CONCLUSIONS: Clients and families often intentionally choose DF home care after negative experiences with other public service options, yet the results suggest that in some Canadian contexts, DF home care is a privilege only afforded to some. Given the growing inequalities that exist in Canadian society, all public home care options must be open to all who need it, irrespective of ability to pay, degree of social support, or competence in the English language.

Engaging post-secondary students in a multidisciplinary aging studies interest group.

Little is known about student aging interest groups (AIGs) in post-secondary institutions. Our study evaluated awareness of a student aging interest group at a western Canadian university with no gerontology program. Additional goals included assessing interest in joining the AIG, participation rates among group members, and preferences for group activities. Using a mixed method approach we analyzed 13 years of administrative data recording 65 meetings and conducted a survey among group members and nonmember students across the university with a potential interest in aging (n = 52). Almost two-thirds of respondents (n = 33) were nonmembers with most of these (n = 24) having no prior knowledge of the AIG; 77% of students already aware of the AIG learned about it from a professor. Sixty per cent of respondents were in health-related faculties, with the remainder representing multiple disciplines and faculties. Group attendance was strongly influenced by student workloads and schedules, with average attendance rising by 27.3% during the shift to virtual meetings in 2020-21. Our results highlight the interdisciplinary nature of aging studies, the key role faculty members play in informing students about AIGs, and the broad range of interests that students have in issues related to age and aging.

Intersectionality, health equity, and EDI: What's the difference for health researchers?

Many countries adopted comprehensive national initiatives to promote equity in higher education with the goal of transforming the culture of research. Major health research funders are supporting this work through calls for projects that focus on equity, resulting in a proliferation of theoretical frameworks including "intersectionality," "health equity," and variations of equity, diversity and inclusion, or EDI. This commentary is geared at individual principal investigators and health research teams who are developing research proposals and want to consider equity issues in their research, perhaps for the first time. We present histories and definitions of three commonly used frameworks: intersectionality, health equity, and EDI. In the context of health research, intersectionality is a methodology (a combination of epistemology and techniques) that can identify the relationships among individual identities and systems of oppression; however, it should also be used internally by research teams to reflect on the production of knowledge. Health equity is a societal goal that operationalizes the social determinants of health to document and address health disparities at the population level. EDI initiatives measure and track progress within organizations or teams and are best suited to inform the infrastructure and human resourcing "behind the scenes" of a project. We encourage researchers to consider these definitions and strive to tangibly move health research towards equity both in the topics we study and in the ways we do research.

Balancing Flexibility and Administrative Burden: Experiences of Family Managers Using Directly Funded Home Care in Manitoba, Canada.

Directly funded (DF) home care provides funding to home care recipients to coordinate their own care and supports, and is available across all Canadian provinces. Current research on DF home care focuses on the experiences of adults with disabilities self-directing their own care, but less is known about the experiences of family members managing services for adults 55 years of age and older. This article presents findings from a qualitative analysis of 24 semi-structured interviews with older adults and caregivers using the DF program in Manitoba, Canada, focusing on family manager experiences. We identify three themes in the interview data: (1) DF home care enhances choice and flexibility for older people and their caregivers, (2) choice and flexibility reduce caregiver strain, and (3) agency services reduce administrative burden. We discuss the importance of care relationships and the role of family managers. We recommend that traditional home care systems learn from DF, and that increased administrative support would reduce caregiver strain.

Carers as System Navigators: Exploring Sources, Processes and Outcomes of Structural Burden.

BACKGROUND AND OBJECTIVES: Structural features of formal care systems influence the amount, difficulty, and complexity of what carers do as they interface with those systems. In this study, we explored how carers navigate health and social care systems, and their experiences of structural burden related to features such as complexity and fragmentation. RESEARCH DESIGN AND METHODS: This qualitative descriptive inquiry drew on data from in-person interviews with 32 carers of older adults, which were analyzed first using inductive thematic analysis and then using structural burden as a conceptual lens. RESULTS: Participant accounts revealed how navigating formal systems on behalf of older adult family members can exact considerable demands on carers in terms of time investment and emotional energy. In this way, care systems exacerbate the stress and structural burden experienced by carers, even when formal services alleviate other forms of carer burden. DISCUSSION AND IMPLICATIONS: Our findings contribute to knowledge of how the structural context of formal services shapes carer experiences and outcomes. To promote equity and prevent burden, system navigation work should be considered as a public, structural issue, rather than an individual-level problem of skills and learning.

Fear, Defensive Strategies and Caring for Cognitively Impaired Family Members.

One topic rarely addressed in the literature on older adults and interpersonal violence is the violence that can be experienced by family carers in relationship with a person living with cognitive impairment. This violence tends to remain hidden and is rarely framed as intimate partner violence. We examine how situations of intimidation and violence invoked fear in family carers and how they interpreted and reacted to these circum- stances. Interview and diary data were collected from family members who had previously or were currently experiencing some form of aggression in caring for someone with cognitive impairment or dementia. Drawing on discussions of fear and applying the analytic lens of defensive strategies, we explore how these carers responded to situations of intimidation and violence.

Using a Flexible Diary Method Rigorously and Sensitively With Family Carers.

Health and social science researchers are increasingly interested in the range of new possibilities and benefits associated with diary methods, particularly using digital devices. In this article, we explore how a flexible diary method, which enables participants to choose the device (i.e., paper notebook, tablet, or computer) and medium (i.e., text, photographs, sketches) through which they narrate their experiences, can be used to promote sensitive and rigorous research engagement with family carers to people with dementia. We used a diary interview method with 10 carers over the course of 6 weeks to explore how they experience and interpret the changing behaviors of their cognitively impaired kin. We reflect on how the quality of diary data can be enhanced alongside the ethical dimensions of research with carer populations, through different forms of diary keeping, regular interaction with participants, reflexive practice, and follow-up interviews.