Communities of care and community care:

perspectives of older Australian and

Singaporean service users

By

Teck Huat Lim

A thesis submitted in fulfilment of the requirements for the degree of

Doctor of Philosophy

School of Social Sciences

Faculty of Arts & Social Sciences

December 2017 --·- -·----·-- ··--·------·-··--··-·------

THE UNIVERSITY OF NEW SOUTH WALES Thesis/Dissertation Sheet

Surname or Family name: Lim

First name: Teck Other name/s: Huat

Abbreviation for degree as given in the University calendar: PhD

School: School of Social Sciences Faculty: Faculty of Arts and Social Sciences

Title: Communities of care and community care: perspectives of older Australian and Singaporean service users

Abstract 350 words maximum: (PLEASE TYPE) This research is an exploration of the perspectives and experiences of community-dwelling older Australians and Singaporeans, beginning with a comparison along the East-West value divide in the area of family and community care. In addition, the composition and quality of their informal support network and formal aged care system is compared in an attempt to draw out the similarities and differences from the two countries' datasets and identify areas where there are convergences, divergences and parallels in the care of an older person.

A total of 30 participants from Australia and 31 from Singapore were recruited through support organisations, which turned out to be all centre-based community care services and community-based organisations. Therefore, all participants are service users and recipients of care, mainly provided by the family, community care services, and include other relationships: namely, extended relatives, neighbours, and friends. Data were collected through face-to-face interviews and the voice-recordings were transcribed verbatim for a general approach to qualitative data analysis and coding. I The findings challenge the notion, particularly held by Eastern proponents of filial piety, that there exists a significant East-West value divide in the ways that families respond to the needs for support and care of older members. In terms of family care, the long-established hierarchy of obligations is affirmedin both countries and the quality of relationships between immediate family members, extended relatives, neighbours, and friends has many similarities. The findings also suggest that the aged care systems in both countries are converging tow"artts a state, family and community partnership. In addition, community care service providers and community organisations that are adopting a more open service model are developing in parallel paths towards deeper community health partnerships and as charitable entities to include healthcare professionals, private donors and corporate sponsors as partof the service users' "community of care". Participants' responses also demonstrated that home-based and community care models have to be designed with the age-time-space factors in mind. Last but not least, this study recognises the contributions of de facto relationships and grandchildren as significant groups of principal carers, deserving further research.

Declaration relating to disposition of project thesis/dissertation

I hereby grant to the University of New South Wales or its agents the right to archive and to make available my thesis or dissertation in whole or in part in the University libraries in all forms of media, now or here after known, subject to the provisions of the Copyright Act 1968. I retain all property rights, such as patent rights. I also retain the right to use in future works (such as articles or books) all or part of this thesis or dissertation.

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FOR OFFICE USE ONLY Date of completion of requirements for Award:

1 December 2017 ORIGINALITY STATEMENT

‘I hereby declare that this submission is my own work and to the best of my knowledge it contains no materials previously published or written by another person, or substantial proportions of material which have been accepted for the award of any other degree or diploma at UNSW or any other educational institution, except where due acknowledgement is made in the thesis. Any contribution made to the research by others, with whom I have worked at UNSW or elsewhere, is explicitly acknowledged in the thesis. I also declare that the intellectual content of this thesis is the product of my own work, except to the extent that assistance from others in the project's design and conception or in style, presentation and linguistic expression is acknowledged.’

Signed ......

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ii COPYRIGHT STATEMENT

‘I hereby grant the University of New South Wales or its agents the right to archive and to make available my thesis or dissertation in whole or part in the University libraries in all forms of media, now or here after known, subject to the provisions of the Copyright Act 1968. I retain all proprietary rights, such as patent rights. I also retain the right to use in future works (such as articles or books) all or part of this thesis or dissertation.

I also authorise University Microfilms to use the 350 word abstract of my thesis in Dissertation Abstract International (this is applicable to doctoral theses only). I have either used no substantial portions of copyright material in my thesis or I have obtained permission to use copyright material; where permission has not been granted I have applied / will apply for a partial restriction of the digital copy of my thesis or dissertation.'

Signed ......

Date ......

AUTHENTICITY STATEMENT

‘I certify that the Library deposit digital copy is a direct equivalent of the final officially approved version of my thesis. No emendation of content has occurred and if there are any minor variations in formatting, they are the result of the conversion to digital format.’

Signed ......

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iii ABSTRACT

This research is an exploration of the perspectives and experiences of community-dwelling older Australians and Singaporeans, beginning with a comparison along the East-West value divide in the area of family and community care. In addition, the composition and quality of their informal support network and formal aged care system is compared in an attempt to draw out the similarities and differences from the two countries' datasets and identify areas where there are convergences, divergences and parallels in the care of an older person.

A total of 30 participants from Australia and 31 from Singapore were recruited through support organisations, which turned out to be all centre-based community care services and community-based organisations. Therefore, all participants are service users and recipients of care, mainly provided by the family, community care services, and include other relationships: namely, extended relatives, neighbours, and friends. Data were collected through face- to-face interviews and the voice-recordings were transcribed verbatim for a general approach to qualitative data analysis and coding.

The findings challenge the notion, particularly held by Eastern proponents of filial piety, that there exists a significant East-West value divide in the ways that families respond to the needs for support and care of older members. In terms of family care, the long-established hierarchy of obligations is affirmed in both countries and the quality of relationships between immediate family members,

iv extended relatives, neighbours, and friends has many similarities. The findings also suggest that the aged care systems in both countries are converging towards a state, family and community partnership. In addition, community care service providers and community organisations that are adopting a more open service model are developing in parallel paths towards deeper community health partnerships and as charitable entities to include healthcare professionals, private donors and corporate sponsors as part of the service users' "community of care". Participants' responses also demonstrated that home-based and community care models have to be designed with the age- time-space factors in mind. Last but not least, this study recognises the contributions of de facto relationships and grandchildren as significant groups of principal carers, deserving further research.

v ACKNOWLEDGEMENTS

The motivation to embark on this academic journey was seeded by my primary supervisor, Professor Richard Hugman. Upon completing my Bachelor degree,

Richard, who was the Head of School for Social Work back then, informed me of the Endeavour Scholarships. By the time I had a serious relook at this undertaking, I have accomplished much in my social work career, am married, and with two young children (and a third child on the way when the program started). My research interest has also changed due to practice experiences and Richard became the best person to supervise this study. Our relationship is special in the way that he is more of a mentor than an instructor. I am indebted to this great person for seeing what I can achieve at every juncture.

I am also grateful to Dr. Katrina Moore, my co-supervisor, for her perspective and valuable input. Special thanks also goes to my UNSW colleagues

Associate Professor Sue Green, Dr. Charlotte Smedley and Dr. Abner Poon for your continuous support throughout this candidature. To my colleagues back home, Dr. Vincent Ng, Dr. Terence Yow, Mr. Low Mun Heng, and Mr. Mohamed

Fareez Bin Mohamed Fahmy, thank you for the camaraderie and encouragement through the years. To the participants and service staff who have provided their time and insight in this research, I am grateful for the privilege to have met you and drawn from your experiences.

To my family who stood by me, I love you and am motivated by your love.

Biggest thanks to my gorgeous wife, Sandra, who has put her life on hold so

vi that I can fulfil this dream. To my three wonderful kids, Jayvon, Xavier, and Zoie, thank you for showing great understanding; knowing that I could not always be around on the weekends as “Daddy needs to work”. To our family back home who supported us, thank you for standing in the gap when our finances ran low and when we needed respite. To my parents, Siew Sang and Chock Boon, you have taught me to do good and left an imprint on me since young that led me to social work and to do the best in my studies. Your pride in me has brought me this far. To my sisters, June and Sharon, thank you for always believing in me.

Last but not least, to my Lord Jesus Christ who strengthens me daily and stirs within me a desire to excel, You are truly my Hope and my Salvation in tough times.

vii TABLE OF CONTENTS

ORIGINALITY STATEMENT ...... II

COPYRIGHT STATEMENT ...... III

AUTHENTICITY STATEMENT ...... III

ABSTRACT ...... IV

ACKNOWLEDGEMENTS ...... VI

TABLE OF CONTENTS ...... VIII

LIST OF ABBREVIATIONS ...... XV

LIST OF TABLES ...... XVIII

LIST OF FIGURES ...... XIX

CHAPTER 1: INTRODUCTION ...... 1

1.1 HOW IT ALL STARTED: FROM PRACTICE TO RESEARCH ...... 1

1.2 BRIEF INTRODUCTION OF AUSTRALIA AND SINGAPORE ...... 6

1.2.1 Early History and British Colonisation ...... 6

1.2.2 Immigration and Ethnic Composition ...... 8

1.3 ACADEMIC DISCUSSIONS ALONG THE EAST-WEST VALUE DIVIDE ...... 12

1.4 RESEARCH AIMS AND CONTRIBUTIONS ...... 18

1.5 RESEARCH METHOD ...... 19

1.6 STRUCTURE OF THE THESIS ...... 21

CHAPTER 2: LITERATURE REVIEW ...... 24

2.1 DEFINITIONS OF AN OLDER PERSON ...... 25

2.2 THE RISE OF AGEING ISSUES IN AUSTRALIA ...... 26

2.3 THE RISE OF AGEING ISSUES IN SINGAPORE ...... 33

2.4 AUSTRALIAN AGED CARE SYSTEM AND STATE SUPPORT ...... 37

viii 2.4.1 Australian Residential Care ...... 38

2.4.2 Australian Home-based and Community Care ...... 39

2.4.3 The Aged Care (Living Longer Living Better) Act 2013 and Current Aged

Care Reform ...... 41

2.4.4 Australian Carers Support and State Provisions ...... 44

2.5 SINGAPOREAN AGED CARE SYSTEM AND STATE SUPPORT ...... 48

2.6 PROBLEMATISATION OF POPULATION AGEING ...... 53

2.7 RETIREMENT INCOME PROVISIONS ...... 55

2.8 RESEARCH THEMES IN INTERGENERATION RELATIONS AND FAMILY CARE ...... 56

2.8.1 Twentieth Century Population Trends Affecting Family Care ...... 59

2.8.2 Myth of Family Alienation and Abandonment ...... 61

2.8.3 Support from Adult Children to Older Parents ...... 65

2.8.4 Support from Older Parents to Adult Children: ...... 74

2.8.5 Grandparent-Grandchild Relations ...... 76

2.8.6 Diversity and Parent-Child Relations ...... 78

2.9 CONCEPT OF FILIAL PIETY AND ITS CONTEMPORARY DEVELOPMENTS ...... 83

2.10 FEMINIST CRITIQUE AND FEMINISATION OF AGEING ...... 91

2.11 NON-FAMILY SUPPORT ...... 95

2.12 NEW COMMUNITY MODELS OF CARE ...... 98

2.13 CONCEPT OF COMMUNITIES AND COMMUNITY OF CARE ...... 100

2.14 INTERRELATED CONCEPTS OF SOCIAL COHESION AND SOCIAL CAPITAL ...... 102

2.15 THE ECOLOGICAL MODEL AS THEORETICAL FRAMEWORK ...... 105

2.16 CONCLUSION ...... 108

CHAPTER 3: METHODOLOGY ...... 109

3.1 JUSTIFICATION FOR AN INTERPRETIVIST AND QUALITATIVE APPROACH ...... 110

3.2 RESEARCHER’S STANDPOINT – VALUES AND ASSUMPTIONS ...... 114

3.3 SUPPORT ORGANISATIONS AND RECRUITMENT PROCESS ...... 117

ix 3.3.1 Australian Recruitment Sites ...... 118

3.3.2 Singaporean Recruitment Sites ...... 124

3.4 DESCRIPTION OF PARTICIPANTS ...... 127

3.5 INCLUSION OF MIGRANTS IN AUSTRALIAN SAMPLE ...... 132

3.6 DATA COLLECTION AND DESCRIPTION OF INTERVIEW PROCESSES ...... 133

3.7 TRANSCRIPTION, TRANSLATION, AND USE OF TRANSCRIPTS ...... 135

3.8 DATA ANALYSIS ...... 140

3.9 ETHICAL CONSIDERATIONS ...... 145

3.9.1 Minimising Risk of Coercion ...... 146

3.9.2 Minimising and Mitigating Impact of Distress ...... 147

3.9.3 Token of Appreciation ...... 149

3.10 RIGOUR AND QUALITY IN QUALITATIVE RESEARCH ...... 149

3.11 CONCLUSION ...... 156

CHAPTER 4: CARE ISSUES WITHIN THE FAMILY CONTEXT ...... 157

4.1 A CASE PRESENTATION: ILLUSTRATING THE COMPLEXITIES OF CARE ...... 158

4.2 LIVING WITH THE FAMILY AND CARE ARRANGEMENTS ...... 164

4.2.1 Spouse as Principal Carer ...... 165

4.2.2 Adult Children and Children-in-law as Principal Carer ...... 169

4.3 PROVISION OF CARE BY THE FAMILY ...... 175

4.4 SOURCES OF INCOME AND FINANCIAL SUPPORT FROM THE FAMILY ...... 184

4.4.1 Sources of Income among Singaporean Participants ...... 185

4.4.2 Sources of Income Among Australian Participants ...... 191

4.4.3 Comparison of Income Sources between Australia and Singapore ...... 192

4.5 HOUSING STATUSES AND CARE ISSUES ...... 193

4.6 DOMESTIC HELPERS IN SINGAPORE ...... 202

4.7 LONELINESS AT HOME ...... 205

4.8 RELOCATION IN OLD AGE ...... 209

x 4.9 DECLINING STATE OF FILIAL PIETY IN SINGAPORE ...... 214

4.10 CONCLUSION ...... 218

CHAPTER 5: CARE ISSUES BEYOND THE FAMILY CONTEXT ...... 219

5.1 EXTENDED RELATIVES’ SUPPORT ...... 220

5.1.1 Reliance on Extended Relatives’ Support ...... 220

5.1.2 Limitations of Extended Relatives’ Support ...... 225

5.2 NEIGHBOURS’ SUPPORT ...... 228

5.2.1 Forms of Neighbours’ Support: ...... 228

5.2.2 “Nothing Much” – Issue of Unremarkable Neighbourly Interactions ...... 233

5.2.3 Negative Experiences of Neighbours ...... 233

5.2.4 Close-knit Neighbourhoods of the Past, Social Intimacy, and the

Urbanisation Thesis ...... 234

5.3 FRIENDS’ SUPPORT ...... 238

5.3.1 Difficulties Maintaining Contact with Older Friends ...... 238

5.3.2 Strategies to Maintaining Contact with Older Friends and the Role of

Community Organisations ...... 240

5.3.3 Friends’ Support and Ad Hoc Sick Care ...... 244

5.3.4 More than Friends – Incorporating Friends into the Family’s Nexus ...... 245

5.4 NON-FAMILY SUPPORT FOR THIS RESEARCH ...... 247

5.5 CONCLUSION ...... 248

CHAPTER 6: CENTRE-BASED COMMUNITY CARE SERVICES AND

COMMUNITY ORGANISATIONS ...... 250

6.1 PARALLELS BETWEEN AUSTRALIAN AND SINGAPOREAN RECRUITMENT SITES ...... 252

6.2 COMMON FEATURES OF COMMUNITY SERVICES / ORGANISATIONS ...... 254

6.2.1 Provision of Safe and Age-Friendly Physical and Social Space ...... 254

6.2.2 Provision of Structured Program ...... 260

6.2.3 Provision of Assistance in Activities of Daily Living ...... 269

xi 6.2.4 Platform for Social Interactions and Making New Friends ...... 278

6.2.5 Provision in Supervision and Monitoring ...... 284

6.2.6 Platform for Volunteering and Mutual Help ...... 290

6.2.7 Creating a Sense of Community ...... 297

6.3 LIMITATIONS OF COMMUNITY SERVICES ...... 302

6.4 STRUCTURAL TRAJECTORIES IN THE GOVERNMENT SECTOR ...... 306

6.4.1 Local Government HACC Providers in Australia...... 306

6.4.2 National Schemes in Singapore ...... 311

6.5 CONCLUSION ...... 316

CHAPTER 7: DISCUSSION ...... 318

7.1 IS THERE AN EAST-WEST VALUE DIVIDE IN FAMILY CARE BETWEEN AUSTRALIA AND

SINGAPORE? ...... 319

7.1.1 Is the Value of Filial Piety in Singapore Overstated? ...... 320

7.1.2 Is the Value of Family Loyalty in Australia Understated? ...... 322

7.2 SUSTAINING FAMILY CARE: STATE SUPPORT IN AUSTRALIA AND SINGAPORE ...... 326

7.2.1 “House for a Home”: Self-reliance through Home Ownership ...... 328

7.2.2 State Support for the Younger Old Carers of Older Old ...... 332

7.2.3 State Support for Healthcare Costs ...... 333

7.2.4 Convergence on State, Family and Community Partnerships ...... 337

7.3 FAMILY RELATIONSHIPS AND CARE ISSUES ...... 340

7.3.1 Impact of Divorce on Family Care ...... 340

7.3.2 Contribution of De Facto Relationships on Family Care ...... 345

7.3.3 Expectations on Children and Grandchildren for Family Care ...... 348

7.3.4 The “Daytime Gap” and Emotional Care ...... 352

7.4 ADULT GRANDCHILDREN AS CARERS ...... 356

7.5 OLDER PEOPLE LIVING ALONE AND POLICY IMPLICATIONS ...... 359

7.6 ENHANCING NON-FAMILY SUPPORT ...... 364

xii 7.6.1 Peer Generation Extended Relatives and Friends as Carers ...... 364

7.6.2 Neighbours as Carers ...... 369

7.7 OLDER PEOPLE FOR OLDER PEOPLE ...... 374

7.8 CENTRE-BASED COMMUNITY SERVICES AND COMMUNITY-FOCUSED APPROACH .... 378

7.9 CONCLUSION ...... 382

CHAPTER 8: CONCLUSION ...... 383

8.1 SUMMARIES AND CONCLUSIONS ...... 383

8.1.1 East-West Value Divide Reconsidered ...... 384

8.1.2 Changes in the Family ...... 386

8.1.3 Enhancing “Communities of Care” through Partnerships and Addressing

the Age-Time-Space Dimensions ...... 389

8.2 CONTRIBUTIONS ...... 395

8.3 LIMITATIONS ...... 396

8.4 FUTURE RESEARCH ...... 399

8.5 FINAL REFLECTIONS: FROM RESEARCH TO PRACTICE? ...... 400

REFERENCES: ...... 402

APPENDICES ...... 433

APPENDIX A: THE DOMAINS OF SOCIAL CAPITAL AND APPROPRIATE NEIGHBOURHOOD

POLICIES TO SUPPORT THEM ...... 433

APPENDIX B: EMAIL TEMPLATE TO SUPPORT ORGANISATIONS ...... 434

APPENDIX C: POSTER (ENGLISH VERSION) ...... 436

APPENDIX D: POSTER (CHINESE VERSION) ...... 437

APPENDIX E: FLYER (ENGLISH VERSION) ...... 438

APPENDIX F: FLYER (CHINESE VERSION) ...... 439

APPENDIX G: INTERVIEW GUIDE ...... 440

APPENDIX H: PARTICIPANT INFORMATION STATEMENT AND CONSENT FORM (ENGLISH) .. 441

APPENDIX I: PARTICIPANT INFORMATION STATEMENT AND CONSENT FORM (CHINESE) ... 444 xiii APPENDIX J: INTERVIEW CHECKLIST ...... 446

APPENDIX K: BRIEFING OUTLINE ...... 447

APPENDIX L: SUMMARY OF RECRUITMENT SITES ...... 448

xiv LIST OF ABBREVIATIONS

ABS Australian Bureau of Statistics

ACAS Aged Care Assessment Service

ACAT Aged Care Assessment Team

ACRS Aged Care Reform Strategies

ADL Activities of Daily Living

AIHW Australian Institute of Health and Welfare

AUD Australian Dollar

BADL Basic Activities of Daily Living

BST Bioecological Systems Theory

CACP Community Aged Care Packages

CAI Committee on Ageing Issues

CDC Consumer Directed Care

CHSP Commonwealth Home Support Program

CMP Commissioner for the Maintenance of Parents

COAG Council of Australian Governments

CPF Central Provident Fund

DAS Disability Assistance Scheme

DHS Department of Human Services

DoHA Department of Health and Ageing

DOS Singapore Department of Statistics

DSS Department of Social Services

EACH Extended Aged Care at Home

EACH-D Extended Aged Care at Home Dementia

xv FSC Family Service Centre

GDP Gross Domestic Product

HACC Home and Community Care

HCP Home Care Packages

HDB Housing & Development Board

HREA Human Research Ethics Advisory

HRSCLCA House of Representatives Standing Committee on Legal and

Constitutional Affairs

IADL Instrumental Activities of Daily Living

LGA Local Government Area

MICA Ministry of Information, Communications and the Arts

MOH Ministry of Health

MSF Ministry of Social and Family Development

NCSS National Council of Social Service

NORC Naturally Occurring Retirement Community

NSW New South Wales

NVPC National Volunteer and Philanthropy Centre

PA Public Assistance

PISC Participant Information Statement and Consent

PPP Purchasing Price Parity

RC Residents’ Committee

SAC Senior Activity Centre

SCC Senior Care Centre

SHC Senior Home Care

SGD Singapore Dollar

xvi TMP Tribunal for the Maintenance of Parents

UK United Kingdom

US United States of America

USD United States Dollar

VWO Voluntary Welfare Organisation

WHO World Health Organisation

Notes:

Currency exchange rate (as on 15 March 2017): 1 AUD = 1.07 SGD.

PPP conversion rate (2017): Australia – 1.403; Singapore – 0.816.

Pinyin system is used to romanise Chinese words.

xvii LIST OF TABLES

Table 1: Ethnic Composition of Singapore Population 8

Table 2: Breakdown of participant demographics by country 128

Table 3: Breakdown of participant demographics by recruitment site 129

Table 4: Participants’ Housing Statuses and Living Arrangements 195

Table 5: Australian Home Ownership Rates by Age of Household Reference Person

197

Table 6: Singaporean Home Ownership Rates by Age of Household Reference Person

197

xviii LIST OF FIGURES

Figure 1: Model of Bronfenbrenner’s Bioecological Systems Theory 107

Figure 2: Illustration of conventions used for participants’ accounts – example 1 136

Figure 3: Illustration of conventions used for participants’ accounts – example 2 137

Figure 4: Working example of coding 143

Figure 5: Working example of a memo 144

Figure 6: Age-Time-Space Dimensions 391

xix CHAPTER 1: INTRODUCTION

This chapter begins by providing the background and rationale for conducting this research, linking practice experience and research interest, thereby making clear the researcher’s position and pre-existing knowledge, which influenced the choices in the design of this study. A brief introduction to Australia and

Singapore is also provided, relating to the basis for comparison between the two countries. The rest of the chapter outlines the academic debates along the

East-West value divide of aged care, the research aims and contributions, methods, and structure of this thesis.

1.1 How It All Started: From Practice to Research

It was the year 2009 when a social worker was tasked to oversee the construction of a new Senior Activity Centre (SAC), which was the first to be tendered and developed from literally the ground up by a Voluntary Welfare

Organisation (VWO) in Singapore. Similar to the majority of SACs, this set up is located at the void deck1 of a Housing & Development Board (HDB) rental block2 and is strategically located to provide drop-in and home visit services to older residents living in the block that the centre is located and any nearby HDB

1 Void deck is a common term used in Singapore to refer to the ground floor of a HDB block; which is usually an empty space from end to end with columns in between. 2 HDB rental blocks in Singapore are similar to Australian public housing, particularly the inner- city medium to high-rise apartments.

2 HDB rental blocks in Singapore are similar to Australian public housing, particularly the inner- city medium to high-rise apartments.

1 rental blocks within a walkable distance – which are collectively known as the

“service cluster”3. Working with older people was not among the researcher’s top preferences, having been in child protection, mental health, and family case management settings. Believed to be a short-term project, the scale of the aged care needs in the community kept the researcher in the role of community care service development and implementation for the next few years until the opportunity to conduct this study was granted. By the time this study was conceptualised, several incidents – of older persons living alone and found dead at home – have altered the researcher’s academic and professional interest and helped focus this enquiry.

One such incident was the case of a single older person living alone in a HDB rental unit who was an ardent and active user of the SAC till the day before he passed on suddenly at home. In the two years since the SAC was operational, he had hardly missed dropping by at the centre daily and had developed a close relationship with the staff and regular volunteers. On the day of his death, the centre coordinator went home wondering why the older person was not seen the entire day and decided to check on him the next morning, thinking he might have fallen ill. The next morning, he was found lying motionless on the floor, near the door of his flat4. As his unit was at the end of the corridor, only one neighbour noticed something different on the way out to work as the older person usually got up early and sang loudly. Nonetheless, the neighbour did not

3 The service cluster size is based on rental housing tenants who are above the age of 60 instead of 65 in more recent Singaporean definitions for an older person. 4 HDB residential units are commonly known as flats in Singapore.

2 feel perturbed enough to check on him. Perhaps, like the centre staff, it was not foreseen that an independent and relatively young older person in his sixties would pass on so suddenly.

When the incident was sensationalised in a tabloid newspaper, it was reported that one of the older person’s legs was in between the door and sticking out onto the common corridor. This was not true. The cause of death was later determined to be stroke-related and it was speculated that he lost consciousness and suffered head injuries. This incident was made known to the present researcher in the course of social work practice. The researcher was at the mortuary and knows this to be the case from practice experience. The negative media report was discouraging to the staff team as it was based on stories provided by one service user accusing the centre of not doing enough.

After that episode, the staff team evaluated the protocols and developed a better system of monitoring that is above the funding requirements, to include older people who live alone and are as yet independent. Since implementing the new system, there have been no more such incidents in that service cluster, highlighting the role of community care service providers in early detection of health and safety issues that might result in accidents and deaths.

Despite being upset about the negative attention, the staff team was focused in organising the funeral for the older person, who had become one of the faces of the centre. With no next-of-kin information provided by the older person, the

SAC took on the full responsibility of the funeral, with sponsorship from a funeral director and got in touch with the pastoral team that had regularly visited

3 the older person on the weekends to conduct the last rite. The staff team also surveyed the service users and decided to charter a bus for those who wished to be at the funeral. The turnout was overwhelming. Perhaps, the older person had lived there for more than thirty years and many neighbours felt that they should be at his funeral. It became a community event and people in the surrounding neighbourhood, who were mostly older people, came along. For the next few weeks after the funeral, older residents who had previously refused to be engaged by the SAC dropped by to registered as members. Instead of an anticipated drop in membership due to the tabloid newspaper report, the membership count increased significantly. Perhaps the newly registered members saw themselves to be in a similar situation and were convinced by this case that they can pass on with dignity with the SAC being there for them.

The word also spread in the neighbourhood that the SAC was a go-to place for older people and associated members from non-rental / purchased blocks became a substantial group.

Another twist in all that was happening was that the older person’s brother showed up at the centre the day before the funeral. The brother found out about his passing from the tabloid newspaper report but did not come forward till he saw the funeral notice in the obituaries, days later. Perhaps, the brother was hesitant to come forward, having retired for a long time and could not contribute to the funeral costs. As one staff insisted, now that there is a family member, the funeral cost should be borne by the family. However, the funeral director refused to accept any payment from the older brother knowing that the siblings had lost contact for many years. Perhaps, the funeral director had determined

4 so from a hierarchy of family obligations? On the other hand, the staff team was just glad to have a family member of the older person at the funeral and that the funeral director demonstrated understanding and compassion. Through it all, the staff team also learned the importance of working with the family, the community, and service partners.

As a practitioner, this case raises many questions that could not be asked during that critical week. Preceded by the many “perhaps” in the account above, these questions could have shed light on the family and community’s responses to care obligations. While the death might not be preventable, it could be noticed much earlier if the older person was living with the family and / or that the neighbours were in regular contact. Nonetheless, the issue of older people living alone and found dead at home is seen as much further down the track when one is left with little or no family support and might not have established dependable community connections. As such, this study is taking a life course approach and not limited to exploring issues occurring only during old age.

In addition, participants are not limited to older people who are living alone – with the study designed to explore the perspectives and experiences of community-dwelling older people in a range of living and care arrangements – expecting to find some answers in enhancing the social and safety networks through constant comparisons between the various groupings. The personal account above also highlighted how much aged care practitioners do know, without a structured enquiry, on the complex circumstances of community- dwelling older persons.

5 The researcher’s Australian connection was forged during the undergrad years and is returning to his alma mater. Practicing as a social worker in Singapore while having lived and trained in Australia, presented the unique knowledge base, appreciation of the socio-cultural-political context, and language abilities for a comparative study between the two countries. The following section provides a brief historical background to Australia and Singapore5.

1.2 Brief Introduction of Australia and Singapore

While the choice to conduct a comparison between Australia and Singapore is based on the researcher’s more recent professional experience and personal relationship with the two countries, it is not a recent development. Comparison between the two countries at the level of everyday life right up to policy, practice and political issues have been an ongoing process since the researcher first stepped foot on Australian soil back in 2001. The following two sections provide a background of the two countries at the point where their histories coincided and the population characteristic that provide a meaningful platform for comparison that can contribute to the field of aged care.

1.2.1 Early History and British Colonisation

Both Australia and Singapore have been depicted as young nations in relation to the countries’ modern history (McCallum & Geiselhart 1996: 17-18; Teo et al.

5 When the two countries are mentioned together, it will be in the order of Australia first in line with alphabetical order.

6 2006: 16). Below is a brief summary of the beginning of British colonisation in the two countries with reference to key historical figures for further reading.

In the case of Australia, Aboriginal Australians were believed to have first arrived on the mainland between 40,000 to 70,000 years ago. Europeans were believed to have first landed on Australian mainland in 1606, in an expedition led by Dutch navigator Willem Janszoon. Several European explorations followed and in 1770, British Lieutenant (later Captain) James Cook charted and ‘claimed the east coast under instruction from King George III of England on 22 August 1770 at Possession Island, naming eastern Australia “New South

Wales”’ (Australian Government 2015). Subsequently, the First Fleet led by

Captain Arthur Phillip landed at Sydney Cove on 26 January 1788 to establish a penal colony. Conflicts between the British settlers and the Indigenous population marked the early contacts and no former treaty was signed. In the next century, more colonies were formed and land explorations were conducted into the continent’s interiors.

From a Singaporean perspective, the history of the two countries coincided in

British colonialism though the establishment of settlement in Singapore was through diplomatic means. On 6 February 1819, British statesperson Sir

Thomas Stamford Raffles – known as the founder of modern Singapore – negotiated a treaty with Sultan Hussein Shah of Johor and the Temenggong

Abdul Rahman for the British East India Company to set up a free trading post on the island (Ministry of Information, Communications and the Arts [MICA]

2009). Prior to colonisation, Singapore had only one or two settlements at any

7 one time in recorded history, dating back to the third century by the Chinese.

The settlements were described as fishing villages and small trading ports and by the time the British established control, such an image remained. In 1819, the majority of the population of 1,000 are the Malays – who were assimilated from the local groups – and there were only a few dozen Chinese settlers.

1.2.2 Immigration and Ethnic Composition

Singapore’s multicultural society can be traced back to the high rates of immigration in early colonial years due to work opportunities. By 1860,

Singapore’s population reached 80,792 with most of the new settlers being

Chinese and Indian immigrants seeking work in the rubber plantations and tin mines (MICA 2009). By then, the ratio among the major ethnic groups has been established (see Table 1 below) and their descendants became the bulk of today’s Singaporeans.

Table 1: Ethnic Composition of Singapore Population

Year Chinese Malay Indian Others

1860 61.9% 13.5% 16.1% 8.5%

2016 74.3% 13.4% 9.1% 3.2%

Source: 1860 data from MICA 2009; 2016 data from Singapore Department of Statistics (DOS)

2016: 5.

8 While Singapore has gained independence – first from the British in 1963 and later expelled from the Federation of Malaysia in 1965 – some colonial influences remain. Since independence, Singapore English, which is adopted from British English, has been the common language of business, government, and the medium of instruction in schools and increasingly so today.

Nonetheless, among the older population, the various ethnic groups would prefer to converse in their native tongues and might have not learned English as before the 1960s and 1970s, schools using other languages than English as the medium of instruction were still popular. In addition, cultural practices and values have been retained within the various ethnic communities with national holidays allocated for the most important festivals of the Chinese, Malay, Indian, and Eurasian population.

In the literature on filial piety and aged care, Singapore is considered to be a

Confucian-influenced, East Asian society due to majority representation of overseas Chinese in its population (Chan 1999, 2005; Goodman et al. 1998; Liu

& Kendig 2006b). In education and business studies, Singapore is considered as a Confucian Heritage Culture (Nguyen et al. 2006). Singapore’s family value and approach to social policy is located in the following excerpt from Mr Lee

Kuan Yew – the nation’s first prime minister and “Founding Father”:

Confucian societies believe that the individual exists in the context of

the family, extended family, friends, and wider society, and that the

government cannot and should not take over the role of the family.

Many in the West believe that the government is capable of fulfilling

9 the obligations of the family when it fails, as with single mothers. East

Asians shy away from this approach (Lee, p. 545).

In summary, Singapore is culturally considered an East Asian society though it is geographically nested in Southeast Asia. Singapore has maintained close relations with China since its independence from Malaysia, who cited

Singapore-Malaysia’s Chinese-Malay ethnic composition imbalances in both countries as the political basis for separation. In which, the political and racial tension escalated into racial violence in Singapore on 21 July and 2 September

1964, catalysing the events leading up to Singapore’s independence on 9

August 1965. Singapore has also established a close relationship with the US and remained a member of the Commonwealth of Nations (joined since 1965), recognising its colonial roots and strategically positing itself politically between the East and the West.

Despite the federation of colonies and formation of the Government of the

Commonwealth of Australia (also referred to as the Australian Government, the

Commonwealth Government, or the Federal Government) in 1901, the country remained a form of constitutional monarchy till today with the current British monarch, Queen Elizabeth II, as the head of state. More recently, a majority of

Australians voted “no” to becoming a republic in the 1999 referendum and the

British crown retained its role in Australian government and law (Australian

Electoral Commission 2011).

10 Culturally, British and European influences remained strong in Australia despite the abolishment of the White Australia Policy in 1970s and restrictions on immigration from Asian and other non-European countries was lifted. As seen in this study, the older Australian participants from Asian and non-European background who had come after the 1970s as skilled migrants and through family reunion visas and retained much of their cultural practices and values.

Prior to the Immigration Restriction Act 1901, immigration to Australia was mainly due to the gold rushes between 1850s and 1870s where around 50,000

Chinese came to work in the goldfields and the subsequent growth of the sugar industry in the 1870s brought in workers from the Pacific Islands. Nonetheless, the influence these non-European immigrants have on today’s Australia might not be as significant due to the influence of the White Australia Policy.

The 2011 Census reflected that the ethnic composition of the Australian 6 population remained mainly of European heritage with eight of the top 10 ancestries reported as English (33.7%), Australian (33.0%), Irish (9.7%),

Scottish (8.3%), Italian (4.3%), German (4.2%), Greek (1.8%) and Dutch (1.6%); the two non-European ancestries in the top 10 were Chinese (4.0%) and Indian

(1.8%) (Australian Bureau of Statistics [ABS] 2012a). However, among the first- generation overseas-born migrants, the proportion originating from Europe has decline in recent years from 52% in 2001 to 40% in 2011 (ABS 2012b). Such a trend would continue to shape the ethnic composition in future generations.

6 The term Australian, in this instance, refers to all people living in Australia for one year or more at the time of the 2011 census.

11 Nonetheless, the historical developments of immigration policy in Australia and

Singapore have led to a cultural distinction between the two countries, particularly among the older population, as representatives of the West and

East respectively – with the East referring to Asian while the West as European.

This is the main basis for comparison between the two countries in this study – which is along the East-West value divide in aged care. The following section provides a background of the academic debates along this line.

1.3 Academic Discussions Along the East-West Value Divide

In 1995, the international conference of Aging East and West7: Demographic

Trends, Socio-cultural Contexts, and Policy Implications was held in Seoul,

Korea, bringing together academics from around the world ‘to exchange ideas and data concerning the social demographic processes of rapid population aging, as well as the sociological contexts, outcomes, and social policy implications facing various Asian and Western countries’ (Bengtson et al. 2000: xi). Following the conference, an edited volume Aging in East and West:

Families, States, and the Elderly was published with the aim to stimulate further discussion and research on the cross-cultural issues of ageing along the East-

West divide (Bengtson et al. 2000: xii).

At the end of the conference, a conclusion was clear that while there are differences between nations of the East and West in approaching ageing issues,

7 Following this academic convention, when the East and West are mentioned together, the alphabetical order is followed.

12 there are also many similarities. The major differences identified from the conference discussions are worth mentioning as they highlight cross-cultural and contextual differences. Firstly, many Eastern societies subscribe to the

Confucian value of “filial piety” while a similar tradition of respect is not explicit in Western societies. Secondly, the rate of population ageing is much faster in

Eastern nations in this century. Thirdly, provision of living arrangements by the family for older people is much more common in Eastern nations. Finally, the provision of financial support by the state for older people is more available in

Western nations (Bengtson, et al. 2000: xi). Similarly, four major similarities are identified. Firstly, the family ‘had been, are now, and would be in the future the major source of social and instrumental support for elderly family members’

(Bengtson et al. 2000: xii). Secondly, there is growing concern for intergenerational issues including the role of older persons in the family and society. Thirdly, there is a rapid increase in public and policy debates about the role of the state in provisions for older citizens, particularly those with little or no family and other informal support. Fourthly, is in balancing the needs of national economic development against the need of the growing financially-dependent older population (Bengtson et al. 2000: xii).

In the following year, the conference on East-West Values in Elder Care was convened in Hong Kong. Participants were invited ‘on the basis of their capacity to contribute to the increasing dialogue between East and West in considering the value and culture-laden issue of caregiving’ (Liu & Kendig 2000a: xiii).

Invitations from the West were restricted to contributors from English-speaking nations of Australia, the United Kingdom (UK), and the United States of America

13 (US). Invitations from the East were restricted to contributors from East Asian

‘countries which are relatively more advanced economically and share a common cultural base of Confucian beliefs in filial piety’ (Liu & Kendig 2000a: xiii-xiv). The countries included were Japan, China, Korea, Taiwan, and

Singapore. The basis for selectivity is to limit the effects ‘attributable to the economic gap between the developed and developing worlds’ so that the differences attributable to culture can surface (Liu & Kendig 2000a: xiv).

Liu and Kendig’s (2000a) conclusion on the East-West contrast in caregiving resembles that of Bengtson et al. (2000), though the former took into account that significant differences exist even among nations of the East and West despite their similar cultural backgrounds and traditions collectively.

Nonetheless, the Eastern values of “familism” and “inter-dependence” are contrasted with the Western values of “individualism” and “independence”.

However, despite the attempt in contrasting, it was highlighted that ‘the processes of industrialisation, urbanisation, and westernisation had swept

Eastern societies’ (Liu & Kendig 2000b: 2) and poses a challenge to the previously “unquestioned and unquestionable” (Liu & Kendig 2000b: 13) stance on family caregiving based on the Confucian virtue of filial piety.

However, cultural values and norms remain important influences on governments’ ideological stance on ageing policies and continue to create counter forces for social and policy change. In East Asia, governments such as

Japan and China had integrated the moral obligation requiring adult children to take care of the needs of their own ageing parents into their constitutions (Liu &

14 Kendig 2000b: 13). Japan is a prime example, staunch in traditional beliefs.

Despite being the most “fully-aged” society in Asia, the Japanese government have resisted pressures and defied predictions by research scholars by maintaining their stance in making no concession to take over the caregiving roles and responsibilities from the family (Koyano 2000 cited in Liu & Kendig

2000b: 16). The influence of Confucianism in Southeast Asia is noted to be weaker than East Asia except in some Chinese overseas communities such as

Singapore (Liu & Kendig 2000b: 13). This is epitomised by the Singaporean government’s promotion of the values of filial piety as a national ideal and the institutionalisation of family obligations under the Maintenance of Parents Act

1995 (Chan 1999, 2005).

On the other hand, Western societies that had long ‘adopted, at one time or another, social values that favoured welfare policy for the state to take care of the old and frail’ (Liu & Kendig 2000b: 11) have redefined the states’ obligation towards the older population in view of rising aged care expenditures. Though a part of the West, Australia’s ageing policy has evolved independently from

Euro-American developments and achieved a middle ground between reliance on welfare and benefitting from stability in core family values (Kendig 2000 cited in Liu & Kendig 2000b: 8). Kendig (2000) posited that family support to older people in Australia could be understood by the concept of intergenerational reciprocity. Families are benefiting from older Australians who have the resources to maintain their independence while contributing to the care of their younger relatives; state provision for aged care is seen as strengthening family ties by supporting family care in the community and providing residential care

15 when family care is not feasible; and, caregiver support in Australia is praised as advancement in aged care, reducing gender inequalities in caregiver by recognising and compensating the work largely performed by female relatives.

In conclusion, Liu and Kendig (2000b) observed that despite the differences of perspectives between Eastern and Western cultures on ageing and caregiving issues, ‘there exist more consensus of opinions than there are differences when it comes to global elderly care for the future when the majority of societies in the world are fully-aged’ (p. 6). Flowing from the common concerns of academics from the East and West, Liu and Kendig (2000b) foresee that the burden of care in fully-aged societies, whether Eastern or Western, would not be able to be fully borne by the family or state alone. Therefore, despite cultural differences along the East-West value divide, an increasing convergence between Eastern and Western perspectives on aged care was predicted.

In recent years, cross-national research using filial piety as a distinguishing factor between Eastern and Western approaches has reopened this area of exploration. Laidlaw et al. (2010) took it furthest methodologically by exploring the attitudes to ageing and expectations for filial piety in three different cultural groups – older Chinese immigrants living in the UK, older Chinese living in

Beijing, and older Scottish living in Scotland. Chappell & Funk (2011) employed a similar sampling strategy to explore the views of Chinese-Canadians, Hong

Kong Chinese, and Caucasian Canadian caregivers. Such an approach recognises international migration and issue of acculturation among Eastern immigrants in Western societies and vice versa.

16 More commonly, recent cross-cultural studies simply explored the impact of

East Asian Confucian values using convenient samples of Eastern immigrants residing in Western societies or in comparison with the dominant Western culture. The cultural groups explored were Chinese-Australians (Bryant & Lim

2013; Lo & Russell 2007), Chinese-Americans (Dong et al. 2012, 2014; Hsueh et al. 2008; Smith & Hung 2012), Chinese-New Zealanders (Li 2011; Liu et al.

2000), Korean-Americans (Han et al. 2008). There are far fewer examples of cross-national studies such as Schwarz’s et al. (2010) comparative study between Chinese and German adult daughters on the issue of reciprocity in intergenerational support.

To this end, the viewpoints and conclusions from the two conferences (and subsequent edited volumes) and the ongoing debates along the East-West value divide in aged care substantiate the aims of this research and provided a starting point for exploration. In the literature review chapter, the historical rise of ageing issues and development in aged care policies for both Australia and

Singapore are explored in detail. It is obvious from the review that Australia has a much more developed aged care system, which can be attributed to a

Western tendency and Eastern avoidance towards state support and service provision. The structural difference is likely to influence the significance and use of family and other informal forms of care and support. The influence of the

Confucian concept of filial piety on Singaporean social policies, aged care delivery, and intergenerational support is reviewed as well, setting up for the basis of exploration between the two countries in policy, practice, and research terms.

17 1.4 Research Aims and Contributions

As mentioned, the rational for conducting this study on the topic of family and community care of community-dwelling older persons is derived from a combination of the researcher’s experiences and connection to Australia and

Singapore, the ethnic composition of two countries, and the debates along the

East-West value divide in aged care. These factors combine for a meaningful comparison along the East-West value divide and led to the following aims of this study:

l To examine whether there is an East-West value divide in aged care

between Australia and Singapore. l To explore the support network of older Australians and Singaporeans and

thereby exploring the similarities and differences in the two aged care

systems. l To explore the strengths and limitations of centre-based organisations and

community services in which the participants are accessing. l To identify areas where there are convergences, divergences and parallels

in the care of an older person in the two countries that has practice and

policy implications.

In addition, this research draws on the perspectives and experiences of older people, providing a platform for their voices to be heard through this study.

18 This thesis makes contribution to the aged care literature with a direct comparison between two countries representing Eastern and Western cultures.

In the course of this study, it was found that direct comparison between

Australia and Singapore in family and community care has not been attempted before. This is also the main reason for choosing the exploratory approach and the findings would contribute to an understanding of the current perspectives and experiences of community-dwelling older Australians and Singaporeans, particularly in their family / informal support networks, and the other components of the aged care system, including home-based and community care services and state provisions.

In fact, direct comparisons between countries representing the East and West with regards to ageing issues have been limited, though the significance has been highlighted by two conferences at the turn of the millennium that such an approach in examining aged care is important to further an understanding of the impact of modernisation on family changes and trajectories in ideological stance of the various states towards aged care. This research can be seen as an extension of the ongoing academic debates between Eastern and Western academics in aged care and has been influenced by the consensus derived from the conferences as discussed in the previous section.

1.5 Research Method

The three aims of the research were: to examine whether there is an East-West value divide in aged care between Australia and Singapore, to explore the

19 support network of older Australians and Singaporeans and thereby identifying the similarities and differences in the two aged care systems, and to identify areas where there are convergence, divergence and parallels in the care of an older person in the two countries that has practice and policy implications. As there is a dearth of research along the East-West value divide of aged care and comparative study between Australia and Singapore, an exploratory design was adopted and qualitative methods provided the necessary stance and strategy for data collection and analysis. In addition, this study is concerned with the perspectives and experiences of older people themselves and the interpretive framework allowed the researcher ‘to interpret [the participants’] actions and their social world from their point of view’ (Bryman 2016: 27).

Data collection is done through face-to-face interviews with participants recruited from support organisations in the community that are accessed by community-dwelling older persons. Participants were recruited from three community organisations in each country, which provided some variation in service usage and geographical locations within Metropolitan Sydney, New

South Wales (NSW) and Singapore. Data collection in Australia was conducted in the late 2014 while data collection in Singapore was conducted in early 2015.

The two blocks of interviews spanned over three months each with one month of difference in between. As the researcher was based in Australia, the

Australian interviews preceded Singaporean interviews due to practical considerations.

20 This research adopted Bryman’s (2016: 587-588) general approach to qualitative data analysis and coding. “Memoing”, a practice promoted by Glaser

(1978), was done concurrently when the codes are identified. This process allows the context of the participants’ accounts to be retained and enabled higher-level themes and concepts to be identified in the later stages of analysis.

The interpretation of data was done inductively with “constant comparison” between codes, themes, and concepts and attention to negative cases (Strauss

& Corbin 1990: 9 cited in Ezzy 2002: 90). In addition, analysis is done is three stages; starting with the Australian set of transcripts, then with Singaporean set of transcripts, and finally a comparison between the two datasets.

1.6 Structure of the Thesis

Chapter 2 is a survey of the relevant literature focusing on issues of ageing, aged care, and caregiving in the Australian and Singaporean context. Major works and research themes at an international or general level are explored to provide a background on the broader issues. An attempt is made to trace the development of ageing issues and aged care system in both Australia and

Singapore. The existing knowledge, concepts, and Bronfenbrenner’s bioecological systems theory are discussed and their usage in this research as the theoretical and interpretive framework is elaborated.

Chapter 3 details the methodological and ethical considerations employed in this research beginning with epistemology concerns and the researcher’s standpoint. The various considerations, steps, and experiences of engagement

21 with support organisations, recruitment of participants, data collection through interviews, and analysis are also documented.

Chapter 4 is the first of three findings chapters. In this chapter, the themes in relation to family care are presented. The chapter begin with a case presentation illustrating the complexities of care in the family and community context. The next two sections establish that the family remains an important source of practical support and personal care for both Australian and Singapore participants. Later sections explore other care issues within the family context, highlighting areas where there are divergence, convergence, and parallels between Australia and Singapore.

Chapter 5 explores care beyond the family context and identifies the possibilities and limitations in expecting extended relatives, friends, and neighbours to provide some form of care. Two specific gaps affecting the provision of care by these categories of care providers are highlighted as well.

Chapter 6 consolidates the perspectives and experiences of both Australian and Singaporean participants with regards to centre-based community care services and community organisations into seven common characteristics that translate to important areas of provision to support older people facing issues of ageing and disabilities to age in place in the community.

Chapter 7 discusses the various findings in relation to the aims of this research and literature. Higher-level themes linking the themes from the three findings

22 chapters are presented here to further emphasise the complexities of care and how the family and other providers of care could complement and address one another’s inadequacies to provide a more comprehensive and responsive support system for the older person.

Chapter 8 lists the key conclusions of this study in relation to the aims of this research with an elaboration of the contributions and limitations of this study and implications for further research.

23 CHAPTER 2: LITERATURE REVIEW

This chapter is a review of the relevant literature on the issues of ageing and aged care that are likely to be applicable for both the Australian and

Singaporean contexts. As the research is exploratory – mainly due to a dearth of comparative studies between two countries along the East-West value divide

– the researcher is drawing from a broader knowledge base to establish the focus for this study. A range of literature from Australia, Singapore, and beyond was thus consulted for the possible issues to be explored and the concepts that would be helpful building blocks for understanding the issues faced by community-dwelling older persons.

An attempt is made to trace the development of aged care systems and state support in both Australia and Singapore. While the existing literature has substantially explored the foundations and models of the aged care systems in these two countries, there are new developments that have not been documented. As such, a range of sources including government media releases and agency reports, newspaper articles, and websites have been consulted to provide an integrated picture. As both Australia and Singapore are seen as modernised societies, major works and themes referring to the impact of modernisation on issues of ageing and older persons were sought. As a large number of foundational works by notable authors were written in the 1980s and

1990s, current statistics are used where necessary to substantiate their viewpoints and propositions that still hold true today.

24 2.1 Definitions of an Older Person

In most studies on ageing issues, the lower limit for a person to be defined as an older person ranges from 55 to 75 years. However, the most commonly used lower age limit is 65 years. This convention has its origins in the provision of retirement income arrangements introduced by developed nations at the turn of the twentieth century (Borowski & Hugo 1997:20). The concept of a retirement age, however, is a discriminatory construction of industrialised societies, where an older person is deemed unsuitable to remain in the workforce due to diminished productivity – measured by tangible output like a piece of machinery

(Phillipson 1982). Defining a person as being old in terms of chronological age has thus been criticised as problematic and demeaning.

Perhaps so, the term “Third Age” has been popularised in Europe to describe the phase of life after childhood – the “First Age” – and a period of maximum work – the “Second Age” (Warnes 1989: 217 cited in Borowski & Hugo 1997:

23). Such a conceptualisation does not suggest a loss of role or onset of dependency the way being labelled as a “retiree” does. It is also applicable for both males and females, and does not exclude those who are no longer in paid employment or those who never or seldom work due to caring responsibilities or other life choices.

For the purpose of international comparisons, this research adopts age of 65 and over as the definition of an older person, based on the established benchmark in most studies on ageing and aged care issues. In some instances

25 in this thesis, the differentiation between a “younger old” – aged 65 to 84 – and

“older old” – aged 85 and over is particularly useful based on the functionality level and service needs experienced by a majority in each subgroup (for an example of such a breakdown, see ABS 2009). The following two sections

(Sections 2.2 & 2.3) detail the rise of ageing issues in Australia and Singapore.

The next two sections (Sections 2.4 & 2.5) trace the historical development and provide an account of the current state of Australian and Singaporean aged care system.

2.2 The Rise of Ageing Issues in Australia

Gibson (1998) drew from the fundamental ideas of Mills (1959) and documented comprehensively on the transition of ageing from one of “personal troubles” to “public issues”. Her discussion and timeline of the development of

Australian aged care services begins with the Aged Persons Home Act 1954 right up to the 1996 federal government’s announcement for the restructuring of residential care. As such, the period of analysis covered by Gibson’s (1998) has been a particularly helpful guide in understanding the rise of ageing issues in

Australia right up to the end of the first national aged care reform in the country.

Kendig’s (2017) analysis began slightly earlier, noting that ‘[i]n the 1940s and

1950s, older people were seldom represented in public affairs except in relation to some residual health and welfare matters’ (p. 23). Similar to the developments of aged care sector in the US, the expectation for state provisions was motivated by the inaccurate perception of family alienation and

26 abandonment (Kendig 2017: 23; also see Section 2.8.2). In conjunction, older people were viewed as “needy and deserving” in the immediate post-war years based on the belief that their ‘age-related vulnerabilities were not the “fault” of people themselves and that [state] support had been “earned” through earlier contributions in war, taxpaying and nation building’ (p. 22). As shown by

Kendig’s (2017: 23) review of successive governments from the Menzies era of government (1949-1966) to the short-lived Abbott’s government (2013-2015), such an “outdated and inaccurate” view on ageing and aged care provisions has remained influential in social and policy developments until today.

The Aged Persons Home Act 1954 marks the beginning of federal entry into aged care, elevating ageing as an agenda of national status (Gibson 1998: 29).

Besides legislating federal funding, the Menzies’ government laid the foundations of modern state provisions, which includes ‘free public hospitals and modest pensions as well as age-specific accommodation augmenting efforts by the church and other charitable bodies’ (Kendig 2017: 23). In the

1960s, poverty in later life was increasingly recognised as a social issue and the provider-driven nursing home industry expanded rapidly. However, such political enthusiasm for increasing residential bed numbers did not impress older Australians who ‘largely detested and feared “old people’s homes”’

(McCallum & Geiselhart 1996: 16).

In the 1970s, the Whitlam government (1972-1975) further recognised older people as “needy and deserving” and introduced universal health, income and care programs (Kendig 2017: 23). During the Fraser and Hawke eras of

27 government (between 1975-1983 and 1983-1991 respectively), state provisions expanded despite rising concerns regarding sustainability of state provisions.

Policy reviews ensued and the Aged Care Reform Strategy (ACRS) was conceptualised partly to slow down the growth of public expenditure (Kendig

2017: 23). The acclaimed Australian “three-pillar” system of retirement income also took shape under the Hawke government with the introduction of employer and public-funded superannuation schemes designed to offset the burden on the non-contributory aged pension scheme (Borowski & Hugo 1997: 8; Kendig

2017: 23).

As detailed by Gibson (1998), the ACRS was precipitated by several uncoordinated developments. On the policy front, four reviews and inquiries were conducted on the aged care sector due to a growing dissatisfaction with residential care and limited options of home-based and community care options for older people. In 1980, the House of Representatives Standing Committee on

Expenditure of a Sub-committee on Accommodation and Home Care for the

Aged was established; in 1981, the Senate Select Committee on Private

Hospitals and Nursing Homes was formed; in 1984, the Joint Review of Hostel

Care Subsidy Arrangements was convened; in 1985, the Joint Review of

Nursing Homes and Hostels was conducted (Gibson 1998: 33). Most noteworthy among the reviews and inquiries are the findings and recommendations of the McLeay Report (cited in Gibson 1998: 32), which criticised the inadequacy of home-based services and exposed the huge disparity between federal provisions for residential care as compared to community care; the absence of any national umbrella for home-based and

28 community care services advocating for their interest; and, financial disincentives for the state and territory governments to pursue development of home-based care due to cost-sharing arrangements between them and the federal level of government.

On the social and political end, the ageing of the Australian population as an emerging phenomenon entered public and political consciousness with the first cohort of post-war population boom of the 1920s reaching the old age in the early 1980s (Gibson 1998: 34). The rapid rise in the numbers of older people aged 70 and over persisted (over the years of the ACRS) from 1981 to 1996, heightening the need for an accelerated response by the state and the aged care sector. More significantly, the population group aged 80 and over within the aged 70 and over group, had been rising more rapidly. This phenomenon is referred to as the “ageing of the aged population”. In 1981, older people aged

80 and over as a proportion of the aged 70 and over group stood at 28%. By

1991, the proportion rose to 30% and by 2001, it was at 34% (ABS 2014). As severe disability rates increase significantly with age and towards the end of life, the rapid rise in the aged 80 and over population group translates to an impending rise in demand for aged care services.

As mentioned earlier, the concern regarding the ageing of the Australian population was more driven by the perceived economic and social costs rather the service needs of older people. Against the backdrop of the 1983 recession in Australia, community care was (wrongly) thought to be a cheaper option as compared to residential care. This option for cost shifting was particularly

29 attractive for the federal government, whose funding to residential care included both capital and recurrent funding (Gibson 1998: 32-34). Despite differing social, economical, policy, and political interests, the developments converged on community care as the preferred solution.

The overall outcome of the ACRS can be summed up as the process of

“deinstitutionalisation”. Gibson (1998: 35) highlighted that the Australian route of deinstitutionalisation had two major trajectories. The first direction pursued was in the reduction of residential care and the corresponding expansion of home- based and community care services. This is markedly different from deinstitutionalisation in the mental health and disability sector where individual residents were moved out of residential care en masse and integrated into the community. Nursing homes simply stopped expanding and ceased taking in new residents when the capacity is reached and older people remaining in the community were linked to home-based and community care services. The second direction was described as deinstitutionalisation within the residential care sector. Service users were directed to hostel care with less intensive provisions of care instead of nursing homes. At the same time, temporary residential care was made available for home-based care users, in an attempt to increase permeability between residential and community care sectors.

The ACRS lasted for a decade and ended formally with the Howard government’s announcement for the restructuring of residential care in 1996. In the broader picture, the ACRS was a part of the Social Justice Strategy under

Paul Keating’s Labor government (1991-1996) before John Howard’s Liberal

30 government (1996-2007) was sworn in. Though a subsidiary of broader social justice movement across various government departments, the ACRS was the most significant period of development for Australia’s aged care system where residential care undergone major restructuring, home-based and community care became a viable option, and better linkages was forged between various sectors of provision (Gibson 1998: 33).

Ironically, it was during Keating’s era of government that means-testing was tightened to increase “targeting” of public resources to the most “needy”

(Gibson 1998: 16; Kendig 2017: 23). Targeting of services to the most needy in terms of physical or mental frailty has been an accepted principle in social policy while targeting based on means of paying for services and / or assets was more controversial and generated considerable debates (Gibsons 1998:

16). Such a shift away from universal provisions is compelled by the recession years in the early 1990s, a period where “economic rationalism” 8 gained significant momentum and neoliberal beliefs in the reduction of the size of welfare state took root (Kendig 2017: 23).

Increasingly, service users and their family are expected to pay and contribute to the costs of service provisions. Related to “targeting” is the principle of

“rationing” where the supply of resources in terms of capital and recurrent funding are budgeted, capped, and stringently allocated to local authorities and

8 Economic rationalism, an Australian term that first appeared during the Whitlam era of government and subscribed by Whitlam himself in opposing protective tariffs and in favour of “free market” policies (Quiggin 1997).

31 service providers ‘who must decide not only who will receive assistance, but also what services (residential versus home-based) will be available to them’

(Gibsons 1998:17). In general, the Australian government and policy makers are increasingly shifting towards user pay and family co-payment arrangements for aged-care services and the “universal” aged pension only be paid to those who are do not have an income (including superannuation) and assets

(including foreign income sources and assets).

In the early 2000s, the Australian Government’s Intergenerational Reports

(Commonwealth of Australia 2002, 2007, 2010, 2015) reflected renewed concerns for Australia’s economic future and the rise of the issue of

“intergenerational equity” and age / cohort inequalities (Kendig et al. 2017). The

Global Financial Crisis of 2007 further ‘heightened concerns for secure retirements and the long-term financial sustainability of government’ (Kendig et al. 2017: 107). Generally, more recent debates and policies on ageing issues assumes that ‘the post-WWII baby boom cohort9 now entering later life includes many who accumulated substantial wealth and other resources’ (Kendig et al.

2017: 107) and as such relatively more advantaged than older and younger cohorts. In view of fiscal constraints and sustainability, measures to address the

‘fairness in the distribution of public resources between generations of

Australians’ (Commonwealth of Australia 2002: 14) is unfairly targeted towards removing and decreasing benefits previously promised to the older generations

9 “Baby boomers” are defined as those born between 1951-1965 who are ‘approaching [and reaching] later lifer after having adulthood during times of increasing employment and housing opportunities’ (Kendig et al. 2017: 108).

32 instead of increasing allocation of resources for the younger generations. As a result, the eligibility age for the aged pension is progressively raised, tax subsidies for superannuation are continued, and the asset test for the aged pension is tightened (Kendig et al. 2017: 107). With the Intergenerational

Reports set to be published every five years (The Treasury 2017a) and using long-term projections and assumptions that are acknowledged to be ‘very unlikely to unfold over the next 40 years exactly as outlined’ (The Treasury

2017b), the reports has been criticised to be using misleading findings, perpetuating myths about the ageing crisis, and concealing “hidden agendas”

(Birrell & Betts 2015).

In summary, intergenerational equity is set to dominate policy and political debates about an ageing Australia (Kendig 2017: 21). Although the concept is relatively new and imported from the UK (notably the works of Piachuad et al.

2009), the principles of analysis has been perceived as a tool for a new wave of economic rationalists to justify further reductions in public expenditures, particularly in aged care provisions. Using a historical perspective of the rise and development of ageing issues enables us to see that the earlier images of the “needy and deserving” older population has drastically shifted towards an image of the advantaged baby boomers who should not be further privileged.

2.3 The Rise of Ageing Issues in Singapore

Ageing issues in Singapore were placed on the national agenda decades later than in Australia. Without an admission of a need for reform or overhaul in the

33 aged care sector, enquiries regarding ageing issues begun in the early 1980s

(for example, see Ministry of Health [MOH] 1984; Ministry of Social Affairs 1983) and subsequently a host of planning groups was state-commissioned to address the issues of ageing and aged care. For example, the Advisory Council on the Aged in 1988; Committee on the Problems of the Aged in 1989; Inter-

Ministerial Committee on the Ageing Population in 1998. Following the enactment of the Maintenance of Parents Act 1995, the Tribunal for the

Maintenance of Parents (TMP) was established in 1996 as a court for older parents to file for a Maintenance Order against their adult children (Singapore

Government 2013).

While the timing for placing ageing issues on the national agenda in Australia and Singapore is at around the same time, the concerns for Singapore’s older population can be seen as anticipatory and benefitting from the lessons in the

West. In addition, the rise of ageing issues in Singapore could be seen as a part of the developments happening in the East and Southeast Asia region. As a whole, the scale and rapidity in which Asian countries are ageing emerged as a public concern in the 1980s and 1990s.

For some Asian countries, the proportion of older people in their population was predicted to rise to the levels reached in the West (and Japan) within a shorter span of 30 to 40 years instead of 150 years or more it took the West (Hateley &

Tan 2003). As such, Asia is experiencing a compressed version of

“demographic transition” and would continue to mature in unprecedented magnitudes. The United Nations (2001: 5) reported that between year 1950 and

34 2000, the world’s older population had tripled, and it would continue to triple in size from year 2000 to 2050. A majority of the growth in the latter period will be in Asia, particularly in East and Southeast Asia. It was predicted that China alone would contribute to a quarter of the world’s growth in the older population in the first half of this century (World Bank 1994: 3).

Most of the reasons for Asia’s rapid rate of population ageing are similar to the

West’s experience of “demographic transition” – in which both fertility and mortality decline from higher to lower levels (United Nations 2001: 5).

Demographic transition is a phenomenon corresponding to modernisation of a nation or society – which encapsulates the processes of industrialisation and urbanisation (Bengtson et al. 1975) – bringing about better healthcare, nutrition, hygiene, disease control, housing, education, and other indicators of standard of living. Such advancements lead to rising life expectancy. Other factors such as decreased infant mortality, increased level of education (especially among women), cramped urban living space, and a nuclear family structure lacking extended support disincentivise people from setting up a family and having children. With less children born and people living longer, the demographic profile is reshaped with increasing proportion in the higher age groups and decreasing proportions in the younger age groups. Population ageing, as such, is a characteristic of developed nations and societies. As highlighted by Hateley and Tan (2003: 1), the irony of what Asian countries like Singapore has

‘achieved in graduating from “Third World” to “First World” status, [is that it] has given them the “First World” problems of rapid ageing’.

35 In the Western experience, inward migration of younger working adults helped to rejuvenate the population at various junctures but such an option is often not welcomed in Asian countries. More importantly and markedly different in the

Asian experience of greying is the even more rapid drop in fertility rates accelerated by highly successful family planning program. The “one child policy” of China is a prime example of the efforts to curb population increase. Many other countries in Southeast and East Asia, including Singapore and South

Korea, have similar policies where ‘[g]overnments provided abortions at low or zero cost with “no questions asked”, sterilisation programmes, subsidised contraceptives, and an array of financial incentives and disincentives, as well as administrative regulations’ (Hateley & Tan 2003: 2).

For the case of Singapore, abortion was legalised in 1970 and by 1974, abortion and sterilisation procedures became readily available at low cost and without the need for spousal agreement (Hateley & Tan 2003: 17). The outcome of such policies is a below-replacement fertility rates. In 1965, the year of Singapore’s independence, the crude birth rate was 29.5 per thousand. By

1986, the crude birth rate dropped to 14 per thousand and fertility rate was at

1.6 (below the replacement rate of 2.1). Despite a desperate attempt on pro- natal policies in the late 1980s, the legacy of below-replacement fertility rates persisted to date, overwhelmed by the effects of modernisation mentioned earlier.

The main reason for such a sudden reversal of belief in birth control is the realisation that below-replacement fertility rates have a profound impact on the

36 make-up of the family unit. Traditionally in Singapore, residential care places have been limited due to moral obligations placed on the family and economic rationale held by the state (Teo et al. 2006: 87-89). Nonetheless, the ideology of the Asian family as the most appropriate social unit to provide care for older members was severely undermined by the unavailability of family caregivers and weakening social ties – due to prolonged periods of below-replacement fertility rates and societal changes brought about by modernisation (Hateley &

Tan 2003).

2.4 Australian Aged Care System and State Support

The current structure of the Australian Government-subsidised aged care sector has been largely moulded during the ACRS in the mid-1980s to mid-1990s. The services are delivered through three main service streams: residential care, community care, and flexible care (Australian Institute of Health and Welfare

[AIHW] 2012: 2, Department of Social Services [DSS] 2013b: 1). Within each of these streams are a variety of accommodations and support programs providing care of varying intensity. With the exception of the Home and

Community Care (HACC) program, aged care services are governed by the

Aged Care Act 1997 and the associated Aged Care Principles (AIHW 2012: 2).

From 18 September 2013 onwards, the Aged Care Act 1997 is ‘administered by the Minister for Social Services, and matters relating to aged care are now the responsibility of the Department of Social Services’ (DSS 2013b: 3). Formerly, it was managed by the Department of Health and Ageing (DoHA), which is now holding only the health portfolio.

37 2.4.1 Australian Residential Care

“Nursing homes” and “hostels” are currently referred to as high-care and low- care residential aged care services, respectively (DSS 2013b: 9). To receive

Australian Government subsidies for providing residential aged care, an aged care service must be operated by an organisation that has been approved by the DSS (i.e. an approved provider). The facilities must be accredited by the

Aged Care Standards and Accreditation Agency. In addition, the care recipient must be assessed by an Aged Care Assessment Team (ACAT) or Aged Care

Assessment Service (ACAS) as eligible to receive residential care – in other words, older people who are unable to continue living independently in their own home (DSS 2013b: 2-3 & 11). The ACAT and ACAS are thus performing the function of gatekeeping for entry into a residential care facility.

While most of the funding for subsidised residential care comes via the DSS, residential aged care for veterans is also funded by the Department of Veterans’

Affairs. Whenever possible, residents are asked to make a contribution to the cost of their care and accommodation. For older people experiencing genuine financial hardship, hardship provision is made available by the government to

‘ensure that these residents have equal access to residential aged care and are not discriminated against’ (DSS 2013b: 4-5).

Nonetheless, gaining entry into residential aged care services is comparatively more challenging since the 1980s as residential bed numbers, particularly nursing home beds, are slashed in the pursuit of deinstitutionalisation and care

38 applicants have to undergo stringent means testing in the name of targeting and rationing (Gibson 1998: 16-18 & 35-37). In 1985, there were 67 nursing home beds per thousand persons aged 70 and over. By 1994, the ratio dropped to 52 per thousand and recently in 2010, the ratio has dropped to 40 high-care places per thousand persons aged 70 and over (AIHW 2012: 14; Gibson 1998: 35).

While it was envisioned in the mid-1980s that the total number of nursing home and hostel beds will maintain at the national ratio of 100 residential beds (per thousand persons aged 70 and over), the sharp drop in nursing home beds was not matched by the increase in hostel beds. The result was a steady drop in national residential beds ratio from 99 in 1985 to 92 in 1994 and the lowest point of 82 in 2002 (AIHW 2012: 16; Gibson 1998: 36). Since then, efforts have been put in place to reverse the trend and in 2007, the Australian Government set a national target ratio of 88 residential beds – 44 each for both high-care and low-care places (AIHW 2012: 13). The overall drop in residential bed numbers also places considerable pressure on the home-based and community care sector, which was also envisioned to expand to enable older people to age in place.

2.4.2 Australian Home-based and Community Care

To prevent premature entry into residential care, specialised community programs were developed to support older persons in the community to remain in their homes for as long as possible. These community care programs are subsidised and regulated directly by the Australian Government. Community

Aged Care Packages (CACP) and Extended Aged Care at Home (EACH)

39 packages supports low-level and high-level care needs profile respectively for older persons who might otherwise require entry into low-level (hostel) or high- level (nursing home) residential care. Both CACP and EACH have case planning and case management components to coordinate a range of support services. CACP are focused on daily needs such as assistance with personal care, meals and domestic duties such as cleaning, while EACH includes clinical care (nursing services), personal assistance, meal preparation, continence management, therapy services, home safety and medication. Extended Aged

Care at Home Dementia (EACH-D) packages are designed for high-level care to support older people with dementia and includes support services specific to their need (DSS 2013a). From 1 August 2013, these packages had been replaced under the umbrella of Home Care Packages (HCP). The new program is designed to support four notable levels of care needs – basic, low level, intermediate and high care. Existing CACP and EACH cases will continue to receive services with the name of the packages renamed as Home Care Level

2 and Home Care Level 4 respectively. EACH-D cases have no equivalent home care level but a new Dementia and Cognition Supplement is being introduced (DSS 2013a).

The HACC program has a similar aim to the HCP program, which is to ‘support frail older people and their carers, who live in the community and whose capacity for independent living is at risk, or who are at risk of premature or inappropriate admission to long term residential care’ (DoHA 2012: 1). The difference between HACC and HCP programs is in the level of their provision of care. HACC provides basic maintenance, support and care services while HCP

40 (also known as packaged care services) supports older people with ‘complex care needs that require an ongoing level of case management’ (DoHA 2012: 8).

The HACC program consists of 19 service types – domestic assistance, personal care, social support, respite care, other (in-home) meal services, assessment, client care coordination, case management, counselling/support, information and advocacy for client, counselling/support, information and advocacy for carer, nursing care, allied health care, centre-based day care, home modifications, goods and equipment, home maintenance, formal linen service, meals delivery, and transport (DoHA 2012).

2.4.3 The Aged Care (Living Longer Living Better) Act 2013 and Current

Aged Care Reform

Prior to 1 July 2012, the HACC program was a joint federal and state / territory government initiative under the Home and Community Care Act 1985.

Previously, the state / territory governments had policy and operational responsibility while the federal government maintained a broad strategic role.

Funding for HACC service is split between the governments with the federal government reimbursing 60 per cent of the HACC program expenditures to the states and territories (DoHA 2012: 1). Currently, the federal government has assumed full funding, policy, and operational responsibility for HACC services with the enactment of the Aged Care (Living Longer Living Better) Act 2013.

The consolidation of HACC responsibilities under a national umbrella marks the beginning of the Living Longer Living Better aged care reform package

41 announced on 20 April 2012 by the Gillard government (2010-2013) (DoHA

2012: 2). This long awaited government response was made possible through sustained advocacy by COTA Australia and various stakeholders, as well as the recommendations of the Productivity Commission’s (2011) Caring for Older

Australians public inquiry report (COTA 2017a). The Department of Health and

Ageing contracted COTA Australia to support the Federal Minister for Mental

Health and Ageing in engaging older people on the proposed aged care reforms.

The Conversations on Ageing consultations were conducted in every state and territory from 19 August 2011 to 1 February 2012, prior to the aged care public announcement. The recurring themes from the Conversations were summarised into 19 statements preceded by what “older Australians want” and further condensed into the following conclusions that older Australians:

l Want quality services available when and where they need them; l Have a clear preference for support to be provided at home, with people

only wanting to contemplate residential care when there is no alternative; l Desire a simplified and streamlined way to access information on healthy

ageing, aged care services available and the quality of these services; l Want to obtain their selected services in an equally seamless way; and l Have strong views about the need to have as much control as possible

over their own death, as well as access to palliative care at home (where it

is required) rather than having to go to hospital (COTA Australia 2017b).

These key messages from older Australians consulted are reflected in ‘an exciting shift from a menu style aged care system driven by government and

42 providers, to a system more focused on the needs and preferences of consumers’ (COTA Australia 2017a). On 1 July 2013, the nationalised one-stop

My Aged Care website and phone line began providing general information about the aged care sector and expanded its functions on 1 July 2015 to include central client records, telephone screening and referrals to Regional

Assessment Service and Aged Care Assessment Team, and service finders.

More significantly, from 1 July 2015, the federal government established the

Commonwealth Home Support Program (CHSP) to ‘bring together under the one program all the services currently providing basic home support’ (DoHA

2012: 2) for a “streamlined” home-based and community care (COTA Australia

2017a). The consolidated programs were the HACC program, the National

Respite for Carers Program, the Day Therapy Centres program and the

Assistance with Care and Housing for the Aged program. The range of services provided by CHSP is similar to the former programs and existing service users will continue with their existing service provider(s). What is new under CHSP is a nationally consistent fees policy and schedule applied to existing and future service providers.

The most significant change under the Living Longer Living Better aged care reform is the introduction of Consumer Directed Care (CDC). Since 1 August

2013, the new HCP are to be “consumer directed” in that service users have more choice about what services are included in their package and how the chosen services are to be provided to them. From 1 July 2015, all HCP must be delivered as CDC. After the Aged Care Assessment Team has determined the level of HCP based on care needs, a set amount of funds is allocated. CDC is

43 defined as the ‘control’ over the allocated funds by the service users (and their family / representative), allowing them to exercise greater autonomy and choice, and shifting the power vested in service providers to service consumers (Gill et al. 2017: 479; McCaffrey et al. 2015: 655). Using discrete choice experiment,

McCaffrey et al. (2015) delineated six key attributes of CDC from the perspectives of service users: choice of provider; choice of support worker; flexibility in care activities provided; contact with the service co-ordinator; managing the budget; and saving unspent funds. However, the new HCP might require user contribution of 17.5% of the single basic Aged Pension or income- tested fee (COTA Australia 2017a).

While studies on CDC soliciting the views of service users, informal carers, and care workers have emerged (Day et al. 2017; Gill et al. 2017; Kaambwa et al.

2015; McCaffrey et al. 2015) with positive findings, critique on the other aspects of the Living Longer Living Better aged care reform is lagging. The current reform is also expected to unfold over a ten-year period similar to the ACRS and the reform to residential aged care is not yet implemented and ‘[w]ork is underway to investigate alternative approaches to determining residential care funding that delivers more stable funding arrangements… [and n]o decisions has been made on options’ (Department of Health 2017b, n.p.).

2.4.4 Australian Carers Support and State Provisions

Howe (2001), who was a key figure during the decade of ACRS, illustrated that the main purpose of the HACC program is to provide for a large population of

44 older people at the base of the aged care pyramid with minimal amount of services to maintain them in the community. The HACC program mainly function as a substitute for family caregivers or in supplementing their efforts. In

Australia, the term “carers” is used for informal or family caregivers while paid caregivers in formal services are referred to as staff or “care workers” (Howe

2001: 111). More importantly for this study, Howe (2001) highlighted that client’s level of dependency is a weak indicator of service usage. Instead, the presence of carer(s) is a stronger mediating factor. Some older people with high-dependency are noted to have lower level of service usage than those with low-dependency. Consistent to such an observation, carers are recognised as clients in their own rights since the establishment of the HACC program and a set of services are designed to assist them in their caregiving role. Not only are carers important in moderating community care services usage, they are recognised as having the capacity to delay entry to residential care, thereby moderating residential care services usage as well.

In 1992, the carer support strategy was announced and the “carers’ kits” to disseminate information on available forms of services and assistance was subsequently developed (Gibson 1998: 39). By 1996, a National Agenda for

Carers was developed in recognition of their contributions towards aged care.

This move was in tandem to the carers’ increased political profile, which was largely attributed by the support through HACC to carer’s representative organisations (Howe 2001: 111). By 2001, carers’ support has been identified as ‘a third strand in long-term aged care system, alongside residential and community care’ (Howe 2001: 111). The political-activist developments for

45 ageing and aged care issues in Australia through carers’ advocacy and support groups therefore differ from the rise of “grey power” in America where older people themselves took the lead (Gibson 1998: 4). Nonetheless, a significant proportion of carers with a voice are older people themselves – being a caregiving spouse or interdependent older couple, younger old caring for their older old parents, and in some circumstances an older old caring for a younger old with disabilities or illness. There is also an anticipation of a movement by the baby boom generation who are reaching old age en masse as they have reshaped society at every stage of their lives and have amassed significant resources and influence in their lifetime (Gibson 1998: 4-5).

In Australia, full-time carers who are unable to participate in paid employment due to caregiving are supported with the Carer Payment (which is similar to the payment rate of the Age Pension). Some carers are further supported with the

Carer Allowance, which is an income supplement for carers who provide additional daily care for ‘someone who is frail aged, or who has a severe medical condition or disability. It can be paid on top of the Carer Payment or an

Age Pension’ (My Aged Care 2015). The payment rate for Carer Allowance is

124.70 Australian dollars (AUD)10 each fortnight. In addition, Australian carers have 63 days per calendar year for respite without affecting their payment(s) and are able to continue receiving payment(s) outside of the country as long as the qualifying conditions are met (Department of Human Services [DHS] 2017c).

10 The exchange rate between Australian dollar (AUD) and Singapore dollar (SGD) on 15 March 2017 is at: 1 AUD = 1.07 SGD.

46 To this end, the role of the family in community care is highly important for older people to age in place. Gibson (1998: 16) highlighted that the family’s willingness and capacity to care is of policy relevance and warned that the way family rationalised trade-offs between care responsibilities and other commitments is complex, may change significantly (and rapidly) over time, and differs across cultures. Whether carers are co-residing with the older person or not, the breakdown in the informal support structure is a key determinant of institutionalisation. While there are reports of older people being abandoned by their families, a large majority of older people and their family caregivers would persist in home-based and community care and consider residential care as a last resort (Cheek et al. 2006).

In terms of direct financial support, the Australian Government has been providing the Age Pension, which is set at approximately 25% of the average wage and is a “non-discretionary provision” for older individuals who meet the age and income & asset requirements (Gibson 1998: 40 & 210). In other words, eligibility is based on individual financial status instead of means-testing that is based on the household income requirements which is used in Singapore (Teo

2006: 84 & 113). The 2016-7 payment rate for Australia Age Pension is 797.90

AUD for a “single person” and 1,203.00 AUD for a “couple combined” on a fortnightly basis (DHS 2017a).

47 2.5 Singaporean Aged Care System and State Support

In Singapore, the “many helping hands” approach has been adopted to encourage various sectors to come together and collaboratively provide a safety net for the needy and vulnerable population, including older people

(Rozario & Rosetti, 2012; Teo et al. 2006). The stakeholders include the ‘family as the first line of defence, followed by the community / neighbourhood or voluntary welfare organisations (VWOs), and state as the last resort’ (Teo et al.

2006: 25). In addition, as highlighted by Goodman et al. (1998: 14-15 cited in

Teo et al. 2006: 25), the ‘ideological context [of five Confucianist-influenced countries in Asia, including Singapore, is that] self / mutual help is encouraged and dependence on the state is discouraged, indeed stigmatized’.

When the Singapore Government was criticised for its ‘antipathy towards public welfare’ (The Economist 2001a: n.p.), the Singapore Government clearly stated its stance as:

Our approach is based on time-tested values of hard work, self-

reliance, family responsibility and community support for those in

need. While we avoid over-generous welfare handouts, we have

substantial state subsidies for education, health care and public

housing (Teo 2010: n.p.).

This stance is evident in financial support for older Singaporeans where individuals are expected to save for their old age and if they are unable to

48 achieve self-reliance, the family and the community should relied upon before finally approaching the state for assistance. Goodman et al. (1998: 14-15 cited in Teo et al. 2006: 25) categorised Asian states like Singapore as

“developmental welfare systems” and are characterised by ‘non-state agencies

– community, firm and family… [which are] expected to play a major welfare role in both financing and providing welfare services’. Consequently, state provision in terms of financial support and aged care services has been kept at a low level in Singapore.

In terms of state provision for older individuals, the Singapore Public Assistance

(PA) / ComCare Long Term Assistance scheme is highly targeted to provide financial support for ‘those who cannot work due to old age, illness or disability … [and] have little or no means of income and family support’ (The

Straits Times 2016: n.p.). The payment rate for the Singaporean PA was raised in 2016 to 500 Singapore dollars (SGD) for a “one-person household” and 870

SGD for a “two-person household” on a monthly basis. Taking into consideration the difference in cost of living11, the Australia Age Pension (see payment rates on page 37) is slightly more than twice12 the payment rate of

Singapore’s PA.

11 The difference in cost of living between Australia and Singapore is compared using the 2017 purchasing price parity (PPP) conversion rates – 1.403 for Australia; 0.816 for Singapore. Source: International Monetary Fund (IMF) 2016 12 For an older individual, the per annum payout for Australia Age Pension is 14827 US dollars (USD) (PPP-adjusted) and for Singaporean Public Assistance is 7352 USD (PPP-adjusted).

49 Nonetheless, in the area of healthcare subsidies for older individuals, there has been significant development since the watershed year of 2014. That year’s

Singapore national budget debate was titled Opportunities for the Future,

Assurance for the Seniors (Ministry of Finance 2014). In line with the Singapore

Government’s approach in using social transfers through subsidies instead of direct cash payment (Teo 2010), the Pioneer Generation Package was introduced in 2014 ‘to honour and thank our Pioneers13 for their hard work and dedication… [recognising that older Singaporeans] have made Singapore what it is today’ (Pioneer Generation Package 2017: n.p., emphasis in original).

The Pioneer Generation Package includes an additional 50% subsidy on outpatient medical consultation and prescription fees (on top of means-tested subsidies for all Singaporeans receiving outpatient care at public polyclinics and

Specialist Outpatient Clinics), a 50% subsidy on premium for MediShield Life

(revised national health insurance scheme) for those born in 1935 to 1949 and full coverage of premium for older Singaporeans born in 1934 and earlier, and top-ups in Medisave (national medical savings scheme) based on age cohort and ranging from 200 to 800 SGD per annum. In addition, Pioneers who require assistance in at least three Activities of Daily Living (ADL) are eligible for additional assistance under the Pioneer Generation Disability Assistance

Scheme (DAS) receiving life-long cash assistance of 100 SGD per month to help with care expenses.

13 Pioneers are defined as older people who are aged 65 and over in year 2014; i.e. born in 1949 and earlier.

50 As listed above, the Pioneer Generation Package is focused mainly on reducing out-of-pocket healthcare costs and providing disability support and can be seen as a significant milestone in terms of Singaporean state support with direct cash payment (for older individuals or their principal carer in the DAS category) as unprecedented. However, there remain criticisms that the Singapore

Government is not spending enough on healthcare in terms of percentage of

Gross Domestic Product (GDP). In 2014, the Singapore Government spent 4.9% of its GDP in healthcare expenditures; in comparison, the Australian

Government spent 9.4% of its GDP on healthcare in the same year (The World

Bank 2016a).

Nonetheless, when comparison is made in terms of “health expenditure per capita” and taking into consideration the purchasing price parity (PPP) conversion rates, the figure for Singapore at 3,372 USD (PPP-adjusted) is catching up with Australia’s 4,298 USD (PPP-adjusted) (The World Bank

2016b). In addition, Singapore’s public healthcare expenditure has doubled from four billion SGD in 2011 to eight billion SGD in 2015 and expected to triple to 12 billion SGD by 2020 (Reuters 2014) with a corresponding upward trend in per capita spending and with greater focus on the healthcare expenditures of older people. On the other hand, the rate of growth in Australia’s per capita healthcare expenditure has regressed from 1.6% in 2013-14 to 1.4% in 2014-15 and the 2014-15 rate of growth is less than half of the average annual growth

(2.9%) over the decade (AIHW 2016: 18).

51 Meanwhile, aged care service provision in Singapore has been slated for expansion. Announced jointly in year 2012 by the Ministry of Health and

Ministry of Community Development, Youth and Sports (renamed Ministry of

Social and Family Development [MSF]), 10 new nursing homes, 56 SACs, and

39 senior care centres (SCCs) (also known by several other names such as day activity centres, social day care centres and integrated day care facilities) were planned to be operational by 2016 to cope with the rising demand (MOH 2012).

In addition, five SACs were designated as “cluster support” and equipped with social workers ‘to provide intensive support to vulnerable seniors through case management and home visitations (up to three times a week)’ (National Council of Social Service [NCSS] 2013: 25). However, to date, there is no consolidated update in reference to the 2012 announcement.

Home-based care services are provided under the Senior Home Care (SHC) program (previously known as Home Help Services). The SHC program provides services in three main areas – meals delivery, escort service (for medical appointments and treatment) and the ensuite package (comprising of personal care, housekeeping, medication monitoring, and basic nursing care such as wounds dressing, tube related services, monitoring of vital signs, and specimen collection). Such services are similar to those provided through the

HACC / HCP program in Australia.

With the strong emphasis on family and community care, the availability of residential care facilities in Singapore is at a low level with 56 nursing homes

(28 VWO operated; 28 privately operated) and 18 “sheltered homes”

52 (Committee on Ageing Issues [CAI] 2006: 35). Comparatively, there are 2,760 residential care facilities in Australia as on 30 June 2011, providing 185,482 operational places (AIHW 2012: 9 & 16). As such, despite the Singapore

Government’s intention to expand aged care service provision in residential, home-based and community care, the number of service users and operational places is relatively much lower than that of Australia.

2.6 Problematisation of Population Ageing

As explained in Section 2.3, the “cause” of an ageing population is not solely a result of a growing older population. The United Nation’s (2001: 5) World

Population Ageing 1950-2050 report concluded that ‘[f]ertility decline has been the primary determinant of population ageing, overshadowing lengthening life expectancy and diminishing the effects of international migration. As such, the older population is unfairly scrutinised for the “consequence” of an ageing population. The “alarmist views” promoted by economists painted a picture of a looming “welfare crisis” as a result of the “burden of care” placed on society and state.

In both Australia and Singapore, the “age dependency ratio” has been used to illustrate how a shrinking labour force is made to support a burgeoning number of dependent retirees (for an Australian example, see ABS 2009: 2; for

Singapore, see DOS 2016: 5 & 40). Defined as the ratio of persons aged 65 and over to the population of those within working age of 15 to 64, it was shown that the “age dependency ratio” for Australia had risen from 6.7 in 1911 to 17.1

53 in 1991 and a projected doubling to 32.7 by 2031 (Borowski & Hugo 1997: 46).

This approach of analysis had been refuted by demographer such as Easterlin

(1991 cited in Borowski et al. 1997: 10) who proposed the use of “total dependency ratio” – which takes into account the overall dependency by the young (aged 15 and under) and old (aged 65 and over). Analysis based of the

“total dependency ratio” revealed that in nine of the 11 countries Easterlin (1991 cited in Borowski et al. 1997: 10) studied, there has not been significant increase for over a century.

For the case of Australia, the “total dependency ratio” has been declining from

56.1 in 1911 to 50.7 in 1991, and is projected to decline slightly in this decade, plateauing at 49-50 before rising slightly into the next decade (Borowski & Hugo

1997: 46). Despite so, the World Bank report (1994) asserts that reduction in childcare costs will not reduce the overall public expenditure as aged care requires higher levels of spending comparatively. To this end, Easterlin (1991 cited in Borowski et al. 1997: 10) argued that the combined private and public expenditures for young and old would remain at similar levels in years to come.

The World Bank also overlooks the fact that three-quarters of older people require little care services until the very end of their lives and that they have been paying taxes for a large part of their lives (Johnson 1996 cited in Borowski et al. 1997: 11). As such, there should be little cause for panic and it has become clear on hindsight that older people have been made a “convenient scapegoat” to divert attention away from a failing economy (Friedmann &

Adamchak 1983: 57-60 cited in Borowski et al. 1997: 10).

54 2.7 Retirement Income Provisions

The World Bank sent a warning in 1994 through an influential report Averting the Old Age Crisis: Policies to Protect the Old and Promote Growth. This report painted a picture where the young have to shoulder the burden of supporting the older population through publicly funded pension schemes, especially in nations employing the “pay-as-you-go” payment system. It was argued that the current contributors would have their lifetime returns lowered due to unprecedented and imminent payouts for the retiring generation. Such a view grossly overlooked that the payout is what older people deserve for their own lifetime contribution to the economy and for supporting the generations before them.

The proposed solution is an expansion of the pension system into a “three-pillar” system of retirement incomes comprising of publicly funded non-contributory pension scheme, private superannuation schemes, and a universal contributory scheme in which employee’s contributions are complemented by their employer’s contributions and in some cases, by the state as well (Borowski &

Hugo 1997: 8). The case of Australia has been highlighted as a “fine example” in its adoption and implementation of the “three-pillar” system (World Bank 1994:

274-276 cited in Borowski & Hugo 1997: 8).

In contrast, Singapore has a markedly different retirement income scheme since the set up of the Central Provident Fund (CPF) back in 1950. Though being heralded as an ingenious scheme and adopted by neighbouring countries such

55 as Malaysia and Vietnam, the CPF scheme has been criticised for below average returns (as compared to private superannuation schemes) as it is being managed by a single government-linked fund agency which channels part of the returns to shareholders and national reserves. Though nations vary in their policies on pension schemes, they are increasingly heeding the message propagated by the World Bank to avert the “old age crisis” by diverting the

“burden of care” onto the individual, families and communities for the care of older people instead of traditional pension and destitution provisions. Public provisions for the older population can be divided into two main areas of retirement income and healthcare. With increasing privatisation, which is a characteristic of neo-liberal governments subscribing to economic rationalism, older people are increasing left to pay for non-subsidised healthcare services from their own retirement pocket.

2.8 Research Themes in Intergeneration Relations and Family Care

The research themes in intergenerational relations are adequately summarised by Mancini & Blieszner (1989) and Suitor et al (2011). Most of the themes and findings highlighted by them are relevant for this research, particularly those that have direct implications on the provision of parental care by adult children and those related to the older parents’ filial expectations.

As categorised by Mancini & Blieszner (1989), the first order themes are: roles and responsibilities, parent-child interactions, relationships and individual wellbeing, and care provided by adult children. Studies surveyed by Mancini &

56 Blieszner (1989) that explored the roles and responsibilities of older parents and adult children are further grouped as those exploring the filial expectations of elderly parents, and those exploring the roles that adult children and older parents play in each other’s lives.

Researches on the theme of parent-child interaction is further grouped as those exploring the frequency of contact, and those exploring the nature of exchanges, assistance, and support. Relationships and individual wellbeing are explored in terms of the impact on wellbeing through contact with adult children, the provision and receipt of support, and relationship quality. Care provided by adult children looked at structural variables that affect caregiving, relationship between affection and caregiving, and the stresses and burden of caregiving.

The studies cited by Mancini & Blieszner (1989) remain relevant till today for two main reasons. The first relates to the context motivating those investigators to conduct those studies. The second relates to the consistency and value of the findings. As highlighted later by Suitor et al. (2011), studies on intergenerational relations and family care of older people conducted in the

1980s and the few decades prior are ‘fuelled by concerns regarding the broad social changes occurring across that period, including the civil rights movement, the anti-war movement, and the women’s movement’ (p. 164). These broad social changes are followed by the rapid entry of women into the labour force and skyrocketing divorce rates – two social changes that are seen as threatening to the provision of family care for older people.

57 Secondly, and related to the first reason, is that studies reviewed by Mancini &

Blieszner’s (1989) are fairly consistent and collectively debunk the “myth of family alienation” (Shanas 1979), demonstrating that ‘parents and children continued to stay in regular contact and children, particularly daughters, continued to provide care to older parents in need’ (Suitor et al. 2011). As such,

Mancini & Blieszner’s (1989) review is summative of the research efforts prior to the “pivotal point” in the 1980s (Suitor et al. 2011: 164) where intergenerational studies moved on from asking whether children provide support to their older parents to factors influencing parent care.

As highlighted by Suitor et al. (2011), the literature on family care for older relatives over the last five decades has majored in the dyad relationships between the older persons and their adult children. This focus is rightfully so as adult children, besides spousal carers, have traditionally been the main source of informal carers – a phenomenon known as the Hierarchy of Family

Obligations (Qureshi & Simons 1989; Ungerson 1987 cited in Finch 1989: 27-

28).

Besides the broad social changes mentioned in the previous page, drastic increase in life expectancy since the turn of the twentieth century rapidly altered family structures and family life cycles in the post-war years. As such, renewed understanding on parental care was required and sparked an exponential growth of studies ‘to identify and explain these new patterns of relations and their consequences on family members’ (Suitor et al. 2011: 161).

58 As the literature in this area is extensive, most of the studies that Mancini &

Blieszner (1989) have cited and discussed are not included here. Instead, the seminal and representative works of Elaine Brody (and her colleagues), whose work is highlighted by Suitor et al. (2011) as well, will be explored in detail.

The structure of categorisation use by Suitor et al. (2011) – support from adult children to older parents, support from older parents to adult children, grandparent-grandchild relations, diversity and parent-child relations – are also adopted as the structure for this section. Prior to that, the population trends affecting family care and the myths of family alienation and abandonment are elaborated to provide a background on family care researches.

2.8.1 Twentieth Century Population Trends Affecting Family Care

As highlighted by Brody and her colleagues (Brody et al. 1983, 1984), several social and demographic changes led them to focus on women’s changing role and the impact on family caregiving. As highlighted in Section 2.6, population ageing is a consequence of modernisation and the ageing of the older population accelerated the increase in the number and proportion of the older old (75 and over) who are most vulnerable to the need for care.

Demographic data presented by Brody and her colleagues highlights how rapid population changes have a drastic impact on American families. In 1900, the number of Americans reaching old age was 3 million and 4% of the population.

By 1976, there were 22.9 million older Americans, representing 10.7% of the

59 population. In addition, service needs are increased disproportionally more so than the rate of population ageing as the older old (75 and over) – ‘who are most vulnerable to the physical, mental, and social assaults that result in the need for care and services’ (Brody 1978: 16) – are increasing more rapidly than the other age brackets. In addition, the life expectancy at birth of Americans increased from 47 years in 1900 to about 72 years in 1974 and had resulted in drastic changes in family life cycle, particularly survival into grandparenthood and the rise of three-generational households – which is highlighted to be a phenomenon in the twentieth century and beyond (Hareven in Brody 1978: 16).

Demographic data describing downwards from older persons revealed that by the mid-1970s, four out of five older Americans have at least one surviving child;

90% of those with children are grandparents, and 46% are great-grandparents

(Shana 1980 in Brody 1981: 473). As such, four-generation families are becoming common as well (Shanas 1978; 1980). These demographic changes led Brody (1978: 26) to include adult granddaughters in later studies investigating the perspectives of family caregivers across three generations and care giving activities undertaken for older family members.

Concurrent to population ageing, there is an unprecedented large-scale entry of women into the labour force since the 1950s, including the middle-aged. As middle-age women have been the principal carers of older family members

(Brody 1978: 13; 1981: 471), concerns are raised about the availability of familial carers in parental care.

60 Such a concern appeared to be valid as applications for residential placements were surging at that time (Brody and Spark 1966). Furthermore, a majority of the older applicants then did have families14. This trend was contrasted with the past when workhouses (commonly known as poorhouses / poor farms in the US)

– which modern Nursing Homes evolve from – existed as a ‘last refuge for the homeless and economically deprived aged person without family ties’ (Brody &

Spark 1966: 1, emphasis added).

2.8.2 Myth of Family Alienation and Abandonment

Besides doubts in the modernised family’s availability to care, several other social myths such as the “myth of family alienation” – relating to the family’s willingness to care for their older members as a result of perceived poorer social ties – are taking root (Shanas 1979). An assumption of social scientists in the

1950s and 1960s was that urbanisation and industrialisation have diluted the importance of kinship, and greater social and geographical mobility have impacted the interactional patterns of adult children and their older parents. In discussing the “myth of family alienation”, Shanas (1979) broke down the assumptions into four parts:

Because of the geographic mobility of the population of the U.S. most

old people who have children live at great distances from their

14 Based on the waiting list for the Home for the Jewish Aged of the Philadelphia Geriatric Center where 85% of the applicants had at least one child; more than half had three or more children; approximately 7% had no interested relatives (Brody & Spark 1966: 1).

61 children; Because of the alienation of old [sic] people from their

children, most older parents rarely see their children; Because of the

predominance of the nuclear family in the U.S. most old [sic] people

rarely see their siblings or other relatives; and, Because of the

existence and availability of large human service bureaucracies,

families are no longer important as a source of care for older people

(p. 6).

Despite the efforts of gerontologists in disproving such notions by the 1970s, the “myth of family alienation” was so persistent and pervasive that Shanas

(1979) refers to it as the “hydra-headed monster”. These myths not only impede the advancement of aged care research and policy development, it generated branch myths such as the “myth of service substitution” in which the provision of formal services is argued to be undermining filial responsibility and encouraging families to shirk filial responsibilities and abandon their older members by dumping them into residential care (Brody 1981: 471).

The assumptions for the “myth of service substitution” is later challenged by

Brody and her colleagues (Lawton et al. 1989) with a large-scale randomised experiment – documenting respite service usage between the experimental and control groups over a year – and demonstrating that there is no evidence that formal services have substituted for informal services performed by the family.

Research on filial behaviour and the role of the family vis-à-vis formal aged care system in the care of older people found that families remain the main providers

62 of aged care – performing 80% of home care to those 55 and over living in the community (US Department of Health, Education, and Welfare in Brody 1978:

18). Other sources of data reveal that families provide up to 90% of medically related and personal care, are involved in managing household tasks, transportation, shopping, linkages to the formal support system, responding to emergencies, and providing care as and when required (including interim periods when formal care arrangements breaks down) (Brody 1985: 21).

In addition, families continue to share their households with older members who have poor health, thus becoming frail and / or requires assistance in activities of daily living due to the onset of disabilities (Brody et al. 1978 in Brody 1985: 21).

There is also evidence that adult children are providing more emotional support to their older parents than past generations (Bengtson & Treas; Hareven in

Brody 1985: 21). Surveying the gerontological researches in the several decades leading up to 1980 on the role of the family in aged care, Brody (1981) concludes that:

The accumulated evidence documents the strength of

intergenerational ties, the continuity of responsible filial behavior, the

frequency of contacts between generations, the predominance of

families rather than professionals in the provision of health and social

services, the strenuous family efforts to avoid institutional placement

of the old [sic], and the central role played by families in caring for the

non-institutionalized impaired elderly (p. 471).

63 Another preoccupation of Brody’s early works is in debunking ‘the myth of family solidarity in the past that was based on three-generational ties’ (Brody

1978: 16) and the “myth of family abandonment” by presenting research findings that family care and intergenerational ties have not diminished when compared to the “good old days” or “golden past” (Kent in Brody 1978: 17) prior to the 1900.

The irony of the “myth of family abandonment” is that population ageing is accompanied by decreasing birth rate, resulting in increased odds of an adult child being called upon for parent care than in the past where there are more children to care for lesser number of parents reaching old age. Research evidence has subsequently demonstrated that ‘nowadays adult children provide more care and more difficult care to more parents over much longer period of time than they did in the good old days’ (Brody 1985: 21, emphasis in original).

Consequently, Brody (1985) argues that parental care is then becoming so widespread that it should be considered a normative life event of adult children.

Brody & Spark (1966) also highlighted that ageing of older individuals should be seen as a family crisis – particularly at the point of service need – and that the intergenerational impact on the “total family” – felt “even unto the fourth generation”15 – requires attention and sensitivity from the helping professionals and policy maker.

15 This phrase was later used by Elaine Brody’s father (Breslow 1980) in a reflective piece on socio-emotional aspects of grandparenthood and grandparenting.

64 2.8.3 Support from Adult Children to Older Parents

Studies on exchanges between the generations are delineated by Suitors et al.

(2011) into support from parents to adult children, support from children to parents, and cost of caring on adult children’s wellbeing. This section focuses on the support flowing from the adult children to older parents, a primary concern of this research. Support in the opposite direction, flowing from older parents to adult children will be discussed in the next section, highlighting older people’s continued contribution to the family and reciprocity between the generations. Studies on the cost of caring on adult children’s wellbeing will not be surveyed as it is not a primary concern in this research and the reviews by

Mancini & Blieszner (1989) and Suitor et al. (2011) can be referred.

The filial responsibility expectations of older parents are investigated in a series of studies by Seelbach and his colleagues (Hanson, Sauer, and Seelbach 1983;

Seelbach 1977, 1978; Seelbach and Sauer 1977). In summary, ‘[t]hey investigated the extent to which parents expect their children to assist them in times of need, correlations of such expectations for filial responsibility, and predictors of the actual types and amounts of assistance that adult children provide’ (Mancini & Blieszner 1989: 276).

The findings of their studies reveal no racial differences in the types of expectations by the parents or in the level of support provided by the children.

However, there are several gender differences. Older females more likely than males to be living with their children if they are unable to care for themselves.

65 Parents who receive high levels of filial support from their children are likely to be female, not married, of low income, and in poor health.

Brody and her colleagues (Brody et al. 1983, 1984; Lang & Brody 1983) investigated filial responsibility from the perspective of multiple generations of women. They were particularly interested in determining whether women’s changing roles in the family and the labour force had any effect on the attitudes about and preferences for parental care. Their findings are published over three instalments, grouped as: Characteristics of Middle-aged Daughters and Help to

Their Elderly Mothers, Women’s Changing Roles and Help to Elderly Parents:

Attitudes of Three Generations of Women, and What Should Adult Children Do for Elderly Parents? Opinions and Preferences of Three Generations of

Women”.

Central to Brody’s studies was the then-emerging phenomenon of “women in the middle”. As implied by the phrase:

[S]uch women are in middle age, in the middle from a generational

standpoint, and in the middle in that the demands of their various

roles compete for their time and energy. To an extent unprecedented

in history, roles as paid workers and as caregiving daughters and

daughters-in-law to dependent older people have been added to their

traditional roles as wives, homemakers, mothers, and grandmothers.

We conjecture that many of them are also in the middle in that they

experience pressure from two potentially competing values — that is,

66 the traditional value that care of the elderly is a family responsibility

vis-à-vis the new value that women should be free to work outside

the home if they wish (Brody 1981: 471).

Brody’s focus on middle-aged women is particularly important as the proportion of widowed older people who require personal care and assistance in ADL rise sharply from the age of 75 and the principal caregiving family member is usually a daughter (and to a lesser extent daughters-in-law) in their middle age. Middle- aged daughters are also helpers of older women in the care of their ailing older husbands (Shanas 1979, Sussman, Townsend, Tobin & Kulys in Lang & Brody

1983: 193).

Later studies reinforced that mothers continue to receive more support from their adult children than do fathers (Silverstein et al. 2002) and daughters are more likely than sons to be the source of support (Chesley & Poppie 2009).

Such patterns of parent care can be explained by feminist arguments that women place greater investment in relationships and are more sensitive to others’ needs (Gilligan 1982; Chodorow 1978 in Suitor et al. 2011). In addition, daughters are also both older mothers’ and fathers’ preferred source of expressive support and help during illness (Suitor & Pillemer 2006).

Two main characteristics of middle-generation daughters are associated with greater provision of care: not married and not working. Being married and / or being employed appear to be competing demands against parental care responsibilities (Lang & Brody 1983: 199). This finding led Brody to speculate

67 that families have a selection process in that the adult daughter with the fewest competing demands is more likely to be called upon for help. The unmarried daughters are also overrepresented among those who live in shared households with their older parents (Shanas et al. in Lang & Brody 1983: 199).

The age of the middle generation daughters is another significant indicator.

Those older middle generation women (aged 50 and over) provide an average of 15.3 hours of help a week to their older mothers as compared to three hours weekly by their younger counterparts (aged 40 to 49). This finding is consistent with the fact that family members age together and that the intensity of care needs increases due to the increased presence of mental and physical impairments in advancing age.

Consonant to the findings of Soldo’s (in Lang & Brody 1983: 199) national data set, the older middle generation women are more likely to live in a shared household with their older mothers. Brody (1978) referred to this phenomenon as the “refilling of empty nest”. In line with the competing demands perspective, the younger middle generation women who lived with a dependent are more likely to have a dependent child under the age of 18 than an older parent (Soldo in Lang & Brody 1983: 199).

In terms of attitudes towards gendered roles in performing care activities for older people (Brody et al. 1983), successively younger generations are found to be more egalitarian, which is consistent with popular beliefs. However, specific tasks such as performing household chores are still perceived to be more gender-appropriate for women than men. This suggests that although women

68 are increasingly expecting more filial responsibilities sharing from men, the expectations are for a more equitable distribution of care responsibilities rather than for equality in performing the same tasks. In addition, a majority of all three generations of women preferred an egalitarian sharing of roles between women and men – signalling a societal-wide transition.

Contrary to the initial hypothesis (Brody et al. 1983: 599), the oldest generation of women are the most receptive towards the use of formal services although all three generations equally agreed that older parents should be able to depend on their adult children for all kinds of help. Nonetheless, all three generations did not think that women should go to the extent of quitting her job to care for their mothers, indicating widespread acceptance of women’s entry into the labour force.

The phenomenon of “women in the middle” is illustrated by some of the findings in the same attitudinal study (Brody et al. 1983) in that middle-aged women – influenced by their dual roles as daughters and mothers – are consistently divided in attitudes toward formal and informal services usage and whether grandparents should expect help from their grandchildren. In addition, while a majority (61%) of the middle-aged participants work, their attitudes toward filial responsibility and subscription of the “old [sic] value” (Brody et al. 1983: 605) of family care for older persons remains strong. These findings suggest that even as women are more likely to work, they would also continue to undertake filial responsibilities. The concern for policy makers and helping professionals should then be focused on supporting family caregivers.

69 The youngest generation of women are surprisingly most emphatic about filial responsibility. While this is a promising indication that filial behaviour would continue to be strong in the next generation of principal caregivers, Brody et al.

(1983: 605) are concerned that ‘[t]heir attitudes may be the result of an inability to project themselves psychologically into situations of providing or requiring service”. Specifically, the youngest generation are the most emphatic in that grandparents should be able to rely on their grandchildren – an attitude that

Brody et al. (1983: 605) terms as “grandfilial responsibility”.

In the third instalment of three-generational findings (Brody et al. 1984: 743-

744), participants were asked more direct questions of “What should children do?” than did the previous report on the women’s attitude (Brody et al. 1983).

The opinions of the three generations of women were first solicited along the lines of gender, marital status, and employment status of the adult children and in regards to appropriate filial behaviour listed as: adjust family schedule, help with expenses, adjust work schedule, and arrange to live with mother.

The nonworking married daughter is most expected (90% or more of all generations) to adjust her family schedule while the youngest generation of women are most in favour of adult children of all categories to adjust their schedules for family care. Again, this might be a reflection of their lack of life experience. The oldest generation of women is least likely to expect all adult children to adjust their family schedule, ‘probably because of the widespread desire of old [sic] people not to be a burden’ (Brody et al. 1984: 744).

70 However, the oldest generation is most likely to feel that all adult children should adjust their work schedules when help is required. The middle generation is least in favour of working married sons to do so, perhaps projecting this category as their husbands. Nonetheless a significant number of the oldest generation and the majority of the two younger generations do not think that adjusting work schedules is appropriate. All three generations are more likely to expect working daughters to adjust her work schedules instead of working sons. Also, they are more in favour of unmarried working daughters than married working daughters to make such adjustments.

All generations are clear that all adult children should help with expenses though they expect the least from nonworking married women, acknowledging that they do not have an income of their own. While the majority of all generations do not see that sharing a household for parental care is appropriate for all adult children, they are more likely to expect a nonworking married daughter and a working unmarried daughter to do so than by other children.

The former finding is consistent with ‘overwhelming evidence that old [sic] people want to live near but not in the same household with their adult children’

(Brody et al. 1984: 744) – a desire known as “intimacy at a distance”

(Rosenmayr 1968). The latter finding is consistent with the expectation that the adult child with the least competing demands should consider a shared living arrangement with their older mother.

The second set of findings is based on preferences for service providers listed as: child, other relatives, friend/neighbour, volunteer/civic group,

71 pension/insurance, and government; for areas of assistance listed as: expenses, housework, personal care, financial management, grocery shopping, meal preparation, home repairs, and confidant(e)/counsellor. A significant finding regarding the middle-aged generation of women then is that even though they hold onto the traditional values of family care, they wish to be independent of their children, expressing preference for non-family providers of instrumental services. As explained by Brody et al. (1984: 745) ‘these middle-generation women may have felt… the pressure of multiple responsibilities… they may have wished to spare their own children the burden of caregiving’.

Another significant finding is that all generations of women prefer adult children to be confidant(e)/counsellor as well as having responsibilities of financial management. This finding reflects that family members remain the most trusted source of provider when emotional closeness and confidentiality is desired. As such, family ties have remained strong, up until the 1980s. Nonetheless, the majorities of all generations rated all the providers as acceptable for most services reflected the practical attitude of “any port in a storm” (Brody et al.

1984: 745). Further differentiation between male and female providers reveal that for older women, having a male provider of personal care is least acceptable. This suggests that these tasks will continue to be performed by women if the trend in feminisation of the older old continues. However, as the participants are exclusively female, there are no data reflecting the preferences of older men and whether the opposite is true – that female carers are unacceptable to care for older men.

72 The low rankings of non-family providers such as friends, neighbours, and volunteers is noted to be a result of sampling, reflecting the lack of childless older women surveyed (Brody et al. 1984: 745). The level of reliance for non- family providers is speculated to be understated for older people with little or no family support, which is confirmed by participants in this study.

In the latter series of reports, Brody and her colleagues explore in more detail the patterns of parent-care and caregiving experience in relation to the principal caregiver’s work status (Brody & Schoonover 1986; Brody et al. 1987), marital status (Brody et al 1992; Brody et al. 1994), and living arrangements (Brody et al. 1995) – which are the three main dimensions along which principal caregivers are selected within families (Lang & Brody 1983).

The most important finding on work status and parental-care pattern is that working principal caregiving daughters provide lesser personal care and meal preparation than nonworkers. However, the overall care hours provided is similar between workers and nonworkers as the former offset the differences by purchasing care (Brody & Schoonover 1986).

In terms of marital status, married daughters fared best in wellbeing, (family) income, and social support as they can rely on their husbands (and children) for socio-emotional and instrumental support (Brody et al. 1992; Litvin et al. 1995).

In relation to living arrangements, never married daughters are the most likely to have never moved out of the parental home. Separated / divorced daughters are more likely than married and widowed daughters to move back to the

73 parental home while widowed daughters had lived in reformed households for the longest.

2.8.4 Support from Older Parents to Adult Children:

Research in this area gained momentum with increasing rates of two- generational and three-generational families in the US around the 1980s due to the return of middle-age adult children (and their children) into previously

“empty nests” (Mancini & Blieszner 1985). The emergence of the “empty nests”

– where all of the children have left home – is recognised as another twentieth century phenomenon and lasted until the 1970s.

In earlier times prior to 1900, parents continued to have children late in life, thus extending childbearing and having their children forming families of their own when they reached old age (Borland 1982). American Census data revealed that from the 1940s to the 1970s, there is a decline in the rate of intergenerational households and a rapid rise thereafter (Shehan et al. 1984).

Family members cite financial and emotional reasons for their return; rising unemployment and divorce rates in particular led adult children to seek social support, assistance with child care, and other forms of aid from their parents via co-residency (Clemens and Axelson 1985 in Mancini & Blieszner 1989: 277).

While the social benefits of multigenerational households – including increased intergenerational understanding and mutual assistance – have been noted

(Shehan et al 1984), the list of problems is much longer. With additional family

74 members, older parents’ plans and activities can be disrupted. Other issues include overcrowding, mismatch in lifestyle, increased household responsibilities and expenses (Clemens and Axelson 1985; Shehan et al. 1984), and increased parental conflict as a consequence of parent-child conflict (Suitor

& Pillemer 1987). However, in a later study, Suitor & Pillemer (1988) find that the frequency of disagreements between co-residing adult children and their parents was surprisingly low - 64% of the respondents reported that they had no disagreements with their resident child during the previous year; only 18% reported having had three or more disagreements.

Despite concerns that adult children would become overburdened with parent care, research exploring intergenerational exchanges consistently found that older parents commonly provide more support than they receive from adult children until they reach their 70s and 80s (Cooney & Uhlenberg 1992;

Umberson 2006). The flow of support between older parents and adult children usually does not change until the former’s health begins to decline (Eggebeen &

Hogan 1990). Nonetheless, the provision of financial assistance is least age- related as older parents continue to provide monetary support to their adult children over the life course (Eggebeen & Hogan 1990: 222). As highlighted by

Suitors et al (2011: 164), other forms of assistance such as providing childcare and performing household tasks – while their ability permits – should also be considered as financial assistance in terms of cost savings.

In situations where adult children are described as refilling the empty nests of older parents (Brody 1978: 25), the provision of housing should not be

75 overlooked as an area of intergenerational support (Suitors el al. 2011: 165).

However, as there is only one case in this study where the adult child (and her husband) had moved into the older parent’s household, this area of support is explored in the opposite direction, a trend noted by Brody (1978) where the

“empty nests” of middle-age adult children are refilled by older parents who require personal care and other forms of assistance.

2.8.5 Grandparent-Grandchild Relations

Research in this area receive increasing attention as a result of three socio- demographic trends that affected the experience of grandparenting (Suitor et al.

2011: 171). The first trend is highlighted in Section 2.8.1 (see pages 59-61) in that the drastic increase of life expectancy meant that most older people would become a grandparent in their lifetime and occupy that role for about one-third of their lifespan (Shanas 1980; Suitor et al 2011).

Second, increased divorce rates affect ties between grandparents and grandchildren as well as between parents and children. For example, the introduction of no-fault divorce law in the 1970s resulted in drastic increase in

American divorce rates - from 26% in 1967 to 33% in 1970; 48% in 1975; and

52% in 1980 (Nakonezny et al. 1995) – meant that a significant number of grandchildren could be cared for by their grandparents.

Third, drastic increase in the rates of birth to single mothers since the 1970s

(Ventura & Bachrach 2000) mean an increased potential for grandparents to

76 return to the parenting roles in their middle age and later life. However, research in grandparent-grandchild relations tends to concentrate on grandparents of young grandchildren or grandparents as surrogate parents

(Sheehan & Petrovic 2008). With increased longevity, more people would reach adulthood with at least one surviving grandparent (Uhlenberg 2004) and a new

“stage” of family life cycle where both grandparents and grandchildren are having adult roles is an emerging area of study (Sheehan & Petrovic 2008).

The potential of grandchildren providing some form of assistance to older grandparents should be high as most adult grandchildren report having a close relationship with their grandparents (Harwood 2001; Hodgson 1992; Pecchioni

& Croghan 2002). However, parents continue to have an influence on grandparent-grandchild relations even when the grandchild reaches adulthood; adult grandchildren who perceive positive relations between their parents and grandparents are more likely to report closer relations with their grandparents

(Hodgson 1992; Mills et al. 2011). Other studies considering the impact of earlier life events indicate that caregiving provided by grandparents when their grandchildren are young accounts for increased attachment in their relationship when the grandchildren reaches adulthood (Brown 2003; Hodgson 1992).

Consistent with patterns of parent-child relations, gender plays an important role in grandparent-grandchild relations in that grandchildren maintains more frequent contacts and deeper bonds with their grandmothers (Eisenberg 1988,

Hodgson 1992). Similarly, adult granddaughters are emotionally closer to their grandparents (Silverstein & Chen 1999). In divorced families, grandchildren

77 tend to have closer relations to their maternal grandparents (Cherlin &

Furstenberg 1986; Gladstone 1988). Among the grandparent-grandchild dyads, grandmothers and granddaughters report the closest relationships (Dubas

2001).

The primary concern for this study is on the factors influencing grandparent care by adult grandchildren. Dellman-Jenkins et al. (2000) found that among young adult family carers (age 40 and below), 47% are daughters, 44% are granddaughters, 5% are sons, and 5% are grandsons. For the grandchildren, the two main reasons for assuming the principal caregiving role are their sense of filial duty in not wanting to place the grandparent in a nursing home (86%) and their willingness to help their middle-age parents with caregiving responsibilities (52%).

The type of assistance provided by grandchildren carers include transportation

(100% of them do so), companionship and emotional support (100%), household chores and meals (100%), organising medical appointments and medication (90%), personal care (86%), and handling legal and financial matters (67%). Interestingly, there are proportionately more grandchildren than children undertaking care in all areas of assistance.

2.8.6 Diversity and Parent-Child Relations

While studies on racial difference in family relations have been an area of interest for scholars for several decades, direct comparisons along racial and

78 ethnic lines only emerged around the 1990s (Suitor et al. 2011: 170).

Earlier studies show that Black families have stronger ties and support systems than White families (Hofferth 1984, Mutran 1985). On the other hand, White parents are able to provide higher levels of financial support to their adult children as compared to minority groups (Berry 2006) though this difference could be attributed to socioeconomic status and structural differences. In terms of provision of childcare support by older parents (Berry 2006) and the rate of multigenerational households (Choi 2003), it is more common among minority groups than in White families. With regards to studies of racial differences in affect, Black mothers and adult children share greater closeness than their

White counterparts; even after controlling for structural differences (Aquilino

1997; Kaufman & Uhlenberg 1998; Umberson 1992).

Brody’s (Brody et al. 1983) research on the changing roles of women and parental care was extended for cross-national comparison between Japan and the US (Campbell & Brody 1985). This study is one of the best background pieces for this research as Campbell & Brody (1985) explore the effects of modernisation on family care with sensitivity towards but not constrained by cultural differences.

The socio-demographic basis for Campbell & Brody’s (1985) comparison between these two countries was that Japan experienced relatively recent but more rapid urbanisation and industrialisation – resulting in population ageing, ageing of the aged population, and increased workforce participation rate

79 among middle-aged Japanese women – and reaching similar levels to that of the US by the early 1980s. In the US, the workforce participation rate of women in the age brackets of 45-54 and 55-64 was 62% and 42% respectively (US

Department of Labour in Campbell & Brody 1985: 584). In Japan, the workforce participation rate was highly similar at 60.1% and 44.8% respectively (Japan

Economic Planning Agency in Campbell & Brody 1985: 584-585). Such a level of workforce participation rate was only witnessed in Australia from around the mid-1990s (ABS 2017) and took a decade more for Singapore to achieve (DOS

2017a).

As revealed in their samples, 68.7% of the older people surveyed in Japan lived with a child as compared to 17% in the US. The adult child that the Japanese older person lived with was usually the son and the principal caregiver was usually the daughter-in-law. As such, the predominant subgroup of the three- generational women surveyed consists of the older grandmothers, middle-aged daughters-in-law, and young-adult granddaughters (who were the daughters of the middle-aged daughters-in-law).

This cultural aspect of Japanese traditions where the “junior wife” had to learn the ways of the household from the “senior wife” who was her mother-in-law

(and passed them on in turn to her son’s wife) was discussed in detail by Plath

(1980 in Campbell & Brody, 1985: 585). Nonetheless, cultural shifts are noted to have taken place and picking up in pace as younger Japanese couples prefer to live separately from their parents after marriage and intergenerational mentoring between the younger wife and older mother-in-law might not happen

80 or in different fashion as the past. The older generation also feel that the vertical parent-child bond is being superceeded by the marriage bond and the daughter-in-law becomes the dominant female figure in the household rather than the mother-in-law (Lebra in Campbell & Brody, 1985).

The attitudinal surveys reveal that women in both Japan and the US generally favour egalitarian gender roles between men and women in providing family care though the mean scores reveal that Japanese women of all three generations cluster closer to the “undecided” point than their American counterparts (Campbell & Brody 1985: 587). Also, the generational differences are greater in the US sample than in the Japanese’s.

These two findings, along with the scores of the youngest Japanese women corresponding most closely to those of oldest American women, are interpreted by Campbell & Brody (1985) as an indication that even though the processes of attitudinal change is taking place in both countries, Japan has a later onset than the US. Interestingly, the oldest generation of Japanese women are the most progressive in expressing positive views towards women having a career.

In terms of receptivity to formal services and expectations of family members, neither the American or Japanese sample show great enthusiasm or rejection of professional and government services. There are also fewest cross-national differences in this data set despite perceptions that Japanese women would value the provision of family care higher than the Americans. This perception is rooted in the Japanese tradition of social obligation where adult children should

81 feel indebted to their parents for their care and sacrifices and reciprocate by caring for them in old age (Lebra in Campbell & Brody 1985: 585).

The similarities in the two samples from Japan and the US are even more striking when the older generation of Japanese women are more receptive of formal services than the younger generations, though generational differences is greater among the American women. Also contrary to popular perceptions in relation to expectations of older people on their family members to provide care, beliefs about family care are more strongly held by the American women than the Japanese. For example, more older Japanese women surveyed agreed to the statement that: ‘[o]nce adult children have families of their own, they should not be expected to keep in touch with their parents’ (Campbell & Brody 1985:

591).

In terms of attitudes towards older people and the ageing process, the responses are mixed in both Japan and the US. Unexpectedly, Japanese women are more negative in their responses agreeing that older people are too powerful and that they are unlikely to get wiser as they age. Again, this is despite the common perception that Japanese society value respect for older people more so than the West. Drawing from Sussman & Romeis (1981 in

Campbell & Brody 1985: 588) a possible explanation for such negative attitudes may be due to more common presence of multigenerational households in

Japan causing overcrowding and potential for domestic conflicts (particularly between older mothers-in-law and middle-aged daughters-in-law).

82 Taking into account cultural differences influencing some unexpected findings,

Campbell & Brody (1985) conclude that the overall similarities of the findings suggest that:

The trends toward an aging population and an increasing self-

determination in women’s lifestyle are worldwide phenomena with

great power to reshape – or at least call into question – many

attitudes rooted in traditional culture (p. 588).

2.9 Concept of Filial Piety and its Contemporary Developments

As highlighted in the Introduction chapter, the basis for comparison between

Australia and Singapore along the East-West value divide hinges on the East

Asian Confucian value and ethics of Filial Piety. The cultural difference is similar to those noted in Campbell and Brody’s (1985) cross-national study between

Japan and the US and in current cross-national literature mentioned in Section

1.3 (see pages 16-17). More importantly for this study, the virtue of Filial Piety has received considerable interest from gerontologists and social workers working with various East Asian communities, and its influence on family life and social policy, whether positive or negative, remains contested scholarly

(Canda 2013).

Filial piety (Chinese: 孝; pinyin: xiao4) is a Chinese virtue of respect for one’s parents and ancestors. It is one of the four virtues (Chinese: 四字; pinyin: si4 zi4) in Confucian ethical philosophy and is considered a key virtue in Chinese

83 culture (Chan et al. 2012; Chou 2011). Originating in ancient China and later propagated through the teachings of Confucius (551-479 BCEChinese: 孔夫

子; pinyin: kong3 fu1 zi3) and Mencius (372-289 BCE; Chinese: 孟子; pinyin: meng4 zi3), its influence remains significant in modern China and has spread across East Asian societies (Canda 2013).

As a moral and cultural norm, gerontologists have been exploring the influence of filial piety on parent-child relations and parental care in Hong Kong (Chan et el. 2012; Ng et al. 2002; Yeh et al. 2013), Taiwan (Yeh & Bedford 2003, 2004;

Yeh et al. 2013), Korea (Park 2015; Sung 1998, 2001), Japan (Tsutsui et al.

2013), Vietnam (Teerawichitchainan et al 2015; Knodel & Nguyen 2015), and among overseas Chinese communities residing in Singapore (Phua & Loh 2008;

Rozario 2012), Australia (Bryant & Lim 2013; Lo & Russell 2007), America

(Dong et al. 2012, 2014; Hsueh et al. 2008; Smith & Hung 2012), Canada

(Chappell & Funk 2011; Chappell & Kusch 2007; Lai 2007, 2010), Britain

(Laidlaw et al. 2010), Germany (Schwarz et al. 2010), and New Zealand (Li

2011; Liu et al. 2000). Common to these studies is the centrality of filial piety as a distinctively East Asian / Eastern value shaping parent-child relations.

The Chinese character for filial piety (孝) is made up of two ideograms that represent an older man (; referring to the father) above the child (子; referring to the son) (Chan & Tan 2004 in Canda 2013: 214). Despite the patriarchal connotation, filial piety is not limited to the father-son relationship and includes all parent-child dyads. A classic example is that of Mencius who took leave of absence from official duties to mourn his mother’s death for three years – a filial

84 obligation underscored by Confucius in reference to the period of total dependence from birth to three (Brown 2012: 30). Nonetheless, parent care responsibilities have traditionally been placed on the eldest son and his wife, with the daughter-in-law as the principal caregiver due to patrilineal, patrilocal co-residency, and gender role norms (Canda 2013).

The main qualities of traditional filial piety can be summarized from The

Analects of Confucius (Chan 1963; Lau 1979 in Canda 2013: 222):

When parents are alive, obey and serve them; when necessary,

admonish them gently and without resentment; harbor them from

severe punishment; give them no cause for worry other than illness;

nourish them with reverence; as they age, be glad for their longevity

and also be anxious about their passing years; when they die, bury

them properly; afterward, commemorate them with proper rites; and

extend the virtue of filiality through benevolence toward others.

From a young age, children are taught to respect and obey their parents and elders (Chou 2011). When they become adults, they are expected to offer both instrumental support (through co-residency, financial support, and assistance in

ADL) and expressive support (through respect, emotional support, and companionship) (Canda 2013). Children are also expected to ensure fraternity among siblings while parents are to take the lead in maintaining family harmony, providing guidance and nurturance. As such, adherence to filial piety goes beyond shaping parent-child relations and parent care practices, influencing

85 family dynamics as well (Chan et al. 2012; Dong et al. 2014).

Filial piety is often seen as a virtue by gerontologists in that filial care behaviour should be spontaneous and arise naturally from a sense of gratitude instead of a contract-like agreement (Chou 2011; Sung 1998). In Confucian influenced societies, parents are seen as givers of life and their selfless care for the child are an insurmountable deed. In return, children are expected to repay the kindness by providing both direct and indirect care and support and in a respectful, reverent manner (Ng et al. 2002; Sung 1998). In practicing the “way of filial piety” (Chinese: 孝道; pinyin: xiao4 dao4), the virtue of reciprocity

(Chinese: 恕; pinyin: shu4) is key (Sung 2013 in Park 2015: 283). As highlighted by Berthrong (2010: 14 in Canda 2013: 221):

Confucius knew that blind reverence for unreflective filial piety… and

respect for elders could be a mistake… There is nothing intrinsically

good about an aged person who is without virtue. Likewise, there

would be something wrong with a young person if they failed to

respect a worthy elder… But concern for each person demands

reciprocity.

The virtue of reciprocity has been adopted as a bridging concept in comparing intergenerational support between Western-Christian culture and Eastern-

Confucian culture (Schwarz et al. 2010). Another stream of research (Chen et al.

2016; Leung et al. 2010; Yeh et al. 2013) advances the Dual Model of Filial

Piety in which reciprocity and authoritarian forms of filial piety have been

86 identified through tracing and analysing its historical developments (Yeh 1997,

2003). In justifying the contemporary role of filial piety and explaining the conflicting findings in previous researches, Yeh & Bedford (2003: 215-216) argue that the beneficial aspects of filial piety found in previous researches can be attributed to the reciprocal form of filial piety and the harmful aspects can be attributed to the authoritarian form.

Similarly concerned with the contemporary usage of filial piety, Lum et al. (2015) developed the 10-item Contemporary Filial Piety Scale (CFPS-10). Another measure, the Expectation of Filial Piety Scale (EFPS) was developed by Dai

(1995 in Kao et al. 2007: 1463) and translated from Chinese to Spanish version and developed for use in Mexican-American population – thus advancing filial piety as a cross-cultural construct (Kao & Travis 2005; Kao et. al. 2007).

In addition, Sung (1998, 2001, 2004; Sung & Kim 2003) has examined the concept of filial piety, comparing contemporary elder respect behaviours in

South Korea, Japan, Taiwan, and Singapore, thereby identifying 13 common classical actions of filial piety and elder respect that remains in practice today.

The range of actions as summarised by Canda (2013: 216; the keywords that

Sung uses to name each item in bold) are listed below:

1. Providing care and services for elders;

2. Serving desired victuals;

3. Bestowing gifts;

4. Using respectful linguistic forms of speaking;

5. Presenting oneself courteously;

87 6. Providing honorable seats or spaces;

7. Celebrating birthdays;

8. Respecting all elders of the general public;

9. Being acquiescent or obedient;

10. Expressing salutations;

11. Giving precedential treatment;

12. Holding funeral rites; and

13. Respecting ancestors ceremonially.

Despite such scholarly attempts (including neo-Confucian scholarships such as

Angle (2010, 2012) to contextualise and contemporise filial piety, the observance of filial piety in modernising East Asian societies is seen as declining and stressful for all involved (Chan et al. 2012; Cheung & Kwan 2009).

Citing Hong Kong’s institutionalisation rate of 7% - which is higher than most developed and Western countries – as an indicator of the impact of social and family changes, Chan et al. (2012) argues that increasingly, adult children could no longer provide direct care due to a number of factors such as ‘time invested in work and employment, the reduction in family size… the decline in intergenerational co-residence, as well as the spatial limitations of Hong Kong resident flats’ (p. 280).

A similar set of social and family change is impacting urban China and nursing home placement is expected to rise in the future (Zhan et al. 2008). Through examining the views of nursing home residents, their family members, and care staff, Zhan et al. (2008) found that the concept of filial piety has been

88 reinterpreted and broadened to accept residential care options, that children who are willing to afford the high cost of residential care are seen as filial, and that nursing home placement is no longer seen as a form of family abandonment.

In the case of Singapore, Mehta and Ko (2004) observed that even though the value of filial piety remains culturally important, the definition and expression of filial piety has shifted. For example, participants in a qualitative study no longer view absolute obedience as crucial (Mehta & Ko 2004: 78). This is despite the view that financial support for older parents remains as an important component of filial piety in Singapore and that co-residence rate in Singapore remains high at 88% (Mehta & Ko 2004).

In the area of social policy, there are examples of East Asian governments justifying the expansion of aged care services and increased fiscal support based on the principle of filial piety (Canda 2013). However, the prevailing trend observed in East Asia is the increasing state pressure on the family to provide home-based care and financial support for their older members despite the challenges facing modern families (Chou 2010; Chow 2004, 2006; Lin &

Rantalaiho 2003; Ng et al. 2002; Park 2015; Rozario 2012; Zhan 2006). In

China and Japan, children’s filial obligations to their ageing parents are stated in the constitution (Chow 2006; Liu & Kendig 2000b: 13). The governments of

Singapore and Korea have gone a step further, introducing legislature for filial piety in 1996 and 2008 respectively (Chan 2004; Park 2015).

89 Mehta and Ko (2004) has earlier revisited the concept and observed that even though the value of filial piety remains important in modernised Singapore, the definition and expression of filial piety has shifted. For example, on the component of obedience as one of the three levels of filial piety, participants in a qualitative study ‘did not view absolute obedience as crucial’ (Mehta & Ko

2004: 78, emphasis added). Nonetheless, financial support for older parents remains an important component of filial piety in Singapore and the high co- residence rate of older Singaporeans with their family members at 88% is used as an indicator of filial piety as well (Mehta & Ko 2004).

As highlighted above, Singapore is a modernised society and experienced a highly compressed period of rapid industrialisation and urbanisation since independence in 1965. Today, Singapore is a world leader in many social and economic factors, including GDP16 (IMF 2017) and life expectancy17 (see Annex

B of WHO 2016), which are comparable to Australia’s. Not only does modernisation impact the observance of filial piety, it influences society’s perception of older people and ageing issues.

As explored by Hugman (2000), the emergence of elder abuse as a social issue is underscored by the devaluing of old age as a commodity in (post-) industrialised (Western) societies. Hugman (2000) highlighted that within social gerontology, scholars have attempted to explain this lose of status from two main approaches. The first of which is the modernisation thesis (Cowgill and

16 Singapore ranked 7th while Australia is 9th (in the world) 17 Singapore is ranked 3rd while Australia is 4th

90 Holmes 1972; Fischer 1978 cited in Hugman 2000: 145) explaining that as societies industrialise and urbanise (i.e. modernise), the number of older people increases and the corresponding “scarcity value” decreases.

While the proponents of the modernisation thesis focuses on the cultural value of older people and old age, the critiques of the modernisation theory (Walker

1981; Phillipson 1982; Guillemard 1983 cited in Hugman 2000: 146) focuses on the economic value of older people. Industrial capitalism was identified as the context underlying the loss of status of older people who are excluded from the workforce and as such are seen as “unproductive” and not capable of making

“useful” contribution to society in which paid employment is highly valued.

2.10 Feminist Critique and Feminisation of Ageing

Before proceeding to the review of literature on non-family support, a final research focus within the context of family care is with regards to gender issues.

Several of the key findings and themes in this area of work have been mentioned when presenting the works of Brody and her colleagues in Section

2.8).

Not only are women exposed to higher risk of institutionalisation in old age and are more affected by the availability and quality of community care services, the burden of caregiving is disproportionately placed on women, even when they are themselves eligible for care provisions. At the dawn of community care in the UK, Finch and Groves (1980: 494) warned using the “double equation” that

91 ‘in practice, community care equals care by the family, and in practice care by the family equals care by women’.

While greater proportions of women have been entering the labour force, the expectation on them to assume caregiving roles remains high, particularly if they are married (Finch & Groves 1980: 502-503). Giving up employment for caregiving roles results in immediate loss of income, reduction in living standards, and adds to cumulative disadvantage which might lead to poverty in old age for themselves. Therefore, the effects of cumulative disadvantage over the life course is especially pronounced for older women, making it a case of

“double jeopardy” for being old and being female (Sontag 1972 cited in Heycox

1997: 94).

Ironically, though older women are the majority in the aged population – a phenomenon known as the feminisation of ageing – their perspectives are subjugated by the dominant male gender and gender issues are often overlooked, masked, or given less attention (Heycox 1997: 94). The feminist critique also led Finch and Groves (1980) to advocate for a “community care with equal opportunities” policy to look into the interest of women who form the backbone of family care, and thereby community care.

Women in general have a higher life expectancy than their counterparts. In

2015, Australian females can expect to live 84.5 years at birth while Australian males, 80.4 years (ABS 2016b). Though the age gap in life expectancy has narrowed from the widest of seven years between 1970s and early 1980s, it

92 remains significantly and steadily at between four to five years in the past decade. The age gap in life expectancy between Australian females and males remain significant in every age juncture. At the age of 45, females can expect to live to 85.6 years old and 3.5 years more than males. At the age of 65, females can expect to live to 87.3 years old and 2.8 years more than males. At the age of 85, where service needs are considerably high, Australian females can expect to live till 92.2 years and 1.0 year more than males.

The Singapore’s 2015 figures of life expectancy at birth are very similar to

Australia’s at 84.9 for Singaporean females and 80.4 for males (DOS 2017c). At the age of 65, Singaporean females can expect to live till 87.1 years and 3.2 years more than Singaporean males. Though the age gap seems to be closing at higher age brackets, the cumulative effects of higher mortality rates for males over the life course means that a disproportionately greater number of females are among the older old. In 2015, the number of older women aged 85 and over in NSW is recorded as 104,504, which is 1.75 times more than the number of older men (59,589) (ABS 2016d). In another words, among the oldest old in

NSW, 63% are female. In Singapore, the 2015 figure is as disproportionate at

66% (DOS 2016: 41).

Older women are also disproportionately represented as residential care recipients in Australia. As at June 2011, 70% of permanent residents were female. However, this figure includes residents in both low-care (hostels) and high-care (nursing homes) facilities (AIHW 2012). With 63% of all female residents aged 85 and over as compared with 43% among male residents (in all

93 residential care facilities), it is assumed that the proportion of older old females in nursing homes might be more than seven out of 10. The reason for having to postulate here is due to a change in reporting structure through the AIHW who before 1998, had separate reports and data for hostels and nursing homes, providing a unobscured picture for comparison, especially in service usage and rates of admission. In the last available separate report on Nursing Homes in

Australia 1996-97: A Statistical Overview (AIHW 1998: 26), the proportion of older old female residents in nursing homes is 81.2 per cent. This figure also suggests that older women have a higher “rate of institutionalisation” as they pass 85 years of age.

Gibson (1998: 141-142) highlighted such a trend and attempted to explain the phenomenon as a consequence of widowhood. However, the rates of widowhood do not increase as fast as the rate of institutionalisation and therefore widowhood can only be a partial explanation. Even with severe disability rates among older women and men taken into consideration, the rate of institutionalisation among older women is two times the rate for older men with severe disability. In terms of community care service usage, data from the

Australian HACC programs revealed similar conclusions where 64% of service users are female and the gender imbalance increases with age (DoHA 2009: 8).

In Singapore, however, the disparity between the proportion of male and female residential care recipients is far less pronounced even though females do outnumber their male counterparts (DSS 2013a: 309).

94 2.11 Non-family Support

It is estimated that about 10% of community-dwelling older people, especially those with limited familial resources, receive regular informal assistance from non-kin such as neighbours, friends, and other unrelated people (Barker 2002;

Nocon & Pearson 2000). While the literature on this area of study is scarce, the importance of non-kin relationships for older people is well recognised by authors from a wide range of disciplines (as listed by Barker 2002: S158).

Applying thematic analysis to 114 interviews with older care recipients and caregivers who are neighbours, friends, and other “nonkins”, Barker (2002) found four distinct style of relationships – Casual, Bounded, Committed, and

Incorporative. These distinct styles of relationships are observed in this study and Barker’s categorisation is used when discussing about non-family support.

Casual relationships are at the lowest level of social intimacy and are emotionally distant in tone when described. This type of association involves

‘mainly socialising, along with assistance with a few non-intimate instrumental tasks (such as bills or paperwork) in only one or two domains of social life’

(Barker 2002: S162). Bounded relationships ‘generally involved more extensive contacts between the parties than did Casual ones, but these were still focused largely on impersonal, instrumental tasks’ (Barker 2002: S163). Committed relationships ‘involved a degree of emotional intimacy and encompassed complex material exchanges and instrumental task performance in multiple domains of daily life’ (Barker 2002: S164). In addition, the duration of

95 relationship before caregiving begun is significantly longer than Bounded relationship and even more so than Casual relationships, providing a stronger foundation for emotional intimacy. Incorporative relationships are the fourth and deepest type of association where there is ‘greater emotional intimacy and involvement in the life world of the care recipient … [where] either caregiver or care recipient, ends up becoming centrally incorporated into the other’s family nexus’ (Barker 2002: S164).

Barker (2002: S164) also explored various characteristics of non-family caregivers. In terms of motivation most mentioned by caregivers, the top three motivations were prior history of volunteering (21%), seeing an unfilled need

(19%), and religious belief (19%). In terms of reward, the top two ranked were: the relationship made them feel good or gratified (27%) and friendship (20%).

The next two most mentioned and equally ranked rewards were: being appreciated (12%) and treasured the opportunity to learn from the older adult

(12%). The top-ranked concerns or difficulties were getting too involved and not being able to set boundaries (28%), getting too attached (16%) and care recipient being too demanding or unappreciative.

Nonetheless, despite probing, the number of positive comments outnumbers the negative comments by a ratio of five to one. It was also noted that cases where heavy physical or long duration of care was required were the ones that resulted in the most negative comments. Caregiver dissatisfaction is also associated to shorter duration of relationship (under 5 years). Non-family caregivers are also found to be resilient and persist in providing care to those

96 with decreasing mental capacity even thought it was revealed as distressing to them. They were able to sustain their involvement with people ‘with increasing mental frailty or with those with difficult personalities because of warm memories of past sentiments’ (Barker 2002: S165).

Non-family care relationships are complementary to family relationships. More than half (53%) of the non-family caregivers provided a supplementary or back- up role to formal services and family. However, more than one-third (38%) of non-family caregivers were the principal (and sole) caregiver providing daily assistance that no one else did. Non-family caregivers were also found to be performing tasks that are more difficult than those performed by formal services and families and in more flexible arrangements that are convenient to the care recipients. During times of emergencies and crisis, non-family caregivers are also willing to step-up the amount of help. This category of caregivers are as such important for community-dwelling older people, especially to those with limited or no family support and in cases where formal services are less developed or available. 60% of the participants in Barker’s (2002) study and two-thirds of Nocon & Pearson’s (2000) participants had not living kin (including extended relatives), either never had children or their children were deceased.

There are also a small proportion of older care recipients in both studies who had distant kin but they were unavailable as they are living far away (including living overseas) or contact had not been established for years (or even decades).

97 2.12 New Community Models of Care

Similar to carers’ support, community support might become a new direction and new strand in aged care. Around the world, new community models of care are being explored, established, and evaluated. In the US, the Naturally

Occurring Retirement Community (NORC) and “Village” models emerged as strategies for community support with explicit aims to facilitate ageing in place by strengthening communities. The “Village” concept originated in 2001 in the

Beacon Hill neighbourhood of Boston where a group of older people came together to help one another live as long as possible in the neighbourhood. An independent non-profit organisation has since been established, governed by the members themselves, and sustained by fee collections and donations.

Central to the operations, an executive director is employed to respond to individual members’ service requests, procure services at discounted rates, coordinate a pool of volunteers to assist with shopping trips and other helps, and work alongside members to organise social activities and education talks.

Most of the 120 and more villages are initiated by the efforts of independent grassroots while at least one in six villages are established through collaborative efforts with health or social service providers (Greenfield et al.

2012).

NORC programs are initiated at the community level bringing together various stakeholders – including residents, local government, housing managers and owners, and local service providers – within a defined residential area – most often an apartment or neighbourhood – with a large population of older people

98 to coordinate a range of services to facilitate ageing in place (Alexander 2006;

Atman 2006). NORC refers to locations that are not originally designed for older people but have over time became comprising of a sizeable number or proportion of older residents due to long-time residents remaining in their homes or in-migration (Ormond et al. 2004, emphasis added). In contrast to

Villages, NORC programs are often managed by community-based non-profit social service providers instead of being freestanding entities. Common NORC services are similar to those offered by villages and includes social services, health care services, education and recreational opportunities, volunteer opportunities, and ancillary services such as home maintenance and transportation (Greenfield et al. 2012).

In Israel, the “supportive community” program was jointly managed by ESHEL –

The Association for the Planning and Development of Services for the Aged in

Israel – and the Israel Ministry of Social Affairs in partnership with non-profit and for-profit organisations for older people and local authorities (Berg-Warman &

Brodsky 2006). The program charges a subsidised fee, pulling together resources to provide ‘a benefit package that includes medical services, an emergency call switchboard, a “neighbourhood facilitator”, and social activities’

(Berg-Warman & Brodsky 2006: 69). This model is found to be a cost-effective way to facilitate ageing in place in meeting many of an older person’s essential needs. The top three benefits reported by older service users are: increasing personal safety (two-thirds), easing the burden on their children (one-third) and enabling them to remain at home (one-quarter) (Berg-Warman & Brodsky 2006:

70). In addition, quality of life is enhanced and the older person’s preference of

99 remaining within their familiar surroundings of the home and the neighbourhood is enabled.

While the paradigm shift from community care to carers’ support and community support is gaining momentum, huge gaps remain in understanding the dynamics of communities and strategies to drawing out their potential to provide a supportive environment for older people. As elaborated below, much knowledge about communities can be drawn from ecological frameworks and studies in the interrelated concepts of “social capital” and “social cohesion”.

2.13 Concept of Communities and Community of Care

Finch and Groves (1980: 494) highlights the importance to examine the concept of the “community” especially when advocates of community care assumes that

‘that there exists some kind of grouping of people who are both able and willing to take on an active caring on a consistent and reliable basis’. In order for such a community care model where care is by the community and not simply in the community, proximity is important for the delivery of care and support and as such a geographical model is necessary.

This research understands “communities” as a geographical area whose residents are connected through ‘some combination of shared beliefs, circumstances, priorities, relationships or concerns’ (Chaskin 1997: 522).

Although often used interchangeably, the definition of a “community” and

“neighbourhood” do not always overlap perfectly. Neighbourhood is often

100 defined as the local residential area or physical environment while a community, though often geographically-bounded, refers to the common bond and identity between residents in a neighbourhood or the social environment. In addition, living in a neighbourhood does not translate to participation and a sense of belonging in a community. As such, to accentuate such as distinction, the anticipation and practicing of local social interaction is described as referred to as “neighbouring” (Forrest & Kearns 2001: 2130).

Ageing in place refers to being able to remain at home despite having increasing need for support and care due to life changes such as onset of disabilities, deteriorating health, widowhood, or loss of income (Pastalan 1990).

This concept has been reconceptualised and broadened to “ageing in community” by Thomas and Blanchard (2009), seeing older people as integral members of their community.

As the person ages, they experience changes in their individual attributes and may be challenged further by their social and physical environment. When the demands from their environment overwhelm their resources, it is believed that the individual is less likely to age in place (Lawton et al. 1997). For example, the onset of disabilities and functional decline in mobility and the need to climb a flight of steps to reach a two-storey home might persuade older individuals and their families to source for alternative accommodation unless their resources

(for example, financially) permits them to alter the environment by installing a lift to remove the physical barrier. Ranjizn (2002) points out that theories of adaptation in ageing predominantly sees the individual as passive respondents

101 with declining abilities and departs to propose that older individuals can adapt, especially when environment barriers are removed, and in adapting, acquires the ability to influence their environment and community.

This research goes another step to propose that the potential of the community has largely been untapped to support the adaptation process of individuals. If the community is supported and attuned to the needs of the ageing individual, a positive cycle might emerge with the community supporting the individual in breaking environmental barriers and thereby enabling older individuals to participate in the community and garner more support by attuning the community to their needs.

“Community of care” is a new concept proposed in this study to encapsulate the influence and potential of communities (and neighbourhoods) – which encapsulates both the physical and social environment elements of that the ecological frameworks have on facilitating “ageing in place” and “ageing in community”.

2.14 Interrelated Concepts of Social Cohesion and Social Capital

Literatures on social cohesion notes that for people who have lesser physical and social mobility – such as children, older people, people with disabilities, and people outside the labour force – spend much more time in the neighbourhood and are more likely to be engaged in community participation (Henning &

Lieberg 1996). Older and poorer people, in particular, ‘show little change in their

102 pattern of neighbouring and are apparently relatively more dependent on local ties’ (Forest & Kearns 2001: 2133).

In addition, the Survey of English Housing and the Scottish Household Survey reveals that the view of poorer neighbourhoods having higher level of

“community spirit” than wealthier estates is erroneous as the generation of

“community spirit” is correlated to the availability of resources (Forest & Kearns

2001: 2131). As such, older people living in poorer neighbourhoods are more likely to experience poorer quality in community ties, lesser support from neighbours, higher risk of loneliness and social isolation, and exposure to crimes and a sense of insecurity. Strategies to strengthen communities are therefore vital especially for disadvantaged older people.

The relationship between social cohesion and social capital is in their operative level. Forrest and Kearns (2001) explains that social cohesion is viewed as a bottom-up process founded upon local social capital, rather than as a top-down process. In other words, the greater the level of social capital, the stronger the level social cohesion is expected. The concept of social capital has been developed mainly by Bourdieu (1986), Coleman (1988), Putnam (1993, 1995,

1996) and Fukuyama (1999) and adopted widely for academic and policy discussions. Similar to the concept of social cohesion, Forrest and Kearns

(2001: 2137) criticises that ‘overuse and imprecision have rendered it a concept prone to vague interpretation and indiscriminate application’. Nonetheless,

Putnam’s (1993) popular approach to defining social capital is preferred:

103 By analogy with notions of physical capital and human capital…

social capital refers to features of social organisation such as

networks, norms and trust that facilitate co-ordination and co-

operation for mutual benefits. Social capital enhances the benefits of

investment in physical and human capital (p. 35).

Despite the variations in conceptualisation and definition of social capital, several themes and domains emerged from theoretical and policy debates.

From their work for Scottish Homes (see Burns et al. 2000), Forrest and Kearns

(2001) identifies eight domains of social capital and the corresponding appropriate neighbourhood policies to support them (see Appendix A). These eight dimensions of social capital can contribute significantly to the wellbeing of older people living in the community.

Dimensions such as “trust” and “safety” may be particularly important for older people living alone or with other older people. The prescribed local policy to foster the dimension of “belonging” can be interpreted as a need to integrate

“age-friendly” features in urban neighbourhood designs (Barusch 2013). The other dimensions, though at a broader level, can indirectly support older people by creating a safety network of monitoring, crisis detection and intervention, informal helps, and thereby creating a “community of care” which is consciously integrated into the neighbourhood’s ethos.

104 2.15 The Ecological Model as Theoretical Framework

In order to understand how communities can be a source of care and support for older individuals, this research adopts the perspective of Greenfield (2012) in employing ecological frameworks in advancing research on ageing in place.

Greenfield (2012) draws from the general ecological model of ageing (Lawton

1990; Lawton & Nahemow 1973) and bioecological systems theory (BST;

Bronfenbrenner 1979; Bronfenbrenner & Morris 2006). Ranzijn (2002: 30) also began discussions with similar theoretical foundations and highlights ‘the potential of the person-environment fit concept to enhance the ability of older people to contribute to society and improve the quality of life of the whole community’ (emphasis added), seeing the individual and their environment as mutually influencing. Lawton’s model emphasises the dynamic interaction between the ever-changing individual and their ever-changing environment to create a person-environment “fit” (also referred to as congruence or match) – which is negotiated by the individual’s attributes and competencies in coping with the demands and qualities of their environment.

Bronfenbrenner’s theory similarly pays attention to how the person-environment interaction influences the individual’s functioning, over time. The individual is seen as embedded within a complex social context like ‘a set of nested structures, each inside the other like a set of Russian dolls’ (Bronfenbrenner

1979: 3). The environment context can be seen as all encompassing and

‘includes the immediate physical surroundings, the social environment (family,

105 friends and acquaintances), the wider community, the political situation, the economic and legal systems, and the local and global cultural contexts’ (Ranzijn

2002: 32).

As such, due to the exploratory nature of this study, the Bronfenbrenner’s BST is adopted as the main theoretical framework in understanding the complex interplay between older persons and various components of their social and community context. Figure 1 on page 107 is an adapted model of

Bronfenbrenner’s BST, depicting the individual as nested in the centre of the various layers – namely, the Microsystem, Mesosystem, Exosystem,

Macrosystem, and Chronosystem. The adaptation is required as the original model was conceptualised as a theory for childhood development. As such, components such as the school is replaced by work and personal attributes such as income and assets are added to reflect the lifestage of an older person.

In brief, the Microsystem is the immediate surroundings and relationships that the individual have direct interactions and activities with regularly. The

Mesosystem is the connection between components of the Microsystem such as interaction between the family and aged care services, which do not involve the individual. The Exosystem are social institutions and relationships that influence the individual indirectly in it is beyond their control. The Macrosytem consist of even broader and structural influences such as cultural values, legislations, and government funding. The Chronosystem is a later addition to the model, relating to the influences of sociohistorical and life events such as war, the global financial crisis, marriage, and divorce.

106 Figure 1: Model of Bronfenbrenner’s Bioecological Systems Theory

MACROSYSTEM Attitudes & ideologies of the culture

EXOSYSTEM

MESOSYSTEM

Social Local MICROSYSTEM Politics Services

Family Peers / Workplace Friends INDIVIDUAL (Gender, age, ethnicity, health, education, income, asset, etc)

Recreation Religious Facility Affiliation

Health & Mass Aged Care Media Services Economy

Neighbours

CHRONOSYSTEM: Sociohistorical conditions and time since life events

Adapted from Bronfenbrenner (1979) and Bronfenbrenner & Morris (2006)

107 2.16 Conclusion

An attempt is made to trace the rise and historical development of ageing issues and aged care systems in both Australia and Singapore, gaining insights from major works in the two countries and available official information. This first part of the literature review from Sections 2.2 to 2.7 provides the background knowledge of the respective country’s aged care system, state provisions, and retirement income provisions that older participants in this study might experience and have perspectives about their efficacy and limitations.

The second part of the literature review from Sections 2.8 to 2.12 informs this study of the research themes and existing knowledge about care within the family context, care beyond the family, and community models of care. The third part of this literature review from Sections 2.13 to 2.15 is a discussion of the concepts and theoretical framework that is adopted in this study.

108 CHAPTER 3: METHODOLOGY

As highlighted in the Introduction chapter, the focus of this study is on the contextual role of the family and the community for community-dwelling older

Australians and Singaporeans. Drawing on the researcher’s background, the contrasting ethic composition of the two countries, and the academic debates on aged care along the East-West value divide, the following research questions were derived to guide the enquiry:

l Is there an East-West value divide in aged care between Australia and

Singapore? l How is the informal support network of older Australians and Singaporeans

like and what are the similarities and differences in the two aged care

systems? l To explore the strengths and limitations of centre-based organisations and

community services in which the participants were accessing. l What are the areas where there are convergences, divergences and

parallels in the care of an older person in the two countries that has

practice and policy implications?

In addition, this research is designed to draws on the perspectives and experiences of older people, providing a platform for their voices to be heard.

While Chapter 2 provides a critique of the existing literature and official information about the aged care systems of Australia and Singapore, this study believes that it is an incomplete picture without the perspectives of older people

109 who are experiencing care themselves. As such, the above research questions were addressed through conducting face-to-face semi-structured interviews with participants who are service users of community care services and community organisations – which are important social connectors within the local communities and a significant part of an older person’s care system as they age in place in the community.

The aim of this chapter is to explain the rationale behind the choice of methods and to detail the steps taken to ensure rigorous research and the ethical considerations that were made throughout the research process. This chapter begin with the justification for an interpretivist and qualitative approach and description of the recruitment sites and recruitment processes.

3.1 Justification for an Interpretivist and Qualitative Approach

At the onset, eliciting and preserving the perspectives of individual older people has been a paramount methodological concern as their voices were lacking in the realm of research and policy-making in the area of community care. As criticised by McCallum and Geiselhart (1996: ix) at the tail end of the ACRS, the aged care sector had ‘assumed that the elderly are a homogenous, disadvantaged group with common interest… [and] policy changes were directed by people with little or no contact with elderly people’. While two decades have passed, the legacies of the ACRS persisted till today as the second Australia-wide aged care reform has only recently begun in July 2013 and changes to the sector are yet to be fully implemented and evaluated. Again,

110 consultation with older people and service providers appears to be lacking in the current reform even though in rhetoric, the policy changes are envisioned to provide older people with more control of their own care package with transitions to consumer-directed care. In Singapore, statistics and information on the state of home-based and community care is not as well documented and readily available as Australia and there is less evidence of consultation with service providers and users by the policy-makers.

As such, for this study, the perspectives and experiences of older participants who are community service users are the main source of data. Consequently, the epistemological position adopted for this study is interpretivist as the focus is on the ‘understanding of the social world through an examination of the interpretation of that world by its participants’ (Bryman 2016: 375).

While McCallum and Geiselhart (1996) were concerned with the source of knowledge that informs our understanding of the needs of older people and ageing issues, Hazan (1994) cautions that:

Ageing as an existential state is not amenable to conventional

sociological explanations, and to the extent to which support systems

for the aged are informed by academic constructs they are

misguided. If the caregiver’s image of the old does not reflect the

experience of being old, then the services rendered, rather than

providing relief and well-being, may serve only to induce further

frustration and degradation (p. 83).

111 An example of a mismatch between academic constructs and an older person’s lived experience and reality became evident early in the course of Wiles et al.

(2011) study on the meaning of “ageing in place” to older people. They noted that ‘the phrase “ageing in place”, so popular among policy makers and service providers, was not familiar to most of the older people who participated in our research’ (Wiles et al. 2011: 360). The older research participants ‘often ask for the phrase to be repeated and wonder what it was supposed to mean’ (Wiles et al. 2011: 360), which prompted the investigators to take a step back and explore their participants’ own understanding of the previously assumed “well- used policy phrase” and develop a working definition for the term “ageing in place” collaboratively. Eventually, the phrase “staying in one’s home or community” substituted for the term “ageing in place” in their questioning and more spontaneous responses were elicited from the research participants.

As such, it was contemplated as unwise to begin this inquiry with surveys and questionnaires that had been preconceived and informed by existing academic constructs and terminology that has little meaning in the participants’ social world and thereby risk eliciting data and findings that would mislead us further.

Therefore, the constructionist oncological position is adopted with the view that

‘social properties are outcomes of the interactions between individuals, rather than phenomena “out there” and separate from those involved in its construction’ (Bryman, 2016: 375). In addition, a more exploratory and open- ended approach of questioning was sought and the qualitative research approach provided the necessary strategy and stance.

112 As listed by Bryman (2016: 375), qualitative research as a research strategy has three main methodological positions: interpretivist, constructionist, and inductivist. As mentioned earlier, the interpretivist and constructionist epistemological and oncological positions are essential in investigating the individual perspectives, subjective experience, and personal interpretations of older service users whose voice has been largely missing in previous policy developments, documents, and evaluations. Inherently, the inductive view that theory is generated from research is fitting for this exploratory study where new knowledge and identification of new streams for future research is desired to be generated through the views of research participants. As highlighted by Bryman

(2016: 27), ‘[t]aking the interpretative stance can mean that the researcher may come up with surprising findings’ as the research is not designed to be theory- testing but rather theory-generating.

The main preoccupation of the forerunners of qualitative research and interpretivism (such as Schultz 1962 and Bogdan & Taylor 1975 cited in

Bryman 2016: 26-27) is about ‘viewing events and the social world through the eyes of the people that they study’ – which was earlier highlighted as the primary methodological consideration for this study. Another characteristics of qualitative approach is in the production of “thick descriptions” (Geertz 1973 cited in Bryman 2016: 384, 394) of the social world of the participants which provides a highly complex and contextualised understanding of social behaviour, norms, values, and beliefs about an individuals or a social group – which in this study are community-dwelling older persons. Presenting a rich description of the data and findings would hopefully attune us towards a deeper

113 understanding of what it means to be ageing in the community and the complex reality of what constitutes family and community-based care for the older population.

As detailed in the Introduction chapter, the expansion in home-based and community care in Australia is part of the deinstitutionalisation process brought about by the ACRS and the consequences and subjective realities of this movement in aged care services needs to be explored and understood through the perspectives and experiential knowledge of older service users who are the direct consumers of care. While Singapore’s home-based and community care sector is developing at a much slower pace than Australia, there is a similar need to consult the views of older service users. Stemming from this epistemological viewpoint and methodological concern, an interpretivist framework for inquiry and qualitative approach to data collection and analysis has been adopted. A detailed description of the qualitative methods and strategies will be elaborated in later sections.

3.2 Researcher’s Standpoint – Values and Assumptions

In employing a qualitative approach and particularly an interpretivist epistemological framework of analysis, it is important that the researcher be aware that prior knowledge, values, and assumptions shape the researcher’s perceptions of the social world under investigation. Using Lynch’s (2000) definition of “philosophical self-reflection”, which involves ‘an inward-looking, sometimes confessional and self-critical examination of one’s own beliefs and

114 assumptions’ (p. 29), the list of values and assumptions generated is as follow:

l Being a social worker professional, the values of the researcher have been

shaped by the profession’s code of ethics (AASW 2010; SASW 2017)

which encompasses a set of the core values: service to humanity; social

justice; dignity and worth of the person; importance of human relationships;

integrity; and, competence. These values have also influenced the

research aim and provide a lens in which issues of service user rights,

service provider responsibilities, and the social network of older participants

might stand out more than other issues of exploration.

l As a former manager of a community care service in Singapore, two biases

are recognised. Firstly, the motivation for undertaking this study stemmed

from a desire to better understand what community-dwelling older people

want and need. From a practitioner’s perspective and someone involved in

developing a community service that was recognised as effective in

addressing issues of social isolation and feelings of loneliness, there is a

tendency to see formal services as an important component of an older

person’s support network and its importance and efficacy might be

overrated.

l Secondly, with an assumption that Australia’s home and community care

sector is more developed than that of Singapore’s, there is desire to learn

more about the Australian system. However, it is assumed that the sense

of community felt by older people is better in Singapore due to the

115 emphasis (by the state) in having a safety net that is formed by “many

helping hands” (see Section 2.5 for elaboration).

l Culturally and socially, the researcher grew up being influenced by

Confucian teachings of filial piety conveyed through school curriculums, the

media, and in the family context. It is easy to simply assume that

Singaporean’s perception of older people and ageing issues is more

positive than those held by Australians. Furthermore, such an assumption

of cultural difference is fed by negative media reports and encounters with

older Australians during the researcher’s stay in Australia. Nonetheless, the

researcher has taken a critical stance in this area and reflects that

journalistic practice in Australia and expression of filial responsibility

through purchase of services should be considered for a balanced view.

l The researcher is aware of possible researcher-respondent dynamics

arising from attributes of gender, ethnicity, religion, age, social class, and

lifestyle (Padgett 1998: 23-24). Although attention is paid to rapport

building at the beginning of interviews, establishing it is not guaranteed. As

such, in interviewing and interpreting issues where participants have

provided a perspective that was different from that held by the researcher,

a sense of curiosity and reflexivity is used to curb the effect of personal

attributes, biases, values, and assumptions that would negatively influence

the research processes.

116 3.3 Support Organisations and Recruitment Process

Recruitment of older participants was designed to be done through “support organisations”, namely, local councils, community / neighbourhood centres and community care service providers, which are important points of contact for older people living in the community who are in need of support and / or actively participating in community, social, and recreational activities. Eventually, all six sites for recruitment were centre-based community care services and community organisations where gaining access had to be secured through lengthy negotiations with gatekeepers and ongoing liaison with frontline stuff.

The sampling process was designed to be purposive and with maximum variation, though in reality, it was heavily influenced by the decisions of the key personnel, becoming more snowballing in nature.

A total of 30 older participants in each country was targeted to achieve significant breadth and variation in demographics such as age, health status and functioning level, availability of family support and living arrangements, service needs and participation level in the community. Through the help of the various supporting organisations, a total of 31 older participants in Australia and

32 in Singapore were recruited and interviewed. In both countries, there was one “revocation of consent” each after the interviews were conducted. Such a response had been anticipated and designed for participants to retain control of the information shared in the course of the interview. The various ethical considerations to minimise the risk of coercion and risks of distress for the participants is elaborated further in Section 3.9 (see pages 145-149).

117 In the rest of this section, the engagement process and outcome of discussion with the gatekeeper and frontline staff of support organisations will be elaborated. To reflect the sequence in fieldwork periods, Australian recruitment sites will be mentioned before Singapore’s. The Australian and Singaporean sites are prefixed with A and S respectively. The listing of support organisations also reflects the chronology in which access was secured.

3.3.1 Australian Recruitment Sites

Initial support for the study was sought from both Australian and Singaporean community organisations as part of the ethics application and to establish linkages before receiving ethics approval so as to expedite the recruitment process. Emails detailing the purpose of the study and nature of the support required in recruiting research participants were sent to various agencies in

Metropolitan Sydney (see Appendix B for the Email Template to Support

Organisations). Despite receipts that the emails had been received and with follow-up calls, the direct approach produced no response.

In the second round of requests, local councils which had a HACC department and / or Aged Council, were selected as the presence of these functions reflected ageing issues as an emerging or existing need in the respective local area and that there is a potential pool of older participants to recruit from.

Contrasted by the subsequent success in obtaining support through the local councils, it appeared that HACC service providers and community / neighbourhood centres responded more readily when the request came through

118 the funding and / or management agency.

Council A responded within the first week and a meeting with the “Manager of

Aged Services” was arranged for a face-to-face discussion. As Council A oversees the operation of the day centre (Site A1), subsequent approval from the day centre’s “Program Supervisor” was granted without much delay.

The “HACC Development Officer” from the Council B replied in following week with an invitation to share the research project with the HACC-funded aged care services in that region during their next monthly meeting. Posters (see

Appendix C) and flyers (see Appendix E) were distributed during the monthly meeting and several service providers left their email addresses for more information to be sent them for consideration. Soon after, a day centre (Site A2) granted permission for the participants to be recruited through their social day care program. In addition, a service user of a community centre in the same regional area saw the poster being put up in the centre’s notice board and contacted the researcher directly.

The “Community Worker” from Council C responded in the following week indicating support to link up with HACC services and community centres in their local area. A visit to a community centre (Site A3), which is run by a public housing tenants’ group, was arranged. After explaining the details of the research project face-to-face, the representatives from the tenants’ committee agreed to assist with the recruitment.

119 The finalised recruitment procedure and processes at each location will be elaborated as follow as each centre has their own protocol and preferences, which was respected and negotiated with research ethics in mind.

Site A1 is one of the community care service managed directly by Council A in the Western part of Sydney, which is providing a range of support services for frail older persons, people with disabilities, people with dementia, and their carers. The service aims to offer assistance so that older people and their carers may maintain an independent and quality lifestyle, which is closely related to the focus of the study. The range of HACC services listed include social day care program, home helps, community transport, dementia support, and carers support. Though a separate team of staff manages each sub-service, the various teams operate from a common location and collaboratively. For example, the community transport team provides the busing need for the social day care program – transporting service users to and fro the centre and on outings.

When discussing the target group for recruitment, the manager highlighted that clients of the social day care program are mostly independent community- dwelling older people. The clients who were home visited were not included as potential participants as they are collectively frailer and some were reportedly having cognitive impairments, which is an exclusion criteria due to ethical consideration related to informed consent. The manager also stated that formal consent from the family and police check had to be in place before the home visited group of clients could be interviewed. Even though Council A was the

120 first to indicate support for the study, access to clients was not as straightforward as compared to the other sites due to the hierarchical management structure. The information was passed down from the manager to the respective program supervisors, and then to the respective frontline staff who facilitated the different day groups.

Following planned ethics considerations, information giving and sign-ups were done through the service staff and facilitated with posters and flyers. Scheduling of interviews was facilitated by the frontline staff and could only be done when the researcher arrive on-site as the staff were unable to confirm clients’ attendance until that morning due to unforeseen circumstances such as illnesses. Despite some ground issues, Site A1 provided access to a high number of clients with varied life experiences, family structure, and living arrangements. Most of the participants have also been living in the area for more than a decade and remained closely connected to the family (who are mostly living nearby), the neighbours, and the wider community. Another requirement from the manager was that the interviews had to be conducted at the centre and a room with sufficient privacy was provided for the interviews.

Site A2 operates in an Eastern suburb of Sydney. Their current premise is a joint partnership between two non-profit organisations. The social day care program is partly HACC-funded and supplemented by the donations from an ethnic community. Though it is set up to provide care to members of their ethnic community, Site A2 welcomes referrals from any sources and has 5% or more clients from other ethnic backgrounds. The aim of the centre is to support older

121 members of the community to live at home, which provided an insight into how community care services envision their role in supporting community-dwelling older people to age in place and continue living independently.

Recruitment was done on-site through direct sharing to two day groups. The manager and frontline staff nominated this arrangement as they see service users as independent individuals who have full liberty to choose how they would like to spend their time at the centre, including participation in a research interview. After the sharing and initial sign-up, participants were individually spoken to for an appointment. Similar to Site A1, interviews were suggested by the manager to be conducted at the centre, though service users of Site A2 were able to override that proposition and several interviews were conducted at the residence of the participants based on their preference.

The public housing estate where Site A3 is located within was constructed immediately after World War II as part of the NSW Housing Commission’s response to post-war housing shortage. Several participants reported being the first group of tenants when they were young children and are living witnesses to the construction of the high-rise blocks. One can imagine the attachment the original residents have of this place and several early days residents remained actively and heavily involved as a part of the tenants’ group that operates the community centre.

The tenants’ group positions itself as a “not-for-profit incorporated organisation”, which had recently received charity status as a provider of services to public

122 housing tenants in their estate. The tenants’ committee, who reports to Council

C, comprised of annually elected representatives within the estate. Promoted as a homely environment, Site A3 impressed with the level and range of support for the tenants, the level of self-organising among the committee and other volunteers, and their collective resourcefulness in improving the physical and social environment of the estate – which was described as a conscious effort to move away from the stereotypical image of public housing tenants and estates.

Their current project is an ambitious attempt to establish a “Wellbeing Centre” within the estate that is envision to be managed by a registered nurse and having clinics throughout the week facilitated by satellite teams from the district’s health services. This public housing estate has a rapidly ageing community and the support for this initiative, which is possibly the first of such in a public housing estate, is mainly driven by the fact that a high proportion of tenants are aged 65 and over. Negotiations with the various stakeholders were in the final stage when the interviewing was concluded in this site.

The vice-chairperson of the tenants’ committee, who is a well-connected and well-respected figure who has lived in the estate “all his life”, facilitated recruitment of participants at this site. Nonetheless, in view of ethics considerations to avoid any potential for coercion (see Section 3.9.1), an indirect approach of recruitment through flyers placed in the mailboxes was employed. Posters were also put up in the community centre and the various block noticeboards. Potential participants were given the option to contact the researcher directly or through the community centre. Half the interviews were

123 conducted in the community centre while the other half were conducted at the residence of the older participants, as nominated by them.

3.3.2 Singaporean Recruitment Sites

Engagement with community care service providers and community centres in

Singapore followed a similar path as Australia. As part of the ethics application, initial support was sought from organisations in Singapore and commitment was first rendered by the Community Service A – which is an established service provider that operates a number of Family Service Centres (FSC) in the country.

Prior to travelling to Singapore, emails were sent out to shortlisted organisations that are providing home-based and community services to older people. Similar to the situation in Australia, a direct approach to community organisations did not produce a response. Follow up calls were made upon arrival in Singapore and the search for partnerships was expanded while a meet up was arranged with the “Executive Director” of Community Service A, which operates the SAC at Site S2. A week later, the “Administrator” of the day centre at Site S1 replied and agreed to assist in recruitment. About a month later, agreement with the

SAC at Site S3 was finalised. A “Service Manager” of a fourth organisation had initially expressed interest in supporting the study. However, a key member of the management committee denied further involvement after a short meet up.

Site S1 operates as a day centre and is an extension of a non-profit VWO under the auspice of a Taoist temple. Similar to the myriad of faith-based VWOs in

124 Singapore, Site S1 is required to be non-religious in their delivery of community care services and is not to refuse service on the basis of one’s religion. The social day care program at Site S1 is similar to Australia’s in that service users are provided with transport to and fro the centre, hot meals, and a range of physical and social activities throughout the day. However, the profile of

Singapore day centre service users appeared to be more frail and nursing staff are on-site to provide care and assistance.

As it is a small setup, the administrator facilitated the recruitment, providing information to potential participants and introducing the researcher to the participants individually. In Singapore, posters and flyers translated in Chinese

(see Appendices D & F respectively) were provided to the support organisation for recruitment purposes in addition to the English versions. Interviews were conducted at the centre, which was the preference of the participants who reported that interviews in their residence would inconvenience their children and grandchildren who they live with – a common living arrangement and concern among the participants at this site.

Site S2 is a SAC of a fairly new home-based and community care service through they have strong support from the parent organisation, which operates several FSCs and a range of community-based social services located in the central region of Singapore. Recruitment and scheduling of interviews was facilitated by the “Centre Manager” of Site S2 and the “Home Visitation

Coordinator” of their befriending program.

125 The befriending program conducts regular home visits to older people who are generally frailer or requires support at home. A network of staff and volunteers provides weekly home visits and help at home to several hundreds of residents in their service boundary. Due to ethical considerations, service users who are having cognitive issues were excluded. Despite the exclusion criteria, the befriending service provided a platform for recruitment of older people who are mainly receiving home-based services. Nonetheless, these participants are not necessarily house-bound or socially isolated, and are encouraged by the service staff and volunteers to remain socially connected to their neighbours and wider community. These participants were mostly interviewed at Site S2, which was suggested by the coordinator of befriending service and in line with their motto to support home-based clients to regain their level of independence so as to remain active and connected in the community.

Site S3 operates as a SAC and has a similar type of auspice to Site S1 in which it is an extension of a VWO whose parent body is a Christian society and charity. Though fully funded by donations and independent from government funding requirements, the SAC provides non-religious services and activities free of charge. Membership is open to anyone who wishes to join and is not restricted by service boundary. With such an alternative service model, Site S3 has attracted several groups of friends who are not living in the same service boundary. Recruitment and scheduling of interviews was facilitated by the

“Service Manager”. Similar to service users of Site S1, participants from Site S3 preferred to be interviewed at the centre as they are mostly living with their family and did not wish to inconvenience them in any way.

126 3.4 Description of Participants

In Australia, 31 participants were recruited and interviewed. One of the participants returned the revocation of consent form after the interview, bringing the total number of Australian transcripts analysed down to 30. The situation was similar in Singapore: 32 participants recruited and interviewed; one revocation of consent; and 31 transcripts analysed. Please see Table 2 and

Table 3 on the following pages for the breakdown of participant demographics by country and recruitment sites respectively.

The number of male participants (16) in Australia is more than the females (14).

This is mainly due to overrepresentation of male participants (seven out of nine) from Site A3 (see Table 3). Site A3 is a community centre (see Sections 3.3, 6.1

& Appendix L for the details of the various recruitment sites) with a strong capability in attracting male service users through activities and programs such as the Men’s Shed. Site A1 also prides itself as a service with exceptional capabilities in attracting male day care clients through the strategy of “men-only groups”. At Site A2, it was observed that there are two men-only tables out of a total of six tables, indicating fair capabilities in attracting male clients as well. All these factors contribute to the unexpectedly high number of male Australian service users who wished to participate in this study.

127 Table 2: Breakdown of participant demographics by country

Details Australia Singapore Total Number of Participants 30 31

Gender Male 14 23 Female 16 8 Age 65-74 11 14 75-84 14 15 85 & over 5 2 Mean Age 77.7 75.2 Marital Status Married 7 10 Divorced 10 2 Widowed 11 12 Never Married 1 7 De Facto 1 0 Living With Alone 14 12 Spouse Only 6 5 Spouse & Parent 1 0 Spouse & Children * 1 2 Three-Generational 5 5 Children 2 2 Grandchildren 1 0 Sibling(s) 0 1 Friend(s) 0 1 Tenant(s) 0 3

* includes children-in-law and adopted children/children-in-law

128 Table 3: Breakdown of participant demographics by recruitment site

Sites A1 A2 A3 S1 S2.1 S2.2 S3 Total Number of 12 9 9 5 13 6 7 Participants

Age 65-74 1 1 9 1 7 3 3 75-84 10 4 0 3 6 3 3 85 & over 1 4 0 1 0 0 1 Mean Age 79.8 82.9 69.9 78.2 73.8 74.7 76.1 Gender Female 7 5 2 4 10 2 7 Male 5 4 7 1 3 4 0 Marital Status Married 3 3 1 3 3 2 2 Divorced 1 2 7 0 2 0 0 Widowed 8 3 0 1 4 2 5 Never Married 0 0 1 1 4 2 0 De Facto 0 1 0 0 0 0 0 Living With Alone 3 3 8 0 9 2 1 Spouse Only 3 3 0 0 3 1 1 Spouse & Parent 0 0 1 0 0 0 0 Spouse & Children 0 1 0 1 0 0 1 * Three- 5 0 0 3 0 0 2 Generational Children 0 2 0 1 0 0 1 Grandchildren 1 0 0 0 0 0 0 Sibling(s) 0 0 0 0 1 0 0 Friend(s) 0 0 0 0 0 1 0 Tenant(s) 0 0 0 0 0 2 1

129 In Singapore, the number of female participants (23) is expectedly higher than the males (8). Notably, all the participants (7) at Site S3 are female and the staff shared that attracting male service users has been their weakness. However, the male participation rate is much higher at Site S2, balancing the overall participation rate of male Singaporeans in this study.

In terms of age group participation, the proportions are more similar in the two countries. There are higher proportions in the 75 to 84 age bracket with slightly lesser number of participants in the 65 to 74 age brackets in both Australia and

Singapore. There are more Australian participants (5) who are 85 and over than

Singaporean participants (2). The higher number and proportion in Australia is mainly attributed by Site A3’s capability in serving clients with higher levels of need. The service is able to do so as their auspices are committed to the service motto for high quality of care and provided funding support to lower staff to client ratio.

With regards to marital status, there are disproportionately more participants who were divorced in Australia (10) than in Singapore (2). This is mainly attributed by the population characteristics at Site A3 who were social housing tenants. In Singapore, the two participants who were divorced are both from

Site S2. Population characteristics of Site S2 parallels that of Site A3 as they are residents of public / rental housing. In Singapore, there were disproportionately higher numbers of participants who were never married and they were mostly (6 out of 7) recruited from Site S2. There is likely a connection between marital status and lifetime wealth accumulation, which is not explored

130 within the scope of this study. The proportions of married and widowed participants are similar in both countries.

The living arrangement of participants is strikingly similar in both Australia and

Singapore. Most of the participants are living alone and followed by those living with their spouse only. There is an almost equal number of participants living with a spouse only and those in a three-generational household. However, those living in a three-generation household are all widowed and have done so due to care needs. The timing of moving into the adult children’s household coincides with the participant’s or their spouses’ decline in health, at the point when the participants are no longer able to cope with their own care or their spouse’s level of need.

In Singapore, there are participants who are staying with their sibling, friend, and tenant(s), which are living arrangements not seen among Australian participants. This phenomenon is due to the requirement for twin sharing among public housing tenants in Singapore and increasing popularity of private renting as a stable income source in later life. In Australia, there is a case of a participant living with an adult grandchild, providing insight into the phenomenon of grandchildren as carers.

In summary, there are both similarities and differences in participant demographics in Australia and Singapore. As highlighted, the differences are mainly attributed by the client and population characteristics of the various recruitment sites and it was not possible to control due to convenience sampling.

131 3.5 Inclusion of Migrants in Australian Sample

In Australia, six of the 30 participants were long-standing18 immigrants from

Asia. The presence of migrants as community service users, including those from Asian background, is expected and reflective of the historical immigration trends since the dismantling of White Australian policies. The 2011 Census found that 36% of older Australians were overseas-born; among those born overseas, there has been increasing diversification since the 1981 Census with

120 birth countries identified and strengthening proportions from countries where the six migrant participants were from (ABS 2012c). Three of them are of

Chinese descent but are born in different countries – China, Indonesia, and

Singapore. The three others are from India, Sri Lanka, and the Philippines.

Their length of stay in Australia range from 12 to 38 years, with a mean of 23.33 years. All of them have obtained Australian citizenship and identify themselves as “Australian” first and foremost when asked about their ethnicity. They are highly proficient in English, preferred English-based social groups / activities

(even though ethnic-specific services are available), and nominated to have the interview conducted entirely in English. In addition, they are all receiving the

Aged Pension and are accustomed to the Australian aged care system. As such, despite their Asian heritage, these participants have been living in Australia for an extended period, have integrated successfully to consider themselves as a part of the Australian society instead of their birth country, and have no intention of returning to their birthplace for the rest of their lives.

18 In the 2011 Census, migrants arriving before 2007 are considered long-standing.

132 3.6 Data Collection and Description of Interview Processes

Data were collected through face-to-face interviews with participants. The interviews were semi-structured in which an interview guide (see Appendix G) with a series of questions regarding seven key areas was used. Nonetheless, the order of the questions depended on where the participants were heading and the questions were phrased spontaneously (Patton 1990: 283). The interviews, which resemble that of a question and answer session and at times like a conversation, were digitally recorded with the written and verbal consent of participants.

Before the interview begin, two copies of the Participant Information Statement and Consent (PISC) form (see Appendix H for the English version and

Appendix I for the Chinese-translated version) were provided to each participant in the written language that they are most familiar with, either in English or

Chinese. The researcher took the time to ensure that participants are aware of the purpose for the interview, aims of the study, that consent is require for audio recording, withdrawal from participation could be done at any stage without repercussions, and that “revocation of consent” could be done even after the interview.

Only when the participants were fully informed of the various ethical considerations designed to protect their rights did the researcher proceed to ask for their consent by signing on the PISC form. In addition, stamped envelopes addressed directly to the research supervisor were provided to each participant

133 to facilitate their revocation of consent without incurring any cost and without the need to go through the support organisation and the researcher in case there is concern of repercussions. The fact that there were “revocation of consent” slips sent to the research supervisor, including from Singapore to

Australia, assured the researcher that the procedure has worked.

Eventually, every participant granted permission for audio recording and note taking was kept to a minimum to avoid distractions. Participants were individually interviewed and in private, bearing in mind confidentiality issues as a consequence of personal disclosures and sensitivity surrounding caregiver and care-recipient relations. As the majority of interviews were conducted at the centre of the support organisations, the caregiver-care recipient relationship was extended to that between participants and the service staff of support organisations.

As highlighted in the Section 3.2, the choice of interview location was entirely determined by individual participants. Although all six support organisation had suggested for the interviews to be conducted at the centre but if the participants were uncomfortable to be interviewed in the centre and that alternative interview location could not be arranged, then the researcher would not have proceeded. However, none of the participants who had any concerns being interviewed at the centre and those who were interviewed at the home were from support organisations that were inclined to let the participants make the decision.

134 With a few exceptions, the interview sessions lasted from between 40 to 90 minutes. Besides ensuring informed consent, time was given for brief introduction, rapport building, and checking for any discomforts.

3.7 Transcription, Translation, and Use of Transcripts

As described in the previous section, data were collected through interviewing older participants. The interviews were digitally recorded and subsequently transcribed verbatim and according to the true meaning of what transpired in the interview. In Singapore, 25 participants were not conversant in English and were interviewed in the Mandarin spoken language. There was also one older participant in Australia who had preferred to be interviewed in Mandarin. The 26

Mandarin audios were professionally translated and transcribed into English transcripts by Mandarin-English translators who are based in Singapore and who are familiar with the accent and linguistic style of Singaporean Chinese.

In staying true to the data provided by the participants – which were analysed as transcripts of interviews – the codes and themes that were induced through the analytic operations described in the Section 3.8 will be illustrated with verbatim quotations from the older participants like the two examples below.

The following is an account each from an Australian and Singaporean participant on the topic of individual consent within the family context. It is used here to illustrate the conventions used when presenting the extracts of transcripts from participants in this thesis:

135 Figure 2: Illustration of conventions used for participants’ accounts – example 1

Font size: 10 Additional information placed To distinguish from block quotes in square brackets.

It is okay for us to sign this [PISC form]. We [referring to older people] are okay

with the interview since it only concerns me, right? If it affects my family

members then that's not good lah […] I will regret participating [in this research]

if this results in harm [for the family]. (XIAZHI, Singapore, Female / 70)

Colloquial expressions or Ellipsis within brackets indicate long pauses translated proverbs / sayings are between two sentences, or that prompting was italicised. required.

Information of participant within parenthesis and at the end of quote. Gender- appropriate pseudonym, location, gender, and age information are included.

136 Figure 3: Illustration of conventions used for participants’ accounts – example 2

Single quotes indicate meaningful expressions, proverbs or sayings. Double quotes indicate quoted speech (of another person) or the conversation between the participant and another person. When my grandchild was born, I bought a very expensive bottle of brandy for

my son. He was ripping the top off, and I said, “No,” I said, “You’re not to have it

now.” “When am I going to have it?” he asked. “When (name of grandchild)

turns 21, I’m going to share with you.” I said and he laughed with me. Recently,

he said to me, “I’m starting to worry about you.” I asked, “Why?” He said, “I thought of it as a joke at the beginning but you’re going to bloody well be here

when (name of grandchild) turns 21.” I said, “If I’m not, I’ll know nothing about

it.” And that’s how I think: ‘if you worry about tomorrow, you don’t get out of

bed’; instead of getting on with your life, you sit in one place and your life goes

by. (JONATHAN, Australia, Male / 73)

Semicolon indicates related Within the quote, information within parenthesis independent clauses. indicate information omitted to protect the confidentiality of the participant (and their family).

137 As presented above, care is taken to retain the true meaning and form of the participant’s account as it was spoken. Words that are added for clarifications are denoted clearly by brackets. Where meaningful Chinese phrases are to be romanised to illustrate a point, the Pinyin (Pin1 yin1)19 system – which is the official romanisation system for Standard Chinese in

China, Singapore, and several other Chinese-populated countries – would be used.

While back-translation (also known as double translation) is often used in cross- cultural and cross-national research between two or more language groups to test the accuracy of translation (Brislin 1970), it was not considered to be necessary for several reasons. Firstly, this procedure was ‘initially developed for situations in which a researcher was not familiar with the target language’

(Douglas & Craig 2007: 30), which is not the case in this study as the researcher is a Chinese Singaporean who is fluent in both English and

Mandarin as first and second languages respectively. In addition, the researcher is familiar with the Hokkien and Cantonese dialects and common

Malay and Tamil terms that are used in “Singlish” – Singapore Colloquial

English.

Secondly, back-translation is more often used in survey and experimental research and focused on translating a questionnaire, instrument, or instructions to participants (Beck et al. 2003: 64; Douglas & Craig 2007: 30) rather than

19 The numbers denote the tone; capitalisation is used for the first letter of the first word in a sentence and for the first letter of a proper noun.

138 lengthy transcripts. Even for documents that are far shorter in length such as a questionnaire, back-translation ‘does not necessarily ensure equivalence in meaning and concepts in each country, and thus the translation… might not be accurate. This is particularly likely to be an issue when idioms or colloquial language is used’ (Douglas & Criag 2007: 31). Consequently, back-translation is most useful when a literal or direct translation is required. In this study where meanings are believed to be co-constructed by the participants, the researcher, the family, service staff, and beyond, the usefulness of back-translation, even for the interview guild would be low. Please see page 300 for an excellent example of participant’s feedback on the accuracy of the terminologies used in interviewing and the adoption of a more meaningful term that would resonate with older Singaporeans in which younger Singaporeans, including the researcher and bilingual translators, would not have used. Ironically, as the equivalent word for community among older Singaporeans is in the Malay language and less commonly used in urbanised Singapore, the back-translation between English and Mandarin done in a bid for translation accuracy would have produced terms that are less relatable to the participants.

Thirdly, a bilingual native speaker often does the back-translation and the researcher is able to perform that task alone (Douglas & Craig 2007: 30).

Nevertheless, to avoid inaccuracies in translation due to the sheer volume of transcription, it was designed that the Chinese audios (from Singapore) are all transcribed and translated into English by bilingual translators, double checked for accuracy by their bilingual supervisor, and rechecked by the researcher. The

139 three-layers checking process is arguably more thorough than back-translation could achieve in this study.

3.8 Data Analysis

This research adopted Bryman’s (2016: 408-409; 2016: 587-589) general approach to qualitative data analysis and coding. Gibbs (2011) delineated four stages in Bryman’s approach which begin with reading through the transcripts as a whole and making notes, identify major themes, usual events / issues, and categorising cases broadly. In line with such an intention to have an overview of the dataset, a one to two pages “vignettes” of each transcript summarising the life of the older person and their key ideas was documented.

In Stage Two, markings of the text (underlining, circling, highlighting) and coding begin. Coding, which is usually the starting point of qualitative analysis, is also a foundation for subsequent analysis and is conducted at different levels throughout the analysis (Punch 2005: 199). Codes are defined as ‘tags, names or labels’ that are induced from the interview transcripts (Punch 2005: 199).

Coding is therefore the process of ‘putting tags, names or labels against pieces of data… [which may be in the form of] individual words, or small or large chunks of the data’ (Punch 2005: 199). Gibbs (2007: 47-48) gave a list of what types of data can be coded, which includes: specific acts / behaviours, events, activities, strategies / practices / tactics, states (general conditions experienced by people or found in organisations), meanings / significance, participation

(area and nature of involvement), relationships / interactions, conditions /

140 constraints, consequences, settings (entire context of the events under study), and reflexive (research’s role in the research process).

In addition, besides performing content analysis of what was said, attention will be paid to the language that was used by older people in describing their social world and reality. Ryan and Bernard’s (2003) techniques to identifying codes, which drew heavily from Strauss and Corbin’s (1990) work on Grounded Theory and qualitative analysis, was found to be helpful in drawing attention to: word repetitions, key-words-in-context, metaphors / analogies, transitions, and connectors. With these guides for coding, a coding list was developed using

Microsoft Excel for easy storage, sorting, and constant comparisons between codes. In addition, a coding frame, which is a list of “code memos” (Gibbs 2007:

40-41), documents the definition of the codes and commentaries regarding how each code should be interpreted and applied. To avoid confusion, code memos are documented in a separate Excel sheet from the memos of extracts from transcripts.

Concurrently in Stage Two, memos, which are generally the researcher’s notes to self about the dataset or extracts from the transcripts (Gibbs 2007: 30), were similarly document in a Microsoft Excel sheet for easy storage and retrieval.

One of the originators of Grounded Theory, Glaser (1978: 83-84 cited in Gibbs

2007: 30 and Punch 2005: 201), paid much attention towards the process of memoing and defined memo as ‘the theorizing write-up of ideas about the codes and their relationships as they strike the analyst while coding’. In this study, the memoing process has been as helpful as what Glaser (1978) had

141 described and on the following pages, a working example of how a section of a transcript is fragmented into codes and the corresponding memo is provided.

As recommended and done in this study, memos are documented concurrently when the codes are identified and iteratively documented and reviewed throughout the various stages of analysis. Memos can be as short as a sentence and as long as a few pages and may include ideas and thoughts that are ‘substantive, theoretical, methodological or even personal’ (Punch 2005:

201). Substantive and theoretical memos are particularly important as they

‘suggest still deeper concepts that the coding has so far produced… [and] may point towards new patterns, and a higher level of pattern coding’ (Punch 2005:

201). Memoing also produce propositions by relating different concepts to each other, which is the aim of the later stages of analysis. Last but not least, memos retains the original thoughts about an extract and retains the context of a passage before it is fragmented by the coding process and thus losing the context of what was said by the participant – which is a major criticism of the coding approach to qualitative data analysis (Bryman 2016: 583).

In Stage Three, advanced coding is done. The first-level codes, which were sieved from going through the transcripts, were reviewed for repetitions and similar codes are combined. These first-level codes are then compared against one another and grouped together by identifying themes and notable patterns.

142 Figure 4: Working example of coding

[Transcript of PHOEBE, Start at Page 14 Line 39, End at Page 15 Line 3]

Well, the services weren’t there. She was 100 over Lack of services miles away, not kilometres. If anything was wrong, Family response to crisis

either my sister or myself would have to race up

there; if she’s hospitalised or whatever. I did go Family visiting regularly (at home a lot though, that was the difference. My own home)

generation, even when both my parents were alive, I Family Care (adult children) would go up at least once a month. I just get the

children to bed, I don’t mind driving in the dark, to Contrast between generations avoid all the traffic on the road. But she chose to Care arrangement (after come to me, after she had the cancer operation, major operation)

and she just stayed on with me. And I think she was

very happy with me, until in the end, she went into Nursing Home (at the very the nursing home. And I went everyday to see her in end of life)

the nursing home. Well, children don’t do that Family visiting regularly (Nursing Home) anymore. Not only because she expected me, I

don’t know whether she did or not, I know she Family obligation

wanted me to be there everyday, but I felt I wanted

to go and see her everyday. People aren’t there Residential Respite Care forever, are they? And when my partner went in for Family Care (spousal care)

respite, just to try it out, he said to me, “You must Family visiting regularly come have lunch with me everyday.” (Nursing Home)

143 Figure 5: Working example of a memo

[Memo of: PHOEBE, Start on Page 14 Line 39, End on Page 15 Line 3]

The participant first mentioned (at Page 5 Line 9) about her late mother when

briefly highlighting that there was no services in the country region where she lived.

I had made a note when PHOEBE did it and waited to come back after she had

finished what she wanted to say about “the family”. I had thought that her care

towards her later mother would shape her expectations on the care that she is

receiving from her family, particularly her adult children. The lack of HACC-like

services in the country is likely part of the reason for her monthly trip to visit her

elderly parents; the reason for her sister and her to be ready to “race up there” in

an emergency situation; and the reason for her mother to relocate to live with her

after a major operation. HACC services could have provided a “lifeline” for her

parents in crisis situation though she might still visit as often due to her sense of

family obligations as a daughter. PHOEBE mentioned briefly that “children don’t do

that anymore”, comparing the level of care that she was providing for her mother to

that of her daughter’s care towards her. Elsewhere, she had mentioned that her

daughter only come to visit her “two or three times a year” (Page 13 Line 43) while

she had visited her parents on a monthly basis, even when the two of them are

both living and in a co-dependent care arrangement. Furthermore, PHOEBE was

managing as a single parent with two young children in those days. In PHOEBE’s

family, the sense of family obligation has not been “matched” by her daughter (her

other child has passed away). Could this be due to changes in the family (values)

impacted by modernisation, the availability of HACC services, or both? In terms of

family structure, financial ability, and proximity, there is no obvious disparity

between PHOEBE and her daughter.

144 Advanced coding is essentially repeating the processes of labelling and categorising to develop higher-level themes and patterns from lower-level codes (Punch 2005: 205). To avoid confusion, second-order codes are called themes. The themes identified in this study are categorised into three categories in relation to “care issues within the family context”, “care issues beyond the family context”, and “centre-based community care services and community organisations”, which eventually became the title for the three

“findings” chapters (Chapters 4, 5 & 6).

Stage four is essentially about identifying links between individual and group of codes and themes, and their relationship to the research question and research literature. Groups of interrelated themes will eventually become “higher-level themes” that will delineate and provide the headings in the discussion chapter

(Chapter 7).

3.9 Ethical Considerations

Ethics approval (approval no. 14 072) was granted by the Human Research

Ethics Advisory (HREA) Panel B in August 2014. In addition to the National

Statement on Ethical Conduct in Human Research 2007, this research was informed by and carried out in accordance to the University of New South

Wales policy for Research Code of Conduct.

Though classified as low risk human research, ethical considerations to minimise risks were prudently deliberated and operationalised in the recruitment

145 and interviewing phases and in the interest of older participants. As a constant reminder to the researcher, an Interview Checklist (see Appendix J) integrating the various ethical considerations mentioned in Section 3.9, and in this section, was developed and used in every interview.

3.9.1 Minimising Risk of Coercion

As highlighted in the previous sections, the recruitment of older participants was designed to be done through the support organisations. Though exclusion criteria were in place and participants in this study are assessed to have the capacity to make an informed decision, their relationship with the support organisation is seen as complex – being the purchaser and consumer of care services, and yet having to rely on the service staff while using the service.

As such, there is a likelihood that older participants might be confused about whether their participation in this research would affect their relationship with the support organisation. On the other hand, support organisations might not make it clear to the participants before the researcher was to be introduced and as such several strategies were put in place to prevent this confusion and minimise the risk of coercion.

Firstly, to protect the confidentiality of older service users prior to expressing their interest to participate, notice about the research were done through the support organisations with posters and flyers to aid the staff in publicity, information giving, and sign-up. In Singapore, both English and Chinese-

146 translated versions were provided. In Australia, the Chinese participant who preferred to be interviewed in Mandarin is literate in English.

Secondly, potential participants were advised to contact the investigator directly through the contact information stated in the posters and flyers. However, as older participants were already familiar with the support organisation, most of them chose to express their interest to participate through the service staff.

Thirdly, when seeking written consent, the investigator double-checked that the older participants understood that their participation is purely voluntary; that this is an independent research and not commissioned by the support organisation or related agencies; their decision to participate, eventual withdrawal, and content of the interview will be kept private and confidential; and, there will be no repercussion for withdrawal at any stage, even after the interview.

3.9.2 Minimising and Mitigating Impact of Distress

As mentioned in Section 3.6 (see pages 133-135) older participants were each asked a series of questions in seven key areas. In answering these questions, participants would need to draw on personal experiences of caregiving and care-receiving, and there is a likelihood that the interview questions may cause some degree of discomfort or anxiety. In particular, the question on family and support network might cause distress depending on their social situation. A set of strategies was put in place to minimise the risk and to mitigate the impact of distress.

147 Briefings were conducted for staff and volunteers of the support organisation who are assisting with the recruitment of service users as research participants

(see Appendix K for Briefing Outline). They were specifically briefed on exclusion criteria and to avoid approaching older participants with recent or unresolved grief and loss issues, poor history or recent onset in mental health issues, and distressful family and social situations such as estrangement, rejection and abandonment.

When seeking written consent prior to the start of the interviews, older participants were informed that questions will be asked in relation to their family and support network and that they might need to draw on their own experiences of caregiving and care-receiving when responding to the questions. This information was clearly stated on the PISC form (see Appendix H) and verbally given as well, not assuming that all participants are literate in English or

Chinese. Participants were also informed that they could pause or terminate the interview at any point if they did not feel comfortable.

Interviews were paused by the investigator whenever any older participants appeared distressed. Arrangement was also made with the staff of the support organisations to provide debriefing and support to older participants if they became upset and needed someone other than the researcher to talk to.

Nonetheless, the choice would be entirely left to the participant who they would like to go to.

148 Contact details of the researcher, supervisor, and the support organisation were also made available at the end of each interview for older participants or a relative to contact for assistance or clarifications. Two withdrawals, one each in

Australia and Singapore, were made by the older participant and a relative respectively using the “revocation of consent” slip and stamped return envelope provided. The reason(s) for these two withdrawals remained unknown as older participants and their relatives has full control to withdraw their consent and were not required to provide any reason for doing so.

3.9.3 Token of Appreciation

A token of appreciation in the form of a pack of biscuits valued under 10 dollars was given to each older participant at the end of the interview. This promise was stated in the posters, flyers, and the PISC forms. Older participants were highly appreciative of this gesture and some even refused to accept the gift – stating that they had enjoyed their time expressing their views and being heard was sufficient reward in itself.

3.10 Rigour and Quality in Qualitative Research

In exploring the issue of rigour and quality in qualitative research, it is important to begin with understanding the fundamental differences between qualitative and quantitative approaches. As highlight by Bryman (2016: 163), ‘quantitative and qualitative research can be viewed as exhibiting a set of distinctive but contrasting preoccupations’. In quantitative research, the four main

149 preoccupations are measurement, causality, generalisation, and replication

(see Bryman 2016: 163-165 for elaboration). To achieve these research aims, procedures in achieving ‘reliability’ and ‘validity’ are employed.

Reliability ‘refers to the consistency of a measure of a concept’ (Bryman 2016:

157). Three factors for determining reliability are: stability, internal reliability, and inter-rater reliability. Stability is often referred to as test-retest reliability and the question is ‘whether a measure is stable over time, so that we can be confident that the results relating to that measure for a sample of respondents do not fluctuate’ when the same sample is retested (Bryman 2016: 157). Internal reliability refers to the relatedness of indicators in a multiple-item measure so as to establish their consistency in measuring the same concept. Inter-rater reliability is concerned with subjectivity among multiple researchers and ‘[w]hen a great deal of subjective judgement is involved in such activities as the recording of observations or the translation of data into categories’ (Bryman

2016: 157).

Validity ‘refers to the issue of whether an indicator (or a set of indicators) that is devised to gauge a concept really measures that concept’ (Bryman 2016: 158).

At the minimum, ‘face validity’ has to be determined in which the measure appears to be related to the concept to be studied and not another concept(s).

This can be achieved as an intuitive process by checking with those who have experience or expertise in the area of study. The other common forms of validity tests are concurrent validity, predictive validity, construct validity, and convergent validity (see Bryman 2016: 158-161 for an exploration).

150 While the criticisms of quantitative research by proponents of qualitative research and vice versa is an important topic (see Bryman 2016: 166-167 and for the discussion), it is more important for the purpose of this study to understand the adaptations qualitative researchers made to the criteria of reliability and validity in establishing quality of quantitative researches.

LeCompte & Goetz (1982) did not depart far from the quantitative terms and discussed about establishing external reliability, internal reliability, internal validity, and external validity for qualitative research. These measures refer to issues of replication, inter-rater consistency, congruence between concepts and observations, and generalisation respectively (Bryman 2016: 383-384). The works of Lincoln and Guba (1985) and Guba and Lincoln (1994) ‘settled the debate for qualitative rigor’ (Morse 2017: 801) in that they provided an alternative to reliability and validity with the criteria of trustworthiness and authenticity.

Trustworthiness is made up of four criteria: credibility, transferability, dependability, and confirmability. These components correspond to internal validity, external validity, reliability, and objectivity respectively – which are their equivalent criterions in quantitative research (Bryman 2016: 384). Morse (2017) provided a summary of Lincoln and Guba’s (1985: 328) techniques for establishing each of these criteria of trustworthiness: l Credibility:

n Strategies to ‘increase the probability of high credibility’, including

u Prolonged engagement

u Persistent observation

151 u Triangulation of sources, methods, and investigations

n Peer Debriefing

n Negative case analysis

n Referential adequacy

n Member checks (in process and terminal) l Transferability: Peer debriefing l Dependability: The dependability audit (including the audit trail) l Confirmability: The confirmability audit (including the audit trail)

The authenticity criteria relates to the wider impact of research and is less influential than the trustworthiness criteria as it has more relevance to action research (Bryman 2016: 386).

In this study, the strategies in establishing credibility such as prolonged engagement and triangulation considered but not employed on practical, methodological, and ethical grounds. As described in Section 3.3, securing support from organisations that would assist in the recruitment of participants has been a tedious process. From the researcher’s experience in social work / community service organisations, it was anticipated that the longer the contact hours required with participants, the less likely an organisation would be willing or able to assist.

In addition, even if the organisations are keen to assist in recruitment, the participant rate might be low at each site, making it less possible to recruit enough participants for sufficient variations. Thus, increasing sampling bias in

152 that those who participate are likely more sociable and / or connected. As older people are considered more vulnerable, more contact hours was thought to be harmful and as mentioned by Australian day centre staff, intruding into their day activities that are partially paid out-of-pocket. The two cases of revocation despite such sensitivity also indicated that the abovementioned concerns are valid.

Instead, other strategies for establishing validity are employed. As argued by

Kvale (1996: 242-244), in interview studies, validity can be attended to through checking, questioning, and theorising and as such a semi-structured and in- depth interviewing format was selected to allow for deeper exploration and clarifications within the single contact and within the course of the interviewing.

The issue of reactivity on the part of the participants was anticipated, particularly from the case of Singapore, which is considered a Confucian

Heritage Culture where ‘saving face’ is valued (Nguyen et al. 2006: 7) and that those who fear ‘losing face’ tend to avoid discussing the topic of conflict or even withdrew negotiations when conflict arise (Tse et al. 1994). Nonetheless, these concern dissipated in the course of data collection as the accounts among of participants in this study demonstrated a high level of openness in disclosing sensitive issues such as the lack of family support, conflict with family members, and even estrangement.

In Section 4.4.1, a total of six accounts from Singaporean participants detailing financial support (and the lack of it) from their adult children are presented. In

153 Section 7.3.3, a rich account of family conflict / estrangement each from

Australia and Singapore are presented. There are many other such accounts that are not included for presentation and the researcher did not have to prompt much after rapport was built at the beginning of the interviews. The researcher is experienced in engaging older people with years of experience in aged care and this was exploited to increase the validity and rigour of this study through attention on ‘craftsmanship’ (Kvale, 1996: 241-244).

Poland (1999) argued for attention to transcription quality as an aspect of rigor in qualitative research and ‘verbatim’ transcription, having a back-up recording device, eliminating factors of poor recording, and non-alteration has been ensured in this study. In addition, attention was paid to Stige’s et al. (2009) evaluation agenda items of ‘processing’ and ‘interpretation’ designed to address

‘the challenge of producing rich and substantive accounts’ (p. 1504).

Processing refers to the treatment of data and as highlighted in Section 3.7, verbatim quotes from the participants are used when presenting their perspectives to preserve the integrity of empirical material. Interpretation

‘involves the act of creating meaning by identifying patterns and developing contexts for the understanding of experiences and descriptions’ (Stige et al.

2009: 1509), which is the approach in analysing and presenting data in this study and with the aim of achieving “thick description” through contextualising participants’ accounts (Geertz 1973 in Stige et al. 2009: 1509).

When selecting the quotes for presentation, all the quotes related to the theme are laid out for consideration and maximum variation was preferred to ensure

154 that more voices could be heard. This method also minimises the risk of overgeneralising from a few examples by representing the maximum number of perspectives related to a certain theme. In general, more than five accounts are required to establish a theme unless it is an emerging issue to be raised for discussion. This is in line with Bryman’s (2003) proposition that the ‘issue should be couched in terms of the generalizability of cases to theoretical propositions rather than to populations or universes’ (p. 90, emphasis added).

In other words, “theoretical generalisation” rather than achieving “statistical generalisation” from choosing representative samples (Seale 1999: 109-113), is the aim of qualitative research and in this study. It is also not proposed that the findings can be generalised beyond the selected “setting” for “theoretical sampling” in which Mason (1996) defined as:

[S]electing groups or categories to study on the basis of their

relevance to your research questions, your theoretical position… and

most importantly the explanation or account which you are

developing. Theroretical sampling is concerned with constructing a

sample… which is meaningfully theoretically, because it builds in

certain characteristics or criteria which help to develop and test your

theory or explanation (pp. 93-94 in Silverman 2010: 144).

To this end, if the scale of the study had been bigger and provided more resources, more complex strategies in enhancing rigour and quality would have been adopted. The implications in omitting some of the popular measures are elaborated in the limitations section (see Section 8.3).

155 3.11 Conclusion

To this end, the ethical considerations were not simply operationalised into a set of protocols to be followed. Respect and appreciation towards the participants and support organisations was observed throughout the engagements to ensure that participation in this research is a pleasant experience. As shared in this chapter, the choices made in terms of adopting the qualitative approach, interpretive framework and inductive analysis is made in view of the value of having users’ perspectives. As can be seen from the presentation of participants’ accounts in the following three-part Findings chapters, the data collection and analytical processes not only produced rich data, the strategies employed retains the essence of the perspectives and experiences of participants involved in this study.

156 CHAPTER 4: CARE ISSUES WITHIN THE FAMILY CONTEXT

From the literature reviewed in Chapter 2, it is evident that family carers in modernised societies like Australia and Singapore has remained as the primary source of support for older people. In fact, the overwhelming evidence and consensus from research in family care and intergenerational relations demonstrated that instead of diminishing commitment in the face of industrialisation and urbanisation, it was established that ‘nowadays adult children provide more care and more difficult care to more parents over much longer period of time than they did in the good old days’ (Brody 1985: 21, emphasis in original).

Towards the end of the data analysis stage when comparisons are made between the scripts of Australian and Singaporean participants, it also becomes clear that currently Australian and Singaporean families organise care for their older relatives in similar ways. This would suggest that in terms of the family care in Australia and Singapore, the East-West value divide might be less distinctive than what Eastern proponents of filial piety – as a distinguishing value between the East and West – had argued. In addition, relating to the fourth aim and research questions of this study (see Section 1.3), there are more areas of convergences and parallels than there are divergences. Much of this chapter seeks to show these findings by presenting similar accounts from the two countries side by side.

157 On the other hand, descriptions of the various forms of personal care were repeatedly mentioned in the interviews conducted in Australia – where the

‘values and norms underlying family relations in Australia may appear weak and equivocal when viewed externally from another cultural perspective’ (Kendig

2000: 109). As shown in a featured case in Section 4.1 and throughout this chapter, the accounts from Australian participants is highly similar to the accounts from their Singaporean counterparts, challenging the myth that

Western families do not care for their older relatives.

4.1 A Case Presentation: Illustrating the Complexities of Care

As with most of the interviews in this study, the exploration begins with questions about the older person’s family and informal support network. The following account is BRIDGET’s answer:

I've got a property that I live in and we’ve got a holiday house up [in another city].

One of my grandsons lives there and he's looking after the place. Another of my

grandsons, he looks after me; I’m very lucky […] he's 30 [years old], the one that

lives with me. I've got a son and a daughter. And my son’s got two boys and my

daughter’s got two boys and a girl. And they all look after me; [I’m] very lucky […] if

I want something done they will do that for me; they will take me out and do

everything I can't do. My son lives in [another suburb], which is just out, not very far

away. My daughter lives up [another nearby suburb] so it's not far. And they ring

me every day so they are in touch with me. (BRIDGET, Australia, Female / 81)20

20 Please refer to Section 3.7 and Figures 2 & 3 for the conventions used in presenting participants’ accounts.

158 In the account above, and typically in this study, the older person describes who constitutes as “the family” and the ways in which they provide care when the participants are asked generally about their “support network”. Those who have family support typically equate their family as their primary support network.

“The family” is deemed to be selectively included by older participants, and commonly consists of the spouse, adult children, adult children-in-law, and the grandchildren. Collectively, they are defined as the “immediate family” and referred simply as the family henceforth. In contrast, more distant kin relations are referred to as “extended relatives”. However, extended relations are not necessarily inferior in intimacy and demonstrated the capacity to provide personal care in a few cases.

In this case example, one of her adult grandchild is living with her and manages the household. Another adult grandchild is living in another property of hers and is looking after that place. This account is the first instance where the principal carer is not the spouse, adult children or adult children-in-law, prompting the inclusion of adult grandchildren as potential family carers in this study. Despite this being one of the only two cases in this study where the adult grandchildren provide significant and consistent care and / or financial support, it has led to the speculation that adult grandchildren would be a significant category of principal carers in the future. The potential of adult grandchildren as principal carers in both Australia and Singapore is further discussed in Section 7.4 (see pages 356-358).

159 In addition, though BRIDGET’s adult children are not living with her, it does not mean “out of sight, out of mind”. As in this case and elaborated further in

Section 4.3, families employ various strategies to keep a lookout for their older relatives while off-site. In this example, the adult children are living nearby and communicate daily via phone. This is not a unique case as several other older persons receive daily calls from their family (typically from adult children) who do not live with them. This is particularly so when the older person have experienced falls and other accidents and / or becoming frail.

While the risk of re-injury is heightened after a fall and other injuries, it does not mean that living arrangements would be altered immediately in view of the preference of the older person. Though family care can be offered off-site, some participants have to relocate in old age to be nearer their family. In the context of Singapore, one would argue that living close-by and communicating frequently are acts of filial piety (see Section 4.9 on pages 214-217).

Comparatively, this Australian case would add to the argument that in Western societies, families do care for their older relatives. The following account from

BRIDGET highlights another way families care for their older relatives through the purchase of services from home and community service providers:

My daughter found out, when my husband was very sick, that I couldn't go

shopping. She does volunteer work in palliative care and got a lady to come so that

I can go shopping. The council [Community Transport] takes me shopping every

second Monday and they told me about the [day centre] group up here and I joined

it when my husband passed away. (BRIDGET, Australia, Female / 81)

160 Elsewhere, the participant mentions that she does not pass the asset test for the Age Pension and financially, her family has been providing for her daily expenses and that they pay for the HACC services as well. As mentioned in the above account, the family is often the initiator and coordinator of care services.

In most cases, the family carer would be with the older person for the assessments and “orientations” and would remain as the contact person for the service providers.

However, there are a significant number of older people who do not have adequate support from the family due to various issues. In Australia, there are

10 participants who are divorced and one who has never married (see Table 2).

All of them are on the Age Pension and only two of the 11 have some form of support from their adult children. In the case of Singapore, there are six participants who were never married and do not have any children (one of the

Singaporean participant who is never married has an adopted child who is her principal carer). In the following two chapters, Chapter 5 and 6, the role of non- family informal carers, the community, and the state will be presented.

Nonetheless, even for older people who are supported by their family like

BRIDGET, people in the local community are important source of care as well:

If I wanted to go shopping, I’ll ring the man across the road from me. He's in

charge of (a charity organisation) in our area and I have been going there [to

volunteer] as well. Do some sewing and knitting and all that for them. If I needed

anything, he will take me up to the shops or anything like that. (BRIDGET, Australia,

Female / 81)

161 The above statement highlights the relationship that an older person can have with their neighbours. In the case of BRIDGET, the level of support from her neighbours is relatively higher than most participants and it is related to her volunteering and community participation. In Section 5.2, the range of relationships older people have with their neighbours and the key finding to having good neighbourly relations will be discussed.

In the following account of BRIDGET, helpful neighbours and a supportive family are mentioned in the same breath as to why ageing in place in the community is sustainable:

I like where I’m living and I don't feel that I need to go into a retirement village or

anything. I’ve got what I want and I can do what I want and I've the family behind

me all the time and I've got all the neighbours behind me all the time too. So, I’m

very lucky. (BRIDGET, Australia, Female / 81)

To this end, this case has been selected for three reasons. Firstly, this older participant (BRIDGET) is cared for by all three main categories of care

“providers” explored in this study – the family, non-family in the community, and community services / organisation. These three main sources of care would combine to provide a holistic view of the support network as experienced by the community-dwelling older person in this study.

Secondly and methodologically, this interview with BRIDGET was conducted around the time when data were becoming saturated and the evidence was building up for a case that older participants in this study were well supported

162 by their family and naturally prefer their support for an extensive range of needs.

This is true even among those who are living on their own and able to manage independently. Such care arrangements where care is provided by the family

(and others) who live elsewhere, have been coined as “intimacy at a distance”

(Rosenmayr 1968; previously mentioned in Section 2.8.3).

Thirdly, as demonstrated through BRIDGET’s case, the various sources of economic support and personal care are not independent systems; working complementarily to form a safety net. In this study, there are various permutations of the support network for the participants. In cases like BRIDGET, there is the family to rely on and other sources of support to fall back on. For a number of participants with little or no family support, BRIDGET’s case also highlighted that non-family and community support, including home-based and community care services and / or the state can be relied upon when they require personal care and / or economic support.

Employing Bronfenbrenner’s BST, the family, extended relatives, friends, neighbours, and the community forms layers of support encircling an older person, who is theoretically placed in the centre from a person-centred perspective (see Section 2.15). The immediate family, extended relatives, and friends are conceptualised by Bronfenbrenner (1979) as components of the

Microsystem (see Figure 1) and are relatively the strongest relationship and source of support in old age.

163 Aged care services are added to the Microsystem of an older person as this component is where individuals have direct interactions and regular activities.

Neighbours are conceptualised by Bronfenbrenner (1979) to be in the

Exosystem with indirect influence though in this study and from the literature on non-family support (see Barker 2002 & Section 2.11), some neighbour relationships are found to be as important as friendship and matures into

Incorporative type of associations where the carer or the older person become part of the other person’s family nexus.

In summary, the context of care for an older person in a modernised society such as Australia or Singapore is highly complex with many “providers” of care intertwining to form a network of support. The capacities and limitations of each category of care “provider” are discussed in the rest of this thesis, beginning with the comparison of Australian and Singaporean families.

4.2 Living with the Family and Care Arrangements

Based on the hierarchy of family obligations (Qureshi & Simons 1989;

Ungerson 1987 cited in Finch 1989: 27-28), the two strongest family relationships in regards to family caregiving are found to be the marriage relationship and parent-child relationship – as listed in that order. The third major source of support is from other members in the same household who are not one’s spouse or children. This would include children-in-law, grandchildren, and in some cases seen in this study, siblings, and other extended and more distant relatives (and their families). As the immediate family remains the

164 common provider of care and support, this section will be focusing on comparing spousal care and care from adult children between Australia and

Singapore.

4.2.1 Spouse as Principal Carer

[Making] new friends is very difficult. I think everybody will tell you much the same.

But, you see, a lot of them got a wife, that helps quite a bit. (BRENDAN, Australia,

Male / 80)

The above short quote was extracted from a longer account on maintaining and managing friendship in later life. This quote has to be read in the context of

BRENDAN’s widowhood. Embedded in this except, is the participant’s own loss of companionship from his late wife. Elsewhere in the interview, the participant described how he used to enjoy frequent road trips with his wife and their friends till she became ill and he became her principal carer until she passed on:

Obviously if you get old, you expect your family, if possible, to care for you. If they

can get some help from the community then that’s fine. In (his home country),

when my wife was very sick, there was none of these. I looked after her myself and

found it very, very difficult. I employed a nurse and she came in only from about 8

o’clock to 12 o’clock, Monday to Friday. The rest of the time I’d to look after my

wife on my own. There was no one coming around to say, “This is what we could

do; we’ll let you have it.” No way. Not in (his home country). Here, yes. Looking

after my wife here [in Australia] would have been a lot, lot easier. (BRENDAN,

Australia, Male / 80)

165 As described by BRENDAN above, it was a difficult time providing care for his wife even when home nursing services were employed for 20 hours a week.

During that period of care, his only child was with her family in Australia due to an employment opportunity and there was low provision of home-based and community care services in his home country that could support him as a carer.

Nonetheless, he provided the majority of personal care for his spouse, in their own home, without the use of residential care or other forms of respite. It was much later when he migrated to Australia and when he became a service user of the HACC program that he realised the range of services and financial provisions carers could access in Australia.

There is a similar example from Singapore where a spouse was the principal carer and the partner was cared for in their matrimonial home till about the time when she passed on:

[My late wife] stayed at home and I cared for her. The rest of it, the maid took care

of it. I take care of her at night as we slept in the same room. I took care of her

when she had any needs. There is no choice. This is my wife. If I don't care for her,

who would? My children have their own families. I believe that husbands and wives

should take care of each other. When she passed on, then that was it. (LIZHE,

Singapore, Male / 70)

As explained by LIZHE above, he views spousal care as a family obligation and did not expect his adult children to provide personal care for his late wife – mainly due to considerations that the adult children have their own family obligations towards their spouses and young children. Similar to the case of

166 BRENDAN, the spouse who needed care was not placed into residential care and it was a conscious decision to provide personal care till their end of life.

Nonetheless, in this case, the adult children supported the older carer through the purchase of services by employing a live-in domestic helper – commonly known as a “maid” in Singapore. The Singaporean approach of employing a domestic helper to provide family care is further discussed in Section 4.6. This is the only few areas in family care that is remarkably different between

Australia and Singapore and can be seen as a divergence in the purchase of services and home-based care arrangements. However, as described by the participant, the bulk of the personal care that the spouse needed was provided by him; with the domestic helper being an assistant and focusing on other household needs. After the spouse passed on, the services of the domestic helper were not retained.

These two cases are selected to highlight that spouses in both Australia and

Singapore continue to be the primary source of family care. Adding support to the literature that spousal care in these two countries could be expected for someone who reaches old age with a marriage relationship. In relation to older people who are previously married, particularly for those who are divorced or separated, the impact of such life events on the provision of family care is discussed in Section 7.3.1.

As interpreted from the accounts on BRENDAN and LIZHE, the location of care is usually the matrimonial home and adult children tend to have moved out by

167 the time that personal care is required. Though BRENDAN was caring for his wife in another country, he is Anglo-Celtic by descent and would have done the same in the Australian context where many of his relatives have migrated earlier in life and have similar family values.

The two cases, along with a few examples that did not get cited here, also provided an example from both countries that in a marriage relationship, male spouses are as willing to provide personal care. The non-gendered nature of spousal care is in line with the long established hierarchy of obligations

(Qureshi & Simons 1989; Ungerson 1987 cited in Finch 1989: 27-28) and do not appear to be shifting in both Australia and Singapore.

The following account is included for added emphasis that spousal care is common in the Australian context and as an example of care by a female spouse:

I do very much get around. I can drive close to home, no problem. My wife is

actually officially my carer because I have this balance problem; I tend to fall

backwards. So she's my carer, she drives me around although I can drive close to

home. That’s it. So it's only Sundays and Mondays that I’m with my wife, all day. I

drive her mad on those days. (MERVYN, Australia, Male / 77)

It was noted that this is MERVYN’s second marriage; he became a widower after nearly 40 years in his first marriage. Despite this marriage being relatively short and that he describes himself as a “difficult” person at times, his spouse has been willingly providing personal care for the past few years. Elsewhere in

168 the interview, he shares that he has only started accessing day care as his spouse had to travel annually to another country to be with her adult child and be a “hands-on grandmother”.

His adult children found out that he enjoyed the day care program and have been paying for the service since about three years ago. The day program has now become a twice-weekly form of respite for his spouse. As such, even when spouses are the principal carers, adult children would actively contribute to the care of their older parents through various means and provisions. The next section focuses more specifically on adult children as principal carers.

4.2.2 Adult Children and Children-in-law as Principal Carer

As mentioned in the previous section, older people in both Australia and

Singapore can continue to expect spousal care. Nonetheless, the surviving spouse who provided care for the late spouse would require care by other members of the family when they in turn require assistance. The next category of family care providers would naturally be adult children in most cases.

With regards to the location of care, it would usually begin in the matrimonial home and care is provided from a distance by adult children who have usually moved out. The following account described an observation by an Australian participant who is herself a carer for her husband and her children have moved out as well:

169 [Loneliness affects] even the men. Some are widowers, their wife died, and they

live in the house alone. The children have their own place. They will only come and

visit on the weekend. Unless the elderly is sick or something, they will need to ask

the daughter to come. The daughter have to take leave because they are working.

So that, that is a bit of a problem there. (BOZHI, Australia, Female / 77)

The account above describes the common care arrangement when an older person is cared for by the adult child(ren) while remaining in their own home.

Visits from children are expected to be on the weekends (due to work and childcare commitments during the week) unless the older person falls ill and requires sick care. As explained by several participants, adult children are not expected to become full-time carers even when they become frail.

As highlighted by the following Singaporean participant, some participants in this study expect to be in a nursing home instead of being cared for by an adult child full-time:

I’ve never thought of [living in a nursing home], like I don’t like it. I think when one

can’t move around anymore, they will all end up there. I don’t want to trouble my

daughter; she has her own family. Her burden is already heavy. She can’t be

taking care of me; she needs to take care of her own family. A domestic helper

these days are as expensive to hire. I’ve thought about it but I haven’t said it out

yet. I can go to a nursing home so that we can rent out my current flat, and the

income can pay off the nursing home fees. (YILUN, Singapore, Female / 76)

As interpreted from BOZHI’s and YILUN’s accounts, the daughters are usually the expected non-spouse family carer that an older person would approach

170 when they require personal care. Similar to research findings, ‘[u]nlike the personal care between spouses, these patterns of support [between parents and children] are highly gendered, with daughters and mothers being carers much more commonly than sons and fathers’ (Finch 1989: 28). The gendered nature of caregiving is extended to the daughters-in-law, particularly if the older person is living with the son and / or they do not have any daughters.

In this study, there is such an Australian example:

Well, [the Home Care Packages] entail somebody coming to help you with the

shower five days a week but I don't think everybody has that. She [the daughter-in-

law] arranged that for me because while I was in the hospital, I was getting a lot of

urinary infections. And then on Tuesday and Thursdays, they drive me to the day

centre and drive me home. And on Wednesdays, somebody comes and does the

cleaning. Mondays, I go shopping for a couple of hours. I can do my own washing

and all that but my daughter-in-law cooks my dinner and puts it in the freezer. But I

can get my own breakfast and lunch. So that's how I manage. (ETHEL, Australia,

Female / 87)

The account above provides much information about the Australian HCP (see page 40) that is designed to enable an older person like ETHEL who require a range of home-based and community care services to be able to remain living in their own home and in the community. Nonetheless, the case highlights that in some cases where the older person does not have a daughter, the daughter- in-law assumes the role of the principal carer instead of the son. Despite having the HCP to assist the older person in core activities, the daughter-in-law provides personal care in between the various services, visits the older person

171 daily, prepares meals, and is the main coordinator of care. The son and daughter-in-law have also arranged for the older person to move closer to facilitate this care arrangement.

In some other cases, the older person decided that it would be best to move in to live with one of their adult child and their families to facilitate caregiving. The move is often accompanied by the sale of their matrimonial home – transiting from homeowner status into a dependent living and care arrangement. Such a move is often irreversible when the proceeds from the sale of the house are used to finance the cost of care services. The issue of home ownership and renting is discussed further in Section 4.5 in relation to self-reliance and family care.

In the case of BRENDAN – who is quoted in the previous section as a spousal carer (see page 165) – he has to go through a bigger transition of migrating to a new country when he in turn requires care:

I was living alone in [the home country]. My wife died some years ago. When my

eyesight deteriorated, they suggested that I come and join them. So I had a sort of

trial period, decided I quite liked Australia and I’ve been living with my daughter,

son-in-law [and grandchildren] ever since. (BRENDAN, Australia, Male / 80)

As highlighted in the above Australian examples, widowhood is a common underlying reason to moving closer or moving in to live with an adult child (and their family). All five Australian participants who have such living and care arrangements have their marital status as widowed. As such, it can be argued

172 that even in a Western society such as Australia, adult children do recognise that the loss of spousal support require a response on their part when the surviving parent requires care.

The situation among Singaporean participants living with their children is similar as five out of seven of the cases are widowed (see Table 4 for participant’s housing statuses and living arrangements). As for the remaining two cases, one of them has never been married and is living with her adopted child and her family. In the other case, the ageing couple are living with one of their adult children as they both require care – one of the spouse is attending day care and the other is primarily cared for by the domestic helper.

The overall portrait of family care provided by adult children and children-in-law in the Singaporean context is similar to the ways Australian adult children and children-in-law organise and provide personal care for their older relatives. As explained by the following participant who was cited in the previous section on spousal care (see page 166), he expects the family, particularly the daughter, to be the main coordinator of his care when he in turn requires assistance:

[My children] know that I can take good care of myself; they will not do too much. If

I am really unable to care for myself, like my wife back then when she was sick, my

eldest daughter would likely employ a maid to care for me. She will be paying for it

as well. (LIZHE, Singapore, Male / 70)

Similar to the Australian case of ETHEL (see account on page 171), cases where the older person do not have any daughters, daughter-in-laws are also

173 mentioned to be performing personal care. In the following example, the daughter-in-law lives close-by and often visits to manage the household chores despite the older person co-residing with her spouse:

Yes, like the kitchen cupboards, when [my husband] stopped working, he helped

me with it. When he was working, my daughter-in-law helped as she knew I can't

climb the ladder to clean the cupboards. She is understanding. (ANQI, Singapore,

Female / 76)

The presentation of these examples do not mean that male children and children-in-law do not provide care in any way. Nonetheless, if the daughters are available to care and if the male child is married, the likelihood of daughters and daughters-in-law providing some form of personal care is higher. While the means through which the family provides care is evolving with family changes and increase availability of professional care services, such a gendered nature of parent-child caregiving has persisted in both Australia and Singapore.

However, there appears to be cultural differences in the gender of the child who the older person is living with for care arrangements. In the case of Singapore, six of the seven participants who are living with their child(ren) are in their sons’ households, reflecting the patrilocal living arrangement common in Confucian- influenced societies (Brody et al. 1983; Canda 2013). The remaining participant lives with the adopted daughter and has never married. The trend in Australia appears to be the opposite. In three of the five cases, the participants have moved in to live with their female child and their families. As for the two remaining cases, the participants do not have any female child.

174 Overall, the decision-making process surrounding family care among adult children and children-in-law appears to be highly organised by practical considerations such as the availability of carers and are still in line with the hierarchy of obligations. While cultural differences exist between Australian and

Singaporeans families in the gender of the child where the older person moves into for family care, the composite accounts are highly similar in the range of ways and level of personal care adult children and children-in-law are providing for their older relatives. In addition, through the various accounts on family care provided by spouse, children, and children-in-laws as presented above, the employment of home-based and community care services, including the employment of domestic helpers in the Singaporean context, to complement and support their efforts, is more common than family carer(s) providing the full load of personal care.

4.3 Provision of Care by the Family

In terms of the more tangible forms of care and support, participants mention a wide range of care activities that they require help in as a result of ageing and disability issues. The ranges of care activities include managing the household

(including basic maintenance and managing bills) and household chores, cooking and meal preparation, groceries shopping, and getting around indoor and outdoor.

The terminologies used for such care activities vary in the literature and aged care documents and have been commonly organised under the ADL framework.

175 The Barthel (ADL) Index (Mahoney & Barthel 1965) is used for assessment in both Australia and Singapore (see Department of Health 2017a: 200 & Ko et al.

2006: 78). In Singapore, the Resident Assessment Form is commonly used for a range of purposes including the assessment of nursing care needs for admission to nursing homes, funding for care facilities and programs, and level of subsidies to individuals and families (Ko et al. 2006). It was developed by

MOH and even though it is a simple tool, ‘the parameters covered include functional, physical, psychological, psychiatric, emotional, behavioural and social needs’ (Ko et al. 2006: 78).

The ADL framework further distinguishes between basic ADL (BADL) and instrumental ADL (IADL) (for example, see Department of Health 2017a: 39-40).

The former relates to basic self-care activities and functioning level while the later involves complex skills for home and community living. Care activities with regards to IADL are more relevant than BADL in this study as they are mentioned more in the accounts of participants and are often performed by family members. Though these forms of care can be rendered by non-kin, such as friends and neighbours and purchased from home-based and community care service providers, participants do expect to some extent that the family perform these instrumental assistance as kinship obligations instead of engaging services from outside of the family.

In addition, there are fewer mentions of personal care in relation to BADL as compared to IADL as a significant number of older participants interviewed are fairly independent and would only ask for help when it poses risk and / or when

176 they are unable to manage it personally. In line with expecting the provision of care as part of the family’s obligation, there is also a tendency for older people to neglect mentioning them specifically, assuming that these ought to be performed by a family member, or that these requests for help are not sufficiently significant to mention specifically.

Below are two accounts, one each from among the Australian and Singaporean participants, which are selected for comparison between family care in the two countries. As can be interpreted from these two accounts, though the description of family support in terms of care activities is short and without much details, it can be expanded to encompass a broad range of assistance that the older participants would require while living with their family and in the community.

In the Australian example:

I get a lot of support from my daughter. I don’t do any shopping or cooking or

things like that. (BRENDAN, Australia, Male / 80)

In the Singaporean example:

I leave all the household things, all done by my daughter and my son-in-law. I don’t

have to cook. (XINYI, Singapore, Female / 81)

Both participants have been invited to move into their adult children’s household due to the need for care. In these two cases above, the families are providing

177 most of the instrumental care activities such as cooking, shopping, and household chores. As the older persons are living in the adult children’s household, the adult children and their spouses generally manage the property and other instrumental tasks. Nonetheless, the older persons remain functionally able in self-care areas such as feeding, bathing, and toileting and the families are able to cope with the low level of personal care required, which would be considered as BADL.

In addition, both families seem to be able to provide the whole range of care without employing external help due to the availability of a stay-at-home carer.

In the case of the Australian participant, the daughter has a flexible working arrangement and mostly works from home. For the Singaporean participant, her daughter works part-time and comes home early in the afternoon to care for her children and manage the household chores. Her son-in-law cooks for the entire household and the older participant has no special dietary requirements at this stage.

The following Australian participant is living alone in his own place and remained fairly independent in managing the household and performing instrumental tasks such as driving a car to get around. While he engages external services to manage his garden and to clean his house, he also asks for help from his family when they visit on the weekends:

If I need any help, my daughter [and her family] come and visit on Saturday or

Sunday, during the weekend. I used to do everything around the place but now, I

don’t want to go up to the ladder to change a bulb, my son-in-law does anything

178 that needs doing. But I try to be as independent as I can. (LUCIUS, Australia, Male

/ 89)

This account is similar to the Singaporean example of ANQI on page 174 whose daughter-in-law visits her a few times a week, and cleans the areas that are harder to reach and which poses a higher risk of falling and injury.

When compared side by side, these following four accounts from Australia and

Singapore are mirror images of the way families in the two countries care for their older relatives.

In the following two examples, the adult children have a car and have flexible work arrangements to be able to respond to the older participants’ need to get around.

From Australia:

My son lives with me. He’s very kind to me. Drives me here, there and everywhere.

He’s a good son. (GABRIELLE, Australia, Female / 80)

From Singapore:

My younger son, he is a salesman and so he needs to have a car. This also makes

it more convenient for us. If I need to go anywhere, I just need to give him a call,

and he will drive me there. (JIAHAO, Singapore, Male / 77)

179 In the following example, the daughter helps out in managing the bills and light chores. She asked to move into the older participant’s household as she has a long-term illness and is financially strained due to the medical costs. While this living arrangement between younger old and older old is less common, this family has worked out a successful co-dependent care arrangement. As for other forms of helps, the older participant relies on the healthier son-in-law instead as elaborated below:

My daughter helps me [with letter reading and bill payments]; not a lot but she

helps me. And I’m happy to have her at home with me. My son-in-law is very good

to me too. If I need to take the garbage out, he takes it. If I need the milk or

something, he goes out and buys for me. He's very good but I am also very good

to them too. (SHERRY, Australia, Female / 92)

While older participants might not require such direct forms of care from the family at an early stage, families do begin to show care by monitoring their safety and wellbeing at a much younger age.

As highlighted on page 178, the following Australian participant is visited weekly by his adult child and her family who lives hours of drive away and is aware of her intention to call daily:

Well, let me put it this way, my daughter rings me every night to see if I am still

kicking. (LUCIUS, Australia, Male / 89)

180 Here is a similar example from Singapore:

I will tell my daughter everyday where I am headed to, so that she is aware of my

whereabouts. She will call me at night to ensure nothing happens to me. She

would definitely visit me once a week. (YILUN, Singapore, Female / 76)

In yet another Singaporean example, it is highlighted that the contacts are not made unidirectional by the family as older people who are mobile and more independent can initiate the contacts:

We communicate quite a lot. Sometimes they will call us first, if not we will call

them. Sometimes we would visit them at their homes. If anything happens to me,

we will call them. When they come to visit us, they will also know if we are sick.

(YAOWEN, Singapore, Male / 78)

Embedded in these accounts is the element of family care older participants are appreciative of, feeling assured that the family is on the lookout for their safety and wellbeing. There are other more subtle means of maintaining regular family contact as the following participant has achieved through being involved in the care of her grandchildren in a three-generational reciprocal relationship.

I go out there [to the sports ground], and I usually watch my granddaughter that

has just turned 12, and then another that is 13, and I watch another that is 15 [play

the same sport]. My eldest son is within walking distance, and they pick me up to

take me out there. I’ll come home with my other son. I really enjoy that so that’s

good. (ELLEN, Australia, Female / 72)

181 Monitoring of safety and wellbeing is also an ongoing process where the family keeps an eye for significant changes for the older person that might require medical and other professional help:

When my sister [whom she was living with] passed away, I don’t know what

happened to me. My daughter took me to see the doctor and found out that I had

some depression. (XINYI, Singapore, Female / 81)

As described by a number of participants in this study who remain closely connected with their family, family members are usually the ones who are actively involved in having them assessed for health issues – making professional appointments and accompanying the older person for various examinations.

As in the above case, once the assessment is complete, the family soon acts on the doctor’s recommendation for day care and progresses to the next stage of organising and purchasing care, that is, if the older person requires specialised care that is beyond the capability of family members and / or if the family is unable to provide the required care.

For the following Australian participant, the family had to convince the older person who is living alone that day care is necessary due to her preference to live alone with increasing frailty:

Look, I told you I have this [degenerative illness]. I had an operation and my

children were actually the ones who said that you have to get out and be in touch

182 with people but I was always out and about. Anyway they started me off.

(MAGDALENE, Australia, Female / 90)

Similarly for the following Singaporean participant:

My child brought me here. My child saw that there was this day centre here and

she came to make some enquiries. (JIAHAO, Singapore, Male / 77)

And for this case where the spouse carer was the initiator:

At first, he [the spouse] didn’t want to come. We [together with a family friend]

brought him together [to the day centre], sit down for the interview, and all that.

(BOZHI, Australia, Female / 77)

As described by the above three participants, family members, particularly adult children and spouses, are the ongoing coordinators for external services as well.

This is particularly so for day centre participants in this study, from both

Australia and Singapore. Day care service providers mention that they are in partnership with the family and will periodically update the family about any progress or decline in terms of functioning levels in the older person for the family to follow up on.

Family members are usually around during the orientation phrase to help their older relatives ease into the new setting such as being in a day centre:

I think there’re a lot of things [community services and programs] out there but you

get a lot of people who complained because they don't take the first step to go

183 there. Takes a bit of courage the first time, like going to kindergarten. It's a new

environment, new people, they think that everybody’s looking at you. The family

comes with them often. They sit down, have morning tea with them. And then take

them home again and maybe do it a second time. (WILLIAM, Australia, Male / 78)

To this end, the variety of accounts from the older participants provides a vivid picture that the family remains a central place for aged care. This is so for families that care for their relatives who are living in their household or caring from a distance. It is also the case when external help is engaged, as family members are involved as the initiator and coordinator of care services.

As attempted, similar sets of accounts from Australia and Singapore have been presented to illustrate that families in both countries provide a range of care activities in largely the same way. However, in the following sections on financial support and housing statuses in relation to the family, self, and the state, there are much more variations and divergences between the Australian and Singaporean participants.

4.4 Sources of Income and Financial Support from the Family

The discussion in this section begins with a description of the financial situation of older Singaporeans in this study. As compared to the Australian cases, the types and sources of financial support reported by Singaporean participants are much more varied in nature.

184 4.4.1 Sources of Income among Singaporean Participants

Slightly more than half of the Singaporean participants (16 of 31) cited that their adult children are their main source of financial support. The adult children usually provide a fairly stable amount of cash for groceries and other daily expenses and go further in paying for utilities, healthcare, and other services for an amount that is often undisclosed or discussed.

As highlighted by the following participant, financial support by the adult children is equated with being filial:

[A community care service staff] told me to apply for financial aid, but I didn't. We

shouldn't be greedy over this because we have children. Even though my children

don’t give me much, but it's sufficient to get by. This way, our children will not be

labelled as unfilial. (YANNI, Singapore, Female / 68)

This perspective is in line with the findings of Mehta & Ko (2004). However, among the adult children, not all of them would be able to provide financially and the amount provided varies according to their individual incomes:

Look at me hah, I’ve got five sons. Only my eldest gives me money every month;

the second son pay for my medical fees only. My third son, he cannot [provide

regularly], because [his industry] now shutting down. When he meet me, he will

give me like 50 or 100 SGD. The fourth son, he cannot even provide for his own

family; I dare not ask him for money. Then the youngest son also in debt, can’t

even support himself, how to support me? (BAOBEI, Singapore, Female / 70)

185 Similarly for the following participant, each adult child will provide according to their personal circumstances:

My daughter gives me 700 SGD. My son would give 400 SGD but it’s not fixed.

Sometimes he will give more; sometimes he will give less. But more importantly it's

enough for me, since I'm alone. (SHIMIN, Singapore, Female / 67)

Despite the varied levels, the participants generally describe the adult children as providing for them to the best of their financial ability. The total amount provided by the adult children is usually described to be sufficient to cover the daily expenses and other costs though some participants hinted that there is not much leftover and they have to be very prudent in their spending.

In the second example above (SHIMIN’s), two of her three children provide for her financially by giving a sum of money monthly while the participant is living with another adult child. There is an inherent understanding that any cost incurred in the resident household is borne by that child who is providing personal care as well. Besides the seeming equitable distribution of financial responsibilities among the adult children, this arrangement also highlights the value and appreciation given to unpaid care within the family context. The rationale adopted by this family parallels the provision of carer support in

Australia, recognising that caring for an older person incurs costs, including opportunity cost from non-participation in the workforce.

Nonetheless, SHIMIN’s case is an ideal example where every child contributes.

The following two participants have a different experience with their family and

186 their accounts highlight that financial support is also dependent on the state of their parent-child relationship:

My children are married. I have four children; three daughters and a son. Only two

of them support me financially, but they don't keep in much contact with me. I am

not in contact with my second and fourth daughter. Only my eldest daughter and

my third son takes care of me. I stay alone. Once in a long while they will bring me

to their home or bring me out. That's about it. Only two of them support me

financially. One of them gives me 300 SGD and the other 200 SGD. It isn't a lot.

(RUINA, Singapore, Female / 75)

As life expectancy increases, there is a greater number of older people who are financially supported by adult children who are themselves entering retirement and old age. The issue of the older old being cared by the younger old is further discussed in Section 7.2.2. Correspondingly, the number of grandchildren reaching adulthood with surviving grandparents is expected to rise and this study speculates that adult grandchildren might become a significant category of family carers in Australia and Singapore – providing some form of personal care and directly supporting their older grandparents or indirectly providing through their older parents. Adult grandchildren as a significant category of family carer is further discussed in Section 7.4.

The following is an account of a Singaporean participant whose adult children have reached or approaching retirement age, and the grandchildren have reached adulthood and begun contributing financially:

187 I have three daughters and two sons. They are all married. They have their own

flats. My youngest child gives me 200 SGD monthly. Sometimes when my

grandchildren visit me, they give me 50 SGD each time. One of my grandchild is a

pilot, another is an accountant. Altogether, I have four grandchildren. (DEXIANG,

Singapore, Male / 81)

In addition, there is a participant who is widowed and receiving financial support from the spouse of her only child who is also providing financially for his own set of parents. In this particular case, seven family members are relying on a single source of income. Though such a top-heavy family structure is uncommon, this case highlights that the demographic changes in the Singapore family, particularly as a result of the two-child policy of the past, can result in some older Singaporeans being inadequately supported their adult children. As a result of the financial strain on the family, this participant is already contemplating to sell her matrimonial home and move into a nursing home once she requires personal care (see account of YILUN on page 170).

Among the Singaporean participants, there is also no obvious pattern to suggest whether the gender and birth order of the adult children remains a factor in expecting financial obligations. It is also noted that among the 16

Singaporean participants who are relying on their family for financial support, none of them have any additional source of income. As explained by the following participant, receiving financial support from adult children is usually the last resort. Similar to the norm in Australia, older people are reluctant to ask for help from their adult children and in some cases, parents will forbid the children to help (Kendig & Rowland 1983). In this case, the older couple are

188 refusing financial support from their children, being considerate of their adult children’s financial commitments for their own households.

I live in a three-room flat and I can still rent out a room and use that money to pay

for my utilities. The two of us are thrifty and eat simply. Our children all have their

own families and their own family expenses. I would seldom take money from them.

My daughter would often attempt to give me money, but my husband and I told her

not to as she has three schooling children. (ANQI, Singapore, Female / 76)

Nonetheless, as care needs increase, the cost of care rises correspondingly.

For older Singaporeans who do not have any source of income to be self-reliant, the pressure is on their family, particularly on the adult children, to bear the care costs and financially support their living expenses as well. The strain of fulfilling such family and financial obligations without external support can be challenging and those adult children who are unable to provide could be labelled as unfilial in the Singaporean context. As highlighted by the account of

YANNI on page 185, older Singaporeans who are inadequately supported by their adult children are unwilling to turn to the community and the state for help, fearful of such stigmatisation on their adult children.

On the other hand, those without family support can rely on the state for financial support with three Singaporean participants reporting that they are on the PA scheme and another participant is dependent on a short-term equivalent of PA, which has a lower rate of financial assistance and often supplemented by monetary support from a charity and / or religious organisation. However, the

Singaporean PA scheme (see Section 2.5), which is a state provision closest to

189 the Australian Age Pension, is highly targeted to the most needy and means tested according to having the ability to work, having family support, and having any savings, superannuation, or any form of income or asset. As explained in

Section 2.5, the Singaporean approach to state provision is similar to other East

Asian states subscribing to the concept of filial piety where family is seen as the first line of defence, followed by the community, and the state last.

For the remaining 15 Singaporean cases, a significant number (11 of 31; 35%) of them can be considered to be self-funded retirees. Among these 11 self- funded retirees, seven are reliant on rental income – with five of those renting out one or two of their rooms while the other two have rented out their entire residential property and moved in to live with their adult children.

For the remaining four participants, one is having income from paid work, one is having a small business, one is having monthly CPF payout, and the last is a former civil servant on a pension scheme. This category is expected to rise significantly as contributions to the CPF scheme (see Section 2.7) in subsequent cohorts of older Singaporeans is rising with greater awareness of the “three-pillar” system of retirement income with a common root to

Australian’s policy developments that can be traced back to the World Bank’s

(1994) Averting the Old Age Crisis report (also mentioned in Section 2.7).

190 4.4.2 Sources of Income Among Australian Participants

In Australia, a majority of the participants (22 of 30; 73%) are on state support, receiving the Age Pension. In report year 2014-5, the DHS made Age Pension payments to 2.4 million recipients (DHS 2015). As such, an estimated 67% of older Australians are receiving the Age Pension (ABS 2016e) and the proportion of Age Pension recipients in this study is similar to that of the national figure.

The remaining eight Australian cases report that they are “self-funded retirees”.

Their sources of income are employment, investments, rental income, and savings through superannuation schemes. That leaves none of the Australians in the “relying on family for financial support” category.

Nonetheless, when looking at the secondary sources of financial support among Australian participants, there are three self-funded retirees and one pensioner who report receiving a stable amount from their adult children. As such, the monetary provision made by adult children and families can be easily masked in the Australian context. In addition, gifts in kind and payment for services should not be overlooked for a complete understanding of the family’s contribution towards an older relative’s care.

191 4.4.3 Comparison of Income Sources between Australia and Singapore

The obvious contrast between the two countries in terms of sources of income and financial support in old age is that in Singapore the family is expected to be the primary providers of financial support while in Australia, the state assumes significant responsibilities.

The current systems of financial provision adopted by the two states have existed for decades and there is no sign of a major reform. The general framework has been retained over the years with gradual changes responding to changes in the family and the respective societies. For example, in Australia, the Asset Hardship provisions are made in view that older Australians who are excluded from the Age Pension, based on the assets test, can face severe financial hardship (DHS 2017b). In Singapore, additional tiers of Public

Assistance was introduced in 2013 to cater for recipients with special needs such as those who require healthcare and hygiene products (MSF 2013).

For the group of Australian “self-funded retirees”, the proportion is significant and has been predicted to rise steadily as each subsequent generation are reaching old age with better life chances (McCallum & Geiselhart 1996). As highlighted in Section 4.4.1 (see page 189), Singaporeans are more likely to maintain financial independence through home ownership and rental income.

For the Australian participants, only one of the participants has taken this route while the rest are maintaining financial independence mainly from savings and

192 investments, including superannuation. Age does not seem to be a limiting factor as three of the eight Australian participants in this category remained financially independent into the nineties. Other factors such as financial preparedness, earning capacity, education level, and the presence of disability and illness might be more influential.

4.5 Housing Statuses and Care Issues

In this study, the housing statuses of older participants have been grouped into three main categories for comparison’s sake. The categories are homeowners

(including various arrangements of co-ownership), living in another person’s property and / or household, and renting from housing authorities. Please refer to Table 4 on the page 195 for the breakdown in participants’ housing statuses and living arrangement. Though the literature on housing situations of community-dwelling older people has identified significant proportions who are renting from the open market (Morris 2009) and homeless (Morris et al. 2005), none of the participants in this study are in those situations. In addition, this study is designed to explore family and community care, as such older people in residential care settings are excluded.

There is a subset of two Singaporean participants who are homeowners, have rented out their residential property, and have moved into their adult children’s households. These two cases are classified as “living in another person’s property and / or household” as they have moved in due to family care arrangements and their children are managing their rental income. Nonetheless, the rental income is used to pay for the older person’s own care costs and as

193 such they are in a more co-dependent relationship with their family than those who do not own any asset and / or other housing option. Together with the abovementioned two cases, the family care arrangement of those who are categorised as living with the family has been substantially covered in Section

4.2.2.

Participants who are living in rental housing are usually not living with any family members and have limited or no family support. Of the 10 participants in

Australia who are residing in rental housing, eight of them are living alone. One of the two other Australian participants is living with the adopted son who has remained single while the other participant lives with his spouse and mother in a co-dependent living arrangement.

Of the seven participants in Singapore who are residing in rental housing, five of them are living alone, one of them is living with the spouse, and the other is living with a friend. Participants in this category of “renting from housing authorities”, particularly those who are living alone, tend to establish more meaningful friendships and community connections that form a large part of their social and safety network. This observation will be elaborated further in

Chapter 5.

194 Table 4: Participants’ Housing Statuses and Living Arrangements

Australia Singapore

Homeowners (Total: 13) Homeowners (Total: 1621)

Living alone 4 Living alone 9

Living with spouse 7 Living with spouse 4

Living with grandchild 1 Living with spouse and son 1

Living with daughter & son-in-law 1 Living with children 1

Living with sibling’s family 1

Living in another person’s property and / or Living in another person’s property and / or

household (Total: 7) household (Total: 8)

Living alone 2 Living alone 1

Living with son’s family 2 Living with son’s family22 6

Living with daughter’s family 3 Living with adopted daughter’s family23 1

Renting from housing authorities (Total: 10) Renting from housing authorities (Total: 7)

Living alone 8 Living alone 5

Living with spouse and mother 1 Living with spouse 1

Living with son 1 Living with friend 1

21 Excluded the two homeowners in the subset; one participant is a sole owner, the other co- owns with spouse 22 Include one case of a homeowner who rented out his property and moved into the son’s household 23 This is a case where a homeowner has rented out her property and moved into the adopted daughter’s household

195 Among Australian and Singaporean participants, homeowners are the majority and their care arrangements are found to be less straightforward and more varied than the other two categories of those who are “renting from housing authorities” and those who are “living in another person’s property and / or household”. There are also differences between Australian and Singaporean participants who are homeowners due to the issue of co-ownership, which is elaborated later in this section.

Home ownership rate in Singapore is known to be one of the highest in the world at 90.9% in 2016 (DOS 2017b). For comparison, in year 2010, home ownership rates24 for Singapore is at 87.2% (DOS 2107b) while Australia is at

67.0% (ABS 2016a). However, among the older population, home ownership rates are currently higher in Australia than Singapore (see Table 5 and 6 on the following page). This is due to historical factors when the “housing crunch” was felt in the two countries and affordable housing was provided as a policy solution.

Historically, home ownership rates in Australia rose sharply ‘from a post-war level of 47 per cent to reach its current level of around 70 per cent by 1961’

(Yates 2011: 6). Comparatively, home ownership rates in Singapore rose more rapidly but later historically from 58.8% in 1980 to 87.5% in 1990 and remained stable around 90% since then (DOS 2017b). The later introduction of public housing policies in Singapore has largely contributed to the lower home ownership rates among the current cohorts of older Singaporeans as compared

24 Home ownership rates for both countries include both owners with or without mortgages.

196 to their Australian counterparts. Nonetheless, home ownership rates for future cohorts of older Singaporeans would likely continue to rise and surpass the

Australian proportions in a decade or two.

Table 5: Australian Home Ownership Rates by Age of Household Reference

Person

Age 1996 2006 2010

55 – 64 83 82 82

65 and over25 82 82 84

Source: Yates 2011: 7.

Table 6: Singaporean Home Ownership Rates by Age of Household Reference

Person

Age 199526 2005 2011

55 – 64 7927 82 85

65 – 74 64 71 75

75 and over 49 53 68

Source: Institute of Policy Studies 2013: 15.

25 No further breakdown in age brackets provided. 26 Year of data selected for minimal discrepancies. 27 Figures rounded up from one decimal place for comparison sake.

197 Among the participants of this study, 13 of 30 (43%) Australians are homeowners with six of them who are sole owners and seven who are co- owners with their spouse or de facto partner (one in seven). Among the

Singaporean participants, 18 of 31 (58%) are homeowners28, with 10 of them who are sole owners, six who co-own with their spouses, one who co-owns with the children, and one who co-owns with a sibling (having inherited the property from their late parents). The relatively lower home ownership rates among participants in this study as compared to the general population is likely due to the fact that participants in this study are service users and recipient of family and community care and / or from the lower income group.

Among those who own a residential property, one Australian participant has multiple properties for residential and investment purposes. As mentioned, two

Singaporeans homeowners who have moved in with their adult children are relying on the rental income from their own residential property to pay for the cost of care services and their own living expenses. This strategy of selling or renting the matrimonial home to pay for care services is likely gaining popularity in Singapore due to increasing home ownership rates in the current and subsequent cohorts of older Singaporeans and the lower rate of financial support from the state as compared to Australia. This possible trend is further discussed in Section 7.2.1.

28 Included the two homeowners who have rented out their residential property and moved in to live in their children’s household.

198 Co-ownership is a norm in Singapore as it is a requirement for purchasing a

HDB flat. One of the two main exceptions, and recently revised in 2013, is the

Single Singapore Citizen Scheme allowing singles who are aged 35 and over and who are unmarried, divorced, and widowed to purchase a 2-room HDB flat in a non-matured estate directly from the HDB. Such provisions were made in view of the rising numbers of unmarried singles past the age of 35 and rising divorce rates in younger Singaporeans. Previously, this group of singles could only purchase a HDB flat from the open market and a significant proportion were unable to afford the much higher resale price.

The other main exception is when their spouse who are co-owners has passed on, which is the case for seven of the Singaporean participants who became sole owners as they are not legally required to have another person to be listed as co-owners to retain ownership of an HDB flat. In Australia, home ownership is predominantly from the private market and as such co-ownership is not a requirement.

Home ownership is related to care issues in a few ways. Firstly, older people who are homeowners are means tested by their asset(s) and often have to pay a higher rate for council fees, healthcare and home-based and community care services. This has posed a problem for older people who are considered “asset- rich and income-poor” and they might choose to forgo services that they would require to age in place in the community. The following extract is from an

Australian participant who is a homeowner and is finding it difficult to keep up with the daily expenditures and various bills. The extract describes the attempt

199 to appeal for an item to be taken off from the relatively high council fees.

Well, I pay 2,400 AUD [council] rates for my house [annually]. There are lots more

fees like that including an environmental levy for six years at 144 AUD. I had a

meeting with the mayor and asked him to take that off for the aged, the disabled

people, the war widows etc, and he refused to do just that. One of the councillors

was saying that if they can’t afford the rate, they should move out. I asked how

would you like it if after 40 years, you have to move out because you can’t pay the

rates? Didn’t get an answer. (LUCIUS, Australia, Male / 89)

In other parts of the interview, this participant describes at length the financial pressures of maintaining the house, which has driven him to actively look for alternative options and contemplating on nursing home admission within a year.

For this case, it is clear that such a move is premature as the older person is able to live independently, is socially and physically active, and highly mobile in the community – getting out daily with his car. The issue of a “house for a home” as a solution for the “asset-rich and income-poor” with care issues is further discussed in Section 7.2.1.

Secondly, families might have to pay for the services instead and might persuade the older person to sell off their property and use the sales proceeds for their remaining years. Several Singaporean participants are partially renting out their residence to pay for their daily expenses and would likely be fully renting out or selling their residential property when their care cost increases significantly.

200 The following extract is about the experience of a Singaporean participant whose adult children persuaded him to move to live with one of them so that his entire unit could be rented out to pay for the wife’s nursing home fees and his day care fees.

If I tell my children that I don’t wish to come to this [day] centre and remain living in

my own home, my children will then need to bear the costs [of my wife’s nursing

home fees]. My house is leased out so that there is some rental income. [My son]

takes my rental income, pays off the fees for my wife and mine [day care fees] .

They also need to bring us to see the doctor often, and they will use whatever that

is remaining. (JIAHAO, Singapore, Male / 77)

This case highlights some of the complexities the older person and their family have to negotiate in terms of financing care services and living arrangements.

As detailed in the account, the participant has to move out of his residential property and live with one of his child so that the entire unit can be rented out at a higher rate to pay for the costs of care services for his wife and himself.

Despite JIAHAO’s initial reluctance to move out of his matrimonial home, he understands that the family has few other options. With this strategy, the participant is able to age in place in the community without adding much out-of pocket financial costs for his adult children. As such, he can still be seen as being self-reliant and financially independent.

201 4.6 Domestic Helpers in Singapore

Care provided by domestic helpers could be seen as a distinctive source of help employed by Singaporean families that is rare in the Australian context. The

Singaporean society, particularly among middle class and affluent families, has in the last decade become accustomed with the option of bringing in female workers from neighbouring less-developed countries as ‘home-based, low-paid, surrogate care domestic helpers’ (Yeoh & Huang 2009: 71; see also Huang et al. 2012).

The rationale and practicality of employing a domestic helper is similar to purchasing care services, which is a common practice in Western societies.

Nonetheless, ideologically, having a full-time foreign live-in caregiver who is non-related to the care recipient and paid an amount less than the national average or minimum wage is unlikely to be accepted by the Australian society.

Despite the possibilities of social and political ramifications (Yeoh et al. 1999), it can be argued that Singaporean families are left with few options to provide family care due to a less developed home-based and community care system as compared to what is available for Australian families (Huang et al. 2012;

Mehta 2000; Yeoh & Huang 2009).

The job scope of a domestic helper is often not limited to providing personal care for the older person alone. They are most likely required to manage household chores, groceries shopping, and cooking for the entire household. In this study, though there are only three Singapore participants who have a live-in

202 domestic helper, there are several other participants who have either a past experience of having a domestic helper or have contemplated on this option of home-based care.

On page 166, LIZHE is supported by a domestic helper in providing spousal care and he envisions that his family would do likewise when it is his turn to be cared for (see page 173). The following account further illustrates the role of a domestic helper in being around the older person and the level of partnership between them and the family in providing care and supervision:

My brother was working and they hired a maid to take care of my mother at home.

Once, she suddenly fainted at home, and the maid called my brother and he sent

my mother to the hospital. We all [the siblings] gave our numbers to the maid for

her to call in case of emergencies. (FURONG, Singapore, Female / 72)

Nonetheless, as explained by the following participant, this option is out of reach for families who are less affluent despite the below average wages of a domestic helper:

There are not a lot of chores to do at home. We don't need a maid. If your children

earns a lot of money or they are high salaried, then it will be a different story. We

are all hard labourers. (MINGZHEN, Singapore, Female / 73)

As evaluated by the following participant and a few other participants, the cost of having a domestic helper, after including the government levy, daily expenditures, and other costs, is equivalent to nursing home care costs:

203 You need more children then it’s possible. My daughter alone can’t. If you hire a

domestic helper, her pay, daily expenses and the government levy, will add up to

be over a thousand dollars. What about other costs? I’ve thought about it before, it

is not worth it. By putting me in an elderly home, it doesn’t sound very nice, and it

will ruin my daughter’s reputation. But we can rent out the current flat, and the

rental income can be used to pay for the bill of the nursing home. Whoever is free

can come and visit me. It is better this way, I won’t be afraid of trouble. The maid

may not be good as well. (YILUN, Singapore, Female / 76)

The above participant further justifies her reluctance to have a domestic helper as carer by citing the risk of elder abuse in such care relationships – where the older person is often left with the domestic helper for extended periods during the daytime when the adult children and grandchildren are out for work and school. With increasing demand and shortage of supply in recent years, the risk of elder abuse by a domestic helper is expected to rise with more families desperate to fill the void of caregiving especially when they have to make quick decisions due to sudden changes in circumstances arising from incidents such as falls and illnesses such as stroke. The concern for elder abuse by a domestic helper and preference for nursing home care is shared by the following

Singaporean participant:

The nursing homes are for those elderly with children who are busy working and

can’t take care of them, and they chose not to hire a maid. Sometimes, hiring a

maid can be worrisome as there are cases of elderly abuse. So some children

choose to send their parents to nursing homes. They won’t be lonely there as there

are doctors, nurses and many other older people for company. If I’m sick and my

children are all working, and there’s no other choice, of course I’ll consider going to

a nursing home. (YAOWEN, Singapore, Male / 78)

204 As highlighted by the two participants above and Yeoh and Huang (2009), domestic helpers are surrogate carers standing in for family members, particularly female members who have to be in the workforce. Based on the interviews conducted in this study, it is also clear that older Singaporeans are well aware that married couples with children cannot afford to forgo having a dual income. Faced with the financial pressures of raising young children and expectations of providing home-based care for the older person in order to fulfil the obligations of filial piety, employing a domestic helper is often the last option before considering residential care.

As seen in the quotes above, Singaporeans participants are surprisingly willing to be admitted into a nursing home given that a majority of older people wishes to age in place. Not only are they willing to consider nursing home admission, they are rationalising such a difficult decision in the interest of their adult children so as to avoid adding on to their burden of care. The possible trend in re-institutionalisation is discussed in Section 7.2.1.

4.7 Loneliness at Home

Another aspect of family support, or rather the lack of it, is in the area of emotional care. Even among participants who are living with the family, there are many mentions of older people being left alone at home in the daytime and feeling lonely and bored. The following song lyrics resonated with their accounts and is extracted from A Month of Sundays by Don Henley (1984):

205 And I sit here in the shadow of suburbia

And look out across these empty fields

And I sit here in earshot of the by pass

And all night I listen to the rushing of the wheels […]

And I sit here on the back porch in the twilight

And I hear the crickets hum

I sit and watch the lightning in the distance but the showers never come

I sit here and listen to the wind blow

I sit here and rub my hands

I sit here and listen to the clock strike, and I wonder if I'll see my

companion again

While these portions of the song describe the later life of an American farmer, there are similarities with accounts of Australian and Singapore participants in this study. As painted by the song lyrics, the world around the older person keeps on moving like “the rushing of the wheels” while he sits alone in his familiar space watching the world goes by and waiting for the day to pass.

Embedded in the lyrics is the lack of companionship, a possible sense of loneliness, and a seeming lack of life purpose.

The following account from an Australian participant is the first mention related to this theme of “loneliness at home” and remains the best description among the participants, resonating closely to the lyrics of the song by Henley (1984):

206 I mean when you’re sitting in the house all day, kids are at school, daughter is

upstairs [working from home], I don’t see her, son-in-law’s at work, so I’m basically

on my own all day. We don’t meet up for breakfast, we don’t meet up for sort of

lunch. Quite often, my daughter and son-in-law go to the gym in the evening so

they probably don’t come back till 9 o’clock. I’ve had my supper by then because

it’s been prepared and just go eat on my own […] in summer they go to the beach,

which I’m not particularly interested in, or they go with [the grandchild] who likes

running, so some race somewhere. And so, most Saturdays and Sundays I put in

my diary, ‘ABBS’ – which is short for “Another Bloody Boring Saturday” or “Sunday”

(BRENDAN, Australia, Male / 80).

These strong words and the tone in which it was presented during the interview attuned the researcher to the level of frustration that has been built up over time.

This account is contrasted with the participant’s various perspectives and aspects of experiences and it is narrowed down to frustration in being left alone at home most of the time, even during the night time and on the weekends when the family is expected to be around more. Elsewhere in the interview, the participant has made it clear on that he is appreciative of the family as they have been doing a lot for him in other aspects of care (see account on page

177); to the point that he do not have to worry about anything around the house and that his practical needs are adequately met.

Nonetheless, in terms of socio-recreational activities, he is “on my own” and not included into the family members’ social networks and there is a mismatch between their interests – mainly attributed to the differences in lifestage and his mobility issues. In addition, he has lost most of his social connections through migration and this issue is further discussed in the next section.

207 The following two shorter accounts from Singapore are also from participants who are living with the family and similarly mentioned elsewhere in the interview that their family has been taking good care of them. These accounts further illustrate the masking effect of living with the family on the lack of emotional care in the home setting:

There won’t be much to do at home. I will be just sitting around, reading the

newspaper, watching some television or reading a book. The thing is, I am staying

in my daughter’s house. And my daughter and my son-in-law have to work, and the

children have to go to school. (JIAHAO, Singapore, Male / 77)

Similarly for the following participant:

It is really boring to stay home alone. What can you do when there is nothing to do?

When you are done with your chores, you are done. (KEWEI, Singapore, Female /

80)

The masking effects of living in the family on the lack of emotional care operate in a few directions. Family members, who are preoccupied with the practical aspects of care, and having to manage their own lives, might overlook the socio-emotional aspect of care. Older persons, being appreciative of the practical aspects of care, might be apprehensive in making more demands on the family members, who are busy with their own lives. Perhaps, the family and the older person might not have the insight in recognising the importance of emotional care until the stage when signs of depression become more apparent.

208 As explained in the case of BRENDAN (see account on page 207), the main reason for being left alone at home is that the younger family members are engaged in their work and school during the day. This identified issue of family care, termed as the “daytime gap”, where the family goes out to work during the daytime is extended to the neighbourhood level in Section 5.2 and further discussed in Section 7.3.4. The underlying issue is the age-group and lifestage difference between the older person and their younger relatives and non-kin relationships at the neighbourhood level and is further discussed in Section

7.6.2.

As mentioned, “loneliness at home” is exacerbated by the loss of social connections in old age and the losses in the various social networks is discussed later in Section 5.1 (losses among peer generation extended relatives), Section 5.2 (losses in the community), and Section 5.3 (losses among peer generation friends). Chapter 6, particularly in Sections 6.2.4 and

6.2.7, discusses the possible solution to this issue through centre-based community care services and community organisations as such settings could provide an older person with the platform for social interaction, to form new friendships, and to co-create a sense of community with other older people.

4.8 Relocation in Old Age

Einen alten Baum soll man nicht verpflanzen (German proverb).

The above German proverb is cited by the following participant to highlight the

209 social implications of “relocation in old age”:

There is a saying not many people have heard of. It is something we say in

German; in English, it’s like: “You can't transplant an old tree without it dying”

[German Proverb]. In other words, when you are old, if you get taken to a new

country, you don't make friends. You know, the young one makes friends easily.

That’s why you see the migrants, the young ones grow [in their social network] but

the parents stayed at home and never made friends and never learned English.

(MAGDALENE, Australia, Female / 90)

As such, “relocation in old age” can be seen as uprooting an older person from a familiar physical and social environment and thus disconnecting them from their established social and service networks. As mentioned in Section 4.2.2

(see page 172), several participants have little choice but to move to live with their family due to increasing care needs. There are exceptions though, as one participant had her adult child and her spouse to move into her household and as such she can continue to age in place in her familiar environment.

Relocation for the purpose of care arrangements is not limited to moving in to live with the family as several participants have moved to a new property to be closer to the adult children and vice versa. The following is an example of such an arrangement:

I was living in a unit at [the previous suburb]. Went up the stairs and fell down;

broke my ankle and my pelvis and I couldn't get up the stairs anymore. So, while I

was in hospital, my son sold that unit and he bought one up at [the current suburb]

where there’s no step and there's a lift. I’m closer to him then; that's why I came up

here. Otherwise I love living in [the previous suburb]. When I was in my sixties and

210 seventies, I was so active and into all sort things; I used to do two days volunteer

work and I used to go to exercise twice a week. I can look after my grandchildren

and I was the secretary of the body corporate. Anyway, I have to give it all up when

I was about eight months in the hospital. And when I came out, I had to move into it

[the new place] and I've never been there before. Couldn't find anything; the

furniture wasn't the same. Couldn't manage on my own after that. (ETHEL,

Australia, Female / 87)

In the first part of the above excerpt, the participant gives an account of the rationale for relocation, which makes sense from the standpoint of providing family care and considering the environment barriers of having steps and no lift to the previous apartment. However, she then goes on to describe the various losses and disruptions due to the relocation into a new place and in an unfamiliar neighbourhood. Through which, she has lost her connections in the community, which took many years to establish and maintain when she was ‘in my sixties and seventies’. In addition, she has lost her sense of independence, not being able to “manage on my own” which could have been alleviated by the familiarity with the home environment, service network, and social connections in the community.

The following participant demonstrates a similar awareness of the implications to “relocate in old age” and decided against such a move despite regretting that it has not worked out in terms of family care in another part of the interview:

My sister’s saying, “Come up here, and live on the Gold Coast. It’s beautiful, the

weather’s good and you know, you’ve got the beaches and all this?” And I said to

her, “I have got one too many moves. I couldn’t stand the thought of packing up all

that’s there, and making the move”. If you’re going to move, don’t leave it till your

211 old age. And if you’ve got husband, well it’s slightly easier to do it when there’s two

of you rather than going on your own, and having to make inroads again to find out

all the services and get your social life moving a bit. (PHOEBE, Australia, Female /

82)

Relocation is also not limited to moving within the country as several participants such as BRENDAN (see account on page 172) have relocated from another country and that is more detrimental to their social network. The following is another example highlighting the family discussion surrounding the relocation for family care:

I have my own house there [in the home country] and I have my own maid

[domestic helper]. I said to my daughter: “I’ll just stay here if any of you feel that it's

too late already”. She said, “No mum, you cannot do that. We will always be

thinking of you because you are alone with the maid and we are all here in a good

place”. I said, “Ok, I’ll just go”. (CATHLEEN, Australia, Female / 83)

Later in the interview, the above participant gives an account of her regrets of migrating in old age as she is left without any social network apart from her family. Similar to BRENDAN’s account on page 207, CATHLEEN’s losses in social connections has exacerbated the feeling of “loneliness at home”:

You know, my children, grandchildren, nobody can help me because I’m living in

another country. All those that lived abroad this is their life. They’re all so busy.

They have their own family to attend to so they have no time for me. Sometimes I

want to cry but no tears are coming out. Imagine they leave their house around 7

[a.m.] and my son is working in the city; the wife is also working there and they

come back at around 6:30 [p.m.] (CATHLEEN, Australia, Female / 83)

212 The following Singaporean participant is also aware of the social implications of relocating in old age and resists the daughter’s suggestion to move into her household despite the health risks:

[After the episode of cardiac arrest] my daughter asked me to stay at her house,

but I didn't want to. I am not used to it and I don’t want to intrude. I have friends

here; it is easier for me to communicate to others [older people]. The younger ones

are not happy if we say too much. Am I right? I like staying on my own. All along

I've been living alone since my husband passed away. (SHIMIN, Singapore,

Female / 67)

For this participant, as long as she is able to manage on her own, she would rather be living alone as it is a lifestyle that she is accustomed to for many years.

Also, she expressed concerns that a premature transition to live with the family might strain their relationship.

Similar to significant changes in living and care arrangements such as admission into a retirement village or nursing home, relocating to live with the family or moving closer but to a different neighbourhood, appears to be considered carefully by the older person and as a final option before considering residential care. This theme is as such situated within the family context as relocation in old age is closely related to the facilitation of familiar care. In additional, the issue of migration in old age has only been raised by

Australian participants and could be explained by differences in immigration policy towards older applicants between Australia and Singapore. In Chapter 6, the role of community care services and community organisations in addressing

213 some of the negative consequences of relocation in old age is discussed – presenting a more balanced portrait of the Australian and Singaporean aged care system that consist of the family, the community, and the state.

4.9 Declining State of Filial Piety in Singapore

As highlighted in the introduction chapter (see Section 1.3), filial piety is held by

Eastern scholars as a cultural value and foundational ideology for aged care.

However, there are some Eastern scholars who have argued that societal attitudes and expectations for filial piety have been in decline as Eastern societies modernise (Chan 2005; Koyano 2000; Mehta et al. 1995; also see

Section 2.12).

The following is an account from a Singaporean participant who has strong views on about the obligations of filial piety, extending to the grandchildren who were cared by her when they were young:

Up till the point when my grandson was born [I was working]. My son told me to

retire to take care of my grandchildren. I took care of one up till he was four years

old, then I took care of another. I took care of yet another after a seven years gap.

That's why they are very grateful. They call me often and tell me, "Granny, I love

you. You must take care". They repeatedly told me so as I single-handedly brought

them up. This sort of kinship has been deeply rooted. As our Chinese ancestors

would say, it is important to sow such deep relationships and remember where the

source of help comes from29 [Chinese proverb] (KEWEI, Singapore, Female / 80).

29 The Chinese proverb is 饮水思源 (Pinyin: yin2 shui3 si1 yuan2).

214 Nonetheless, she is mindful that younger Singaporeans of her grandchildren’s generation might not uphold the values of filial piety as strongly as the previous generations; attributing the difference to the influenced of “Western” education and values:

I feel that the culture in Singapore has deteriorated so much. It is not like the past.

It is okay for my son's generation. They are relatively filial to the parents. It has

become worse for my grandchildren's generation. They receive such Westernised

education. They only care for their own enjoyment. They do not give much thought

to their families. In life, our parents are most important. Our body is given to us by

them. How can you just leave them in the lurch? (KEWEI, Singapore, Female / 80)

The views of this participant is supported by Ho and colleagues (2010) who have observed that cultural transition in Singapore has long taken place with a fusion of Eastern and Western values influencing family decisions on care and medical treatment. As highlighted in the literature review on the concept of filial piety (Section 2.9), Mehta and Ko (2004) have found that Singapore has for quite some time departed from the authoritarian form of filial piety.

Intriguingly, two Singaporean participants (LIZHE and DEXIANG) have explicitly mentioned a saying that has taken root in the Singaporean consciousness in recent years about the declining state of filial piety. The Chinese saying “(昔日)

养儿防(今日)养儿烦恼”30 is translated as “(In the past) children are a source of security in old age; (nowadays) children are a source of worry”. This saying

30 The Pinyin for the Chinese saying is (Xi1 ri4) Yang3 er2 Fang2 lao3; (Jin1 ri4) Yang3 er2 Fan2 nao3.

215 highlights the distinct cultural shift in Singapore towards family care; not limited to the extent that older Singaporeans have lower expectations in family care from their adult children but that the older person might be expected to help their children instead. The account of LIZHE is as follows:

As an elderly, you need to make plans for yourself. You can't depend on your

children. It can be worrying. In the past, children are a source of security in old age

[Chinese saying]. Nowadays, we raise children and have to depend on ourselves in

old age. Times have changed. You have to make plans for yourself so you will not

lead a difficult life in old age. (LIZHE, Singapore, Male / 70)

Elsewhere, the participant KEWEI highlighted media reports of cases where the older person was taken advantage by their own children:

There are many news reports of children who have forsaken their parents. They

told their parents to sell their houses to move in with them. In the end, the children

told the parents that there’s no space for them and asked the parents to look for

their own houses. There are many such reports in Singapore. When I hear this, I

feel sad. How can one abandon one's parents? (KEWEI, Singapore, Female / 80)

As explained in the literature review on modernisation and elder abuse (see

Section 2.9), reports of elder abuse and abandonment in modernised Singapore is expected. As observed by the Singaporean participants, the form of filial piety that is practiced by current generation of adult children has departed from the strict traditional forms that were practiced by their generation when their parents were ageing and required care. As explained by KEWEI, the next cohort of adult children (in reference to her grandchildren) are expected to

216 depart further from the traditional teachings of filial piety, being influenced by

“Western” values – which should rightfully be attributed to modernisation rather than westernisation (Hugman 2000: 145). As pointed out by this Australian participant, what is happening in Singapore has happened in Western societies and the transition happened not too long ago and in the participant’s lifetime.

I don’t feel my grandchildren have tremendous respect for my generation and for

me. My grandfather spoke a foreign language, which we had to learn to speak to

him. He could speak in English but he said, “I can’t.” My grandfather died at 93 and

he was the head of the family. At least once a week, we would visit him, and then

when he became disabled, he lived with us. And we adored him. But that doesn’t

exist anymore. Well, my grandfather’s generation were kings and queens. Do you

know what I mean? Everything revolved around them. Now it doesn’t. We fit in

somewhere but it’s in a distance. (PATRICIA, Australia, Female / 76)

This observation made by PATRICIA is similar to the observation of KEWEI on page 215. Both of them have sensed a decline in the value of old age within the context of their family. While KEWEI blamed westernisation for the devaluation,

PATRICIA’s account refuted such a cultural explanation as Western society had undergone the same transition when modernising. Another possible assumption of KEWEI is that the value of filial piety is uniquely Eastern as few would have known that Western families in the past – and arguably before the impact of modernisation – had very similar family values, norms, and traditions.

217 4.10 Conclusion

This chapter began with a brief case presentation of a participant to highlight the important role of the family in the later life, the role of significant others in the community such as a concerned neighbour, and the role of the family in connecting an older person to the community and community services. In the subsequent sections, the role of the family in providing personal care and the way the family influences and organises care and living arrangements are explored in greater depth. This was illustrated with quotes from Australian and

Singaporean participants and their accounts were comparatively similar. One area of distinct difference was highlighted with the availability and acceptability of having domestic helpers employed by Singaporean families to perform home-based care in lieu of the adult children and children-in-law. Loneliness at home and relocation in old age are also explored in this chapter as they are occurring in relation to the way family cares (or does not care) for the older person. Last but not least, the state of filial piety in Singapore was explored with comparison between participants from Singapore and Australia suggesting that the foundations of filial piety are similar to Western family values and norms prior to modernisation and that family care in Singapore has been moving closer to that of Australia as the former modernises and progresses in demographic transition.

218 CHAPTER 5: CARE ISSUES BEYOND THE FAMILY

CONTEXT

This chapter is a presentation of the support network experienced by community-dwelling older participants beyond the support they receive from their immediate family. In this study, members of the immediate family in reference to the older person is narrowly defined (see page 159) to include the spouse, children, children-in-law, and adult grandchildren who are collectively higher in the hierarchy of obligations for the provision of family care where the marriage and parent-child relationships are the principal basis for family obligations.

As presented in the previous chapter, adult grandchildren do assume responsibilities in providing financial support and in one Australian case, a grandchild is living in the older participant’s household and performing various care activities. These grandchildren are in their adulthood and it can be interpreted that they are assuming care responsibilities on behalf of their ageing parents.

Exceptions to such norms are illustrated in the following section where older siblings and distant relatives are living in the same household (or close by in some cases) in a co-dependent living and caring arrangement. This is usually the case when the older persons are never married, never had children, or their children are deceased leaving them without family support based on the marriage and parent-child relationship norms of family obligations.

219 In this study, support from kinships besides the immediate family will be termed as support from “extended relatives”. Their support is presented in this chapter alongside support from other significant others, particularly neighbours and friends and collectively termed as “non-family support”. Similar to the previous chapter on family support, there are more similarities than differences between the experiences of Australian and Singaporean participants. As such, the same approach to place Australian and Singaporean accounts side by side is chosen and remarkable differences are highlighted and separately discussed.

5.1 Extended Relatives’ Support

Accounts about extended relatives mostly emerged in the interviews when participants were asked to describe their support network. While participants usually begin by describing their immediate family, as illustrated by the accounts presented in Chapter 4, they tend to move on to describe their relationships and interactions with their siblings and distant relations.

5.1.1 Reliance on Extended Relatives’ Support

While a majority of the accounts about the immediate family are positive, a number of participants gave accounts of strained relationships, inadequacy or absence of immediate family as a resource and as such having to rely on extended and non-family relationships. For such participants with little support from the family, extended relatives in the peer generation take primacy as told by the following Australian participant:

220

Parents have died, of course. But I have one son. He’s a teacher [overseas] and

he married a girl from [that country]. So my sister is my support network. I’m part of

her family. She has children, grandchildren and great grandchildren. And my son

doesn’t have any children. So (name of sister) is my support network. But it’s good

because I have that. Very close to my sister and her family includes me in all

celebrations and everything else. (DOROTHY, Australia, Female / 70)

Elsewhere, this participant describes that her relationship with her son to be strained and that he has not been supporting her financially and their contact has not been frequent. Her son is described as “leading his own life” overseas with no intention of returning to Australia in the near future. DOROTHY might have to relocate like BRENDAN (see page 172) and CATHLEEN (see page 212) to another country if she needs care, particularly IADL support as explained in

Section 4.3.

In contrast with the numerous Singaporean accounts on support from extended relatives, it is noted that DOROTHY’s is the only significant account from

Australia in this category. While there are other accounts where older

Australians (ANNA and GABRIELLE, whose accounts are cited for other topics but not this) are in regular contact with their extended relatives – particularly siblings and cousins (and their adult children) – care is not yet required and not expected from their extended relatives as they have children. On the other hand, there are more Australian examples of non-family support from friends and neighbours, which are presented in the later sections. These accounts were solicited when participants are asked: ‘who could you turn to for help when you

221 need care or when something urgent happen?’. The answer to this question is left open to allow for all possible permutations of care relationships. At times, participants were prompted ‘is there any other source of help you would want to include?’.

The difference in the categories of carers Australians and Singaporeans turn to for help beyond the immediate family can be attributed to the East Asian and

Confucian belief that the individual exist within the family context, and the family include extended relatives. The sense of affinity and mutual obligations is particularly strong in East Asian culture with regards to relatives who share a common ancestry – usually traced many generations back and patrilineally.

People with common surname / family name are often seen as belonging to a

“clan” and live in villages carrying the surname / family name (see Gao 1999 for an example – the Gao Village – in rural China).

In Singapore, though some 300 clan associations, distinguished by surname and locality, have been set up since 1819, renewal and redefined role due to modernisation have been highlighted as pressing issues (Singapore Federation of Chinese Clan Associations 2017, n.p.). In terms of the declining role of the

“extended family”, a Singaporean service manager summed it up as: “the family was the community” (emphasis added) – referring to big families of the past, which include extended relations who gather often for festive celebrations and important life events such as the birth of a child, weddings, and funerals.

222 Nonetheless, for the current cohort of older Singaporeans in this study, extended relatives remained as an important source of care and support in the community. The following is a Singaporean account:

My sister in law [living in the same household] accompanies me to the doctor's

often. She would accompany me every time I have to go to [the hospital].

(MINGZHEN, Singapore, Female / 73)

In MINGZHEN’s case, her younger brother’s spouse is her principal carer as

MINGZHEN has never been married and has no other source of informal support. Due to her singlehood, MINGZHEN’s parents insisted that the siblings live together after they pass on and left behind their flat for this living arrangement.

Similarly for the following Singaporean participant, an extended relative became the principal carer, as she has remained single when her health deteriorated:

My aunt would call me often and asked me how I am getting along, if I needed

company to go to the doctor's. After I was discharged [from a major operation], I

had to go back to the hospital once every three days. She accompanied me. My

aunt is really a great woman. She is in her 70s, going onto 80. (TINGTING,

Singapore, Female / 66)

For MINGZHEN and TINGTING, there was no immediate family members to turn to for help and their extended relatives become their primary source of support when they become frail and require assistance to and fro medical

223 appointments. Such trips for medical appointments are specifically mentioned as it is the furthest distance they would travel after their onset of mobility issues and poor health and they will require an escort.

For the following participants, their extended relatives keep a look out for their safety and well-being and are their source of crisis support. The first participant has adult children and yet purposively came up with a mutual “monitoring” arrangement with a sibling by living close to one another:

If something happens? Where I stay, in my block, my wife's sister stays just a few

units away. We will call each other if something happens. If there's no one at home,

I can call my wife's sister and she can do the same. I wish that nothing bad would

happen though. It's good to have relatives living near you. You can rely on them for

help. (DEXIANG, Singapore, Male / 81)

In the second case, the Singaporean participant has remained single and her late parents had arranged for her and the brother to purchase a flat that is close by. The brother’s adult children have also been raised to look out for the needs of CHENXI:

I got nieces and nephews, got sisters and brothers. Once a week, they will call me.

As I told you, special day they will invite me, to go over. During school holidays,

they also come and visit me […] so long as I’m strong it’s okay. If I really fall sick or

not very good, I will usually go my sister’s house and stay for two days; she can

look after me. (CHENXI, Singapore, Female / 70)

224 The above accounts provide a list of care activities performed by extended relatives, suggesting that in the absence of immediate family support, extended relatives are a possible source of care and support and should be further explored by care professionals and academics. For CHENXI, MINGZHEN, and

DEXIANG, care is provided by “age-peers” who are defined as within ten years of each other (Barker 2002), referring particularly to siblings and their spouses.

In the case of CHENXI and in one other Singaporean (BIREN’s) account, adult nieces and nephews are involved in their care as well and it is observed to be stemming from a high level of social intimacy with the older participant being a regular part of their family life since their childhood. In addition, TINGTING provides a unique case where there is an inversion of the usual socio- demographic pattern of care, with an older person being cared for by an even older person who is not an age-peer.

5.1.2 Limitations of Extended Relatives’ Support

Nonetheless, as CHENXI described below, reliance on extended relatives is expected to be for the short term. When long-term help is required, extended relatives are not expected to have the same level of care obligations as immediate family members:

Because I have no family, nobody have the time to take care of me. If I can walk, I

will stay in my own home. One day when I cannot move around, I want to go to a

nursing home because there will be people to take care of me there. If I were to

stay here, mati [Malay word for death] nobody knows. You depend on the nephew

225 and nieces, they come, they do come, once in a while, by the time they come, I

also gone case. (CHENXI, Singapore, Female / 70)

Similarly as described by XINYI below, her extended relatives have care obligations for their own immediate family members and she does not find it appropriate to approach them for any assistance:

Although I do have [extended] relatives and we are close, but I don’t ask them for

any help, because every family has its own problem. I still have a brother, who is

older than me; I’m not going to approach him for anything, right? I have a younger

sister, she also has a family, and her son is supporting her and her husband, and

so I don’t approach them for help; because if I can manage on my own, I try to stay

on my own. (XINYI, Singapore, Female / 81)

Other participants describe difficulties even in maintaining regular contact with extended relatives especially when they themselves and their peer generation are “getting on” with age and travelling is difficult due to health and mobility issues. Long distance and migration are added reasons for the difficulties in maintaining regular contact with extended relatives.

In Australia:

I have some cousins in [European country of birth] still. Most of my late wife’s

family live in [another Australian city], and also there’s a nephew and his family in

[yet another Australian city]. I’m on good terms with all of them. When I was

travelling I used to stay with them but as travelling now is difficult for me, I haven’t

managed to get across to see them. They’re all getting old, they’re all in their 80s.

226 My oldest brother-in-law is 93, and we keep in touch by phone and that sort of

thing. So I don’t think there’s any possibility of them coming to visit me. My sister-

in-law is quite sick, last time I spoke to her, she’s thinking of going in to a

retirement home because she’s got [a medical condition] and all sorts of things,

and the rest of them are all sort of getting on. (BRENDAN, Australia, Male / 80)

In Singapore, alike:

I’ve not been there for the last few years, usually I go back to Malaysia [across a

land bridge] once a year, to visit relatives, nothing much, my sister, her children,

not much, and as I get older, I don’t visit as often. (MEIJUAN, Singapore, Female /

85)

While others shared that they had very limited extended relatives networks with infrequent or no contacts since awhile back:

One cousin I have but he passed away and his widow, we talk on the telephone

every some months once, but that’s nothing, but I have some friends. (LUCIUS,

Australia, Male / 89)

And for the following case from Singapore:

I am the youngest in my family. We lost contact many years ago and from what I

know, they are not around anymore. I have never married. But I go to church often,

so I keep in contact with my church members often. So, I will usually call them

should I have any need of help. (MINGJUN, Singapore, Male / 74)

227 As highlighted in these two quotes above, older people do look beyond their immediate family and extended relatives network for support when kinship resources are limited or exhausted. In the next section, the role of neighbours in supporting older people in the community is elaborated.

5.2 Neighbours’ Support

In this study, older participants are spontaneous on describing their relationships with their neighbours and provide a high number of accounts. This is attributed by the original focus of the research on the role of the community and community organisations in creating a “community of care”.

Though most of the accounts are positive, there are a number of accounts describing neighbours relations that remain at a superficial level with little expectation in progressing into a caregiving relationship. There are also negatives accounts highlighting that experiences with neighbours may not always be pleasant, let alone dependable.

5.2.1 Forms of Neighbours’ Support:

The following are selected positive accounts highlighting the range of help and experience older people have with concerned neighbours. For an example of looking out for the safety and wellbeing of the older person and their properties:

228 I’ve got a very nice neighbourhood. No problem, they look after each other’s house.

If somebody’s gone somewhere, they tell us, oh we’ll be away for a while and just

keep an eye on that […] so sometimes a bin was lying, you know, empty bin lying

near the road so we pick it up. We make sure that nobody knows that if somebody

home or not. (NOEL, Australia, Male / 76)

Sharing homemade and handmade goods, especially edible items:

All my neighbours are very good. Sometimes, you don’t cook, they will cook for you,

bring it to you. Sometimes I cook, I will bring it to them. Sometimes they have

anything, we share. Know what I mean? Give and take. Sharing, share together.

(BAOBEI, Singapore, Female / 70)

Socialising and running errands:

The one staying next door is really good, courteous. We do talk. If I have any

problem, I will get help. And I will help too if they encounter any problem and asked

me to help take care of the grandchild while they go out for a while, I will help. If it's

something I am able to do, I will help. (TIANYI, Singapore, Female / 76)

Providing repairs and installations:

[My neighbour] is very helpful, because he is a handy person, and he put in my,

that railing, what you see on the steps, you come up and if I, anything I needed,

help me to put in the screen doors at the back and he put together my computers.

(LUCIUS, Australia, Male / 89)

229 Responding to emergency situation and incidences:

I think two neighbours have helped [when the water pipe burst] but I'm sure the

others would if anything drastic happen. I'm sure they are quite good at that in our

block of units because most of them are fairly old themselves […] but I don't see a

great deal of them but I think they're quite a good community as far as unit block

goes. I’m sure most unit blocks won't know anybody but these are quite

neighbourly, you know. (ETHEL, Australia, Female / 87)

Up to this point, these accounts illustrate one of the four styles of non-kin relationships that Barker (2002) classifies as Casual (see Section 2.11 for elaboration on the four distinct style of “nonkin” relationships). Older participants in this study mention such acts of support as being “neighbourly” and what

“good neighbours” are expected to do.

The following positive accounts illustrate a deeper association between neighbours in which Barker (2002) describes as Bounded. In this study, cases in this category appear to be preceded by longer periods of contacts or are preceded by a crisis situation such as sudden death of an older person’s spouse. Noticeably in these accounts, participants tend to include greater details about their association and occasion when neighbouring becomes caregiving.

I will look for the neighbour who lives on the 7th floor. I will call them. They help me

with groceries when I can't walk. Their father drives a taxi [as well] and we got to

know each other through that. When we got to know each other, we greet and chat

with each other often and we became friends (TINGTING, Singapore, Female / 66).

230 This participant above describes how she became friends with her neighbours through an older person in that family. The older person is working in the same industry as TINGTING and most likely with the same (taxi) company.

Interpreted together, the accounts of TINGTING above and that of BRIDGET’s

(see page 160), suggest that added layer(s) of commonness and secondary bonds beyond just being neighbours appear to be a crucial factor in determining whether neighbours establishes caring relationship:

If I do fall sick, I have really good neighbours, I could ask them for help. There is a

volunteer [introduced by a community service provider] who stays opposite me, I

ask her to help with errands often, buying food like porridge or noodle soup, and

she would help me (YANNI, Singapore, Female / 68).

The above two participants highlight that community organisations – such as local councils, community centres, and community service providers – are important network hubs for older people living in the community. As some of the participants have experienced, relationships with neighbours do not usually progress beyond the Casual level mainly due to the lack of opportunity or incentive to interact socially in modern urbanised neighbourhood. Their perspectives and experiences are presented in the next.

The following participants provided descriptions of a time of crisis where the neighbours helped and cared for the older person beyond the incident itself.

These accounts are distinctively different from the account provided by ETHEL on page 230 where the neighbours responded to an emergency situation and there was no follow up action or deepening of relationship thereafter:

231 On two occasions, one when [my whole] family was away on a holiday for a month,

so I was alone in Sydney, and I was making soup at about 1 o’clock in the morning,

and I fell on my back and I broke my pelvis. Fortunately I remembered their [the

next-door neighbours] telephone number, and they had my keys. They came in, he

was a doctor, and they were just wonderful, you know, they rang the ambulance

and they were terrific, she visited me in hospital and she visited me again in

January in hospital. So I have very good relationship, I love all her little ones, and

they all come to the house every day. (PATRICIA, Australia, Female / 76)

When my husband just passed away, my neighbours came over daily, an

Australian man and his wife [from the same home country as the participant]. They

kept talking to me so that I am not so grief [sic]. They came, everyday, for two or

three weeks [before the couple encouraged the participant to attend day care].

(LILI, Australia, Female / 83)

The last account fits into Barker’s (2002) category of Incorporative relationships.

However, the caregiving aspects in the case of GABRIELLE appears to be at an early stage whereas fully matured Incorporative type of associations have a significantly longer duration of relationship with a mean of 18.2 years in Barker’s

(2002: S163) study.

I’ve got a neighbour, when she goes down to the shop she [would] say, “Do you

want anything down the shops?” She’s (from a different ethnic background) but I

do a lot of paperwork for her. It's not, I do that for you and you do this for me. It's

not like that at all. She's now like a daughter to me. She’s gonna be naturalised

soon and I’m going with her. I’m going to be her sponsor. (GABRIELLE, Australia,

Female / 80)

232 5.2.2 “Nothing Much” – Issue of Unremarkable Neighbourly Interactions

Despite the numerous positive accounts provided by the participants in this study, there are many accounts regarding unremarkable interactions and limited expectation of support from neighbours. The accounts in this category often contain the phrases “nothing much” and “it’s not there” or similar forms – for example, in Singapore, one participant commented:

Well not much interaction. We get out of the house, and into the lifts, and when we

pass each other, we make small talk, “Good morning!” or “Off to the market?”

Nothing much. (MEIJUAN, Singapore, Female / 85)

Similarly, in Australia, one participant said:

Well, as I said, for example this lady next door, for couple of years, I put out her

garbage every day, every time. Now, her nephew lives here. Wouldn’t even dream

of him putting my garbage out. And I am not going to ask him. It’s [a sense of

community] not there. (LUCIUS, Australia, Male / 89)

5.2.3 Negative Experiences of Neighbours

The following two quotes details the more negative experiences the older people have with their neighbours that are frustrating and / or intimidating.

Not every neighbour is good though. This neighbour who stayed next to me, owed

the loan shark money. When they just shifted here there was paint being poured,

red, yellow and black. It's so scary! I don't know what time do they come.

233 Sometimes I would smell of paint when I open the door, and I would see the whole

door reeks of paint. He later sold the unit to a [migrant] family. They are not good

neighbours as well. They don't greet. (FURONG, Singapore, Female / 72)

As for us, we get along well with our neighbours. But the man who stays next to me

is a little queer. He would pour dirty water into a pail and water his plants. The

water would then flow to my side and leave a stain there. The smell is unbearable

at times. But when we talk to him to not do this, he would still do it deliberately. My

children wrote to the authorities for someone to look into this matter but this man

refused to listen. (ANQI, Singapore, Female / 76)

5.2.4 Close-knit Neighbourhoods of the Past, Social Intimacy, and the

Urbanisation Thesis

When describing neighbour relations, several participants made reference to the past when they were growing up and how it was starkly different in less urbanised environments during their childhood years.

People in the kampongs [Malay word for villages] were kinder. We were closer.

Staying in flats not so good. Everyone only cared for themselves, they don't care

about others. Everyone just shut their doors and they don't care about what

happens to others. In the past, there was more care. Not now. (DEXIANG,

Singapore, Male / 81)

When we used to live in kampongs, we would be looking out for one another.

When you’re at home, you can just shout and there would be people coming to

help you. Last time we were all very okay with one another. My mother used to

suffer from eye problems, they would cook for her. (YILUN, Singapore, Female / 76)

234 In Australia, similar views were expressed, for example:

It was great [in the past]. Everybody knew everybody. We knew everybody in our

street, everybody knew you. Everybody helped out when there was, something

went wrong, they would offer to help. As kids, we were always in somebody else’s

house or they were in my house. Don’t see that these days. (RICKY, Australia,

Male / 67)

In summary, these participants describe how in their memories, relationship between neighbours in time past tend to be more open, sharing deeper bonds and trust. It was common practice for neighbours to leave their households open for visitors throughout the day and neighbours were described as more responsive in offering assistance. In the case of YILUN, significant care from neighbours was experienced. The following accounts of a recently migrated

Australian participant (CATHLEEN) and a participant who grew up in the country and moved to the city for work since early adulthood (PHOEBE) adds weight to the urbanisation thesis:

I like my [home] country. You open the door, oh somebody is walking pass and

then he said, “How are you? When did you come back?” Oh my God, around 30

minutes talking and talking you’ll enjoy. Here, no! You open the window, you’ll not

see anybody. They have a higher fence, you know. And then when it’s 7:30 [p.m.],

you’ll see the road full of cars but nobody out there. When they see you [in the

morning], they just [participant waved her hand]. That’s all, they drive, they go [to]

their work. (CATHLEEN, Australia, Female / 83)

235 I could talk to the wall or talk to the 90-year-old neighbour. Because everyone’s so

busy these days, and you just don’t see, I grew up in the country, and we knew

everybody by name, whole of the street. I couldn’t tell you the names of our

neighbours. I know a few of their first names, but when you go out, you go out in

the car, and you wave to them and you go, “Bye,” but there’s no conversation. If

you’re in the city, everyone’s too busy. (PHOEBE, Australia, Female / 82)

Studies on neighbours and non-kin relationships (Nocon & Pearson 2000;

O’Bryant 1985 cited in Barker 2002: S169) have found that proximity and social intimacy are key aspects of caring relationships among neighbours. In the case of urbanised Australia and Singapore, it can be argued that proximity among neighbours might be even closer than before with a significant proportion of citizens, particularly in Singapore, living in smaller residential units built side by side and separated only by a brick-wide wall. Therefore, the focus of community building should be on the latter factor of social intimacy, which Barker (2002) illustrates in her study that the level of care performance among neighbours and non-kin increases with deeper levels of social intimacy.

Nonetheless, looking at the accounts of TINGTING and BRIDGET on page 230, a platform for neighbours to meet and interact might facilitate secondary bonds to be formed where naturally occurring connections are less likely to happen.

For example, as highlighted by several participants, their experience of living in an affluent neighbourhood was relatively more isolating. From personal experience, highly meshed relations between neighbours are the norm in a closely knitted village-like neighbourhood, as children attend the only school in town and marriages between neighbours are far more common, creating

236 kinship relations that thread through the neighbourhood. There are also get- togethers during weddings and festivals where the entire village is welcome to attend and where guests are allowed free seating. To this end, the accounts from older participants suggest that such naturally occurring networks have ceased to exist in most urban communities. On the other hand, accounts about community organisations (such as the local council, community centres, and community care services) reveal that neighbours and unacquainted members of the community could be provided with a platform for interaction and bonding.

The discussion will take place in Chapter 6.

Before proceeding, it is important to note that Barker’s (2002) category of

Committed relationships is not found among neighbour relationships in this study. In fact, if the distinguishing factor of either the older care recipient or caregiver being ‘incorporated into the other’s family nexus’ (Barker 2002: S164) is disregarded, there are no mention of cases in this study that qualifies for the deeper two level of relationships. A possible explanation is that even though the participants in this study are service users, their level of care needs are either not to the stage where they themselves, their family members, and the community services, could not meet. Another explanation is that there are no participant in this study that can be considered as socially isolated – being all service users – and are childless and spouseless. It is as such a sampling issue.

237 5.3 Friends’ Support

The other significant category of non-family support included in this study is that of friends. In total, participants in Australia and Singapore shared twice as many accounts of their relationship with friends than those of extended relatives.

However, in general, the expectation on friends to care in old age is much lower and further down in the hierarchy. This section first present the difficulties in maintaining contact with friends and then move on to the nature of friend support as informed by the participants.

5.3.1 Difficulties Maintaining Contact with Older Friends

The following two participants presented their reality of maintaining contact with

“old friends” who they have known for many years and it is clear that for participants who are much older (aged 85 and over) that there are major constraints in meeting up due to the onset of mobility issues, disabilities, and relocation. For the first participant:

I used to have a lot, a lot of friends but everybody is getting older. They can't go

out by themselves, I can't go out by myself, so we speak on the telephone, we

keep in touch. It's very rare that you can all get together like here [at the day

centre], with the old friends that I’ve got. (SHERRY, Australia, Female / 92)

Similarly for the next participant:

And your friends die or something or a lot of them have to go into care. My best

238 friend is 99 and I haven't seen her for about five years. I’ve only seen her once

since I came up to [a new suburb]. She lives in [the previous suburb] still and that's

what happens when you get old and you lose some. I remember my mother, she

was 95 when she died, and she lost all her friends. (ETHEL, Australia, Female / 87)

As mentioned by SHERRY, the opportunity to meet up with old friends can be rare and this can be seen as a service need or an obligation of the family to facilitate. How important this need is for an older person remains to be explored.

Similar to meeting the emotional needs of an older person in the family setting

(as highlighted in Section 4.7 on page 208), the socio-emotional need to maintain contact with friends might continue to be subjugated even when recognised, as other care priorities take precedence. Losing friends in old age is another significant theme among older participants. Besides getting on in age and relocating to a new neighbourhood, the following participant presented migration as a reason for losing friendship network:

When I was living in [home country], I’d be out most Sundays, either visiting friends

or out joy-driving […] And meet somebody for coffee. I don’t do that these days

because nobody to meet for coffee. (BRENDAN, Australia, Male / 80)

In this study, the impact of migration is exclusively expressed by Australian participants, particularly those who migrated in the later part of their lives. Even though the number of migrants in Singapore is steadily rising, the proportion of migrants is significantly lower than Australia. The migrant population in

Singapore is also relatively younger. For the case of Singapore, this issue will likely become significant in a decade or two as the migrant population ages.

239 Losing friendship networks can happen at a much younger juncture for some.

Older people who had been working for much of their adulthood are expected to have developed friendships with colleagues, and the workplace as a platform for establishing and maintaining friendships is no longer accessible upon retirement.

I did lose a lot of friends. You have many friends at work. When you stay home,

you will lose contact with these friends completely. When you call them, they will

tell you that they are really busy. If they are retired and they stay home like me,

they have to take care of the family, they can't keep in contact. (XIAZHI, Singapore,

Female / 70)

5.3.2 Strategies to Maintaining Contact with Older Friends and the Role of Community Organisations

Yet, despite these physical and practical difficulties that have been mentioned, older participants are proactively and creatively finding means to maintain established connections with friends who remain able and available.

While BRENDAN has lost much of his friendships due to migration (see account on the previous page), he has resorted to technology for long-distance video calls:

I still keep in contact with a friend, we haven’t seen each other for 30 years. But we

keep in touch with Skype and we speak to each other probably once every week. It

sounds a bit odd, but [he’s] a friend that I’ve had for 50, 60 years. Though we

haven’t seen each other, we still got things to talk about, you know, we talk about

240 something, what happened in our past, or you know, when I was at his wedding or

this, that. And you feel quite close. (BRENDAN, Australia, Male / 80)

The following participant made an effort to be at the club for older people as that’s the only platform where a group of his friends would frequent:

I don’t mind that being at home alone. I don’t have [to go to a club] but most of

these friends don’t get out other than playing bridge together, otherwise I’ll not see

them very often. (LUCIUS, Australia, Male / 89)

For some participants who are relatively healthier and without mobility issues, the activities enjoyed with friends remained similar to those in adulthood:

I go out with my friends so sometimes we go to [a nearby city centre]. We sit down

sometimes, we go to RSL Club, get one, two drinks, and get home. (NOEL,

Australia, Male / 76)

I still keep in touch with those closer to my age. I have a few other friends whom I

meet up monthly for meals and teas. We go for chats, shopping and just to spend

the day. (KEWEI, Singapore, Female / 80)

Some, I got friends, [we frequent the nearby] coffee shop, we always gather

together for lunch, after [spending the morning at the SAC], I will go there, sit

together, makan [Malay word for eating and having meals], we share, we joke.

(BAOBEI, Singapore, Female / 70)

However, for those participants with a limited friendship network in old age, meeting and making new friends is difficult. As highlighted by the participant

241 below, tapping on the friendship network of other family members is unlikely due to lifestage and interest disparity.

I don’t really meet a lot of other people, that’s the problem. Occasionally my

daughter, son-in-law has somebody from their gym, he’s around for supper or

something like that. Friends of mine, I don’t get invited to their house, or you know,

my daughter or son-in-law gets invited, I don’t get invited. (BRENDAN, Australia,

Male / 80)

The case of BRENDAN is the most extreme example in this study as the quality and size of his friendship network is severely impacted by multiple factors.

Albeit, he has the most insightful accounts and his journey in meeting people and making new friends at the day centre is encouraging:

Well at my age I find it difficult to meet friends. (Name of fellow day centre service

user) is probably my best friend. You know, we live close together. He’s a very

good cook. I enjoy curry so he always brings me some curry […] so today I bought

him a couple of bottles of wine ‘cos he enjoys his red wine. (BRENDAN, Australia,

Male / 80)

The following participant also highlighted that community care services in

Singapore similarly provide excellent platforms for meeting people and making new friends:

I am closest to (name of a fellow SAC service user). In the afternoons, after our

meals at 6 p.m., we will go to the coffee shop. At about 7 p.m., he goes home and I

will continue watching the television [at the coffee shop]. From Mondays to Fridays,

almost daily […] This elderly service offers comfort and helps us to kill time and to

242 make friends. When we get older, we lose some of our friends. When I was

younger, I had lots of friends. I don’t have that now. They now have their own goals

and their own plans. (DEXIANG, Singapore, Male / 81)

As mentioned in the previous section, community organisations such as community care services can provide a platform for people living in the same neighbourhood to meet up and form social bonds. In the case of BRENDAN, the day centre is the only platform he has in getting out of his home and meeting someone in the neighbourhood due to mobility issues. Ever since the friendship connection was established, the fellow service user who lives on the same street has regularly visited him. This fellow service user-neighbour-friend has also aided him in an emergency situation when he had a bad fall at home and his family were away.

The process can be from the opposite direction with friends connecting older people to community care services (and other community organisations); and in turn participants were introduced to new people and form new friendships.

A friend suggested that I come along and I came as her guest […] What I saw [at

the day centre] made me very happy. They seemed to have the right idea, it's a

lovely feeling and I made some friends here. (HARPER, Australia, Male / 91)

My friend told me about this [SAC] and asked me if I wanted to participate in it as

well. So, the three of us came here together. (TINGTING, Singapore, Female / 66)

The friends of TINGTING subsequently stopped attending after a few months but she continued engaging in the activities daily for another three years by the

243 time of the interview. Through the centre activities, she has made a new set of friends who are fellow regular service users and has also started volunteering for the centre and various community organisations.

5.3.3 Friends’ Support and Ad Hoc Sick Care

We shall now look at friends’ support in terms of caring activities beginning with an example of two friends who met at the SAC. Over the years, their level of social intimacy deepens and at the point of the interview, they are in a co- dependent caring relationship:

For my friend, with her quick temper, it is harder for her to get help. She is a

changed person now [after much counselling from the participant]. I told her to call

me if she needs any help. She has a landline; she doesn't have a mobile phone. I

gave her my mobile number [...] I told her to give me a call should she fall sick and

I would go to her. I'll bring food for her. (YANNI, Singapore, Female / 68)

Elsewhere, the participant cited a time when her friend cared for her instead:

Once, I was at the clinic with flu and fever, and the doctor didn't really care, and I

had to queue. She rushed into the room and told the doctor that, “This person is

running a fever, and you still will not see her yet?” They then allowed me in. She

helped me up and gave me medication. She gave me ice pack as well. She only

left when my fever subsided. (YANNI, Singapore, Female / 68)

For older participants like YANNI and her friend who consider themselves to be living independently, times of sickness are reportedly the only period when they

244 most require care by other people. As such, these two accounts above regarding friends caring for one another are significant in that for an older person that has limited family and extended relatives network, friends (including other non-kin in the community) are potentially capable of filling this “void” of providing ad hoc sick care.

This area of need can be seen as a “void” or a service gap as older people who are living independently are unlikely to be accessing community care for the long term and would not be able to activate the service within a short notice.

With increasing proportions of older people in Australia and Singapore living alone and without kinship support, there is an urgent need to explore community resources, non-family relationships, and innovative services that can aid this subgroup who might fall within such a service gap.

5.3.4 More than Friends – Incorporating Friends into the Family’s Nexus

While the case of YANNI seems exceptional, there are three other participants who reported even deeper relationship with their friends, which resembles the

Barker’s (2002) Incorporative type of care relationship (see Section 2.11 for elaboration). These are their accounts:

Well, I’ve got three very close friends. One couple lives in (a suburb; an hour’s

drive away), we shared a house together for about nine years. Very, very good

friends. Another family lives in (a city; three hours’ drive away), occasionally stays

up here, we go fishing, comes up to go fishing or stay at my place. (RICKY,

Australia, Male / 67)

245 There will come a time when I can't get around or sometime then I just got to rely

on, I have some very good mates and they always come to help, always. If there

ever is a problem, they'll be there like that [participant snaps his fingers]. I only got

three really good mates, we've known each other for a very long time. They talk

behind your back, you know, but if there was a problem, they’ll be concerned they

said: “Look, (name of participant) is too bloody old, we better see what we can do

about it or find out that sort of stuff, and staying with them”. And I hear from those

fellows probably once a week, once a fortnight. I'm welcome at their places any

time. In fact, they more or less treat me like bloody family. (DAMIAN, Australia,

Male / 67)

I brought in a friend to stay with me because I cannot hear, he only come back

from work during the night. I cannot hear clearly on the phone, so whenever I am

sick, I ask him to phone the ambulance for me […] If I have a fall again, I have my

friend with me, if it’s at night. If it’s in the day, I’m here [at the SAC]. All the time.

Except lunch time and dinner. (ZHIQIANG, Singapore, Male / 80)

In the case of ZHIQIANG, the friend has become a live-in principal carer similar to living with and being cared for by the family and other kin. While ZHIQIANG might eventually choose to be placed in a nursing home as he does not have any living family members (being youngest among his siblings and all of them have passed on, and he has never been married), this care arrangement has been helping him to remain living in the community despite the hearing impairment and history of falls.

As for RICKY and DAMIAN, they are confident that their friends will be there to provide care for them or be in a co-dependent care arrangement, having lived with them or staying over often. Both of these participants are divorced and

246 estranged from their own family and they found their friends to be more caring and family-like (in the sense that they appear to see these relationships as being what family “ought” to be like).

5.4 Non-family Support for this Research

Notably, the friend of ZHIQIANG and two other carers of Singaporean participants (BIREN and TINGTING) are the only carers who are nominated by the primary participants for secondary interviews in this study. The carer of

BIREN is a volunteer with a community care service provider who continued caring beyond the scope and length of time that the service provider has designated. This phenomenon is not new as observed in past studies of non- family carers (see Barker 2002). The carer of TINGTING is an extended relative.

All three carers who are nominated and willing to participate incidentally fall within the categories of carers focused on in this chapter. All three carers are also older people. This suggests that older people caring for other older people is already common and might become more so in the future. As highlighted by several participants, the quality of care by an older person can be superior as compared to the care provided by a younger person (such as adult children) despite physical constraints of old age (see Section 6.2.6). This is mainly due to peer awareness of what an older person really need and how best to meet it.

On the other hand, the lack of support from family carers for this study can be interpreted from the many accounts stating that family members are often too busy with their own matters and basic care of the older family member that

247 there is little room for anything out of the routines. Here is an account, for example:

They have no time [...] although they don't work on the weekends, they need to do

household chores. After that, they go out for meals. They stay in [a suburb far

away]. (FURONG, Singapore, Female / 72)

Other participants like XIAZHI (see account in Figure 2) expressed the concern that participating in a research might bring harm to the family member. Again, such fears of nominating a carer to participate in a research deserve further investigation due to methodological implications.

5.5 Conclusion

In this chapter, the capacity and limitations of the various “providers” of non- family support have been discussed. As the many accounts from the participants in this study have shown, caring relationships in old age are highly varied. Although family care takes primacy for most participants, there is a significant proportion of participants who do not have family members to care for them or are not willing to tap on their family for support. Instead, they are relying on extended relatives and non-kin, and in some cases, setting up a co- dependent care arrangement with other older people.

As illustrated with similar accounts, non-family relationships with extended relatives, neighbours, and friends in Australia and Singapore are highly similar in the areas of the (non-)expectation for extended relatives – particularly those

248 in the peer generation who are getting on in age – for personal care and financial support; the low quality of neighbourly relationships – except when deeper bonds are forged through embedded relationships; and the losses in friendship network in their peer generation as one ages.

Notably, by the number of accounts in each category, Australian participants have higher expectations on friends to provide support in old age and not so much with extended relatives. The situation in Singapore is the opposite, citing a divergence in non-family support. In terms of neighbourly relationships and friendships, there is a potential for community care service providers and community organisations to provide platforms for older people to meet others in the community, which is discussed in the next chapter.

249 CHAPTER 6: CENTRE-BASED COMMUNITY CARE

SERVICES AND COMMUNITY ORGANISATIONS

This is the third and final chapter for the findings in this study. The discussion has moved from care issues within the family context to care issues beyond the family context – concerned with non-family informal networks – and to community care services and community organisations, concerned with the broader and formal community context.

In relation to Bronfenbrenner’s BST (see Section 2.15), the abovementioned three main areas of focus in the findings chapters is naturally the most cited by participants in this study as they are within the Microsystem layer – where direct interactions happen. Although, for individual participants, the family, other informal relationships, and community services / organisations are ranked differently in terms of significance and more often as a result of a lack of support in the other components of the Microsystem. As previous studies have long- established, the usage of various support systems and providers of care is a matter of practicality in which Brody et al. (1984: 745) referred to as “any port in a storm”.

Community services and community-based organisations can also be seen as more significantly influenced by the components of the Exosystem (see Figure

1), which includes but not limited to local politics, social policies, economic conditions, and government provisions. Theoretically, the Exosystem is defined as having an indirect influence on the older individuals and beyond their control.

250 The influence can be experienced – and often negatively perceived by the participants (see Section 6.3) – when they are accessing community services that receive funding support from the state and are required to adhere to government prescribed standards and protocols. The historical and current structural issues impacting the delivery of community services in both Australia and Singapore were presented in Sections 2.2 to 2.5.

Snippets of the various features of community services / organisations were mentioned in the previous two chapters. For older people who are living with the family, community organisations are able to provide care while the family members are at work and / or school. For older people who have limited or no family support, community organisations are even more important, taking on some of the roles of the family such as monitoring of safety and wellbeing and organising care arrangements.

Community organisations can also be important network hubs for older people to meet fellow older people and other groups of people – particularly volunteers

– who are sensitive to the needs of an older person. The various roles and functions of community organisations will become clearer as we look at some of the accounts of older participants in Section 6.2. This chapter begins in Section

6.1 with a comparison of recruitment sites in terms of their modus operandi, highlighting where the six recruitment sites converge and diverge. This discussion differs from Section 3.3 in looking at the centres’ characteristics, service models, and practices in meeting the care needs of older service users.

251 6.1 Parallels between Australian and Singaporean Recruitment Sites

As mentioned in the Methodology chapter, participants were recruited with the help of support organisations that were in regular contact with community- dwelling older people. While posters and flyers were distributed through several community centres and local councils where there was open access, all the participants that signed up were closely connected to the recruitment sites as regular service users.

As highlighted, these community organisations were protective of the participants, taking time to understand the purpose of the study and peruse the

PISC form before requesting for a face-to-face meeting with the researcher to set up the boundaries, and made provision for the interviews to be conducted at their grounds during operational hours. Therefore, community organisations can be seen as important gateways in the community and are concerned about the interest of those who have come to rely and trust in their abilities and discretion.

Eventually, participants were recruited from a total of six recruitment sites, three each in Australia and Singapore. A table summary of the six recruitment sites is included in the appendices (see Appendix L). This table provides an overview and easy reference when specific site(s) are mentioned later in this chapter.

Details of the operational model, the estimated daily average attendance (which ranges from day to day in a week depending on the program), the management and overseeing body, main funding source(s), and table grouping considerations (for day centres) are listed.

252 In Australia, two sites are operating under the day care model and one site is a community centre managed almost exclusively by older tenants in a public housing estate where 85% of the population are aged 65 and over. In

Singapore, one site is operating as a day centre while two other sites are SACs.

While analysis of differences between the two countries is important, the accounts of participants reveals more similarities in terms of the beneficial outcomes of community organisations. As such, the parallels between community services / organisations accessed by participants in this study is emphasised. Notwithstanding, there are only subtle differences between the day care model adopted by the Australian and Singaporean sites where admittance is restricted to authorised visits. This is expected to change within the next few years when the principle of CDC is extended from the HCP to

CHSP.

There are also parallels between the Australian community centre and

Singaporean SAC. Both models operate on a more open basis as compared to the day centres. Service users can freely access the centres and the premises are conveniently located among them. As a response to the growing medical needs of its service users, the Australian community centre recently established a medical centre in their estate with funding secured from the NSW Ministry of

Health and professional support from the local hospital. This direction is similar to that of SACs in Singapore where collaborations with community health teams from the hospitals have been increasing over the years.

253 In addition, the Australian community centre, though managed entirely by volunteers, provides monitoring, outreach, and crisis response similar to that conducted by Singaporean SAC staff and volunteers. The community centre’s management committee members have been providing round-the-clock on-call response to lockouts, medical emergencies, and even suicides. The valuable lesson learnt from these progressive community organisations is that the range and depth of services provided is continuously evolving with increased understanding of what community-dwelling older people need.

6.2 Common Features of Community Services / Organisations

In this section, the common features of community organisations and how they collectively benefit older service users are elaborated. Specific features of the three operational models will be highlighted as well.

6.2.1 Provision of Safe and Age-Friendly Physical and Social Space

The first common feature of the six recruitment sites is the availability of safe spaces for older people to congregate and interact. While older people can gather at public open spaces and semi-public spaces such as cafés and clubs, the physical and social environment might not be age-friendly and supervised.

As highlighted by the following Singaporean participant, prior to the construction of the SAC in her block of public housing units, she was hesitant to go out and socialise with her neighbours as she had witnessed casual gatherings at the void deck ending in heated arguments.

254 I have been staying here for more than 10 years and when the centre was first

opened, we were really happy. There is now a place we can go to. In the past, we

would just stay at home and do nothing. It was really boring. I would just sleep at

home or go to the market. As you grow older, there's really no good place you can

go to. When we sit around at the void deck, the neighbours would gather around

and gossip about others and they may even quarrel over it. (YANNI, Singapore,

Female / 68)

Interpreting the above account as an extension of the disengagement-activity psychosocial theories of ageing debate (Quadagno 2014: 48-51), there is a sense that “structural” barriers in the community – which in this case is the lack of safe social and physical spaces – had left YANNI with little option but to spend much of her time at home.

As highlighted in Section 2.14, Forest & Kearns (2001) explored such concerns in terms of social capital and required neighbourhood policy responses. Having a sense of safety in the community is one of the eight dimensions of social capital (see details in Appendix A). Noteworthily, subsequent studies (Alley et al.

2007; Barusch 2013; Fitzgerald & Caro 2014) investigating neighbourhood factors from the perspectives of older persons uses the phrase “age-friendly” as introduced by the WHO (2007) guide for creating Global Age-friendly Cities.

Several participants from Site A3 describe the community centre as a safe space and also a social space providing the platform and focal point where community networks and reciprocal relationships among fellow tenants begin to develop over the years. As highlighted by the following Australian participant,

255 having a community centre in the public housing estate has been pivotal for the social life of older tenants:

The community centre has been amazing. What would people be without this

centre? We more or less go home, close our doors, do what we have to do;

wouldn’t necessarily have this [community] network. I‘ve got two [social networks].

I’ve got the family network that I can rely on. And some of these people here we

rely on each other; we help one another. (DOROTHY, Australia, Female / 74)

The following Australian participant is also impressed and appreciative of the safe and age-friendly facilities provided through the day centre:

It’s a very good set up they’ve got here. I mean, all this land, and the function

rooms, kitchen, toilets for disabled persons to use. The food is variable. But the

day here costs each person 10.80 AUD […] It’s obviously very well subsidised by

the council[-led HACC service]. (BRENDAN, Australia, Male / 80)

As highlighted by BRENDAN, the out-of-pocket fees Australian HACC / CHSP service users pay to enjoy the facilities and services is at an affordable rate for self-funded retirees and older people on the Age Pension. Similarly in

Singapore, day care services are subsidised by the state.

As explained by the service managers of all three day centres in Australia and

Singapore (Sites A1, A2 & S1), service users who are not able to afford the client contribution portion can receive further help based on means-testing and / or other sources of funding such as private donations. In order to provide for the many needs of service users and to assist older people who are unable to

256 afford care, all three day centres organises regular fundraising events. This is particularly so for Site A2 where the staff-client ratio is much lower than stipulated and the current facility is purpose-built with the most advanced design and equipment available in the late 2000s. For the past three years, the service was reportedly in the red if not for the auspices of a peak community- based ethnic organisation. As for the Australian community centre and two

Singaporean SACs, most services are offered free of charge and when payment is required, only nominal fees are charged.

The level of trust service users have of the service staff, community centre committee members, and volunteers that carry out the operations of the centres is largely based on their own experience and long-term observations of the service attitude. While there are mentions of negatives (see Section 6.3), there are much more positive examples of how the centres have made the lives of the participants better. This is despite methodological considerations to ensure a safe interview environment, repeated prompting for exceptions and negative examples, and assurances that privacy and confidentiality is maintained.

However, sampling bias due to voluntary participation at the level of the recruitment sites and older participants is noted as a limitation of this study (see

Section 8.3). Support organisations that participated on a voluntary basis are likely more confident in the quality of their services and as such more willing to be scrutinised in a research project. The participants are also recruited on a voluntary basis and those who are satisfied with the quality of the recruitment sites’ services might have been encouraged to participate. This is despite

257 methodological considerations to ensure that information about the research are verbally broadcasted to all service users of the recruitment sites and supplemented with the use of flyers and posters (see Section 3.3 for detailed description of the recruitment processes at each site).

The following Australian day centre participant, who claims to have “given a hard time” to the staff and volunteers, is prompted for negative examples and instead provided a detailed account of the ways in which service staff and volunteers have helped him to pursue a new interest at the day centre:

Nothing is too much. I’ll give you an example. You know the work that I do on these

collages? I haven't quite an artistic bug in my body. Never did anything artistic and

(name of volunteer) is here on a Tuesday showed me the works that he did and

said to me, “Give it a go”. And he brought in a fortune of parts of old analogue

watches, sat next to me for a few weeks and got me started. So that’s a case of a

volunteer who got me involved. I decided to do a couple of projects, where the

background needs to be painted and one of the staff has done a painting on these

boards for me. That's another example of the help they give; they cannot do

enough. And then the drivers of the buses, everybody. The beauty of the whole

thing is they’re always there to help and to guide. And when I've finished; I'm

invariably late. They say leave it, don't worry, we will pack it and put it away for you.

That’s the attitude that they have. (MERVYN, Australia, Male / 77)

From MERVYN’s account, it is “everybody” at the centre that creates a social space / environment that is safe, age-friendly, and conducive for developing an interest. Similarly for the following Singaporean SAC participant, the attitude of the staff is an important factor:

258 This place is really good. It is well run. The staff here are very courteous, they don't

look down on you or command the elderly to do things. Some people who are in

high-ranking positions tend to look down on others, but not the people here.

Everyone here treats the elderly very well. Yes, they treat us like family. (CHENXI,

Singapore, Female / 75)

The attitudes of staff and volunteers also contribute to the social environment and in creating a home-like atmosphere:

And the workers, the volunteers, they’re just all so wonderful. They look after you,

and make you feel at home. I mean, that’s all you can expect at a community [day

centre]. (PHOEBE, Australia, Female / 82)

The following short quote from a Singaporean SAC participant highlights that a welcoming social environment is perhaps the most important consideration for older people to consider spending the day at the centres:

I feel the warmth [in this SAC]. If I don’t feel that, I won’t come. (ZHIQIANG,

Singapore, Male / 80)

And this view is shared by an Australian counterpart:

I think here in [the public housing estate] it’s just so healthy for people to come out

and talk. They don't have to be in their places all alone. The community centre is

here because there are other people to talk to. It’s a welcoming place. It’s not just a

[physical] space that we all share. (DOROTHY, Australia, Male / 74)

259 Collectively, the accounts from participants presented in this section about centre-based community care services and community organisations can be summarised as the “provision of safe and age-friendly physical and social space”. As interpreted from the accounts of YANNI and DOROTHY, the provision of a physical space alone, without the “supervision” from a staff or volunteer to ensure a safe environment, would not work even if the space is age-friendly.

6.2.2 Provision of Structured Program

Equally as important as the physical and social environment is an engaging and enriching program. Many participants go into much detail about how the centres structure the day with physical, mental, and socio-recreational activities. The following Australian day centre participant describes how a typical day at the centre is like from being picked up to being dropped off back home:

Actually it is a very nice [at the day centre] because the family go out in the

morning and they come back in the evening, you know, and you will be lonely the

whole day. But I come here, two days a week for this social group on Monday and

Wednesday. The bus comes to take us here at 9.30 a.m. We have morning tea

here and from 11 [a.m.] to 12 [p.m.], we have very interesting program. Today they

[the guest speakers] are discussing about money. From 12 [p.m.] to 1 [p.m.] we

have lunch. And after that, some programs; sometimes we have bingo, quiz and

things like that. And the bus drops me back at my place at 3:30 p.m. (SANDIP,

Australia, Male / 80)

260 As highlighted by SANDIP, the day centre program fills the void in the day when his family are out at work (and school). As mentioned in the account, he would have faced loneliness at home if not for the day program that keeps him occupied and engaged. His wife has passed on recently and as mentioned by several participants – namely, BRENDAN, KRISHNA, YAOWEN, LIZHE, and

DEXIANG – having a partner in late life provides companionship and emotional support. In Chapter 4, widowhood as a precursor for “relocation in old age” for care arrangement and the issue of “loneliness at home” was mentioned on pages 165 & 172.

At Site A1, when asked about the program provided by the day centre, several participants took out a colour printed program list with pictorial illustration that detailed the month’s calendar of events such as guest speaker’s topic, subject of peer discussion / peer sharing, and outing itinerary. The program list is made foldable into pocket size and given out a month ahead to keep service users well aware of what to expect. Site A2 provides a monthly calendar as well though they do not go into such lengths as Site A1 to be age-friendly. However, they have several notice boards in the centre listing such program information.

The day centre program at Site S1 as detailed by the following Singaporean day centre participant is highly similar to that of the Australian counterparts in the previous page:

Over here, when we come in the morning, we first have our exercise at about 9

a.m. By 9.30 a.m. we will have breakfast; at 12 p.m. we have lunch; at 2.30 p.m. is

exercise time; 3 p.m. we have tea. After the breakfast, there is a period of time,

261 and they would have an activity for us to do some craftwork, or some other

activities. Then there is a regular time to play games. (JIAHAO, Singapore, Male /

77)

The range of activities in the SACs in Singapore is similar to that of day centres though the resources at their disposal are much lower relative to the overall lower level of need of their service users. The program is also largely dependent on the skill set of staff and volunteers, service partners, and additional funding sources such as private donors and corporate sponsors. For example, Site A2 is able to pay for professional music and dance performances with allocated funding from their auspices, which is an exception rather than the norm. The key to understanding the operations of a SAC is that it is fundamentally a drop-in centre. Besides conducting social and recreational programs at the centre, staff and volunteers have to conduct regular house visits to frail and / or homebound public housing tenants (who are unable to come to the centre), conduct regular door-to-door outreach and home befriending services (for those who do not wish to join the centre activities), respond to emergency alerts and inter-agency referrals.

As explained by the following participant, SAC staff are observed to be responsive to requests for assistance and would even provide help with financial assistance applications:

If the elderly were to come for help at this centre during the opening hours, they

[SAC staff] will help them in whatever ways they can. It’s good. If they are sick or

need help with application, the staff at this centre will assist them in applying for

262 financial aid. (MINGJUN, Singapore, Male / 74)

Almost all rental flats in Singapore have been installed with pull-cord (and remote controlled) alarm system, which are housed at the SACs. For blocks that have the new alarm systems installed, tenants are able to use the intercom to communicate directly with SAC staff. During non-operational hours, alerts are sent to SAC centre managers, key operational staff, and volunteer block representatives via their mobile phones. Below is an account by a SAC participant who is also a volunteer block representative responding to emergency alerts:

There is this silent alarm [with LED indicator]. Should anything happen, you can

just trigger the alarm. I would then check which unit it is from and go to their place

to see what help they need. It could be calling the police or the ambulance. It

happens quite often, especially from some of them who live on their own.

(MINGJUN, Singapore, Male / 74)

Coming back to the centre activities, the following SAC participant from Site S2 describes how he (and other SAC service users) could be selective about which activities to participate in and weave the centre program into his day.

I arrive here [SAC] at 9 a.m. and do morning exercises. I will then play mahjong till

10 a.m. and return home for lunch, rest and take a nap. I will come back here at 2

p.m. and stay till 5 p.m. and then return home. I will go back for a shower, have

dinner and meditate. (DEXIANG, Singapore, Male / 81)

263 Here is an account from a participant recruited at Site S3 describing the activities that she would make a trip to the community centre for:

I come twice or thrice in a week. One day for English lessons, one day for “Chicken

Soup for the Soul”, that is conducted in Chinese. We have [peer] interaction as well

as a teacher to guide us. On Saturdays, we learn knitting. (KEWEI, Singapore,

Female / 80)

The following participant at Site S2 has a similar account while highlighting the involvement of corporate sponsors and their staff’s contribution to the SAC program, which is a monthly highlight for the service users:

I will come down when I am free. They usually play mahjong but I only play

dominoes. If there’s anything interesting, we will come down. Every month they’ve

got birthday celebration, sponsored by [a bank]. They celebrate the birthday for the

elderlies who were born in that month, all gather together, cut the cake, play bingo,

win prizes. Everyone gets to enjoy the fun. (BAOBEI, Singapore, Female / 70)

As mentioned on page 253, SACs are increasingly working with service partners to provide community health services. At Site S2, the SAC is working with doctors in Family Medical Practice and Traditional Chinese Medicine to provide free consultation (and prescription) at their centre. SACs usually have a purpose-built room that can provide adequate privacy for medical consultations that are not intrusive:

Every Tuesday, they get a Chinese physician to come. Every alternate Friday a

Western doctor would come. The Chinese physician provide all free of charge, but

264 the Western one only consultation is free. If you need medicine, you pay lah. A few

dollars only, quite cheap what? There are some elderly people who can’t walk far

or stand up for long; if they come here, very fast; though they have to queue, seats

are provided and there’s [sic] people to talk to. (BAOBEI, Singapore, Female / 70)

In addition, many SACs are working with community teams from the hospitals on fall prevention programs and increasingly, community mental health teams are working with the SACs to be on the lookout for community-dwelling older people with psychiatric issues requiring regular follow-up.

Highlighted in Section 6.1, there are parallels between the two SACs (Site S2 &

S3) in Singapore and the community centre (Site A3) in Australia. The following account from a community centre committee member of Site A3 provides a summary of the range of activities and happenings on her volunteer day and it is comparatively similar to that of the Singaporean SACs presented above, with some regular programs and collaborations with service partners:

Well, my day is Tuesday. It starts off at nine o’clock. I have some elderly Chinese

come for English class for an hour. People come in with problems. As you see I’ve

got the keys if they lock themselves out. Some need help to pay their bill. That

finishes at three o'clock. Also on Tuesday, OzHarvest [perishable food rescue

organisation] comes. So we gather together to sort the food out and be ready for

[distribution] the next morning. Salvation Army come at seven o'clock and

everyone knows they can come down and get a cup of soup, coffee, tea. They're

given pies and bread and they're happy about that. (DOROTHY, Australia, Female

/ 74)

265 Participants and staff at the various centres speak about the attention given to national and festive celebrations spiritedly. With a turn out of over 200 people per event, Site A3 has the biggest celebration among the recruitment sites:

We have regular barbeques. When there is a public holiday like Australia Day and

ANZAC Day, we will have a sponsored lunch. All the residents can gather, have a

drink, sing-along, dance a little. It fosters a sense of family and belonging, you

don’t feel like you’ve been forgotten. (WENWU, Australia, Male / 69)

Another area that the community centre has begun organising is regular outings to places of interest that is often nominated by service users:

We also have outings. Go on a bus trip, visiting gardens, farms, beaches, National

Parks, Blue Mountain, we visit different places each time. We get lunch provided,

tea, and catering even for elderly on wheelchairs; they board and alight at the

entrance; it’s so convenient, there’s no need to walk too far to catch the train or bus.

The entire bus is chartered for us for the entire day. So our lives become full and

exciting. Of course, most of the time, they have a quiet life, busy with their own

things. (WENWU, Australia, Male / 69)

As explained by another participant, the bus trip serves as an “ice-breaker” for fellow older tenants:

The bus trip is another opportunity [for older people to build relationships]. People

sit by each other, “My name is such and such,” and they talk. Now, from that point

onwards they know their face, they know their name. They can take their walkers

with them. We pack it all away [when they get on the bus]. When they get out, we

help them off the bus. It’s very safe. We are very aware that some of them are

266 struggling. So we make allowances, we don’t hurry. And they like it. They ask when

is the next bus trip. (DOROTHY, Australia, Female / 74)

Outings are usually organised on a monthly or quarterly basis as it is resource intensive, requiring at least a staff and several volunteers per bus group to assist service users who have mobility issues and might need special transport for wheelchair users. Nonetheless, outings have been repeatedly emphasised by participants in this study as the climax of the centres’ program. Outings hold such a special place that Singaporean participants who are Chinese-speaking are able to mention it in English, likely picking up the term from the service staff.

Some participants are upset that they were excluded from some outings due to limited bus seats. This is particularly so for SAC service users as the SACs relies mainly on sponsorship and are perennially tight on resources such as staff and volunteer availability. However, during festive seasons such as

Christmas and Chinese New Year, sponsorship would pour into the SACs as they are known to be serving older people who are vulnerable and / or requiring financial assistance. The “many helping hands” approach to social service delivery adopted in Singapore (see Section 2.5) with contribution from private donors and corporate sponsors is illustrated in the following account:

We had an outing last week, they brought us out for vegetarian food. It was

sponsored by a [private donor]. It was a treat for 11 tables, that’s more than 100

people. Everyone also received an envelope with 25 SGD worth of [groceries]

vouchers. These [private] organisers often help us with such gifts to make life

easier for us. (YANNI, Singapore, Female / 68)

267 As for day centres, there is no known constraint in organising outings on a monthly basis and it is done for each day group. The following day centre participant explains why:

It is 10.80 AUD per day when we come, and when we go on outings, once a month

for the Monday group, once a month for the Tuesday group, we have to pay extra,

that is, 29.70 AUD (LILI, Australia, Female / 83)

Despite the need to pay extra for outings, it is highly popular and fondly described by the participants. There is no mention of any service user who would opt out of outings even though it is almost three times the day rate and when a service user attends multiple groups, they are being charged for multiple outings per month. As interpreted from the account of the following participant, the cost of outings is not a concern for fee-paying day centre users and that the opportunity to be “taken out” is much appreciated:

Twice a month, they take us for outing. Monday group people, take us for outing

once a month. And Wednesday group also once a month. So, that means that we

go for outing twice, to the RSL clubs and nice places and all, we have a lunch there,

lovely meals, sort of buffet. (SANDIP, Australia, Male / 80)

To this end, the kaleidoscope of centre-based programs, festive celebrations, and outings fills the day for older people with engaging, enriching, and exciting activities. As mentioned by the following participant, it keeps her “alive”:

The staff kept thinking of [new] things. You can't have the same thing all the time.

With Bingo we play every afternoon but that's only for a couple of hours and rest of

268 the day they have to be thinking of this and that and we go out for lunch sometimes

and various programs and quizzes, for interest. Speakers sometimes, discussions

and those sort of thing. So keeps you very alive. (ETHEL, Australia, Female / 87)

For the following participant who had great difficulties convincing her husband to join the day centre program (see page 183), the change of heart in him after attending a few sessions is remarkable:

I got him to come a few times and now he asks, “Is it Monday? We going there?”

So now he is looking forward to come to the day centre. That is his only outlet.

(BOZHI, Australia, Female / 77)

The main reason limiting the option of BOZHI and her husband in community participation is the onset of dementia. While good programming is vital in attracting and maintaining participation, the provision of a safe and age-friendly physical and social space (as detailed in the previous section) remains fundamental in ensuring access for older people with disabilities and those needing assistance with ADL. As such, the common features are interrelated.

The following section will be focusing on the specific areas of assistance that participants have highlighted that has facilitated their participation.

6.2.3 Provision of Assistance in Activities of Daily Living

Assistance in ADL is commonly categorised into domestic (performing housework chores), meals (preparation, delivery, and nutrition), self-care

(eating, dressing, grooming, bathing, and toileting), mobility (walking or moving

269 around the house and outdoors), transport (driving and using public transport), communication (difficulties with speech, hearing, or comprehension), home maintenance (lawn mowing, gardening, repairs, and such activities to keep the home environment safe and habitable) and in activities for social and community participation (shopping, banking, participation in recreational, cultural or religious activities, attending day centres, managing finances, reading, and writing letters) (extracted from Department of Health 2017a: 39-40).

While centre-based community services are not set up to provide the level of

ADL support that home-based services do, the centres in this study go to great length in assisting service users to ensure accessibility and participation in the various centre-based activities and outings. As mentioned in the account of

SANDIP on page 260, Australian day centres provide transport for service users to and fro their place of residence and the centre. The following participant at the other day centre goes into more details about the level of care centre staff

(or trained volunteers) provide when conducting the bus trips with assistance for those with mobility and / or other issues:

You know when the bus come there's a driver but there’s also a lady in the bus

who gets out for every single person, and helps the person from the gate of the

house to the bus and into the bus and the same when you get out. And sometimes

she comes and she wants to take the bag and I said “it's ok, it's ok”, takes the bag,

and when I get out of the bus I said “go back, go back”, it's cold, it's windy, it's rainy,

no, she goes and puts you on the footpath. (MAGDALENE, Australia, Female / 90)

270 The next case offers an excellent example in understanding the level of support day centre staff and volunteers are willing to provide. This participant became partially blind recently in old age and requires additional assistance from pick up to returning home. The staff and volunteers have to guide her around the centre from activity to activity and periodically come around to check on her. This would not have been possible without the support of the entire staff team and the understanding from fellow service users.

In fact, when the participant was introduced to the researcher, there was no visible sign that she has a disability nor did the other service users give it away by behaving any differently around her. It was only towards the end of the interview that this participant gives an insight of the difficulties she faces in trying to navigate her way around the community independently and that this account reflects the value of the centre’s assistance in getting her out of the house regularly so that she can remain socially connected:

The thing I find frustrating is not able to get out on my own. I can just walk down

the street but I have problem with the eyesight. I got on the bus thinking I’m gonna

[sic] give this a try. Got the two dollars fifty in my hand and my pension card out.

Said to the driver, “To the shops, please”. He said, “Oh, love. Just go and sit down”.

He didn't take the money or the card because it's not operative any more. There’s

this machine there. He was kind enough to know I wasn't aware. (GABRIELLE,

Australia, Female / 80)

The following participant has moderate mobility issues simply due to age- related disability and frailty at the age of 92. Elsewhere in the interview, she

271 was describing at length about becoming depressed and socially isolated after failing the medical review under the older driver licencing system.

They will come and pick me up from home and take me back home. And when I’m

with them, I have a walker. I’m very grateful that there are these people around. I’m

a bit lonely because I like people [and] sometimes I’m alone. What can I do? I

watch television and that's it. [Previously] I am a person who is very independent, I

miss my independence, to be able to open the door and go out and do what I want.

I can't do that because of my legs, because I haven't got the car, and I have a few

steps at home, it's very hard for me to do these things. (SHERRY, Australia,

Female / 92)

Though the accounts presented in this section thus far are from Australian day centre participants (Site A1 & A2), the other centres offer comparable attention to assistance in mobility and transport. As highlighted by participants

DOROTHY and WENWU (see accounts on page 266), the community centre

(Site A3) committee members and volunteers are mindful of the assistance required by older people on their outings – physically helping them up and down the bus, managing their mobility aids, and making careful considerations of the travel itinerary including drop-off and pick-up locations, and walking distance. In addition, the community centre often liaises with service partners such as community transport on behalf of service users requiring assistance in communication type of ADL needs. This includes assisting public housing tenants from Non-English Speaking Background.

272 The local council personnel that oversees the community centre added that this particular public housing estate has approximately 60 known service providers and many of them would get in touch with the community centre especially when they are unable to locate their service user. Circumstances for liaison include sudden admission to hospitals, relocation to live with the family or into residential care, and deaths. There are also mentions of incidences where tenants were referred to a service provider and tenants were afraid to respond to their door knocking or are unable to hear or get to the door and the community centre has to step in to facilitate the intake process.

The following participant was a recipient of such assistance provided by the community centre for a period of more than six months:

The hospital gave me a person for about two weeks to help me do the shopping

because I was very weak at the time. After the operation, I looked like I was ready

for the grave. I felt pretty weak. They gave me all the supplements to muck me up.

I had to wait six months before I could get on the floor and push that [television

power cord] into the wall plug. (JESSICA, Australia, Female / 70)

As experienced by JESSICA and another Australian participant (PATRICIA), post-acute care that is coordinated by the hospitals upon discharge is short- term – usually lasting two to four weeks. While care arrangements can be transferred to a community service provider, JESSICA had great difficulties in getting help being bed-bound for about six months.

273 Elsewhere, the participant shared that she was referred by the community centre for Meals on Wheels and brought groceries by their volunteers when she regained the strength to prepare meals. When the participant was introduced, she was holding a packet of groceries and a bottle of milk that she was about to deliver to a tenant who had a bad fall and required assistance with shopping.

Apparently, JESSICA became involved as a volunteer of the community centre, reciprocating the assistance she had received during her period of recovery from the major operation.

As mentioned earlier on page 253, the Singaporean SACs are conveniently located in the residential estates and within walking distance for most of their service users. Nonetheless, the SACs are similarly sensitive to the ADL needs of service users in the centre and on outings. At Site S2, staff and volunteers are trained to transfer service users with significant mobility issues onto a wheelchair and transport them to the centre so that they will not be excluded from the centre-based day activities.

In discussions with sponsors and service partners, SAC service managers and staff would advocate for service users requiring mobility assistance to be included in logistical planning and budgeting, as they would require special transport such as wheelchair accessible taxis.

One of the participants (ZHIQIANG) from Site S2 has a history of falls and on one occasion was unable to call for the ambulance due to hearing difficulties and had to wait in pain for many hours till his co-tenant returned home from

274 work to find him lying on the floor. Soon after the SAC began operations, this participant has been coming to the centre daily and staying throughout the day for his own safety. In this case, the SAC has been utilised as a refuge and at a level that is close to a day centre.

Last but not least, the highest level of ADL assistance provided by the six centres is at the Singaporean day centre. During the visits to Site S1, at least two nursing aides were on duty at any one time. Their duties include performing nursing procedures such as dressing change, administration of medication, guiding service users in basic rehabilitation exercises, nursing assessment and maintaining proper documentations. Such nursing activities were not observed at the Australian day centres though a few professional staff has nursing background. As understood from the service providers, the availability of professional staff and care services is dependent on the profile and needs of service users. The following excerpt from a Singaporean day centre participant highlights the care provided by the nurses:

Well, when we sit and need to stand up or whatever, the nurses are on hand to

help. If you start coughing badly, they will pour a glass of water for you to drink.

When it’s time for your medication, they will bring it to us, remind us to have our

medicine. (MEIJUAN, Singapore, Female / 85)

Besides mobility and transport assistance, another main area of provision by community organisations that has been mentioned in part in this chapter by various participants is the provision of meals and groceries. For both Australian and Singapore day centres, service users expect to be served hot meals during

275 lunchtime and provided with morning and afternoon tea as well (see accounts of

SANDIP and JIAHAO on pages 260 & 261 respectively).

Over here, there’s someone to cook for you, take care of the meals, serving at set

times. If we were on our own, it wouldn’t be as regular. At home, sometimes we

would eat, sometimes not. Cooking for oneself is so troublesome. What can you

cook? We just eat something to make us full. Over here, we have hot food and it’s

delicious. (MEIJUAN, Singapore, Female / 85)

The Singaporean day centre participant specifically pointed out above that the provision of hot meals is an important benefit of being at the day centre. As highlighted by an Australian day centre staff that has been probing service users about their eating habits, older people are found to be neglecting their food and nutrition intake particularly with the onset of age-related disabilities and increasing frailty. For older people without sufficient physical strength and with cognitive impairments, meal preparations can be hazardous. Day centre staffs are aware of such issues and would plan the menus with care to ensure that meals are nutritious and to avoid repetitions.

Singaporean SACs are usually not equipped for meal preparation though some centres have been able to provide light snacks and tea for the service users and collaborate with service partners and donors to provide packed lunch.

Many SACs are also a popular choice for individual and corporate donors who provide non-perishable food items on a monthly or quarterly basis. The service users at Site S3 have also been pulling together resources from fellow service users self-organising monthly potlucks:

276 Once a month, everyone brings something here. They call it the ‘kampong spirit’

[popular Singapore term referring to a close-knitted sense of community]. Everyone

would buy something and we would all eat here. There is roasted meat, stir-fry

vegetables, stir-fried bee-hoon [rice vermicelli]. (RUPING, Singapore, Female / 93)

As mentioned by DOROTHY (see account on page 265), the community centre has been partnering with OzHarvest and to distribute perishable food rescued from the supermarkets on a twice-weekly basis to about 150 tenants. For tenants who are unable to collect the food packet at the community centre, the volunteers and neighbours would hand deliver to their unit. In addition, the community centre is stocked with warm pies and sausage rolls available for purchase during operational hours and a vending machine outside the centre.

To this end, the participants from the various centres visited in the course of this study highlighted a range of assistance in ADL that has enabled them to get out of their home and remained socially connected in the community. Together with the previous two common features, the provision of assistance in ADL are the fundamental characteristics of a community services / organisations. For those with mobility and other ADL needs, this area of provision undergird the provision of an age-friendly environment / space. The other common features that are considered less tangible and more related to enhancing the social environment are elaborated in the next four sections.

277 6.2.4 Platform for Social Interactions and Making New Friends

As discussed in the previous chapters, older people experience losses in their social network as they age due to reasons such as relocation, onset of disabilities, and death. As told by ETHEL in the previous chapter (see account on page 238), for the older old who are aged 85 and above, the losses can be so severe that they have no surviving friends at the end of life. For the following participant, the loss of his best friend and many others in his social network was so significant that he was hesitant to be among new people:

One of the biggest shock of my life was I had a wonderful friend who was as old as

I […] We used to do road trips and everything else together and one day I lost him.

So since that time I was not as satisfied with life itself. I’m now not looking [to make

new friends] because I have lost in the last 20 years, many friends. I was the

president of a club. The members has dispersed or died and so it's rather sad that

I'm still around and they’re not. (HARPER, Australia, Male / 91)

Paradoxically, just before sharing this account, HARPER mentioned that he has made a few new friends in the day centre and that he was invited to join by a long-time friend from the club (see account on pages 243-243). Though the losses have affected him emotionally and lowered his expectation of forming new relationship, the day centre has provided a platform for HARPER to make new friends. As described in the following account, HARPER shares of a new association he has made, progressing to the stage of identifying and having shared interest:

278 It’s nice while I’m here, nice to look forward to another week to have pleasant

memories and look forward to renew that relationship. In fact, I met one of the

fellows here and we exchanged records. He likes certain music and I too like it so

we listened to each other’s and that's a positive thing. (HARPER, Australia, Male /

91)

While losing long-time social networks in old age can be seen as an inevitable and irreversible process, a number of participants in this study report having a new social network of at least one close friend they have not met before coming to the centres and having companionship from many other service users who they are friendly with. Service users can be seen as survivors of their peer generation and community organisations are excellent platforms for them to be acquainted with people outside of their long-time social network to form new networks. The following participant goes to two day centres and made separate sets of friends. She is referring to friends made at Site A2 as “new people” as she had been with the other day centre for a longer time:

I have made new friends in the other place and when I go with here, I’ve made

friends here. There’s [sic] new people because the other ones won't come here. So

you meet other people. (SHERRY, Australia, Female / 92)

One of the participants who has immensely benefited socially through the day centre is BRENDAN. His case has been repeatedly mentioned in this thesis as the composite of social circumstances he is facing is one of the most extreme encountered in this study. As a result of relocation in old age, widowhood, and the onset of disabilities, he experienced significant losses in his long-time social

279 networks. At the time when the interview was conducted, the day centre had become his primary social network in the community:

I’d only been here [in Australia] a short time and I’ve not known that many people

outside of the [day centre] groups. I haven’t any experience with the community at

large. I mean the people I meet are my daughter, my dentist, eye specialist; they’re

the only people I meet outside of this sort of community […] My boundaries of the

community are really these here [the day centre]. (BRENDAN, Australia, Male / 80)

With the accounts about developing new friendships through the centres, the process appears to be naturally occurring, without any intervention from service providers. Nonetheless, at a structural level, service providers (especially so for the day centres) are aware that having a common identity besides being older is necessary for friendship development and would diligently assess and group service users into “tables” according to their background – native language and dialects, country of birth (if they are migrants), gender, and age bracket. The following Australian participant has been observing this practice astutely:

Because they get to know each other, they talk about their children or maybe

where they been on holidays so it's a friendship. Because people come from

various countries that has got people from Russia sit together, people from

Hungary sit together. So they can speak their language if they want to. They sort of

have a men’s table but most of them are females because their husbands have

passed away […] Look, in life you sort of have friends. And those friends, why do

you have those friends? Because you got something in common with them […] I’m

not trained, I don't know, that's how I see it. (WILLIAM, Australia, Male / 78)

280 At the community centre, a high proportion of participants provide accounts of friendship developed only when they started accessing the place. When the accounts are placed side by side, the foundation that the community centre committee members and volunteers operate from is friendship. Beyond their service to the community, they are interested in one another’s lives in a network of reciprocal relationships, socialise frequently outside the centre, and are inclusive in bringing in new tenants into their social circle.

The following account is from a participant who, a year ago was feeling alone in the public housing estate, was invited to an event at the community centre, and was subsequently drawn into the core group and even began volunteering:

Well, it was last year, Melbourne Cup day. Didn’t feel like going anywhere, then I

was told they were having a sweep and so I came down [to the community centre].

Somehow I got talking to [two community centre committee members]. Ended up

having a few drinks with them and, that’s how [the friendship] all sort of started. A

couple of weeks later, [one of them] rings me up, says, “We’re short for Trivia,” so I

filled in. I am asked to come every second week for Trivia now. And because I

come down [to the community centre], start reading the paper and doing the

crossword, next thing I know, I’m helping out here. (RICKY, Australia, Male / 67)

Here’s another account from the community centre for comparison:

I’ve made friends here. People on the committee are my friends now. We more or

less socialize together and we go out together as a group. And these people live

alone so we come together and we have a good time. So there it is. I mean,

without the committee here we probably would not have met each other. So it has

281 all been very positive. We watch movies together, sometimes we go to concerts.

So that’s really good. I’m very lucky. (DOROTHY, Australia, Female / 74)

In contrast, the Singapore accounts are more general when social interaction and friendship connections at the centres are mentioned. This might be explained by the longstanding political and cultural expectation for families to care for their older relatives and considering care options beyond the family context is unusual. Singaporean families remained a key source of physical, emotional, and financial support for around 80-90% of older respondents living in HDB flats (HDB 2014). The proportion of older Singaporeans in residential housing living with their spouse and children is 86% (MSF 2015) as compared to 68.2% in Australia (ABS 2013). As such, the corresponding need for companionship and reciprocal relationship outside the family might be lower than that of Australian older people.

The following account from a SAC service user typifies the general nature in which Singaporean participants describe the centre as a platform of social interaction and making friends:

We are now elderly and we have stopped working and it can get boring. Coming

out for activities like these allows us to interact with others and make friends. It is

easy to get dementia if we just stay at home all day. We need to leave the house

for activities, to socialize and to learn. (KEWEI, Singapore, Female / 80)

Similarly from Singaporean day centre service users, quotes are short and more general:

282 Very few [cannot get along]. Most of them make friends here. After the quarrel,

they soon forget about it as well. (MEIJUAN, Singapore, Female / 85)

Nonetheless, having companionship can be a priority for some older participants, overshadowing the other benefits of accessing community organisations as elaboration in the other sections. For this participant, the only reason to keep him coming to the day centre is to avoid being at home alone:

So, as far as using the [day] centre, it is only for that I’m not sitting at home. I have

company and friends there, sitting at the table, discussing things; it’s pleasant.

(LUCIUS, Australia, Male / 89)

Similarly for the following participant, having companions makes her day:

Some days are better than others. Today is a good day because I am with people.

When I am at home I’m not as happy as I should be. (SHERRY, Australia, Female /

92)

To this end, having companionship directly addresses the gap in modern family care when family members are busy with work and school in the day, resulting in “loneliness at home” for older people. Some family carers recognise this gap and the need for companionship is one of the main reasons for day centre application. Besides having companionship at the centres, there is another common reason for families to encourage the older person to access the services. The following section will focus on discussing the area of supervision and monitoring that is providing by the centres to ensure the safety and wellbeing of service users.

283 6.2.5 Provision in Supervision and Monitoring

Supervision refers to keeping a lookout for the safety of service users while they are with the service. For the community centre and SACs, the scope of supervision is not limited to the centre. The community centre committee members are concerned with the safety of the entire estate and beyond operational hours. Examples provided include making police reports of drug dealing activities and controlling the population of feral cats that was posing a health and safety risk for older tenants. As mentioned in section 6.2.2 on page

263, SACs are stewards of the alarm system connected to every unit with an older person in their service cluster and perform regular house visits to those who are homebound.

Monitoring refers to keeping note of changes in the older person over time.

Examples of change include physical changes such as decline in vision, loss of balance, and loss of strength while cognitive changes in comprehension, speech and memory are also noted. Mindful monitoring for the first signs of deterioration and functional decline translates to early detection and allows service providers the ability to anticipate the assistance in ADL required by the older person in future. Service providers also regularly pass on information obtained through monitoring to family carers so that they can seek professional help early and make adjustments in care arrangement. This is the most likely area in which community services will get in touch with families of the service user when the older person has integrated into the program.

284 In the case of the following Singaporean participant, a psychiatrist had advised her and the family to apply for day care. This is despite her relocating to live with her adult child. While it is not explicitly stated, the psychiatrist’s concern likely stemmed from the lack of supervision at home for an extended period of time during the day when the family members are out for work and school:

I was on this treatment of depression but I was improving, and the doctor said you

must come to the day care to mix around and you don’t feel so lonely, so I did that,

and from then onwards, I’m in the day centre. (XINYI, Singapore, Female / 81)

Despite XINYI’s subsequent recovery from depression and as such a lower risk of harm to self and others, the older person remains with the day centre citing the companionship of fellow service users continues to “take away my worries”.

Another Singaporean participant is more specific about the need for some older people – herself included – to be at the day centre due to the “daytime gap” in modern family care:

It’s dangerous. No one else at home, just the elderly by themselves. During the day,

when everyone is out at work, they [the family] are concerned about the elderly

who are all by themselves at home, if they were to fall or anything, and so they

send them to this place, see. (LIMING, Singapore, Female / 79)

Incidentally, a fellow service user of the above participant had a bad fall when her son is out at work:

285 No one [the neighbours] leaves their door open. So no one knew when I fell down.

There’s hardly anyone around. Many people are working. So very few people at

home at four or five o’clock [in the afternoon]. (MEIJUAN, Singapore, Female / 85)

Earlier in the interview, she described how upset her son was with the fall and interpreting from the entire interview, the initial reason for accessing day care is likely to prevent similar incidents from happening:

I fell down, was hospitalized, and had a surgery. After my surgery, my son came to

me, the surgery went fine, but he was concerned that I might have another fall. He

was so upset, he cried. (MEIJUAN, Singapore, Female / 85)

Even though MEIJUAN had fallen down along the common corridor, there was no neighbour passing by her unit about three hours before her son returned from work. The “daytime gap” is as such a helpful concept that can be extended to the neighbours and neighbourhood level.

As discussed in the previous chapter, while there are mentions of neighbours providing crisis and ad hoc assistance and some performing care activities, few participants have mentioned receiving much help or even getting to meet their neighbours during the daytime, on a weekday. Community organisations, particularly centre-based community services are likely the most reliable providers of supervision for older people who are vulnerable and at risk of harm.

As presented throughout Chapters 4 and 5, the level of care that can be provided by families and others like neighbours in both Australia and Singapore

286 has many similarities. Families in both countries are willing to provide care for their older relatives with a significant proportion living together but are unable to provide adequate supervision during work hours. The rationale for day centre placement cited by LIMING on page 285 is highly similar to the family situation of the following Australian day centre user:

I live with my daughter, son-in-law, and two grandsons. My husband is just, two

years ago, passed away. That’s why I come to the centre, because I can’t stay at

home alone, my son-in-law, my daughter they are working. My daughter doesn’t

feel safe if I am alone at home. If something happen, nobody knows. And so, my

daughter searched the Internet, and ringed them. (LILI, Australia, Female / 83)

Nonetheless, not all older people are living with their family and as such day centres and similar community care services are not a form of respite care per se. In Singapore, there is an increasing trend of “one-person aged resident households” from 7.5% in 2000 to 11.9% in 2014 (MSF 2015). According to newspaper report, the number of older Singaporeans living alone has tripled from 14,500 in year 2000 to 42,100 in 2015 (The Straits Times 2015c). That is a rise from 6.15% of the older population in year 2000 to 9.15% 2015 (DOS 2016).

Though the proportion of older Singaporeans living alone remains low, the rise in numbers over the past 15 years has been overwhelming for the aged care sector and the rate of increase is expected to rise rapidly in the next few decades (The Straits Times 2015c). In Australia, the proportion of older people living alone is at a staggering 25.4% with higher proportion of females (32.3%) than male (17.4%) living on their own (ABS 2013).

287 Nonetheless, a number of older participants in this study have mentioned that it was their family members, who are not living with them, that approached the day centres and other community care services for assistance and placement.

For the following Australian participant who prefers to live on her own despite being 90 years old, it took years of convincing for her to enter the care of the day centre. Elsewhere in the interview, she shared about getting a call from her daughter after her day at the centre asking: “How did it go? How was your day?”

From the account below, it is apparent that the family is concerned about her safety and risk of fall (due to a degenerative condition diagnosed after a bad fall) and wishes that she be at the day centre more than she has currently agreed to:

Look, until I got this [degenerative condition] about a year ago, I did not quite come

to terms with the fact that I'm almost 90. Whenever there was talk about going into

a community [care service] with older people I said “Nay, I don't want to.” It was

again mainly my daughter who made me realise that I am old and I should accept it.

So okay, I accept it now. Which doesn't mean I like it, that I want to be surrounded

by all older people. (MAGDALENE, Australia, Female / 90)

Supervision includes supervised activities, particularly group activities conducted at the day centres and SACs. Even at the community centre, group activities such as English classes and craftwork are supervised by volunteer committee member(s) and instructors engaged by the local council respectively.

This area of supervision is closely related to the theme of “provision of a safe and age-friendly physical and social environment” discussed earlier in Section

6.2.1. For the following SAC (Site S2) participant, who was advised by her

288 doctors to exercise regularly to regain her muscle strength, supervision while exercising is essential as she is wary of re-injury if she is exercising on her own:

I used to experience pain in this hand but the exercises helped me. I had a fall and

for a few months, I went to the doctors and they told me that it would take a period

of time to recover. I started exercising but we can't exercise on our own for fear of

hurting our joints. We need supervision and help. (ANQI, Singapore, Female / 76)

At Site S2, mass exercises are supervised by staff and volunteers. The staff and volunteers are trained by the community team from the nearby hospital, who is partnering with the SAC to prevent falls among community-dwelling older people. During the partnership phase of six months to a year, the mass exercises are conducted and supervised by a team of physiotherapists and nurses. While the program is ongoing, staff and volunteers of the centres are provided with classes and on-the-job training to equip them with the expertise to continue conducting and supervising the mass exercises after the partnership period.

As previously mentioned, day centres in Singapore are staffed with nurses who are expected to guide service users in basic rehabilitation exercises. The following is a case where the older person has a domestic helper to provide supervision and care at home and yet chooses to be at the day centre for supervised exercises and peer motivation:

Yes, the helper can help [look after me], but I wanted to come here, do a bit of

exercise, there are people here who lead us in exercise but at home, I need to do it

289 myself, and I can’t remember the steps as well. Over here, all of us exercise

together. So I come here. (LIMING, Singapore, Female / 79)

Thus far in this chapter the focus has been on the provisions made by the community organisations. This might imply that older people requiring various forms of assistance are passive recipients. The next section is focused on the theme of volunteering and mutual assistance within the context of community organisations where older people are contributing to the care of others.

6.2.6 Platform for Volunteering and Mutual Help

As mentioned repeatedly, the committee members of the community centre

(Site A3) are all providing care for fellow public housing tenants on a voluntary basis. The current committee is formed entirely of older people, and with 85% of the estate population aged 65 and over, it is a prime example of a service by older people for older people. What the committee has achieved over the years has been remarkable. Besides establishing partnerships with community service providers and charitable organisations, they are able to bring in corporate sponsors and have been successful in various government grant applications.

For their latest and largest project undertaken, the committee brought together representatives from the local council, Housing NSW, NSW Health, and the hospital serving the local government area (LGA) and solicited their help in establishing a Wellbeing Centre in their estate – the first of its kind in Australia

290 and likely a model to be replicated in other public housing estates. Their next project is to obtain charity status to be more effective in fundraising for the

Wellbeing Centre and future initiatives. One of the participants from the community centre has been volunteering for the centre for more than ten years and their pool of volunteers is increasing yearly.

As explained by the committee members, the centre is a platform for them to

“give back” to the estate and an opportunity to shape the social and physical landscape in which they are residents. Their accounts on the latter are presented in the next section on community building.

The following account describes how volunteering has helped an older person to “feel at home” in a new environment. Even though friendship is mentioned in the account, it is not the primary reason for he would have gone ahead with the transfer to another public housing estate to be with his long-time friends. What the community centre has offered him is much more than just friendship; it is a platform for making contributions and gaining a sense of worth and belonging:

Some of our best volunteers initially wouldn’t touch you with a barb. And slowly

they start to come over. I met one guy who is now helping in the community centre,

he’s here today. He shifted here about 3 years ago, didn’t mix with anybody,

became very depressed, applied for a transfer. He wanted to leave but didn’t, and I

said, “Why aren’t you going?” He said, “Because now I feel at home.” He said, “I

was only wanting to go to [another public housing estate] because I had friends

down there, but here we got Trivia Pursuit, we can come over to the centre, we can

do this, do that.” He said, “Now, I’m happy.” (JONATHAN, Australia, Male / 73)

291 Through the interviews with Singaporean SAC users, it is clear that volunteerism among service users is encouraged. It appears that SAC staff at both Sites S2 and S3 are actively engaging service users in the planning and execution of centre-based activities, outreaches, and regular home visits.

As explained by the following participant, there are limits to the range of activities service users can be involved with due to the need to protect the confidentiality of fellow service users. Nonetheless, when the service user become experienced with the operations of the centre, the level of involvement can be as high as that performed by the staff:

It depends, not paper work though. If I help the elderly at the Senior Activity Centre,

it is usually with exercising, playing games, these sort of activities. We help to

arrange the timing of the activities; we are exercising our brains in this way, so that

we don't get dementia. (MINGJUN, Singapore, Male / 74)

Service users are also involved on regular house visits and outreaches to other older people with the intention of having a visitation partner who is sensitive to the needs of their age-peers.

If there is a need for help, if we can do it we will definitely help. To take care of

elderly, to show concern towards them, if we can do it we will do it. Sometimes it is

not for a whole day, but for a few hours, to go and visit some elderly. We would

also go to nursing homes to visit the elderly. (YAOWEN, Singapore, Male / 78)

292 The above participant is with Site S2 while the following participant is from Site

S3. Their accounts on their role as visitation partners with the respective SACs are similar:

I go with them [the SAC staff], they do what you are doing [conducting interviews]

now. They will write and write and I will listen. I ask them [those being visited] how

are they, they say they are fine. (TIANYI, Singapore, Female / 76)

It is also noted that some SAC service users are highly active in the community and that the SAC is one of community organisations that they volunteer with:

Then sometimes we go help with packing. The chairperson of the Residents’

Committee will call me gather a few people to help pack the goodie bags. I will also

sell tickets for them. (BAOBEI, Singapore, Female / 70)

The Residents’ Committee (RC) are formed by volunteers who are residents within a designated “zone” comprising of a few residential blocks of flats. They are part of the Singaporean grassroots networks and highly similar to the Site

A3 in terms of the area size and number of households they represent.

Nonetheless, unlike Site A3, the RC represent residents from all age groups and as such organises events that caters to the young as well.

The following participant helps out at a Singaporean community centre, which is one level higher in the grassroots system overseeing a number of RCs:

I help out in the community centre as well. If they need any help, I will go help them

if I have time […] [For the Pioneer Generation public education project] the

community centre will bus the elderly down, give them food and we will interview

293 them when they are done eating. We ask them where do they go if they have

medical issues, and if they are aware of the rebates they can get when they go to a

doctor. Then there will be visitations and the same thing [assessment and

information giving] will be done. (TINGTING, Singapore, Female / 66)

The following participant was cited earlier on page 292 as a volunteer of the

SAC. During his free time, he would visit older people who are in the hospitals and nursing home – some are done through the SAC and others on his own accord.

I would go for visitations, at the hospitals, or at the nursing homes [...] Some of

them are my neighbours, some of them I got to know at the SAC, some I got to

know at the church. So, I visit them frequently. (MINGJUN, Singapore, Male / 74)

As for the day centre service users, volunteering at the centres is less likely due to more rigid service provider – service user boundaries. Nonetheless, service users do provide mutual help that is altruistic and not based on any obligations or friendship.

There’s a guy out there doing craft work and I saw him out there last week, it's

beautiful. So today I brought him a bit of jewellery I had. Picked out the stones and

a couple of old watches I’ve got at home I brought them here today because he’s

building a Harbour Bridge out of old things. (GABRIELLE, Australia, Female / 80)

The recipient of the help is another Australian day centre participant (MERVYN) in this study whose account about getting help from staff and volunteers was presented on page 258. In another part of the interview, he mentioned about

294 GABRIELLE providing him with the craft material and shared that he was highly appreciative and pleasantly surprised of the kind gesture as he had not expected getting help from a fellow service user and without asking.

According to national surveys and in the literature, volunteering is common among older people in both Australia and Singapore. In this study, a significant number of participants are currently engaging in volunteer activities, had been volunteering since young, or embark on volunteering as soon as they retire from full-time employment.

In Singapore, the rate of volunteerism among older people is at 17% in year

2012 – which is a sharp rise from 4% in year 2004 and 10% in 2010 (National

Volunteer and Philanthropy Centre [NVPC] 2013: 10). In Australia, the rate of volunteerism among older people is at 31% in year 2015 (Volunteering Australia

2015: 4). More importantly, older Australians are more likely to be volunteering with “welfare / community” type of organisations (37.4% for aged 65 to 74; 36.7% for aged 75 and over) than any other age brackets (ABS 2011). In all the other age brackets, the highest proportion of volunteers are with “sport and physical” type of organisation.

There appears to be a shift in volunteering when a volunteer reaches old age or people who are retiring embarking on volunteer with welfare and community type of organisations. Community organisations are as such a favoured platform for older volunteers in Australia. As for Singapore, there is a lack of data on the type of organisations older volunteers prefers to contribute to

295 though the findings in this study suggests a similar tendency as Australia. For example, the following Singaporean SAC participant had made plans to volunteer even before retiring to contribute in the community as a RC member:

Then later I plan for my retirement, just before I retire, I joined the grassroots [as a

volunteer]. The moment I retired, I become a grassroots [committee] member in the

RC and took on a different role. (BIREN, Singapore, Female / 75)

Similarly for this Singaporean SAC participant:

Then last time I’m working in the law firm. The lawyer wanted to retire so that firm

was closed down, and I was retrenched. I was getting old so I didn’t go and find

any other job. Then I do volunteer work. (CHENXI, Singapore, Female /70)

Even more remarkable is a case of a Singaporean day centre participant who continued to volunteer weekly and her enthusiasm has been supported by the family and day centre who recognises that volunteering aids her in the recovery from depression and in maintaining her mental health:

So I have improved a lot, that’s why I’m doing a lot of volunteer work to keep my

worries away […] I have a lot of freedom [at the day centre] because I’m doing

volunteer work. I go out occasionally, just tell the office I need to go out to do some

work and they allow me to go out. (XINYI, Singapore, Female / 81)

As highlighted by the following Australian day centre participants, some of the volunteers are older than service users:

296 Someone who’s here [volunteering], she's 83, never missed coming. Some of the

volunteers are older than the clients. The clients, some of them are not well and

that can happen at any age. (WILLIAM, Australia, Male / 78)

While conducting the research, many volunteers at the various centre were noted to be aged 65 and above. This is also the case for some of the staff and this phenomenon deserves more attention. Last but not least, at the Australian community centre, there is a case of a professional reaching old age and looking for an opportunity to contribute to the wellbeing of fellow older people with his medical expertise:

He’s the medical practitioner from [a nearby suburb] who’s actually, he’s nearly

retired and so he comes here, he wants to be the doctor here. And when we get

the medical centre downstairs operating, he will probably be our main volunteer

doctor. (RANDY, Australia, Male / 70)

6.2.7 Creating a Sense of Community

Finally, what the various community organisations have done well for the service users in this study culminates in creating a sense of community. Having a safe space that is physically and socially age-friendly, having a structured program with a range of engaging and meaningful activities, providing assistance in ADL, providing a platform for social interaction and making friends, providing supervision and monitoring, and providing a platform for volunteering and mutual help contributes to a caring environment that is tailor made for older service users, who recognise that it is done by people who truly care.

297 Questions were posed about the participants’ perceptions and experiences of the community and it emerged very early in this study that the people older service users meet at the community organisations are considered part of their community and for some, the only “community” that remained.

For the following Australian day centre participant – who is unable to “get out” of the house by herself and does not have the family helping her to “get out” regularly – the day centre is cited as her main “community” when asked to give a definition of what is a community:

My community will be the people here [the day centre] and I suppose people in the

block of units I lived in because I have lost lots of contact with people in the

previous place that I used to live. I've never get to go anywhere much to make any

friends in this new place and because I don't go out much so I’ve got this [day

centre] for a community. Knowing all the people. (ETHEL, Australia, Female / 87)

As presented on page 280, the case of ETHEL is unfortunately not unique as

BRENDAN had also mentioned: “[M]y boundaries of the community are really these here [the day centre]”. While the experience of these two participants are extreme cases of older people who has very limited social network in old age, the circumstances that led to their current situation and their perspectives provided insights that few other cases have.

One such insight is that of losing community connections and networks in old age and it can be in the form of losing family networks. As elaborated in Section

5.1.1, ethnic identities in Singapore have been preserved by clan associations,

298 which are organised under a family name or dialect group (Vasoo 2001).

Nonetheless, in the face of modernisation, such cultural heritage is losing support from the younger generations (Singapore Federation of Chinese Clan

Associations 2017). Family size has also decreased significantly, increasing the likelihood of people reachign old age with little or no family support.

Back to the case of ETHEL, she had lost her community in two main areas. First, her family network through migration when she was a youth:

If you got a big family, see when you’re a migrant, you leave all your relatives

behind that's the thing. I've got an aunty and I've only got a sister left, she’s living in

[her home country]. My other sister and brother have died and I got cousins and

they're all over there but I haven't got any of them over here. So that's what

happened to me, you don't realise when you are young, you gonna [sic] loose your

family unless you've got a big family of your own but I've only got one son and

that's the way it is. (ETHEL, Australia, Female / 87)

Subsequently, she had lost her non-family social network that she sees as her community when she had a bad fall and had to relocate:

When I was in my 60s and 70s I was so active and into all sort things. I used to do

two days volunteer work and exercise twice a week. I can look after my

grandchildren and I was the secretary of the body corporate. Anyway, I have to

give it all up when I was about eight months in the hospital. While I was in hospital,

my son sold off that unit and bought the one up here. Haven't got any other

community now. Well I probably would have but I can't get around enough to have

a community. Before I broke my ankle, I had a big community because I was doing

all sorts of things. But I haven't got that now. (ETHEL, Australia, Female / 87)

299 In addition to the difficulties experienced by ETHEL, the following participant highlights from his experience that the sense of community in urban neighbourhoods could be lacking:

Well, there are communities, like you heard on the news that they were looking for

the little boy who was missing, The whole community go together because it’s a

smaller place where the people know each other. You see, I lived in this street for

47 years. I know my next-door neighbour, two house further away, and then two

houses away. That’s it! We are not sitting in each other’s houses, we’re not friends,

we are neighbours […] the sad part is, in some of these neighbourhoods, people

lead their own lives. When I was 15 years younger, an old lady, she was a widow, I

took her garbage bin in and out. But now I get to my age, nobody does it for me.

I’m just saying there would be a community if the neighbours will sort of be more

attentive to each other. (LUCIUS, Australia, Male / 89)

The following account provides the perfect juxtaposition to the above account.

For the following Australian community centre participant, there is a tangible sense of community when his fellow public housing tenants ask about his whereabouts when he is not seen for an unusually extended period of time:

When you got a community or a number of people around, they tend to look out for

others. I mean you can say, “Did you see so and so, I wonder whether he’s going

alright?” So people tend to look out for you like around here if I'm not seen around

for half a day they’ll want to know, “Where the bloody hell is he?” They’ll ring you

and say, “You’re alright?” “Yeah I’m just doing something.” “Oh, alright.” In the

community there's a lot of safety because people tend to see people around all the

time and you don't see them for three or four days, you said “So and so, is he

crooked or gone hospital or what?” (DAMIAN, Australia, Male / 67)

300 While DAMIAN appears to be referring to the entire public housing population, the collective accounts from Site A3 informed that the estate did not have a cohesive and caring community prior to the set up of the community centre and it is achieved after years of community outreach, community integration, and community mobilisation.

Till today, the committee members have difficulties engaging two-thirds of the estate population. Nonetheless, for the one-third of the estate who have been participating in the various activities, there is a reported sense of community, looking out for one another. For another example of community bonding, see the account of WENWU on page 266

In Singapore, the word “community” was first translated in the Mandarin form and did not elicit responses as well as the Malay form. Even with the older

Chinese population, the term “kampong” resonates better when referring to the community as this was the term they have been accustomed to growing up in villages. Although the word “kampong” was used in an earlier interview, the following participant is the first to use the term “kampong” for community.

This is the neighbourhood. I will bring them to the doctor when they are sick. It's

like a family staying together in a kampong. A community is like a kampong. Do

you understand what a kampong is? (YANNI, Singapore, Female / 68)

Thereafter, the term “kampong” is recognised as synonymous with community and Singaporean participants continue to use the term when prompted with questions about the community. This research experience is similar to that of

301 Wiles et al (2001) who had to replace “ageing in place” with “staying in one’s home or community” to elicit a more spontaneous response (see page 112).

The following participant specifically used the word “kampong” to describe a sense of community experienced in SACs, suggesting that more SACs should be established to cater for the growing older population:

They have to open a few more loh. So that all can get together in each [SAC], feels

like a kampong. One kampong, one kampong [colloquial expression; meaning

many of the same kind]. It’s fun for the elderly. They want [to participate]; this

model is good. (BAOBEI, Singapore, Female / 70)

Last but not least, there is evidence to show that community organisations serve as platforms for older people to be socially connected, enhancing relationships in a small community. What the SAC did for this participant is similar to the “ice-breaking” nature of outings described by DOROTHY on page

266.

Now when I go to the different blocks I feel that they are all so friendly, like family.

There aren't facilities [SACs] like this in [another housing estate]. Before such a

place existed, we [people living in the same neighbourhood] would see each other

but not greet one another (YANNI, Singapore, Female / 68).

6.3 Limitations of Community Services

While there are far more positive comments about centre-based community services and community organisations, there are several accounts that highlight

302 that there are limitations and weaknesses by examining the complaints and negative comments from service users. The following account highlights that the quality of the community services is highly dependent on the attitudes of the service staff and not entirely due their attributes and skill level:

Even though the nurses here are mainly Filipinos, so they don’t speak the same

language, but we can still communicate with them. I know a little bit of English, I

don’t speak it very well, but when they ask me questions, I can understand some

words. Unlike in the other centre, they have Chinese nurses who can understand

us but they don’t talk to us. And even when we didn’t do anything wrong we get

scolded by them. It’s horrid. After a while, I told them that I have to pay in order to

come to their centre, it’s not free for me. So they can’t just scold me when they

want to or do as they please (JIAHAO, Singapore, Male / 77).

In JIAHAO’s case, his son was able to find another centre within two months and the participant do not have to endure the harsh treatment by the service staff that can be considered to be a form of verbal and emotional abuse. There was no complain made to the authorities and even if so, it is unlikely to result in repercussions for the offending staff. As the following accounts have highlighted, there is a shortage of day centres in Singapore.

There’s another centre at [an estate five kilometres away]. I think so. There’s none

in [my estate], right? There are several residents from [my estate] who have to

attend this centre. (LIMING, Singapore, Female / 79)

303 Similarly for the following case:

It’s not easy to come in. They don’t have a lot of people here. They won’t be able to

handle too many people too. When I applied, they told me to wait to see if there

would be an opening, and so we had to wait. (MEIJUAN, Singapore, Female / 85)

The centre management of Site S1 disclosed that retaining staff could be a challenge for an under-developed day care sector that is generally under- resourced – requiring substantial private donation to cover operational cost. As the following account presents, service users are enlisted for fund raising and this participant was actively involved in a bid to sustain the centre for the long- term:

I was here from the beginning [as a volunteer, about 20 years ago]. They were

selling the [symbolic] bricks in a new [religious building] to raise funds, and a brick

would sell for 888 SGD, 88 SGD. I bought one for myself too. And I also helped to

sell off some raffle tickets, one book for 20 SGD. I was selling these books in the

coffeeshops. The shop owners would help too. I would ask my friends and they can

also buy a single ticket for 2 SGD. (LIMING, Singapore, Female / 79)

The negative accounts from Australian participants are focused on unreasonable regulations and over protective staff, limiting their sense of autonomy, choice, and independence which at the centre:

You want an example? Every time something happens, “Oh, you’re not allowed to

use that.” They stopped [a service user with lower back issues] last week. So he

has to bring his own. That’s what I can’t understand. What are they doing? Cutting

304 cost or cutting what? What’s he gonna do to the cushion? Or sometimes we can’t

go in the kitchen. Even the volunteers can’t go in the kitchen. They have to wait

outside to take the food [when serving lunch and tea]. (NOEL, Australia, Male, 76).

While it might be understandable that a younger service user might feel so, another participant who is older had a similar view:

Well, I mean one thing is already they collect and bring you home. And also while

you are here when I wanted to get up to get a cup somewhere, you are not allowed

to take a cup but you got to ask a volunteer to take the cup. Why? I can do that.

“You might fall and it's their responsibility.” You suddenly are nothing… a baby! I

got up to do it and one lady who has been here for a long time said, “Sit down, sit

down, sit down, you can't do it.” (MAGDALENE, Australia, Female / 90).

Addressing such criticisms of community services is one of the main agenda of the recent Living Longer Living Better aged care reform (see Section 2.4.3 for the review on the current reform). The nation wide implementation of CDC since

1 July 2015 adoption would be a welcome change for service users who felt that their sense of independence and choice have been compromised. Though currently CDC is only available for HCP service users, the Wellness and

Reablement Review is underway for the home and community care sector and would likely lead to changes similar to the CDC for CHSP service users

(Department of Health 2017c, n.p.).

As for the case of Singapore, the work required in transforming the home and community care sector is much more complex and pending indefinitely. As detailed in the Section 2.3, ministerial attention on the aged care sector was

305 afforded between the mid-1980s and mid-1990s. The community service model developed then has persisted till today and there is no indication of another round of reviews or reform.

6.4 Structural Trajectories in the Government Sector

Thus far, the findings presented in this chapter have been focused on the inputs of care provided by community organisations and predominantly within the context of the various centres. At the structural level, participants have noted some positive trajectories that are shaping aged care in both Australia and

Singapore. For the case of Australia, the positives of Local Government HACC service providers have been highlighted by several participants while in

Singapore, the positive changes at a national level emerged.

6.4.1 Local Government HACC Providers in Australia

As highlighted by BRENDAN on page 256, the local council operates the day centre he is attending. Local councils providing HACC services are collectively known as Local Government HACC providers. In the state of NSW, an Ageing and Disability officer is based in 70 of 152 councils looking into service development and delivery; this role has existed since the inception of the HACC program in 1985 and is supported at the state government level by the NSW

Ageing, Disability and Home Care, Department of Family and Community

Services and at the federal government level by the Commonwealth DoHA

(Local Government NSW 2013: 8).

306 In addition, prior to the current sector reforms, local councils are receiving block funding for the number of clients they serve through HACC service areas such as domestic assistance, meals delivery, centre-based day care, community transport, and home modifications. These funding arrangements and support are currently under threat in the Living Longer, Living Better reforms with the proposed transition to the Consumer Directed Care payment model – where service providers have to rely on payments through individualised packages

(likely on a per use basis) where the budget is first allocated to the package recipient who has the final choice in which services to engage.

Due to the uncertainty in funding arrangements and extra cost to the councils in subsidising HACC services, two councils have returned their HACC funding in late 2012 with more councils likely to follow suit (Local Government NSW 2013:

4). This trend can adversely affect a large number of older people who are currently served by their local councils and their ‘legislated mandate to focus on the participation and engagement of older people in community life’ might vanish from the aged care sector (Local Government NSW 2013: 7). While the reforms are affecting all HACC service providers and the sustainability of Local

Government HACC providers is not the concern of this study, the possible loss to the sector based on the positive accounts from older participants who have benefited from this community focus deserves a closer look.

The following statements highlight the perception and experience of an older person who live in a LGA where the council is a HACC provider and her knowledge of the level of service provision in the LGA that her friends are living

307 in where the councils are likely not a HACC provider:

This is the best council in the whole of Sydney. Everyone says that. I’ve got friends

living in other parts of Sydney and they get no help whatsoever. (PHOEBE,

Australia, Female / 82)

Her account is contrasted by another participant who lives in a LGA (in the service boundary of Site A2’s ethnic-based HACC provider) where the council is a HACC service provider (for home maintenance and home modification services only) but do not do as much for the older residents:

I told you, I’m a member of the [council’s] Older Persons’ Advisory Committee. And

I always complain that in this particular council, they do very little for the

pensioners and the disabled and they should do more. (LUCIUS, Australia, Male /

89)

Based on the above accounts, older people do expect councils to provide a wider range of HACC services. While these accounts are considered subjective, the participants do gather information about what the different councils have to offer through their own social networks and make comparisons. Furthermore,

LUCIUS is a service user of a centre-based day care and is a member of the

Older Persons’ Advisory Committee and therefore likely is aware that his local council could be funded to develop new HACC services.

308 For the following participant, the range and level of community care services has significantly influenced his decision to reside in Australia and in the particular LGA where the council operates Site A1:

I think it’s a wonderful service. I live in this area for the last 26 years, and at a

certain age then I started using it. I can go back to [my home country] and live on

the Australian dollar and I can live like a king, right? But why am I not going?

Because of the medical services, that’s the main reason. Number two, it’s because

of the services that this [Local Government HACC provider] do for older people.

Otherwise I have no reason why I should live here. (KRISHNA, Australia, Male / 76)

And for BRENDAN, the concept of a community to him is embodied by the local council and what it has been doing for older residents:

Well, a community I suppose is personally the sort of stuff that the council do for

old people. The meetings [at the day centre] and you got an occupational therapist

comes [to look into home modifications] […] Well, I think the council, for me, is

doing a very, very good job. (BRENDAN, Australia, Male / 80)

This Local Government HACC provider has been operating for 25 years, having the opportunity to interact at a local level and be informed by the community directly for service planning and provision over the years. That is a significant advantage over operators wishing to establish new HACC services and conducting independent resident needs surveys might be beyond their capacity.

The current range of services in the LGA of Site A1 is reported by the following participant to be more than adequate and known to older residents:

309 There are a lot of activities offered in this region of Sydney. If somebody wants to

meet people and do something, there's a big range. The council offers a lot of

things. I think we are very fortunate here that community transport can take people.

I think we are pretty well serviced. (ANNA, Australia, Female / 73)

While information on HACC services can be found online through the

Community Information Directory (www.datadiction.com.au/lincs), individual council’s websites, and the newly consolidated federal government’s My Aged

Care (www.myagedcare.gov.au) national portal, few participants have mentioned accessing these avenues when asked how do they know about the available HACC services. Instead, printed copies of the HACC service listing that have been regularly distributed by the council were presented, demonstrating such conventional methods of publicity as more effective with older people than online information.

Another aspect that the Local Government HACC providers has done well is in engaging contractors providing home maintenance and home modification services at affordable rates for older residents. As highlighted by the following participant, contracted tradesperson engaged by the council for lawn mowing and other jobs are perceived to be more trustworthy than a free-lance tradesperson and she is assured that the rates are reasonable and subsidised:

You don’t know if you’re getting an honest tradesperson or what you’re getting, do

you? Whereas for me, I can be assured that they’re going to be honest people and

it’s going to be a very reasonable charge [for changing a light bulb]. I think that is

possibly subsidised by the government? I think it is. And also, they have a lawn

mowing service. That’s engaged by the council. (PHOEBE, Australia, Female / 82)

310 As voiced by the various participants who have benefited from a Local

Government HACC provider that is well established in service development and delivery, the value of having council-led HACC service planning and provision in

Australia should not be overlooked. Nonetheless, the advantages of having a community-focused service provider needs to be further explored and evaluated against the other groups of service providers.

6.4.2 National Schemes in Singapore

As for the case of Singapore, there are more positive views that emerged about the level of state support than negative. This was not expected due to the relatively low provision of community services and government expenditure compared to countries like Australia.

In financial year 2012, the number of older Singaporeans served by the SACs,

SHC (meals and escorts), Befriending service, and such home-based and community care services is 51,379 (NCSS 2013: 24). The total state expenditure is 22.6 million SGD and highly targeted to meeting the needs of

Singaporean residents who are assessed to be “isolated and vulnerable elderly”

(NCSS 2013: 24). In year 2012, the population of Singaporean residents

(citizens and permanent residents; excluding non-residents) was at 3,818,205 with 378,636 who are aged 65 and above (DOS 2016: 44).

In comparison, the Australian Government spent a total of 1.15 billion AUD in financial year 2014-5 for the state of NSW providing Home Care and Support

311 Services, which include main spending on Home Care (levels 1-4) (389 million

AUD) and the Commonwealth HACC Program (591.8 million AUD) (see Table

13A.4 in Productivity Commission 2016). The number of older people served in

NSW through HACC that year is 275,256 (see Table 13A.3 in Productivity

Commission 2016). In year 2014, the Australian state of NSW has a population of 7,518,472 with 1,163,086 who are aged 65 and over in year 2014 (ABS

2016d).

As such, bearing in mind the discrepancy in the year the data that is available, the per 1,000 rate of older people served by HACC services in NSW (at 236.7) is more than twice the number served by similar services in Singapore (at

135.7). However, the rising needs of older Singaporeans have been recognised by the state and the range and level of home and community services are likely to be expanded rapidly in the next decade (The Straits Times 2015c)

What has been noticeable from the accounts of older Singaporeans in this study is the change in their perception and experience of state support over the years.

The Singapore Government treats the elderly well now. It didn't use to be like that.

(DEXIANG, Singapore, Male / 81)

The government is helping out all the elderly people. Not like before, they don’t.

Now, they do lah. (BAOBEI, Singapore, Female / 70)

312 Nonetheless, the “family first” policy adopted by the Singaporean state in aged care remains and is legislated under the Maintenance of Parents Act 1995. As described by the following participant, the Singapore Government would only provide financially for older people without financial support from the family, particularly from adult children:

It isn't so bad now. If your children don’t take care of you, the government takes

care of you. They will give you some form of financial help. You can only receive

help if you have no children. (RUINA, Singapore, Female / 75)

As mentioned in the Literature Review chapter (see page 49), PA is usually provided for older people who are unable to work and receive little or no means of income and financial support from the family. Comparatively, the criteria are more stringent than the Australian Age Pension scheme and the payment is relatively low. However, older participants have found ways to live on the budget provided and the following PA recipient has similar views that he is being taken care of by the state and appreciates the progress the state has made to improve the citizen’s living standards:

When you age, the government will take care of you. Even if your family members

do not take care of you, the government will take care of you. We didn't have that

in the past. The government cannot even take care of themselves. In the past,

Singapore was not so prosperous. When PAP [People’s Action Party] first took

over, Singapore was really poor. We stayed in kampongs, we had no electricity.

We used water from the well to cook and drink and also for showering. We didn't

have it as good as what we have now. (MINGJUN, Singapore, Male / 74)

313 Nonetheless, for older Singaporeans who have an asset like a HDB residential unit, they will be advised to sell or rent out their unit partially before any formal financial assistance could be applied:

I don’t want to apply for PA. That means Public Assistance. I’m not until that stage

[that I am] so poor. And second thing, the government also won’t give because I

still got a flat. They will say, “If you have no money, go and sell the flat.” Many

years back, I worked. I live on my savings, and if I [am] really desperate, I can rent

out one room. (CHENXI, Singapore, Female / 70)

For the group of “asset-rich income-poor” older people, how the state is supporting them to remain living in the community is through subsidies in utilities, public transport fares, medical consultation and prescription costs in public hospitals and polyclinics, and Goods and Services Tax rebates:

Okay, what the government give, if I am living in a three-room [purchased] flat, they

will subsidise the water, and then electricity, and they give pioneers priority

(queues in supermarkets). All these are okay. (CHENXI, Singapore, Female / 70)

The state of Singapore has also put in place the Medisave national medical savings scheme in April 1984 and the MediShield Life (replacing MediShield) scheme from 1 November 2015 onwards, which is a basic health insurance plan providing protection for all Singaporeans, for life, including pre-existing conditions (MOH 2015). The premiums of MediShield Life can be fully paid through Medisave and with no out-of-pocket costs for most residents contributing to the CPF superannuation equivalent savings scheme. The following participant is a beneficiary of such medical insurance provisions and

314 had her entire medical operation and hospitalisation fees covered:

I didn't know that I bought MediShield. In the past, the government got us to only

sign if we don't need it. So, I am automatically enrolled in it. Later they [the hospital

staff] told me that I can make all the deductions [for the operation]. Only then did I

know that I was covered under insurance. When I was discharged, I asked if I was

still under the coverage, they said yes. (TINGTING, Singapore, Female / 66)

The state also provides support for families caring for their old through subsidising day centre costs and other support services:

When I first came here [the day centre], I had to pay. But then we applied for

assistance from the government, and now I don’t. (JIAHAO, Singapore, Male / 77)

Through all these accounts from the older participants, it appears that the level of state support in Singapore is increasing. Whether the current level of state support is adequate for older people and their families requires a much larger sample size. Although there are accounts from participants wishing that more can be done, they are not critical. Overall, there is a recognition of the progress made by the state and an expectation that state support will continue to rise in the near future.

315 6.5 Conclusion

This chapter began with a comparison of the six recruitment sites, focusing on operational model they have adopted. The Australian and Singapore day centres were categorised as closed settings while the Australian community centre and Singaporean SACs operates on an open basis. The latter model allows the centres to be more progressive and responsive to the changing needs of older service users and there are parallels in the Australian community centre and Singaporean SACs to move towards community health partnerships and fundraising as charitable entities – drawing healthcare professionals, private donors and corporate sponsors as part of the “community of care”.

Thereafter, the seven common characteristics of community services / organisations most mentioned by the participants were presented. This set of common characteristics are areas of provision that centre-based community care services and community organisations are capable of providing to aid community-dwelling older people in social and community participation.

To this end, the accounts from the participants form a composite picture of what older participants are appreciative of and feel supported by community services

/ organisations. Nonetheless, as highlighted by individual participants, they differ in ranking what are the more important features according to their own set of needs and community services / organisations might not be able to fulfil them all. As highlighted in Section 6.3, there are also negatives and limitations, which can arise from internal and external factors such as staff attitudes and

316 government prescribed service standards respectively.

In the third part of this chapter, the government-level trajectories in Australia and Singapore were discussed separately as divergence and unique developments in each country. Staying with the data, the strength of community-focused Local Government HACC providers in Australia and the development of national healthcare and subsidies schemes in Singapore were highlighted by the perspectives and experiences of participants.

317 CHAPTER 7: DISCUSSION

This chapter lists out and discusses the “higher-level themes” (Punch 2005: 205) in relation to the three findings chapters (Chapters 4, 5 & 6). The discussion includes an elaboration of how the various themes are interrelated and how a group of themes addresses the research aims and questions.

The themes relating to the first research aim and question of a comparison between Australia and Singapore along the East-West value divide is identified and deliberated in Section 7.1. The discussion centres on the strength of the cultural and family values held in both Australia and Singapore towards family care. Theoretically, it is focused on the Macrosystem in Bronfenbrenner’s BST

(see Figure 1).

Section 7.2 focuses on state support for older people and their families.

Theoretically, it is an interaction between the components of the Exosystem and

Microsystem in Bronfenbrenner’s BST. The discussion draws on the prediction of academics debating along the East-West divide (see Section 1.3) that fully- aged societies from both the East and West would likely converge on a state- family partnership in aged care delivery and provisions due to the effects of modernisation. In addition, as this study also explores the pillars of community and community care, the state-family-community partnership model is conceived.

318 Progressing inwardly towards the core of Bronfenbrenner’s BST model,

Sections 7.3 and 7.4 list the broader themes according to the limitations of family care due to issues of divorce and the “daytime gap” and recognises the contribution of de facto relationships and grandchildren as principal carers.

Section 7.5 discusses care issues for older people who are living alone, who require attention at all levels of intervention and have practice and policy implications.

Section 7.6 moves further away from the family context in discussing broader themes on non-family relationships with regards to their capacity and limitations in providing care for community-dwelling older persons. Drawing from the strength of “age-peer” relationships and receiving care from someone in the same lifestage, the theme of “older people for older people” is discussed in

Section 7.7. Last but not least, the broader themes related to the common characteristics of centre-based community care services and community organisations, combining with the community-focused approach is elaborated in

Section 7.8.

7.1 Is there an East-West Value Divide in Family Care between Australia and Singapore?

One of the aims of this comparative study between Australia and Singapore is to examine, through the voices of older people in the two countries, whether there is a distinctive East-West value divide in terms of the way families provide care for their older relatives.

319 In Chapter 4 on family care, the various accounts from older Australian and

Singaporean participants are placed together to illustrate the level of similarities in their collective experiences. Such a conclusion is in line with Campbell and

Brody’s (1985) cross-national study between American and Japanese women

(see Section 2.8.6 for the elaboration of the findings) in which it is concluded that ‘[d]espite the many cultural contrasts that we have noted and notwithstanding the divergent characteristics of the two samples, the differences should not obscure the overall similarities in the findings’ (p. 588).

Whenever mentioned in this study, similarities in family care between the two countries refer to the equally wide spectrum of living arrangements Australian and Singaporean older participants are having and equally varied range of care activities undertaken by their Australian and Singaporean families, with accounts from neither countries at a distinctive level that is considered more superior than the other. The fulfilment of this primary aim in comparing family care in the two countries is one of the central themes for this study, adding a new set of findings to the two-decade-old enquiry along the East-West value divide of aged care and opening up many other lines of enquiries which are discussed in this chapter.

7.1.1 Is the Value of Filial Piety in Singapore Overstated?

The similarities in which Australian and Singaporean families care for their older members would suggest that the Confucian values of filial piety might have less of an influence than previously perceived. This is despite the Singaporean

320 government’s structural intervention in promoting the values of filial piety as a cultural ideal and the institutionalisation of family obligations under the

Maintenance of Parents Act 1995 (Chan 1999; 2005).

The main reason for such a low influence of filial piety in Singapore could be attributed to the modernisation thesis. As explained by Eastern academics (Kuo

1998; Wong & Chau 2006), the concept of filial piety itself has not been constant over time and is subjected to interpretations across cultural and national context. With Singapore being a modernised and multicultural society, the interpretation of filial piety in reality would have departed considerably from the traditional form, becoming less distinguishable when compared to family values held by other cultures, in particular for this study, the Australian culture.

As highlighted by Singaporean participants, expectations on their children to provide financial support and personal care when they need it are kept low as they have witnessed the rapid transformation of Singapore in their lifetime and observed the impact rapid urbanisation has on Singaporean families in their structure and capacity to provide care. The financial pressures faced by their children have also influenced their decisions to be self-reliant for as long as possible so that they would not add to their financial and care “burden” (see accounts of YILUN on page 170 and LIZHE on page 216). It appears that in modernised Asian societies like Singapore, the expectations of values of filial piety can be increasingly challenging to uphold. This would be especially so for adult children who are not financially able to provide for their own families, let alone financially provide and care for their elderly parents.

321 The mitigating factor for Singapore might be that while rapid modernisation is taking place, the general population are benefitting from a correspondingly rise in the standard of living. The appreciation that the current generation of older

Singaporeans has towards the state in achieving social and economic progress was presented in Section 6.4.2 (see pages 312-313). Nonetheless, in view of global economic slowdown and rising cost of living, this study is making suggestions that the Singaporean government take a more active role in supporting older people in view of changes in the family and contemporary developments of filial piety. An elaboration of the recommendations for state support will be discussed further in Section 7.2.

7.1.2 Is the Value of Family Loyalty in Australia Understated?

While debate in the East with regards to the influence of filial piety and modernisation has on family care is ongoing, Western scholars such as Kendig

(2000: 109) had cautioned that despite the Western socio-political tendency towards the value of individualism, [f]rom within Australian culture, however, family loyalty is widely held as a primary value which has strong personal, social and political significance’ (emphasis in original).

As Australia and Singapore are culturally diverse and participants in this study are not culturally homogenous (see Section 3.5), the strictest socio-cultural differentiation between the accounts of an Anglo-Celtic Australian and a

Chinese Singaporean is applied wherever appropriate. What eventually emerged from the data not only challenges the frequent assumptions that every

322 account from the East would support the filial piety thesis, the Australian accounts – as representative of the West – do not always support the individualism thesis either. Under such scrutiny, there remain examples of

Anglo-Celtic Australian participants who are receiving personal care from their family members at a level that is comparable to that provided by Chinese

Singaporean families.

The most positive example of this is the case of BRENDAN, who is living with not only his adult child but also welcomed by her spouse and their children in a three-generational setting. While living with the family does not equate to living well as highlighted by BRENDAN in several instances during the interview (see accounts on pages 207, 239 & 280), the willingness of Australian families to live together and provide personal care for one another does challenge the notion of

Western individualism. Furthermore, BRENDAN’s living and care arrangement was initiated by the family, demonstrating their concern for his wellbeing and their willingness to provide care at their own expense and inconvenience, when options such as hostels and nursing homes are available, with provisions from the Australian state, and within their financial means.

The perception of Australian participants in their families’ willingness to provide care when they need it is also repeatedly mentioned. This is exemplified in the accounts of BRIDGET who does not require much assistance as yet but is confident that she is able to continue ageing in place in the community because

‘I've the family behind me all the time’ (see full account on page 162) and ‘if I want something done they will do that for me’ (see full account on page 158).

323 These accounts above from Anglo-Celtic Australians can easily match up to the most positive accounts from Chinese Singaporeans in this study. As such, the data on family care reflecting families’ willingness to care for their older members did not position family values held in Australia and Singapore as polar opposites. For the case of Australia, the ‘Western value of individualism [, which] presupposes that caregiving is essentially a service rendered by a caregiver regardless of the nature of social ties’ (Liu & Kendig 2000b: 9) would deserve deeper exploration, if it has not already been addressed by Australian examples in this study.

While Australian carers can be seen as being renumerated by the state through

Carer Payment and Carer Allowance to provide what is essentially a family obligation, the fact that service provision is also available when families are unable and / or unwilling to care would support Kendig’s (2000) argument that family loyalty as a social value, remains widely held value within the Australian context. At the very least, Australian families have been described in this study to be coordinators of care, purchasers of services, and be on the lookout for their older relatives.

As a whole, the collective voice of Australian participants who have an intact family support network presents a positive outlook and the assurance of state support in terms of Age Pension and service provision for individual older person gives them confidence that they can age in place with some support from the family and even so when they require significant level of assistance in

ADL.

324 At this juncture, the answer to the question of whether there exists an East-

West value divide in family care between Australia and Singapore as supported by the accounts from older participants in the two countries is a “no” in terms of what families in general are willing to provide. However, this conclusion is limited to cases where an older person has an intact family network and / or has at least one family member who is willing to provide care on a consistent basis.

For a significant proportion of participants in this study, family support is very limited or not available at all due to strained relationships and estrangement.

The breakdown in family relationships can happen long before they reach the stage where the family would need to contemplate on care arrangements. By the time the older person requires care, adherence to family values and norms could become irrelevant or secondary to family members who have long ceased to maintain contact.

Comparatively, there are more such cases among Australian participants in such situations than their Singaporean counterparts, suggesting a closer look at family relationships and dynamics in the Australian context. In Section 7.3, the family relationships and dynamics in the Singaporean context are also covered in view of changes in family demographics that suggest similar concerns to that of Australia. Before that, and following on from the discussion on family care, the next section is dedicated to another conversation between Eastern and

Western scholars on balancing state and family obligations in aged care.

325 7.2 Sustaining Family Care: State Support in Australia and Singapore

While this study has established that families in both Australia and Singapore are willing to care for their older relatives and that family values in both the East and West appear to be binding that willingness to provide family care, there emerges a concern whether families in these two countries would continue to have the “capacity” to care, even when they wish to.

Examining families’ “capacity” to provide care is critical as it affects families’

“willingness” to provide care. In view of practical considerations such as earning a living, families’ values, willingness and capacity in providing parental care can be challenged. At the very least, there would be a segment in the Australian and Singaporean population who would require substantial external support in providing family care due to financial constraints, disabilities, and circumstances beyond their control.

In the aspect of state support for older people and their carers, it would appear that much has been done in the case of Australia. As detailed by the following

Singaporean participant who visited Australia and found out what the Australian government has provided during her stay:

I went to Australia in 2003 for a week. I stayed in the house of my daughter's friend.

Both of her elderly parents are not working, and they would wait for the bus

[referring to Community Transport] to fetch them to do their grocery shopping. As

they are not working, the [Australian] government gave them money [referring to

the Age Pension]. Their daughter is a nurse, and now turned 65 as well. The

326 Australian government is giving her a few hundred dollars [referring to Carer

Payment and / or Carer Allowance]. She has stayed there for a long time and she

is not married. She has a house and a car. She has everything. She just uses this

money for her daily expenses. (FURONG, Singapore, Female / 72)

The Singaporean participant then went on immediately to compare the level of state support between Australia and Singapore:

It is enough [referring to the Australian Age Pension]. It is better for these people

overseas. It is harder for us Singaporeans. Everything cost money. You need

money just to visit the public toilets. It used to cost five cents, then ten cents, and

now twenty cents. We don't even need to talk about other things; you can see the

difference by the toilet charges. It is tough to live in Singapore. The government do

give us subsidies of a few hundreds yearly. But how is that enough? (FURONG,

Singapore, Female / 72)

As evaluated by the above older Singaporean, her Australian counterparts seem to be better supported by the Australian state in terms of financial and service provision than her experience of the Singaporean state. While she acknowledges that the Singaporean government is providing some forms of subsidy, she does not think that it is enough to compensate the rising cost of living, let alone be considered a form of state support for older people and their families per se. While this participant has some concerns and wish to have more state support, her family is still coping financially with family care while some other participants and a proportion of Singaporeans would need greater levels of state support.

327 Nonetheless, even among older Australians, there remains a category of

“asset-rich and income-poor” who have expressed that more could be done to enable them to age in place in the community. Incidentally, Singaporean participants have raised a similar concern highlighting that with certain ageing issues the Australian and Singaporean society would intersect due to similarities in their socio-economic developments; which was highlighted in the

Introduction Chapter as one of the reasons for comparing these two countries along the East-West value divide (see Section 1.3 from pages 12-17).

7.2.1 “House for a Home”: Self-reliance through Home Ownership

Among Singaporean participants, the dominant voice in relation to the older people’s expectation on family care is that they are doubtful of their adult children’s capacity to provide care for them on top of their own needs and providing for their own family if they are married and / or have children. The capacity of the sandwich generation to provide care for their older parent(s) is thus being questioned and is reflected in the following account of YILUN on page 170.

While YILUN is at a stage of contemplation, in the case of JIAHAO (see account on page 201), his house has already been rented out to pay his wife’s nursing home fees and his care costs. Such an option to rent or sell the residential property should be widely available for older Singaporeans and their families as the country has one of the highest ownership rates in the world.

328 Comparatively, the home ownership rate in Singapore is at 90.8% in year 2015

(DOS 2017b) while Australia’s is at 68.1% in year 2011 (ABS 2016a). In the example of JIAHAO and YILUN mentioned above, the family will likely be managing the rental income and payment of nursing home fees and other cost of care. A good level of trust between older Singaporeans and the family member who is managing their finances is necessary for such an arrangement to work out. In view that such financial and asset arrangements would become more common and thereby exposes a significant older Singaporeans to potential financial abuse, there are legal, policy, and practice implications to be considered (Tilse et al. 2011) and could be explored in future research.

The account of YILUN (on page 170) also highlights a common decision- making process of older Singaporeans seen in this study when discussing about care arrangements in relation to the family. Generally, Singaporean participants are unwilling to impose the values of filial piety on their adult children, explaining that it would be unfair to place the “burden” on them as they have their own family. This is in line with Lang & Brody’s (1983) speculation that families have a selection process in that adult children, particularly daughters with the fewest competing demands are more likely to be called upon for help.

As the participants have observed, younger married couples today are finding it hard to go on without dual income, let alone have sufficient left over to financially provide for their ageing parents. In addition, while engaging domestic helpers to provide personal care is becoming a common Singaporean home care option, it is out of reach for families who are less affluent (see page 203).

329 As such, older Singaporeans like YILUN are looking inwards and preferring to remain “self-reliant” by committing themselves into a nursing home when they require personal care and paying from of their own pocket by renting out or selling their residential property.

Such a “house for a home” option is also seen in an Australian account where the participant was in the midst of searching for a nursing home and planning to sell his house to pay for the fees instead of moving in with his family and feeling that he is imposing on them:

I mean, they [government agencies] should advertise more the retirement places

that are available for less than 400,000 AUD because people eventually downsize,

and they want to move in to somewhere where there’s medical supervision.

(LUCIUS, Australia, Male / 89)

Nonetheless, LUCIUS’s primary reason for moving out of his house and into a nursing home is slightly different from YILUN’s in that his house has become a liability due to the council rates and various property fees (see page 200). While the practice of selling or renting the family home to pay for care is described as an “old strategy” in Australia (The Sydney Morning Herald 2014a), it appears to be an unexplored area of Singapore aged care. Furthermore, the manner in which Singaporean participants described admission to a nursing home as an attractive option was unanticipated. As can be seen in the following

Singaporean account, nursing homes are rationalised as a place for social interaction and fun activities:

330 Everyone wants that [to age in place in the community]. But my thinking is, if you

get to a certain age, you may go to a nursing home. There’s a lot of people in the

nursing home, and you can chat with them, you can play games together, things

like that. You won’t become senile or get dementia. So I think that is a good thing.

(JIAHAO, Singapore, Male / 77)

What is emerging in this study is a likelihood that the demand for nursing home beds in Singapore would rise sharply as a result of older people’s perception that families are no longer able to either provide personal care or afford to support them financially. When this happen, the efforts to deinstitutionalise aged care would have a considerable setback. Nonetheless, the situation can be ameliorated by further expansion of home-based and community care services but progress in this aged care sector has been slow.

Direct financial support to carers might also help to sustain family care and assure older Singaporeans that the costs in providing family care is not overwhelming for their families. The key to understanding this concern is that it is coming from older people themselves and if adult children are to respect their parents’ decision as an expression of filial piety, it would be difficult to convince them otherwise.

As Singaporean families are increasingly reliant on alternative care arrangements such as engaging domestic helpers to provide personal care for their older members, it would not be unconceivable that older Singaporeans and their families would consider residential care options and on a scale that might overwhelm the residential care sector.

331 As for the case of Australia, the decision to sell or rent the family home to pay for care would likely remain with the older person as well. However, the number of new decisions would unlikely result in a spike in demand for nursing home as it already has. There is also a likelihood that in the future cohorts of older

Australians, the proportion of those who can execute such an option might decrease with falling home ownership rates due to rising housing prices and lifestyle changes – such as taking longer to settle down and setting up a family

(The Daily Telegraph 2016).

7.2.2 State Support for the Younger Old Carers of Older Old

Changing demographics have also resulted in the phenomenon of the younger old looking after the older old. As highlighted in the following account where the older participant is 93 years old, her carers are older people themselves:

My daughter brings me dishes and I cook rice for myself. I would eat twice a day

and my daughter would come with enough food for the two meals. She stays

nearby and her husband has retired. He would drive her here daily. (RUPING,

Singapore, Female / 93)

In an Australian case, the older participant had asked her elderly daughter and son-in-law to come live with her. Her daughter and son-in-law are both elderly and have no children. While the son-in-law is able to help the participant out with some chores (see account on page 180), she is in fact a bigger help for them in terms of relieving them financially. Nonetheless, without deliberating who is benefiting more in this living arrangement, this case has highlighted a

332 variation in the phenomenon of young old and older old providing care for another in an interdependent arrangement:

I have my daughter and her husband living with me because the house is big and

my daughter is not feeling very well. She need an [organ replacement] and she has

[another critical condition] so I said you pay a lot of rent for the house, come and

live with me. (SHERRY, Australia, Female / 92)

The key concern here is how long can such a living and care arrangement be provided without affecting the carer’s physical, emotional, and mental wellbeing.

If the younger old are unable to cope with the demands of providing care, there could be a snowball effect down the generations. As Australia is debating about intergenerational equity between the younger and older generations (Kendig

2017: 21; also see Section 2.2), the scope should include middle-aged and older carers and consider provisions beyond Carer Payment and Allowance.

7.2.3 State Support for Healthcare Costs

The next issue regarding the family’s capacity to care is in relation to concerns raised by both Australian and Singaporean participants about healthcare costs.

In a street poll on the attitudes and perceptions people have about death and end-of-life issues, the top three fears about death among Singaporeans are being a burden for family and friends, medical cost, and pain (Lien Foundation

2009). In a later survey, medical cost became the top fear about death emphasising that ‘financial costs – even after one’s death – weighed heavily on the minds of our respondents’ (Lien Foundation 2014, n.p.). The account of the

333 following Singaporean participant represents such a concern and calls for greater state support:

The government should give more subsidies to older people. They are not working

into their seventies. Though our children are working, they have their own families

to support. They'll just give a small sum of money to their parents. For the elderly,

it’s all fine if you don't have to see the doctor. If you have serious sickness, you

need to see a good doctor but that is costly. I often hear this saying it is better to

die than have prolonged illness.31 (FURONG, Singapore, Female / 72)

Such a view that the state is required to support older people and their families in terms of healthcare cost, is also shared by an Australian participant:

I feel that the state has to support my generation, [but] in this particular time, the

[Australia Government] is cutting back on Age Pension and medical assistance.

Now, those things didn’t exist when I was a child because it was more like Europe

where the grandparents lived with the family. And they helped bring up the children.

Well we do that too, but from a distance. The respect, in my case, is still there, and

they love me, but it fits into their time. (PATRICIA, Australia, Female / 76)

As highlighted in the above account, while Australia is considered a welfare state and has a good track record in supporting older people and their carers, privatisation and cutbacks on healthcare subsidies have resulted in significant public concerns in recent years.

31 Translated from the Chinese saying 能死能病 (Pinyin: neng2 si3 bu4 neng2 bing4). This saying has been commonly used to describe the worry Singaporeans have about the rising healthcare cost. It is used in a Chinese article on the recent 2015 Singapore Elections (BBC Zhongwen 2015)

334 On the other hand, recent policy developments in Singapore would suggest that the Singaporean government has shifted in its political stance as the last line of defence and responding much better to the healthcare needs of the older population in reducing their out-of-pocket healthcare cost, which is more likely borne by the family rather than the older person who ceases to have a stable income upon retirement.

Detailed on pages 50-51, the Pioneer Generation Package can be considered as a ground-breaking step towards caregiver support that is comparable to that of Australia’s Carer Allowance. Concurrently, with additional public spending on healthcare through the Pioneer Generation Package, the per capita healthcare expenditure by the Singapore Government is set to catch up with Australia’s and concurrently more targeted towards the older population. In the light of what Singaporean participants like FURONG have expressed (see account on page 334), the Pioneer Generation Package is not just a bundle of subsidies and direct payments but a form of social and economic security, alleviating their greatest fear of medical costs (Lien Foundation 2014).

Although the interview with FURONG took place after such provisions for healthcare costs were announced, there is a lag in public education as the approach to provide information is person-centred. Incidentally, a Singaporean participant was volunteering as an ambassador of the Pioneer Generation

Packages and the community and home-based approach is detailed in her account:

335 The organisers will send the elderlies to us for interview; at the [nearest]

Community Centre. They will bus the elderly down, provide them with lunch, and

let us interview them when they are done eating [...] We ask them about their

healthcare needs and if they are aware of the various subsidies they can get when

they visit the doctor. Then, there will be follow-up home visits and the same thing

process will be repeated. (TINGTING, Singapore, Female / 66)

As can be seen in the account of TINGTING, the Pioneer Generation Package public education exercise requires considerable community partnerships and volunteer coordination – highlighting the ability of the Singaporean government in community mobilisation. This strength will be further discussed in relation to community care in Section 7.3.3. In addition, the individualised approach also reflects the Singapore Government’s approach to have maximum outreach and information penetration rate.

In this section, the concerns that older participants have with regards to their families’ ability to care for them have been presented and discussed. Where appropriate, an exploration of the state support required to sustain family care is added to the discussion. Before moving on to the next section on family relationships and dynamics, a key debate between Eastern and Western scholars on aged care is relevant to the preceding discussions and deserves another mention.

336 7.2.4 Convergence on State, Family and Community Partnerships

A conclusive remark from the conference on East-West Values in Elder Care is that despite the social-cultural-historical-political differences between the East and West, ‘[w]hen all societies are fully aged in the next two decades, plans to have a state-family partnership in elder care may converge between the East and the West’ (Liu & Kendig 2000b: 20, emphasis added). Following the conference on Aging East and West: Demographic Trends, Socio-cultural

Contexts, and Policy Implications, Kim et al. (2000) made similar predictions:

Thus, in the face of population aging, the imperatives of their distinct

cultural and socioeconomic histories are now causing Eastern

societies to turn to the state, while Western societies are increasingly

recognizing the important role of family care. In the future as the

economic conditions across industrialized societies reach similar

levels, we might expect that East and West nations will increasingly

face common population aging dilemmas. Under these conditions,

their solutions and policies may also converge (p. 7, emphasis

added).

As such, there is a consensus from the two conferences that across modernised societies in both the East and West, a middle ground where aged care is viewed as both a family and state responsibility is anticipated. That would require a policy shift by Eastern states to provide greater support for older individuals and their families and a value shift in Western families and

337 communities to provide personal care and / or financial support for their older members.

As provided by the accounts of participants in this study, the shift towards a state, family and community partnership is already happening. As mentioned,

Singapore’s Pioneer Generation Package signals a political and policy shift towards state and family partnership instead of previously held self-reliant and

“family first” stance in late life financial provisions and care issues.

In Australia, the shift from ground-up is observed in some of the accounts in this study. As highlighted by PATRICIA (see account on page 334), the Australian government’s intention to cut back on aged care and healthcare provisions raises concerns that the state is no longer as keen to provide adequately for older Australians. As explained by another Australian participant, the Age

Pension would still require recipients to live within their means:

You know you got your priorities right. I'm a pensioner and I'm allowed work so I

got that extra bit. I need a car for the work I do to drive this lady somewhere [as a

carer]. So it serves me well because the money I earn can go towards me being

able to use my own car for my own purposes. On the pension alone I find it very

difficult to get the car repaired, registered, all of that. What the pension does very

well is it enables you to travel [via public transport] anywhere you want for very little,

enables you to feed yourself, and maybe for your telephone bill. It covers the

basics but there's not a lot left over. If you smoke and drink, well, no you won't

have enough money. (DOROTHY, Australia, Female / 74)

338 As explained by DOROTHY above, the Age Pension is insufficient to budget for additional expenses other than the “basics” of living expenses. If the Age

Pension rates are decreased in the future, older Australians with little family support like DOROTHY might not be able to make ends meet. There is also unease towards formal service providers to provide beyond the basics as perceived by the following participant:

I think organisational community care is not as good as the care that can be

provided by the people who actually live in the community, who understand what’s

going on in the community. These people who come from outside, are public

servants for a start, so it’s just their job. They don’t have any commitment to

improving [the community] long-term, you know. It’s a bit of a bandaid kind of thing.

I mean, I know that people appreciate what they do, with Meals on Wheels and

home care and a lot of things, but there’s no substitute for owning your own, you

know, your own sense of community. (RANDY, Australia, Male / 70)

As explained by the following participant from Site A3, the interactions public housing tenants have with service providers have led to community self- organising and service creation that will be managed by the tenant-led committee. Combining these accounts from Australian participants, there appears to be a shift among older Australians towards self-reliance and community self-organising as they anticipate a decline in state support towards financial support to the individuals and their carers and adequate funding for quality service provision and innovation.

339 Nonetheless, despite progress in the two countries towards such a middle ground, the pace of change over the past two decades has been slower than predicted by the editors of the two volumes as it was anticipated that the East-

West convergence in state and family partnership would be close to completion by year 2020 (Kim et al. 2000: 7; Liu & Kendig 2000b: 20). As derived from the accounts of older Australians and Singaporeans and looking at the policy developments in these two countries, the convergence might take another decade or two as the pace of change is unlikely to pick up so long as Eastern families and Western states are able to sustain their level of contributions.

7.3 Family Relationships and Care Issues

The second part of Chapter 4 on the family was a presentation of the participants’ accounts on family relationships. While enquiring about the family network of older participants and what worked for them in terms of family support, another equally dominant and negative voice emerges. Those participants with surviving family members and yet receiving little or no family support would go into details about their strained relationships with their (ex-) spouse and children so as to provide an explanation as to why the level of family support they are receiving is limited or not available.

7.3.1 Impact of Divorce on Family Care

As mentioned in Chapter 4, there are a number of older participants who are divorced and this translates to the loss of their spousal caregiver – which has

340 been established through research in both the East and West as the strongest dyadic relationship for the provision of family care for older people (Qureshi &

Simon 1987 cited in Finch 1989: 138). Being divorced thus has implications on later life care issues and the availability of family support thus deserve greater attention in policy, practice, and research.

Several Australian participants in this study are able to remarry or establish de facto relationships and be cared for by their spouses or de facto partners. The most positive case in this study is a participant who remarried in old age after his wife of nearly forty years passed away. The second marriage has worked out well for him, integrating into one another’s family, and his spouse has been his principal carer for several years. On the other hand, there is an Australian participant who had remarried and subsequently divorced for a second time and is not in contact with his ex-spouses and a stepchild, and having limited contact with only one of his biological children.

As highlighted by older participants who are divorced, the breakdown in their relationship with their spouses affected their relationship with their children as well. This is especially so when the divorce happened when their children are young and the children have not lived with them since. In such cases, parent- child dyad of care, which is recognised as the second strongest category of family obligations (Qureshi & Simon 1987 cited in Finch 1989: 138) can also be lost or severely impaired. Paying attention to the category of older people who are divorced (and separated) is thus important for policy and practice as it flags out possible care issues.

341 In the Singaporean context, applying the principles of filial piety on adult children who have divorced parents and did not receive consistent care and frequent contact from the non-resident parent since young would be challenging to oblige them to provide financial support and personal care. As such, people who are divorced can reach old age with similar social circumstances as those who are never married – without spouses and adult children as caregivers.

However, in policy and practice, such an understanding might not be offered and the older Singaporeans might be advised to apply to the TMP / CMP to establish the fact that their adult children would not provide for them financially before formal assistance can be applied.

In 2011, more than half (57%) of the Australians remained married in old age

(ABS 2012c). The next most common marital status among older Australians was widowed (26%). A small proportion was never married (4.6%). The rest of the older Australians were separated (2.4%) or divorced (9.8%), combining for

12.2%. The marital status demographics among older Singaporean are similar in that in year 2010, slightly more than half (59.1%) of the older population were married (DOS 2011). The next highest proportion was being widowed (33.3%).

The proportion of those who were never married (defined as “single” in

Singapore) is the same as Australia’s at 4.6%. However, the proportion of those in the “divorced / separated” category was much lower than Australia, at 3.0% combined.

342 Based on the statistics above, Australia appears to have a bigger concern than

Singapore. Nonetheless, the Australian government have long ago acknowledged the issue of marital breakdown and taken steps to address the rising divorce trends. The House of Representatives Standing Committee on

Legal and Constitutional Affairs (HRSCLCA) (1998) investigated the direct cost of separation and divorce for the Australian community to be at 3 billion AUD in reporting year 1994-5 and successfully justified the need for policy and legal reforms around marriage and divorce.

More importantly, HRSCLCA found that the courts and Family Law Act 1975 are unable to operationally support marriages and families in preventing separations and divorces. Subsequently, government policy initiatives such as

Men and Family Relationships Initiative (1999-2000) and the Strong Families and Community Strategy (2000-2009) were designed with a preventative approach through premarital education and marriage counselling services

(Hewitt 2008: 1). Despite some successes, it was found that couples who are most at risk of marriage breakdown and divorce were least likely to use the services and greater targeting of the “at risk” groups was deemed necessary

(Halford et al. 2006 cited in Hewitt 2008: 2). With a fiscal commitment of 397.2 million AUD over four years from 2005 to 2009 (Hewitt 2008: 2), the budget on preventive measures is also far smaller than the procedural and other costs. As such, significant reversal of divorce trends should not be expected.

In Singapore, pre-marital and marriage counselling are available through a network of FSCs housed with professional social workers and counsellors. For

343 Muslim couples, premarital and marriage counselling is offered through several

Islamic-based VWOs and the Syariah Court, which operate using a separate system of family law and has jurisdiction over Muslim marriages, divorces, and related matters. The Syariah Court has a long history in addressing Muslim divorces, established in 1958 primarily to mitigate divorces under Muslim law.

The rate of Muslim divorces was brought down from 493 per 1,000 to 273 per

1,000 in its first year of operation and halved again in the second year of operation; the significant drop in divorce rates can be attributed to the introduction of mandatory marriage counselling when a divorce application is filed (National Library Board 2017).

While the rate of divorce in Singapore over the past decade has only been increasing marginally annually, there are two rising trends that might impact later life care issues. The first trend is the rising age profile of divorcees. In year

2005, the median ages for male and female divorcees were 39.1 years and

35.4 years. By 2015, the median ages rose to 42.9 years and 38.8 years respectively. While Singaporeans are marrying later, they are also divorcing later in life, reducing the chances of remarrying and having a partner in old age.

At the tail end of this rising trend is the significant increase in older women initiating divorces in their fifties and sixties and only when their children are grown up (The Straits Times 2015b). As highlighted in the newspaper report, the adult children would usually take the side of their mothers and support the decision for divorce, leaving their elderly fathers without much family support in old age. The account of AMITA (see account on page 350) supports this

344 observation that the adult children would take sides though for her case, the gender is reversed in that it is the ex-husband who initiated the divorce and she is left without family support from the children.

7.3.2 Contribution of De Facto Relationships on Family Care

With regards to spousal relationships, there is one case of an Australian participant who is in a de facto relationship who does not require care from the partner as yet. Though this case would have been rendered statistically insignificant or even omitted in a quantitative type of study, it has drawn attention in this study as an area that has policy, practice and research implications.

De facto partners are recognised under Australian law – Section 4AA of the

Family Law Act 1975 – to be in ‘a relationship as a couple living together on a genuine domestic basis’ (Federal Circuit Court of Australia 2016, n.p.). In year

2006, the proportion of Australian de facto relationships among those who identified their relationship as “socially married” – that is those who are either in a registered marriage or de facto relationship – is at 15%; that is a steady rise from 12% in 2001 and 10% in 1996; and is expected to rise further yearly (ABS

2012d: 261 & 263).

In view of the similarities in family dynamics and living arrangements between registered marriages and de facto relationships, care provided by a de facto partner would need to be examined as similar to a marriage relationship in its

345 nature as a spousal dyad. Nonetheless, this study also recognises that more comparative research between a de facto and a registered marriage relationship would be needed, especially in the strength of the relationship and the potential for de facto partners to provide care in old age.

With regards to statistical data, there is a need to include the category of older people who are living in de facto relationships. In Australian statistics, the

“marital status” of older people does not usually include this category or are at times included under the category of “spouse or partner”. De facto partners would include same-sex couples and most likely to be placed in the category of

“single” in Singaporean statistics. The specific contribution of de facto partners in aged care can thus be obscured.

The need for clearer statistical presentation is highlighted by the general population data where 70% of de facto partners were classified as “never married” and 27% had been through divorce or separation, subsequently choosing to cohabitate instead of progressing to marriage (ABS 2012d: 263). It can be speculated that a significant proportion of older people who are listed statistically as never married, divorced, separated, or even widowed are in fact in a de facto relationship and receiving care from their de facto partners and / or their children and other family members their from previous relationship(s).

Though de facto relationships are legally recognised in other countries such as

New Zealand and Canada, they are not recognised under Singaporean family law and in many other countries, including the US. In this study, there is a

346 Singaporean participant who is divorced and has a partner who could fit the definition of a de facto partner in the Australian context. As de facto relationships are not legally recognised in Singapore and consequently statistically tracked, policy-makers, researchers, and even professionals who are working with older people might overlook this category of carers.

In view of traditional Eastern cultural norms, being in a de facto relationship in the Singaporean context could be perceived as socially unacceptable though societal values towards cohabitation without marrying is rapidly changing.

Nonetheless, among the older population, traditional values are likely to be held more firmly and this is reflected by the Singaporean participant’s unwillingness to go into details about her de facto-like relationship. The stigma surrounding de facto-like relationships might have significant psychological impact on this category of carers in Singapore, affecting their ability to care for their partners.

For example, they might have to repeatedly mention their relationship as friendship when filling up official forms and be subjected to scrutiny by professionals and government staffs who might be unsympathetic towards their request for carer support. This speculation is based on the Singaporean participant’s perceived need to conceal the true nature of her de facto relationship by mentioning the partner as a friend and appeared embarrassed when the researcher realised they were living together. The stigma would likely be stronger for same-sex couples in the Singaporean context.

347 7.3.3 Expectations on Children and Grandchildren for Family Care

When analysing family support in this study, a voice is coming through from both Australian and Singaporean participants that their relationship with their children and grandchildren is very different from what they witnessed when they were growing up.

As expressed by the PATRICIA (see account on page 334), the lower status of older people and correspondingly lower expectation on their family to provide financial support and care has implications for the state (and the community) to step in. The low level of social intimacy between older people and their children and grandchildren is similarly felt by another Australian participant who started by saying she does not have a family anymore even though she immediately mentioned that her daughter and her family are visiting her. What she was likely referring to was that at an emotional level, she does not feel that the family is there for her as her daughter only visits occasionally:

I don’t have the family anymore, so I have to make the best of what I’ve got. I only

see my daughter about two or three times a year. I see her [on] Mother’s Day, I

would see her [on] Christmas Day. Her in-laws live at [a suburb not far away], so

they usually call in to see me in the morning, have a cup of coffee, piece of cake,

they go on to the other, to her husband’s relatives group. He’s [got] the bigger

family, and all those children get together, I can understand that. Not much fun for

the grandchildren just being with Grandma. (PHOEBE, Australia, Female / 82)

348 Embedded in the above account is the social effect of having a big family. In this account and a few others in this study, big families provide social interaction for young children (with their peer generation) and the social bond is expected to carry them through life as a protective factor. As mentioned by the participants, extended relatives in both Australia and Singapore do get together regularly, particularly during festive celebrations and in some cases, usually insisted by an older person and / or by family traditions to be fulfilled on a weekly basis. Nonetheless, in the case of PHOEBE, widowhood, mobility issues, migration from the country region to the city in her youth, and dispersion of her peer generation have resulted in significant social disconnections from all her extended relatives.

Overall, the accounts from Singaporean participants with regards to their relationships with their children and grandchildren are more positive than their

Australian counterparts. A possible reason is there exists a higher proportion of three-generational living arrangements where older people would help provide care for their young grandchildren while their adult children go out to work.

I took care of all three of [my grandchildren] on my own. I retired when my first

grandson was born. I was working before that. My son was grateful that I helped to

take care of all three of his sons. They [the three grandchildren] are all grateful too.

(KEWEI, Singapore, Female / 80)

Nonetheless, there are only a few accounts that suggest that older

Singaporeans are willing or given the opportunity to care for their grandchildren.

There are also negative accounts of family relationships highlighting the erosion

349 of traditional family values, which suggests that more attention should be paid by policy-makers and professionals in the aged care sector in anticipating the need for formal interventions.

The following account by a Singaporean participant highlight that some older

Singaporeans are left without family support and that the TMP was not able to secure financial support in all the applications:

Nobody. I don’t have relatives here. They [ex-spouse and children] don’t want to

have anything to do with me. I am divorced for about 16 years this year. My eldest

daughter lives [overseas] with her three children, she doesn’t call me. My youngest

daughter is [in another country], on my birthday [this year] she called and I was

thanking god a hundred times that she called me. I went to the Tribunal to ask help

from my children. They say they don’t want to help me. My two sons went to see

the mediator and they bluff so many things about me […] so I am working, slogging

to pay my bills, to feed myself. They won’t give even 50 SGD, nothing. (AMITA,

Singapore, Female / 74)

In year 2016, 63% of the 66 cases heard by the TMP were awarded maintenance, with 19% per cent dismissed and 9% of the parents withdrawing their petitions (Maintenance of Parents 2017b, n.p.). For the remaining cases, some had no outcome as the older person passed on before the case was heard. Since 2011, older Singaporeans seeking maintenance have to go through mediation session(s) with the Commissioner for the Maintenance of

Parents (CMP) before the dispute is heard by the TMP. In terms of the number of cases with the CMP, there were 216 cases in 2016 and 80% of the cases reached settlement at this stage (Maintenance of Parents 2017a, n.p.).

350 As highlighted by AMITA’s account in the previous page, the effectiveness of the CMP / TMP in securing financial support for older Singaporeans can be limited. In addition to dismissed and unheard cases, there are variation cases where payment amount can be lowered and there are possibly cases where the children have defaulted in payment.

As highlighted by Mehta (2006: 48), the low number of applications signifies that the TMP ‘functions mainly to serve as a form of preventive strategy against future abandonment by children and to reinforce the social values of filial responsibility’. In addition, the CMP / TMP might be seeing the tip of the iceberg.

Similar to speculations that incidences of elder abuse in Singapore are unreported (Mehta 2006: 54), older Singaporeans are likely unwillingly to come forward due to face issues and fear of further straining the already fragile family relationships. There is also no guarantee that the number of applications would remain low in the future even if “early intervention” and “upstream” approaches such as those implemented by the Australian government (see page 343-343) are explored to prevent the breakdown in family relationships.

A recommendation to be considered by Singaporean (and Australian) policy- makers on family matters is in designing and delivering low-fee or free public seminars for new parents, focusing on strategies in building and maintaining parent-child bonds, positive parenting methods, and raising the awareness of support services for parents. While the hospitals in Singapore, both public and privately operated, provide much information for new parents during the maternity stay and in follow-up appointments, it would likely not be appropriate

351 to discuss about longer term parenting issues at such an early stage.

With the “many helping hands” approach and network of FSCs, community centres, and such VWOs and civic organisations, community outreach and public education in Singapore has a good track record and could be leveraged in engaging young parents. Public education to parents would likely be most appropriate for those with school-age children as it would complement the schools’ effort in inculcating the values of filial piety and respect for an older person through civic and moral education modules (Phua & Loh 2008: 668).

7.3.4 The “Daytime Gap” and Emotional Care

Another important theme that emerges in the context of family care is the period of time during the day when the older person are left on their own at home when their adult children and grandchildren go to work or are in school. In short, it will be referred to as the “daytime gap”.

In the literature, particularly in medical research on falls and emergency response, ‘some health care providers refer to patients found [helpless or dead in their homes] as “found down”, with the amount of time that the patient is helpless referred to as “down time”’ (Gurley et al. 1996: 1710). As found by

Gurley et al. (1996):

352 The median age of the persons found helpless or dead was 73 years;

51 percent were women. The frequency of such incidents increased

sharply with age, from a rate of 3 per 1000 per year among those 60

to 64 years of age to 27 per 1000 per year among those 85 years of

age or older. The highest rate was among men 85 years and older

who were living alone (123 per 1000 per year). In 23 percent of the

cases, the person was found dead; an additional 5 percent died in

the hospital. Thus, total mortality was 28 percent. Of the patients

found alive, 62 percent were admitted to the hospital. The average

hospital stay was eight days, and 52 percent of those admitted

required intensive care. Of the survivors, 62 percent were unable to

return to living independently. The total mortality was 67 percent for

patients who were estimated to have been helpless for more than 72

hours, as compared with 12 percent for those who had been helpless

for less than 1 hour (p. 1710).

More importantly for this study, the above findings led Gurley et al. (1996) to conclude that ‘elderly people who live alone, becoming incapacitated and unable to get help is a common event, which usually marks the end of their ability to live independently’ (p. 1710). Fortunately for MEIJUAN (see account on page 286), she was able to recover and remain living in the community despite having a down time of around four hours. While empirical research noted the non-availability of “quick helpers” in the community (Porter et al. 2013:

13), the daytime gap was mentioned in passing and not explored in-depth as the focus of the study is ‘to compare intentions of subscribers to a personal

353 emergency response system (PERS) and nonsubscribers’ (Porter et al. 2013: 6).

As most of the research on fall prevention are focused on the risk factors and etiology of falls instead of neighbourhood and protective factors, the phenomenon of daytime gap offers another angle to this area of study.

An assumption of older people who are living with their family is that they would not feel lonely because of available companionship from various family members. However, as explained by a significant number of participants in this study, loneliness and boredom at home is often felt during the daytime. The case of BRENDAN (see account on page 207) highlights how loneliness arises within his family as different members are busy with their own activities and he is not included in any of their social gatherings. Even in the nights and on the weekends, his family members rarely take him out due to his disabilities.

A possible explanation for such a mismatch is the difference in lifestage.

Another explanation could be the loss of the status of older people in the family context as BRENDAN feels ignored, which he knows is unintentional, but cannot help thinking that the family can do more to include him. Besides the feeling of sadness, there is a sense of anger and frustration in his account as he describes how he would mark his diary with “ABBS” describing every weekend as “Another Bloody Boring Saturday / Sunday”.

The main issue here is the masking effects of living with the family, leading to an assumption that older people would not feel lonely and be emotionally neglected within the family context. Another issue is that older people like

354 BRENDAN would choose to suppress their emotions so as to preserve their relationship with their family, as any request for emotional attention might be perceived as being demanding when the family is already providing financial support and personal care. It is speculated that in some cases, older people might not even be able to recognise their own emotional needs, and public education to older people and their families is likely necessary.

Greater exploration of this issue in terms of policy, practice and research is also needed. The masking effects of the family could have resulted in the dearth of research on the issue of loneliness while living with the family. Parallels can be drawn from the dearth of research on loneliness within the nursing home context (Drageset et al. 2011). At the same time, lessons can be drawn from the research with nursing home residents that ‘[e]motional closeness to significant others from which one derives a sense of security appears to be important for loneliness, and the frequency of contact with family and friends did not explain the experience of loneliness’ (Drageset et al. 2011: 611). As such, being in the company of family members when living together and being in frequent contact with other people in the community might not curb feelings of loneliness and might even exacerbate such feelings due to the lack of emotional closeness.

In this study, the issue is equally important for both Australia and Singapore with similar number of mentions of loneliness and boredom at home by participants from both countries. Research comparing northern European countries and more family-orientated southern European countries also revealed that it is a myth to assume that older people in individualistic societies

355 are lonelier (Dykstra 2009). As such, it cannot be assumed that the situation in

Singapore is any better than that of Australia.

7.4 Adult Grandchildren as Carers

A secondary finding of this study that requires further exploration is in the untapped potential of adult grandchildren as carers in the portrait of care for older Australians and Singaporean. While the literature on intergenerational relations recognises the phenomenon and contribution adult grandchildren as a category of family carers (see Section 2.8.5), this area is underexplored in both the Australian and Singaporean context.

The possibility of a grandparent-grandchild dyad is first highlighted by the case of BRIDGET where the older participant is living with her grandchild in a two- person household with the adult grandchild managing the household and performing some care activities. In Singapore, DEXIANG mentions that his grandchildren are grown up, having well paying jobs, and would give him cash every time they visit. There are also mentions of younger grandchildren who are keeping a look out and providing assistance at home for those participants who are in three-generation living arrangements.

The literature on grandparent-grandchildren relationships is predominantly uni- directional and focused on grandparenting issues. As such, the contributions of grandchildren as family carers have been overlooked in the caregiving literature and the numbers of studies in this specific area of caregiving is limited. In the

356 literature and in reported data, grandchildren who are carers are often overlooked and classified under the category of “other relatives” (Hale 2007;

Ihara et al. 2012: 622). When grandchildren are mentioned as carers, it is most likely in relation to being an assistant to their parents who are caring for their grandparents (Blanton 2013).

However, as the literature on grandparenting suggests, there would be a substantial proportion of households where the middle generation has not been around and grandparents have to perform the role of parents and in return, grandchildren who have been raised in such living arrangements would likely grow up to reciprocate the care that they received from their grandparents. A report on informal caregivers estimates that grandchildren constitutes 8% of informal caregivers in the US (Foundation for Accountability & Robert Wood

Johnson Foundation 2003 cited in Ihara et al. 2012: 622) and the proportions and numbers should continue to rise. Similar to the category of de facto partners as carers (see Section 7.3.2), the number of adult grandchildren can become a substantial category of carers and requires serious explorations, particularly due to the larger two-generational age gap.

The phenomenon of older people living to the age when their grandchild(ren) reaches adulthood is not new; though proportions would have been low before the 1900s due to the lower life expectancy. The proportion during the years of rapid modernisation where people marry and have children later than previous generations would have been low as well. Uhlenberg (2004) found that between

1900 and 2000 the proportion of 30-year-olds with a living grandparent more

357 than tripled from 21% to 75%. By the year 2020, 80% of 30-year-olds are estimated to have at least one living grandparent and 40% of them are estimated to have two or three grandparents. Uhlenberg (2004: 77) also argued that compared to a century ago, grandparent-grandchildren relationships are set to be more positive as older people today are generally healthier and wealthier than the past to lavish on their grandchildren. As grandparents are living longer, they can be present throughout their grandchildren’s childhood and early adulthood to be a constant source of care and support. There are also fewer grandchildren to compete for their attention allowing stronger grandparent-grandchildren bonds to be forged individually.

This demographic change has both positive and negative policy implications.

While the pool of grandchildren as carers would likely increase and become a new norm as a significant category of carers, they might become a second layer of the sandwich generation and having to care for three generations of dependents (grandparents, parents, and children) in some cases. However, this is as yet an unexplored aspect of social change in relation to the care of older people that will require further detailed research in the future.

Thus far, the discussion has been on the family context of care and the ways the state can engage and support the family in their care. The next section will focus on the care of older people with little or no family support and / or living alone.

358 7.5 Older People Living Alone and Policy Implications

As mentioned previously, the number of older people who are living alone in

Singapore is rising (see Section 6.2.5, pages 284-290). Though not all of them are without family support or other sources of informal care, it is speculated that a significant proportion of those living alone would have little or no family support. This is particularly so for older people who are with the HDB’s Public

Rental Scheme as the availability of family support is one of the exclusion criteria.

In terms of the proportion, there was 9.2% of the older population in Singapore who were living alone in year 2014, up from 6.2% in year 2000 (DOS 2016; The

Straits Times 2015c). The proportion in Australia was much higher with 25.4% of the older population living alone in 2011 (ABS 2013). In both countries, the proportions are projected to rise due to family changes and increasing numbers of older people preferring to live alone (ABS 2015; Teo et al 2006: 23).

The following account of an Australian participant highlights one of the reasons for older people to prefer living alone:

No, I wouldn't want to live with any of them. They [the adult children] all still have

their children and it wouldn't be good. Even if I would have my own quarters, [the

answer is still] no. It's nice to visit them but that's it. It's better to have it here and

have it nice and quiet. Talking about music, they couldn't tolerate my music and I

couldn't tolerate their music. Can you imagine the opposite of classic and pop?

There you go. (MAGDALENE, Australia, Female / 90)

359 Besides having different lifestyles and in different lifestages, the lack of fit and familiarity with the physical and social environment at the neighbourhood level can pose as a push factor. As explained by the following Singaporean participant, moving in with his adult children who have moved to a new neighbourhood when he was setting up his own family meant that the participant has to move away from a familiar environment and make significant adjustments in old age:

I have stayed in many different places. I have stayed in this town's central area for

twenty years. When my son successfully obtained a flat [in a newly developed

housing estate], he told me to sell my flat and move to live with him. My wife and I

could not get used to living there so we came back to this estate [by ourselves] and

it has been four years since. (WEIBO, Singapore, Male / 77)

As seen in this study, living alone can be a personal decision on the part of the older person. While the issue of older people living alone is not new, concerns have been raised when there was a noticeable increase in number of older people passing on at home without anyone knowing. The above cases would likely not fit the profile of those found dead at home as in both cases, the family connection is strong.

In the same newspaper article mentioned above (The Straits Times 2015c, n.p.), it was reported that ‘[b]etween 2007 and 2011, at least 50 elderly people have been found dead in their homes’. Another Singaporean newspaper reported that in year 2007 alone, there were 45 such cases though this figure is unconfirmed as ‘[t]here are no official numbers because no one is keeping track’

360 (The New Paper 2010, n.p.). This awareness has prompted The New Paper to raise funds for Project Helping Hands and to partner with a VWO for community outreach and engagement and a polytechnic was engaged to design and install motion sensors in the homes of the older persons to detect unusually long motionless periods and alert the nominated carer via SMS.

Public concerns were also raised in Australia in 1993 with the cases of two

Sydney older persons found dead in their homes (McCallum & Geishehart 1996:

87). Similar to Singapore, there is no agency in Australia that tracks the number of older people living alone and found dead at home.

It can only be speculated that with greater state support for older people in

Australia and availability of HACC services, the number of older people falling through the cracks should be lower than in Singapore. In Australia, assistive technology for falls detection and inactivity monitoring is available for purchase and rental with installation fees with funds allocated under the Home Care

Package (My Aged Care 2017). Nonetheless, as recent as July 2011, the remains of Natalie Wood were found in her inner city home eight years after she passed on. Dubbed as the “the woman Sydney forgot”, her case highlighted how an older person living alone in a densely populated area can escape detection, prompting the estate specialist interviewed to comment that: ‘[i]t is an indictment on society, on all her relatives, her neighbours, the gas people, water people, social security’ (The Sydney Morning Herald 2014b).

361 As in the case of Natalie Wood, media and public interest in the issue of an older person found dead at home can be triggered with every report. This

“public issue” can also be related as a “personal trouble” (Mills 1959) when individuals ponder on their own fate when they are fall into the same situation leading up to such tragedies. In fact, it was this issue that first sparked the interest to conduct this study (see Section 1.1) as the researcher had encountered several such cases as a practitioner and sought to know more about the issues faced by community-dwelling older people and their support system in the community. Though these incidences are considered on the extreme end, they are likely far more common than thought and require serious investigation.

The case of Natalie Wood also highlights that when an older person is deemed to be with little or no family support, the blame is likely to be shifted onto the community and the state. However, as Finch & Groves (1980: 494) pointed out, policy-makers and proponents of deinstitutionalisation can fall into the trap of romanticising the concepts of the community and community care by assuming that there are pre-existing community groups who would care for older people without some form of community mobilising.

While the deinstitutionalisation movement fits the preference of older people to age in place and be supported to live independently in their home and community, at the point when an older person begin to require assistance in

ADL, special attention has to be paid to every individual older person in terms of their support network in the community without assuming that there is definitely

362 someone who would assume the caring role and keep a lookout for their safety and wellbeing.

What could be done at the policy level for this group of older people who are living alone in both Australia and Singapore is providing higher levels of community and state interventions. Perhaps a registry of older persons living alone or with another older dependent could be established and shared with service providers and community organisations that could provide community outreach, engagement, and monitoring. In Taiwan, such a registry is kept by the

Ministry of Health and Welfare and during days of severe weather conditions, a pool of volunteers contact every older person on the register at least twice a day. Again, the hurdle for implementing such a program would be concerns for the privacy of older persons (and their families) and resource allocation issues with the former a greater concern for the Australian public and the latter a greater concern for the Singapore Government.

Much has already been done in Singapore’s social policy and practice to target older people living in public rental housing with a network of SACs being set up across the country and placing them strategically at the void decks of rental blocks with high proportion of older people. However, issues remain with those who are living in purchased HDB flats and private housing, who are assumed as financially able for self-reliance and with adequate family support.

The cases of older people who are asset-rich and income / cash-poor have been raised in the media in both Australia (ABS 2016c) and Singapore (The

363 Straits Times 2013) though the ownership of assets would likely continue to mask their financial and social status. With most home and community services in Singapore using means testing and targeting those in the lower-income group, such an assumption that people with assets are likely better off financially and socially might be held by policy-makers.

There is as such a need to investigate and establish the issue further in terms of the numbers and severity of financial hardship and social isolation faced by this group. If a registry is set up nationally to include older people in every social strata, the asset-rich cash-poor group could be included in the safety net

7.6 Enhancing Non-family Support

Chapter 5 went beyond the immediate family context of aged care and explored other relationships and care arrangements experienced by community dwelling older participants. The higher-level themes that emerged from the accounts are a collection of means to enhance the support from extended relatives, friends, and neighbours.

7.6.1 Peer Generation Extended Relatives and Friends as Carers

This area of support is anticipated to be gaining importance as longevity raises the possibility of spouses passing on and lengthening the period where the remaining spouse is without spousal support. The possibility of widowhood increases substantially towards the older old group – as seen in the case of

364 LUCIUS, SHERRY, MAGDALENE, MEIJUAN, and RUPING who lost their spouses through death. In fact, only one participant above the age of 85 has a living partner, though the partner is much younger than him.

Nonetheless, while older people can experience significant losses in their overall support networks (see accounts of ETHEL and HARPER on pages 238-

239 and 278 respectively), support from friends and extended relatives - particularly those of the “peer generation” such as siblings, sibling-in-laws, cousins and even more distant relatives – are cited by participants in this study as possible options (see Sections 5.1.1., 5.3.3 and 5.3.4). For example, there is a case of a single Singaporean participant (XINYI) who was living with her sister in a co-dependent living and care arrangement after her adopted child moved out upon marrying.

However, the general sense from the participants in this study is that older people and their families rarely put this on their agenda and only discuss “when the time comes” and especially at the point that only the residential care option remains:

Well, look, we have a house, we do have some steps. I've always tell people “Get

rid of the steps, move, go into a unit that don't have steps”, and yet I've got the

steps. At this stage we try to live there and be as independent as we can, as long

as we can. But I’m not stupid; when the time comes [emphasis added], I’m not

going to fight it. I'm not going to ring my son and say, “Come over, I have to go

downstairs. Help me.” (WILLIAM, Australia, Male / 78)

365 Similarly, and with many more such accounts among Singaporean participants, reflecting a laissez-faire attitude toward later life planning:

I live one day at a time. There is no point to think too much about it; I will just make

plans when the time comes [emphasis added]. I will go where the government

[decides]. (MINGZHEN, Singapore, Female / 73)

This suggests that formal interventions could be considered by both states and service providers in terms of providing public education for the population who are reaching old age and engaging them and key family members in aged care counselling, and exploring the range of community and residential care options that could be considered at different stages in old age, with different levels of care and support expected at each stage.

Besides co-dependent living arrangement with peer generation, older people with limited or no family support can rely on their extended relatives for less tangible support such as the case of participant DOROTHY who has been included by her sister and her family regularly in family celebrations, making her feel a part of their family and to which she valued as her support network (see account on page 221). The Singaporean participant, CHENXI (see account on page 224), who has never married has a similar experience with her siblings’ families, being included in their festive and family celebrations.

However, support from extended relationships who are not of their peer generation would likely decrease or cease when their peer generation relatives pass on or when their peer generation relative requires more care from their

366 own family – making additional commitment to older relatives beyond the immediate family possibly overwhelming.

The low expectation on extended relatives who are not in their peer generation, such as nieces and nephews, is highlighted by the accounts of CHENXI who mention that such care activities as visits from their nieces and nephew are not expected to be as frequent as she need to prevent admission into a nursing home when she requires care. In the case of BRENDAN (see account on page

226), the meetings with his late wife’s nieces and nephews who are living in another Australian city have completely ceased since her passing on and when his mobility became limited and he could not travel far to visit them as before.

Issues limiting support from friends in the peer generation is largely similar to issues limiting support from extended relatives in the peer generation, they are mainly due to age factors. As highlighted by the older old participants like

SHERRY and ETHEL (see page 238 for their accounts), their circle of friends who they are in regular contact with, shrinks as they get older mainly due to age-related issues such as friends passing on, becoming frail and / or have mobility issues, relocated further away for family care arrangements, or have been admitted into residential care facilities. Other factors for losing their friendship network can be retirement and withdrawal from the workforce (see account of XIAZHI on page 240) and migration to a new country (see account of

BRENDAN on page 239) which can happen at an earlier stage of old age.

Nonetheless, several participants in this study perceive that the strength of the relationships with their long-time friends are as strong as family bonds,

367 expecting their friends to take care of them when they are in need. Incidentally, the two Australian participants (RICKY and DAMIAN; see accounts on page 245) who have such confidence in their friends share some similarities in that they had been divorced for many years, while their children were young, are non- resident parents, and both of them did not remarry. As mentioned in Section

7.3.1 (see page 342), older people in such family situation are similar to being single and never married, likely having little or no family support from their adult children, let alone their ex-spouse.

In line with the suggestion for early intervention and planning, RICKY and

DAMIAN have been strengthening their friendships over the years, albeit naturally occurring. For the Singaporean case of ZHIQIANG who has never married, he too has a strong relationship with his friend who is single and willing to move in with him to provide care.

Including RICKY and DAMIAN, participants from Site A3 are generally without much family support, have self-organised to provide care for one another, refer to fellow tenants in the inner circle as friends, and consider one another as their support network. Not surprisingly, their perception of friends as potential carers is more positive than the rest of the Australian and Singaporean participants.

In addition, they are a special category of neighbours – or rather fellow residents in a small, enclosed neighbourhood – who have become close friends through regular social activities and mutual aid. Such examples of older individuals with limited family support and / or simply preferring to lead an

368 independent lifestyle apart from their family, is likely common in Australia with a quarter of older Australians living on their own. Examples in Singapore could likely be found in more “matured” housing estates and perhaps through SACs that have been established for a longer time. Parallels can be drawn from the

NORC and Village model in the US that have been receiving much research attention, exploring various aspects of these community approaches to ageing in place (see Section 2.12).

7.6.2 Neighbours as Carers

As highlighted in Section 5.2, participants in this study from both Australia and

Singapore have observed that neighbour relations have weakened significantly in their lifetime. Nonetheless, neighbours are still perceived as important and examples of neighbours providing a range of helps have been mentioned by the participants (see Section 5.2.1).

However, if neighbours are expected to be carers or provide part of the range of care, then there has emerged two key areas in the findings that suggest where formal intervention is most needed. First, is in improving neighbourly relations through community networking. Second, the void during the day when few neighbours are around to offer help needs to be addressed.

The first finding relates to the strength of the relationship between neighbours.

While the spirit of being a “good neighbour” remains and that neighbours are a good source of crisis support due to their proximity, modern neighbour

369 relationships do not usually go beyond casual ‘socialising, along with assistance with a few nonintimate instrumental tasks’ (Barker 2002: S162).

In contrast, the cases of TINGTING and BRIDGET (see accounts on page 230) who know their neighbours in another context, highlight that more matured neighbourly relations can be built through having more than the single bond of being just neighbours. It is thereby speculated that the more layers of common identity between neighbours and having more relational linkages such as being parents of classmates or classmates themselves, colleagues or business associates, fellow members of a social club or volunteer group, etc, evolves the neighbour relationships to a level that consistent care might be offered.

For the case of BRIDGET, she is confident to be able to age in place in the community not just because of strong family support but that her support network includes her neighbours, and in particular, a fellow volunteer whom she has known for many years. If consistent non-kin care is expected to be provided in the community, policy-makers would need to have a paradigm shift from passively hoping for “good neighbours” to voluntarily act, to taking an active approach in creating community platforms for “more-than-neighbours” relationships to be forged. The target age should be pre-retirement, middle-age population who would likely have more time in this lifestage than early adulthood when they have heavier career and family care commitments.

The second finding in terms of neighbours as potential carers is derived from the account of participants like CATHLEEN (on page 235) and PHOEBE (on

370 pages 235-236) who describe their neighbours as busy with their own lives and often in a rush to and from work, rarely stopping for a chat. In addition, when

MEIJUAN fell during the day just outside the house (see account on page 286), there was no one passing along her corridor for hours, let alone having a “good neighbour” coming to aid.

The “daytime gap” where most people in the neighbourhood are at work or in school, including family members, is as such an important neighbourhood factor to be addressed for the safety and wellbeing of community-dwelling older persons. Older people getting around in the neighbourhood during the day are not just exposed to the risk of having delayed medical attention, they can become targets of crime as well when there are few people around the neighbourhood who could intervene spontaneously.

Finch and Grove’s (1980: 494) cautionary statement that it cannot be assumed that ‘there exists some kind of grouping of people [in the community] who are both able and willing to take on active caring on a consistent and reliable basis’ needs to be evaluated based on the “daytime gap” as well. Even if neighbours are willing to provide some forms of care, they might not be able to do so during the day when they have other commitments.

Extrapolated from BRENDAN’s family experience (see account on page 207), the “daytime gap” can extend to the weekend when younger people are engaging in their own social and recreational activities, leaving very little room to address the social-emotional needs of an older person, particularly if they

371 have mobility and other disability issues that require assistance in ADL. As mentioned by BRENDAN, the weekends are worse than the weekdays when he could be at the day centre, being taken out and meeting other people. As such, service provision during the weekend is likely a service gap that can be looked into by policy-makers, service providers, and volunteer groups.

The application of the ecological framework when looking at community factors in relation to ageing in place in the community (Greenfield 2012) has also been useful in understanding the “person-environment fit” of community-dwelling older participants in this study, particularly in relation to non-family relationships.

On the discussion of peer generation support from extended relatives and friends, which includes neighbours who developed friendship through community networks, the age factor as an interfacing condition has been highlighted (see page 367).

On the other hand, and more specifically, the following participants highlight that neighbour relations can be limited by the age-group / lifestage differences:

No, my neighbour don’t do anything [together with us]. They are different, you

know, age-group. These are my next-door neighbours, they are a young couple

with young children, going to school. So it’s different from us, because we are

elderly. And on the other side, also, a middle-age couple, they have adult children.

So we all don’t click because it’s not the same age-group. (BOZHI, Australia,

Female / 77)

372 Community-dwelling older persons are as such a special group in the community whose lifestyles are not in sync with a large proportion of the younger population. This might explain one basis of loneliness and social isolation among community-dwelling older people, particularly those with mobility and disability issues as observed by the following participant who has been actively volunteering with the community centre and reaching out to fellow public housing tenants for many years:

Where the disability is very obvious, I think those people are very, very lonely.

People don’t bother with them so much, you know. And they keep to themselves

too, because of their disability. (RANDY, Australia, Male / 70)

Combining the participants’ experiences of the community and their neighbours, the age-time factors can contribute to both risk and protective factors and should warrant attention from various informal and formal community stakeholders in facilitating better “person-environment fit” for community- dwelling older persons.

To this end, the participants have said much about being beneficiaries of centre-based community services in addressing their needs and enabling them to better age in place in the community. While this community service approach is not facilitating better “person-environment fit” with the community per se, it is community-based and is accessible for older people to get together and co- create a sense of community as a sort of an enclave.

373 At the same time, the more outreach-oriented community services would bring elements of the community to the homes of more frail and homebound older persons through home visitations. With assistance in ADL capabilities, older people with less severe mobility and other disability issues can also be taken out on outings, and be transferred to the centres for socio-recreational activities.

The enabling characteristics of community organisations have been presented in detail in Chapter 6 and will be further discussed in Section 7.8. Before that, the potential of “older people for older people” is elaborated and is related to addressing the “daytime gap”.

7.7 Older People for Older People

After assessing the modern state of neighbour relations in both Australia and

Singapore, and identifying the age-time factors when examining “person- environment fit” of community-dwelling older persons, questions are raised with regards to who remains in the community, particularly during the day, who could offer help. With regards to more reliable sources of help during the daytime, few exceptions are mentioned like the following account, where neighbours are stay-at-home carers of pre-school children and / or other older people:

If something goes wrong, I have a few neighbours I can get help from. The rest of

them goes out early and comes back late. I don't get to see them often. There are

two households with housewives. I see them sometimes and we will chat a little.

(XIAZHI, Singapore, Female / 70)

374 An Australian participant, GABRIELLE (see account on page 232), has also mentioned receiving help from a neighbour who is a stay-at-home-mum. Their relationship is much deeper with high level of reciprocity and social intimacy, with the participant referring to her neighbour as “like a daughter”.

Sources of daytime help would also include domestic helpers in the

Singaporean context who are commonly engaged as carers for young children and older people and provide care and supervision during the day when other family members are out working or in school.

These sources of help are however the exceptions and is not available for the majority of the participants in this study. This is particularly so when they are managing independently and either themselves, the family, or the neighbours see the need to establish a helping relationship.

With regards to sources of daytime help, there are many more mentions of older people providing help to another older neighbours in this study (for example, see account of BRIDGET on page 160), including participants being asked by another older person to supervise her grandchild while she goes out to run errands (see account of TIANYI on page 229). Community-dwelling older persons should therefore be seen as a much-needed source of volunteers to address the daytime gap.

375 While older people as volunteers has received greater attention in recent years, this area of resource is likely insufficiently tapped by the aged care sector in

Singapore. In 1998, the non-profit organisation RSVP Singapore was set up with a vision ‘[t]o be Singapore’s premier organisation of active seniors serving and enriching lives through volunteerism’ (RSVP Singapore 2017). RSVP

Singapore was reported to have over 300 active volunteers in 2015 (The Straits

Times 2015a), which is a small proportion when there were 459,715 older persons that year and 285,056 of them between the age of 65 and 74 and

132,996 between the age of 75 and 84 (DOS 2016). The report by the presented a much more positive picture citing volunteerism rate among older

Singaporeans as 17% in year 2012 and with an upward trend (NVPC 2013: 10).

Nonetheless, there is no breakdown in what type of organisations that older volunteers are giving their time to though figures of the overall volunteering population showed that 53% are volunteering informally and 23% are with religious organisations.

In Australia, the ABS provided a clear picture with a detailed breakdown and figures indicating that volunteerism rate among older Australian is at 31% in

2015 and that they are more likely to volunteer with “welfare / community” type of organisations (ABS 2011). There is therefore a greater likelihood that there exist a proportion of older volunteers who are focusing on helping other older people in Australia, which can be explored further. While the motivations and benefits of volunteering for older people are well documented, there are few researches that investigate their direct impact on older beneficiaries, thereby establishing a stronger case in support of “older people for older people”.

376 As described by Australian participants in this study, their interactions with older volunteers who are their age-peers are all positive. Older volunteers are described to be relatable, sensitive of the needs of an older person, helping service users to feel at ease almost immediately due to their commonness, and thus enabling service users to adjust faster than anticipated in the centres.

Older volunteers are also described as excellent facilitators for social interaction and bonding among service users and are instinctual in creating a sense of community in the centre. While the following account does not directly refer to older volunteers, the participant perceive that those in the same age group are more likely to understand their common need:

You know, when you are an older person, you can understand elderly peoples’

need and all that. But when the young couple who have got young family, their

lifestyle is different. They won’t understand what you need. (BOZHI, Australia,

Female / 77)

The community centre at Site A3 also provides an excellent example where older people can get together and organise a system of care based on volunteerism, mutual help, and self-organising. What the state and community can do for older people who wish to participate in volunteering and self- organising is focusing on empowerment and removing barriers, including ageist attitudes towards entrusting older volunteers to be able to care for another older person. As highlighted by an Australian participant, older volunteers do not need much motivation to volunteer when they decide to come forward. In an example provided by WILLIAM (see page 297), a volunteer who is 83 years of age persists in volunteering weekly and has never missed coming to the centre,

377 demonstrating a stronger desire to give back to the society among older volunteers. To this end, the potential for older people to contribute in aged care should not be underestimated and ideally, their efforts to be active community participants should be renumerated in some form of formal arrangement.

7.8 Centre-based Community Services and Community-focused

Approach

The various issues in family care and support from extended relatives and non- kin relationships have been discussed in the preceding sections and in

Chapters 4 and 5. Various inadequacies in the family and neighbourhood context have also being highlighted. What has resonated throughout Chapter 6 in relation to Chapter 4 and 5 is that the common features of community organisations can be seen as solutions to filling those inadequacies in family and non-family informal care like missing pieces of a jigsaw puzzle, and in a complementary manner.

As organised in Chapter 6, there are seven main common features of community organisations that are repeatedly mentioned by older participants who are service users. Though the features are common among the six recruitment sites and community service centres, they can manifest in varying degrees and forms according to their modus operandi.

For example, the participants, staff, and volunteers at the day centres are considered as a closed group with substantial in-house capabilities, and with

378 fewer partnerships with the external community stakeholders and service providers. On the other hand, the Singaporean SACs and the Australian community centre operates on an open basis, usually in partnership with a wide range of community stakeholders, conduct frequent home visits to less mobile and frail members, and regularly perform outreaches in the nearby community.

The seven common features of centre-based community organisations and services that have been presented in detail in Chapter 6 are as listed:

l Provision of a Safe and Age-friendly Physical and Social Environment l Provision of Structured Program l Provision of Assistance in Activities of Daily Living l Platform for Social Interaction and Making New Friends l Provision of Supervision and Monitoring l Platform for Volunteering and Mutual Help l Creating a Sense of Community

In view of the benefits of each common feature, the more features each centre can incorporate and maximised in capabilities, the better an outcome is expected for its service users. Having an innovative and capable team of staff and volunteer is as such an important human resource concern for community service providers and sector developers.

Presented as the first common feature is the acknowledgment of a dedicated physical space that caters to the needs of an older person, such as having accessible toilets and non-slip flooring. Being purposed-built to be age-friendly

379 and with the provision of staff supervision, older service users feel safe in the centres and social interaction with other service users can be naturally occurring.

As highlighted by YANNI (see page 255), the establishment of the SAC has been life-changing for older residents like her who did not feel safe to gather at the void decks, having witnessed heated arguments among neighbours who do so in an unsupervised environment. This view is reflected in the Australian context as well, particularly among service users of the community centre who wonder, ‘[W]hat would people be without this centre?’ (extracted from the account of DOROTHY on page 256)

As highlighted by the following Singaporean participant, urbanisation has resulted in the loss of community spaces where older people in the past could congregate and spend their day together:

[In the past,] there are many older people gathering to chat at the pavilion and the

young children will be playing together nearby. They will keep an eye on all the

children. It is better in the kampong. We don't see such spaces among the flats

[nowadays]. We can only go downstairs. Other than that, we have nowhere else to

go. (TIANYI, Singapore, Female / 76)

While older people can gather at social clubs and meet up over a meal, such a lifestyle can be beyond their financial abilities for a significant proportion of community-dwelling older population who have limited income and / or relying on state support. As highlighted by the following Australian participant, for older people who have limited mobility issues, meeting up beyond their immediate

380 neighbourhood can be highly difficult without assistance:

We used to have a circle of friends. It started with a few of us where the husband

works even on a Saturday afternoon. So, in order not to be left by ourselves and

our children are already grown up, we decided to meet. We became up to about 10

women and then it gradually became less and now we are usually three or four.

Some couldn’t get up onto a bus. So if we are going to one place, I go around and

collect [the ladies in my car]. If it is here in [this suburb] they said it's too hard for

them to come so we decide to go to a coffee lounge [nearer some of them].

(MAGDALENE, Australia, Female / 90)

As such, the provision of transport and with assistance in ADL is essential for the group of older people with mobility and other disability issues to be able to be taken out of their house. The physical premise, which is relatively enclosed and specially catered for older people, also helps to reduce the stigma of having to get around with assistance. Together with an engaging structured program – which is the core of centre-based community service – older service users are enabled to spend their day meaningfully.

The top three common features – provision of a safe and age-friendly physical and social environment; provision of structured program; and provision of assistance in ADL – are thus highly related and omission of one would be much less effective. For example, older people who gather for an exercise group in a rented or borrowed space might not go on to develop friendship if they do not have additional activities beyond that meeting and have an opportunity to socially interact. Those who have an onset of disability might become excluded

381 too when they require significant assistance in ADL to get to the meetings and be able to participate in the activities of common interest which are not necessarily designed to be age-friendly.

Without getting into further details of the common features of centre-based community services – which has been sufficiently covered in Chapter 6 through the accounts of both Australian and Singaporean participants and with examples representing each model – such community service provision with a purpose-built physical space within the neighbourhood adds the dimension of

“space” to the age-time factors in assessing “person-environment fit” among community-dwelling older persons. Through the collective voices of older participants in this study, a fitting environment factoring into age-time-space requirements summarises what community-dwelling older persons would need to age in place in the community.

7.9 Conclusion

This chapter is an elaboration of the higher-level themes identified in this study that combine the perspectives of older Australians and Singaporeans across the family, other relationships, community context of care. The capacity and limitations of each context and part of the aged care system is mentioned in the chapter. In addition, how the various “providers” of care complement one another was highlighted. To this end, the various “providers” of care are all important in themselves, and at the same time combine to form a “community of care”.

382 CHAPTER 8: CONCLUSION

In this chapter, the conclusion is an attempt to summarise the key findings and discussions in relation to the original aims of this study. The summaries and conclusions are listed in the order that is used for the analysis chapters and the discussion chapter – which are issues concerning family care, informal care beyond the family, and community services / organisations. Subsequently, the significant contributions of this research and its limitations are listed. Finally, suggestions for future research are provided.

8.1 Summaries and Conclusions

The overarching aim of this study is to provide a channel for the voices of older people – who are experiencing family and community-based care – to be heard through the use of their accounts. During the period of data collection, participants have through many ways provided feedback about their pleasure of being a part of this research. Being heard in an interview setting has been empowering for many of them, who in turn shared openly about their life experiences and perspectives as an expert. Their varied perspectives and experiences have contributed to the many findings presented in this thesis and the rest of this section is a summary of the key learning points.

383 8.1.1 East-West Value Divide Reconsidered

In the Introduction chapter (see Section 1.3), the renewed interest in this branch of cross-national / cross-cultural gerontological research was presented.

However, most of the studies cited recruited participants who are migrants from

Confucian-influenced societies and comparing their perspectives to the that of those who are native to the dominant Western societies. As such, there is a dearth of similar research that is directly comparing perspectives of participants who are both natives of their respective dominant Eastern and Western societies.

In fact, cross-national / cross-cultural studies such as Laidlaw et al. (2010) who compared perspectives from three cultural groups – older Chinese immigrants living in the UK, older Chinese living in Beijing, and older Scottish living in

Scotland – is proclaimed as the first of its kind and as such adopted an exploratory approach. With multicultural Australia and Singapore and the experience gained from conducting this study, there is a potential to be the first in the world to compare perspectives from four cultural groups – namely, older

Anglo Australians in Australia and Singapore, and older Chinese Singaporean in Australia and Singapore, for example.

Nonetheless, this is one of the few cross-national studies between Australia and

Singapore on ageing and aged care issues. As highlighted in the Introduction chapter (Section 1.3), this exploratory study is guided by the debates between

Eastern and Western scholars who are concerned with the question of whether

384 there is an East-West value divide, particularly in terms of family care and complementary support from the community and the state. As proposed by academic representatives from the East, the concept of filial piety is seen as a distinguishing value though representatives from the West such as Kendig

(2000) defended that the value of family loyalty in the West is as socially binding.

As there is no direct mention of cultural issues in the accounts of participants, the accounts of Australian and Singaporean participants are presented alongside instead to illustrate the many similarities in their perspectives on family care (see Sections 4.2 & 4.3).

How families organises care in the two countries, with a nominated principal carer and a range of support from other family carers, and complementary informal assistance from relatives, friends, neighbours and community organisations, and purchased services from community care services and domestic helpers, is functionally similar. The level of support from families who are reported to be performing the bulk of the care, is similar to that observed in past studies on family care and intergenerational relations (see Section 2.8.2), particularly the seminal work of Brody (1985) who proposed that parental care is becoming so widespread for adult children that it should be seen as a normative life event of adult children.

This has led to the conclusion that in modernised societies like Australia and

Singapore, the East-West value divide in family care is not conspicuous when

385 comparisons were made using the users’ perspectives and experiences. This finding was not unexpected as family values surrounding parental care between the East and West were predicted to converge (see Section 7.2.4). What is unexpected is the level of similarities in which Australian and Singaporean families provide care with neither value systems being distinguishably superior when evaluated by participants in terms of the ways the families organise and provide care. This finding suggests that the value of filial piety esteemed in

Eastern societies might be overstated in the light of modernisation (see Section

7.1.1). On the other hand, the value of family loyalty in Western societies like

Australia might be understated, especially when viewed from an external position (see Section 7.1.2). Interpreting from the perspectives and experiences of older care recipients has thus been insightful in understanding the state of the respective value systems.

8.1.2 Changes in the Family

In addition, the users’ experiences affirm that the hierarchy of obligations in family care (Finch 1989) has remained relatively intact with the marriage relationships (see Section 4.2.1) and parent-child relationships (see Section

4.2.2) as the two main bases for the provision of personal care. The third basis for personal care is also affirmed as older people who require care are invited to live closer or with their adult children to facilitate caregiving (see Section 4.8).

The gendered nature of care is also evident in this study with the daughters and daughters-in-law performing the roles of the principal carers within the context of the household and even when caring from a distance (see Section 4.2.2).

386 However, due to family and demographic changes, two new categories of family carers are identified, which are under explored in the literature, particularly in

Australia and Singapore. The participants’ descriptions of their lives raise the possibility that these relationships will become more significant in the near future. They are de facto relationships (see Section 7.3.2) – which include same-sex couples – and adult grandchildren (see Section 7.4). De facto relationships might be expected to mirror marriage relationships while in cases where the middle generation has been absent adult grandchildren might be expected to mirror that of parent-child relationships. Nonetheless, as there is only one example of each of these two categories from Australian and

Singaporean participants, it is difficult to interpret beyond recognising their potential to provide personal care and financial support.

From the accounts of both Australian and Singaporean participants, the issue of marital breakdown raises concern that a significant proportion of older people would reach old age without family support (see Section 7.3.1). While it is established that families do continue to provide care for their older relatives in both countries, marital breakdown affects the “non-resident” parent to the extent that adult children would not render care at all, let alone the ex-spouse. Besides, even in the context of Singaporean where family obligations are institutionalised through the Maintenance of Parents Act 1995, adult children who have not received consistent care and contact from the non-resident parent would likely be exempted from providing financial support.

387 With regards to financing care in old age, home ownership is found to be both an opportunity and a liability for the “asset-rich and income-poor” (see Sections

4.5 & 7.2.1). Having asset(s) in terms of residential properties affect the means- testing outcome and require various payments of council rates and fees, while renting the property out has provided some participants an option to remain

“self-reliant” and maintain financial independence. With lower state support for the asset-rich in both Australia and Singapore, there is a likelihood that selling the residential property to finance nursing home care might gain popularity among the older population. Such a “house for a home” strategy has implications for the residential care sector and both countries might see a trend in “re-institutionalisation”.

In the context of the family, “loneliness at home” is identified as a gap in the provision of family care (see Sections 4.7 & 7.3.4). It is in part attributed by the

“daytime gap” when older people are left on their own at home when their adult children and other family members go to work or are in school. However, it extends to the evenings and weekends for some participants as their family members are at a different lifestage and busy with their own activities. The neglect of emotional care in the family context warrants deeper research exploration and the age / lifestage factor has been identified to be an important dimension in assessing the “person-in-environment” fit and corresponding needs for community-dwelling older persons to age in place in the community.

There are also implications for policy and practice to address this gap in family care.

388 8.1.3 Enhancing “Communities of Care” through Partnerships and

Addressing the Age-Time-Space Dimensions

Theoretically, Bronfenbrenner’s BST model (see Figure 1 & Section 2.15) is adopted and adapted to conceptualise the interrelatedness between various support systems of an older person. What emerged from the findings and themes are added factors to the model that can extend the understanding and provide a tool of assessment for professionals working with older people. The added “dimensions” are illustrated in Figure 6 as added levels to

Bronfenbrenner’s BST model.

Throughout the data collection and analysis stage, the ultimate question in mind is ‘What do older people really want / need?’. The conceptualisation journey that ensued was arduous with voluminous number of codes that are organised into the three main categories of care providers and presented in the main findings chapters. The higher-level themes that are presented in Chapter 7 are added layers of understanding pointing towards the dimensions of “age-peers”,

“daytime gap”, and “safe age-friendly spaces”.

These dimensions relates to the top three factors where the strengths and weaknesses in each component of the systems can be assessed by. For example, if component of family in the Microsytem layer of Bronfenbrener’s BST model can provide age-peer carer (such as spousal carers and / or peer- generation extended relatives), during the daytime, and in a safe and age- friendly home environment, besides fulfilling fundamental needs, the older

389 person can be seen as supported. Similarly, where there are gaps in family care along the age-time-space dimensions – for example, as a result of the daytime gap – other components in the Microsytem such as peer-generation friends and volunteers with community services can be engaged to fill the void.

Recruiting users of community services / organisations as participants for this study has also aided in the conceptualisation of communities and community care. As presented in Section 7.2.4, the debate between scholars along the

East-West value divide predicted a convergence in terms of state and family partnership. In terms of state support, this study has found that there is shift by the Singaporean state towards supporting older individuals and / or their carers, particularly in terms of healthcare subsidies through the Pioneer Generation

Package (see Section 7.2.3). On the other hand, Australian participants are sensing the state’s intention to withdraw areas of financial support and service provision. Participants from Site A3 – who have concerns about the level of sensitivity from formal services providers – have also taken an active approach through self-organising as a community. There is as such evidence to suggest a shift towards a convergence in terms of state, family and community partnerships, even though the progress over the past twenty years since Liu and Kendig’s (2000b) prediction was made has been slow.

390 Figure 6: Age-Time-Space Dimensions

391 The rest of this section is a summary of the findings that led to the identification and conceptualisation of the age-time-space dimensions.

In the area of informal care beyond the family context, there are fewer than expected examples of non-family carers, and participants do not expect much care and support beyond the family context. Depictions by Australian and

Singaporean participations suggest that urbanisation has affected the quality of neighbourly relations to the level of “nothing much” and “it’s not there” (see

Sections 5.2.2 & 7.6.2). In addition, the age-peer / lifestage factor in assessing community-dwelling older persons’ social networks is identified as participants highlighted that being in a different lifestage to their neighbours is a barrier to social interactions between them. On the other hand, accounts from the few participants who are receiving some form of care from their neighbours reveal that secondary (and multiple) bonds between neighbours strengthen neighbourly relations to the point that care can be potentially provided (see

Section 5.2.1). As such, there is a role for community stakeholders to contribute in terms of community building and providing platforms for neighbours to socially interact and forge secondary bonds.

Concerns are raised for older people who are living alone in the light of the

“daytime gap” which extends from the family context to the neighbourhood level.

Community-dwelling older people are deemed to be more at risk of delayed assistance and being targets of crime during the daytime than in the evenings and weekends when more neighbours are likely to be home. This has implication for various community stakeholders in addressing this gap at the

392 neighbourhood level by forming a community safety network in the daytime for the older residents. Together with “loneliness at home” due to the “daytime gap”, the real-time dimension in assessing “person-in-environment” fit was established.

The age-peer / lifestage factor is also affirmed by the strength of peer generation extended relatives and friends to provide mutual care and support.

Based on the accounts of participants in this study, older people who have little or no family support are more likely to receive assistance from someone in their peer generation whether it is a relative, friend, or a neighbour (see Section

7.6.1). Combined with a better appreciation of the time factor, the answer to the question regarding who remains in the community as a resource for older people during the daytime is other older people. This has prompted the discussion of the concept of “older people for older people” (see Section 7.7).

With regards to the community model that is aim to be derived from a comparison between Australian and Singaporean aged care system, a possible answer is found in centre-based community care services and community organisations. Possessing several enabling physical and social elements, centre-based community care services and community organisations provide a designated, supervised, safe and age-friendly space that community-dwelling older persons can feel safe to explore new social connections, provide mutual assistance and support, and co-create a sense of community (see Sections 6.2

& 7.8).

393 Besides addressing the space dimension required by a community-dwelling older person to age in place in the community, centre-based community care services and community organisations are also able to address the age-peer / lifestage and daytime gaps found in modern family care provisions and urbanised neighbourhoods. While other forms of community models are being explored, the findings in this research suggest that the various community stakeholders, including policy-makers and practitioners, should consider an expansion of the existing network of centre-based community care services and promoting its capacity to address the total needs of a community-dwelling older person along the age-time-space dimensions.

To this end, the answer to the question of “where is the community in community care?” is more likely found within the context of centre-based community care services and community organisations and with older people themselves. As summarised by a statement made by participant BRENDAN:

‘My life is bound up with the people I meet at these meetings [at the day centre]’.

As such, the “community” for an older person is often limited to the family, friends, neighbours, and people they meet on a more regular basis. Some participants like BRENDAN who do not get taken out of the home would even include medical professionals and care staff in their list. The challenge for researchers, policy-makers, and practitioners, is in attuning to the age-time- space dimensions and explore ways in creating a “community of care” for community-dwelling older people that decreases social isolation, increases community participation, and addresses their composite needs, which include emotional care.

394 8.2 Contributions

As an exploratory and comparative study, the many aspects of care for a community-dwelling older person in the Australian and Singaporean context have been identified and discussed as listed in the previous section.

With regards to the East-West value divide in family care, the findings in this study have added evidence from Australia and Singapore to this area of ongoing academic debate. In addition, the similarities between family care in

Australia and Singapore would suggest that there is a shared value system that can withstand the challenges of modernisation, particularly if the family is supported in their caregiving roles. The focus for future research, policy and practice could be looking at political and policy trajectories in the context of modernised social values and expectations.

This research has also provided evidence affirming the hierarchy of obligations and that the marriage relationships and parent-child relationships should remain as the focus in policy-making and formal interventions targeting to preserve the provision of family care. In addition, the identification of the categories of de facto relationships and adult grandchildren as potentially significant sources of family care in the future opens up research territories that have remained underexplored in the Australian and Singaporean context.

The identified daytime gap, “more than a neighbour” principle, and age-peer / lifestage dimension can advance understanding of the importance of peer-

395 generation relationships between extended relatives, friends, and neighbours, and aid policy-makers, practitioners, and other community stakeholders to narrow the scope when designing programs and services that can better serve community-dwelling older persons and encourage community bonding.

Exploring the issues of family and community care using the broad-based

Bronfenbrenner’s bioecological systems theory has laid the foundation for maximum space for learning from the perspectives of older service users. The crystallisation of learning points from community-dwelling older participants into the age-time-space dimensions would add to the area of ageing in place research employing the ecological framework. It is also a useful concept for policy and practice when assessing the needs and gaps in the care plan of a community-dwelling older person who wishes to age in place in the community.

The effectiveness of centre-based community care services and community organisations in addressing the needs of community-dwelling older people along the age-time-space dimensions would support the need for service expansion in this area and opens up room for further research into enhancing this community model of care.

8.3 Limitations

While much has been explored in this study, the concept of “community of care”

– that encompasses creating a system and network of care providers for a community-dwelling older person through organising various segments of the

396 community – has not been sufficiently substantiated from the perspectives and experience of older participants in this study. More concrete conclusions could not be made except that within the centre-based community care services and community organisations, there is a potential to create such a “community of care” through a community-focused and outreach approach and by engaging various community stakeholders as partners in providing care.

While the gendered nature of care has been mentioned and presented (see

Sections 2.8.3, 2.10 & 4.2.2), the gendered needs of a community-dwelling older person has been underexplored among other dimensions and aspects of care due to the lack of specific mention by the participants or accounts that can infer gendered needs. This could be a main focus area in future research, elevating this topic area to the forefront.

Due to ethical considerations, the decision to participate in this study is purely voluntary and designed to minimise the risk of coercion (Section 3.9.1). As such, those who chose to participate in this study could be those who are more sociable and less apprehensive in meeting a stranger, even when introduced by the support organisations. The risk of sampling bias is acknowledged as a limitation despite the request made to support organisation staff (who were briefed based on the Briefing Outline – Appendix K) to broadcast the information to all their service users instead of selecting the participants or anticipating the service users the researcher would like to hear from.

397 The small number of participants in this study, restrained by practical considerations that the amount of qualitative data to be collected and analysed might become unmanageable, has limited generalisation of the findings to the wider population. As highlighted in Section 3.10, the aim of qualitative research and in this study is in theoretical generalisation rather than statistical generalisation. In such a pursuit, the understanding gain from this study can only be applicable to the setting of investigating, which is limited to community- dwelling older persons who are service users of centre-based community care services and community organisations.

The generalisability of the findings is also limited by the omission of specific populations such as those living in rural / country regions, with cognitive issues

(including dementia), indigenous Australians, and same-sex couples. While the former three omissions are mainly due to selection in setting and scope, and practical and ethical considerations, the latter is due to non-presence of participants who are in a same-sex relationship in the samples. As reviewed by

Fenkl (2012), older lesbians, gay men, and bisexuals overwhelmingly prefer health and social services within the gay and lesbian community. In Jacob’s et al. (1999) study, all of the 71 surveyed participants reported accessing gay and lesbian specific services only.

While some of quotes used are based on recollection of past events in earlier stages of the participants’ life, it is not the intention or part of the methodological design to rely on retrospective interviews. The participants are all service users at the point of the interviews and their “present” experiences and perspectives

398 about care and the community was sought. Nonetheless, this study acknowledges that there are limitations in the accuracy of some accounts due to the quality of recollection though it is not to the extent faced by retrospective studies as noted by Silverman (2010: 192).

8.4 Future Research

Continuation from this exploratory research is in studying specific areas that has been identified to be important aspects with regards to the care of community- dwelling older people.

As mentioned in the limitation section (Section 8.3), the concept of “community of care” can be further explored with a case study design and with participants from a specific self-organising community group. The findings in such a study would provide a community model that can be replicated across various contexts. Precedence of such a study is mainly found in the US, exploring community factors through the NORC and Village models (see Section 2.12).

Nonetheless, in Australia and Singapore, examples of such studies are likely to be few.

As mentioned in the contributions section (Section 8.2), comparative research between the East and West could focus on political and policy trajectories for greater impact in terms of understand the range of state provisions older people and their families would be better supported by. Participants might be policy- makers and other key government personnel who are directly involved in

399 service planning and development and family carers. The data from this study can be use to complement and contrast the findings in this future research.

The age-time-space dimensions in relations to the concept of “person-in- environment fit” in ecological frameworks (see Section 2.15) can be further explored and presented in a multidimensional model (see Figure 6) encompassing details along the continuum of each dimensions. For example, age groups that best support an older person, the period of time when risk is higher, and the location of safe spaces in the community can be explored.

Last but not least, the categories of de facto relationships and adult grandchildren as principal carers are exciting areas for future research.

Particularly for the latter category, where there are only a handful of studies conducted around the world.

8.5 Final Reflections: From Research to Practice?

As mentioned in the Introduction chapter, this study has been influenced by the researcher’s personal background, academic journey, and practice experiences.

Prior to embarking on this study, the researcher was excited about the lessons that can be learned, particularly from older people. “It’s the opportunity of a lifetime,” he thought and the interviewing phase was truly the most enjoyable phrase in this study. While this study does not promise any direct benefits to the participants, the data collected weighs heavily on the mind of the researcher to

“put them into good use”. At this juncture, the findings suggest that it would be

400 useful, though the researcher is dissatisfied to stop here and is determined to bring it into practice and revise the home-based and community service model that the researcher was involved in designing. If there is an opportunity for further research, there are many exciting paths to undertake, particular in the under-explored area of de facto relationships and grandchildren as carers. As such, this research is concluding with as much, if not more, hopefulness and excitement as it had begun.

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432 APPENDICES

Appendix A: The Domains of Social Capital and Appropriate

Neighbourhood Policies to Support Them

Domain Description Local Policies Providing support to community That people feel they have a voice groups; giving local people which is listened to; are involved in Empowerment “voice”; helping to provide processes that affect them; can solutions to problems; giving themselves take action to initiate local people a role in policy changes processes Establishing and/or supporting That people take part in social and local activities and local Participation community activities; local events organisations; publicising local occur and are well attended events Associational That people co-operate with one Developing and supporting activity and another through the formation of networks between organisations common formal and informal groups to in the area purpose further their interests Creating, developing and/or That individuals and organisations supporting an ethos of co- co-operate to support one another Supporting operation between individuals for either mutual or one-sided gain; networks and and organisations which an expectation that help would be reciprocity develop ideas of community given to or received from others support; good neighbour award when needed schemes Developing and promulgating an Collective ethos which residents recognise That people share common values norms and and accept; securing and norms of behaviour values harmonious social relations; promoting community interests Encouraging trust in residents in That people feel they can trust their their relationships with each Trust co-residents and local organisations other; delivering on policy responsible for governing or serving promises; bringing conflicting their area groups together Encouraging a sense of safety That people feel safe in their in residents; involvement in local Safety neighbourhood and are not crime prevention; providing restricted in their use of public visible evidence of security space by fear measures Creating, developing and/or That people feel connected to their supporting a sense of belonging co-residents, their home area, have Belonging in residents; boosting the a sense of belonging to the place identity of a place via design, and its people street furnishings, naming Source: Forrest and Kearns 2001: 2140.

433 Appendix B: Email Template To Support Organisations

Dear ______,

I am writing to you in request for your support in a research project with older people (aged 65 and over) who are living in the community.

My name is Teck Lim, a PhD candidate pursuing a degree in the School of Social Sciences at the University of New South Wales (UNSW). My supervisors are Professor Richard Hugman and Dr. Katrina Moore.

Prior to embarking on this candidature, I was a social work practitioner and manager of a community aged care service providing a range of centre-based and home-based services in my home country, Singapore. This research is an extension of my interest, work experience, and training across cultural contexts.

What is this research project about?

The title of the research project is Communities of Care and Community Care: Perspectives of Older Australian and Singaporean Service Users. It is a qualitative study designed to explore the contextual role of family and community care from the perspectives and experiences of community-dwelling older persons.

In addition, the information gathered in Australia and Singapore will be compared in an attempt to tease out the value-laden nature and socio-cultural aspects of caregiving.

What does the research hope to achieve?

The perspectives and experiences of older Australians and Singaporeans would aid in the understanding of the contextual nature of family care, home-based and community care, and state support in the two countries. A deeper understanding would likely translate to better design and delivery of care for older people who wish to age in place in the community.

What would the research cover?

The study is NOT an evaluation of the community care programs and community- based services. The assistance from your organisation is greatly valued because of your focus and quality work in assisting and facilitating older people to remain at home and in the community for as long as possible.

The research questions would be focusing on a few areas – family and support network, living and care arrangement and factors for decision-making, views about the community, community involvement, and service usage.

I hope to be able to interview community-dwelling older people in contact with your agency. The interview period is tentatively planned to be from ______to ______.

What would you need to do?

Centre-based services:

434 Kindly grant permission for an A3-sized poster to be placed at your centre’s reception area or notice board(s).

Nominate a liaison person who is able to make arrangement for a briefing session with staff and / or volunteers who can assist in information giving for older service users who have any general queries about the research.

Interested participants would be advised to contact me directly through the contact information stated in the poster.

Home-based services:

Nominate a liaison person who is able to make arrangement for a briefing session with staff and / or volunteers who are conducting regular home visits to home-based service users.

They will be briefed on the purpose of the research, selection and exclusion criteria, and information to disseminate to potential participants.

An A4-sized flyer is prepared to be hand-distributed to older home-based service users. Interested participants would be advised to contact me directly through the contact information stated in the flyer or mail the tear-off portion at the bottom back to me using the stamped return envelope provided.

This research has received ethics approval (approval no. 14 072) from HREA Panel B at UNSW.

Thank you in advance for the help. Do feel free to contact me by email or call me at 04XXXXXXX should you require further details or clarification.

Best regards, Teck Lim PhD Candidate School of Social Sciences University of New South Wales [email protected]

435 Appendix C: Poster (English Version)

Participants Needed University of New South Wales Community Aged Care Study

I am Teck Lim, a PhD candidate pursuing a degree in the School of Social Sciences at the University of New South Wales (UNSW). My supervisors are Professor Richard Hugman and Dr. Katrina Moore.

This research aims to understand the role of the family, community, and home-based and community care services through the perspectives of older service users.

If you are: • Aged 65 and over; • An Australian citizen; • Living in the same community for the past five years; • An active participant in community-based social and recreational activities; and / or • A service user of community aged care services.

Then you would be ideal for this study. Your views can help to shape the future of community aged care.

If you are interested in sharing your views over a one-hour interview, please contact me at 04XXXXXXXX.

In appreciation, a packet of biscuit is prepared for your participation.

This research has received ethics approval (approval no. 14 072) from HREA Panel B at UNSW.

436 Appendix D: Poster (Chinese Version)

征求参 新南威尔士大学社区乐龄护理研究

是林德发，现读于新南威尔士大学的一社会科学博士生。的督师是 Richard Hugman 教授 Katrina Moore 博士。

本研究专注了解社区对于邻里乐龄服之间的系. 希望征年长服用者看护 者的点。

如果你是一: • 十五岁以; • 新坡民; • 在过去五年居住在一个社区; • 积极参邻里，社交，基层活 • 社区乐龄护理使用者。

你将是理想的研究对象。你的意可以帮塑造社区乐龄护理的未来。

如果您有趣分享你的点，请联系。的电话是 9XXX-XXXX. 采访将会长达一 小时。了表示感谢，参者准备了精致饼干。

本研究以获新南威尔士大学 HREA Panel B 的伦理批准批号14 072)。

437 Appendix E: Flyer (English Version)

Participants Needed University of New South Wales Community Aged Care Study

I am Teck Lim, a PhD candidate pursuing a degree in the School of Social Sciences at the University of New South Wales (UNSW). My supervisors are Professor Richard Hugman and Dr. Katrina Moore.

This research aims to understand the role of the family, community, and home-based and community care services through the perspectives of older service users.

If you are: • Aged 65 and over; • An Australian; • Living in the same community for the past five years; • An active participant in community-based social and recreational activities; and / or • A service user of community aged care service,

Then you would be ideal for this study. Your views can help to shape the future of community aged care.

If you are interested in sharing your views over a one-hour interview, please contact me at 04XXXXXXXX.

In appreciation, a packet of biscuit is prepared for your participation.

This research has received ethics approval (approval no. 14 072) from HREA Panel B at UNSW. YES, I am interested to participate in this research. Please contact me to arrange for an interview.

Here are my details: Name: ______Contact Number: ______

438 Appendix F: Flyer (Chinese Version)

征求参 新南威尔士大学社区乐龄护理研究

是林德发，现读于新南威尔士大学的一社会科学博士生。的督师是 Richard Hugman 教授 Katrina Moore 博士。

本研究专注了解社区对于邻里乐龄服之间的系. 希望征年长服用者看护 者的点。

如果你是一: • 十五岁以; • 新坡民; • 在过去五年居住在一个社区; • 积极参邻里，社交，基层活 • 社区乐龄护理使用者。

你将是理想的研究对象。你的意可以帮塑造社区乐龄护理的未来。

如果您有趣分享你的点，请联系。的电话是 9XXX-XXXX. 采访将会长达一 小时。了表示感谢，参者准备了精致饼干。

本研究以获新南威尔士大学 HREA Panel B 的伦理批准批号14 072)。

好！ 愿意参这个研究，接你的访问。 这是的联络资料 姓______电话______

439 Appendix G: Interview Guide

1. For a start, please tell me about your family and support network. Do include: • Parents, siblings, spouse, children, grandchildren and other close relatives • People who are not relatives and you can turn to them for help when the need arises.

2. Living in the community usually requires a reasonable level of independence and access to services to maintain independent living. Would you consider yourself to be living independently?

3. Research with older people has shown that living in one’s own home in the community, also known as “ageing in place”, is preferred over a retirement village, group home, hostel, or a nursing home. I would like to know your preference on accommodation and living options and what factors are important for your consideration?

4. A community is usually described as having two main components – the social relationships and physical environment. What is your idea of a community?

5. Older people are seen as part of their community and as a participant, there are roles, responsibilities, and privileges. Can you tell me what is your involvement in the community?

6. Community aged care services were designed to assist older people to remain in their own home for as long as possible. Are you receiving such services on a regular basis? • If you are, please tell me more about these services and how are they helping? • If you are not, please tell me how you came to know about this study?

7. I am interested in how communities can be supported to facilitate community care and support older people in their midst and I wish to know what are your thoughts about this?

440 Appendix H: Participant Information Statement and Consent Form

(English)

Approval No. (14 072)

THE UNIVERSITY OF NEW SOUTH WALES

Communities of Care and Community Care: Perspectives of Older Australian and Singaporean Service Users

I am Teck Lim, a PhD candidate pursuing a degree in the School of Social Sciences at the University of New South Wales (UNSW). My supervisor is Professor Richard Hugman and co- supervisor is Dr. Katrina Moore.

[Participant Selection and Purpose of Study] You are invited to participate in this research as you are: an older person (aged 65 and over), an Australian or Singaporean, living in the same community for the past five years, a service user of community aged care services and/or is an active participant in community-based social and recreation activities.

The aim of this research is to understand the role of the family, community, and home-based and community aged care services through the perspectives of community-dwelling older persons.

[Description of Study and Risks] I will require a once-off interview that will likely last between 30 minutes to one hour. The interview will be voice-recorded with your consent only.

You will be asked a number of questions about your experience of family and community care, involvement in the community, and views on the relationship older individuals have with the family, community, and home-based and community care services. Please note that you will likely need to draw on personal experience of caregiving and care-receiving and there is a question regarding family and support network. These questions might be upsetting. If you feel uncomfortable at any point, please let me know immediately.

The insights gained from this interview would potentially add to the body of knowledge on the delivery of home-based and community care and indirectly benefit community care recipients and service providers. However, we cannot and do not guarantee or promise that you will receive any benefits from this study.

[Confidentiality and Disclosure of Information] Any information that is obtained in connection with this study and that can be identified with you will remain confidential and will be disclosed only with your permission, except as required by law. If you give us your permission by signing this document, I plan to use the quotes from this interview to illustrate the various learning points and research findings. The research findings of this study are expected to be published in an academic thesis, journals and conferences. In any publication, information will be provided in such a way that you cannot be identified.

[Recompense to Participants] In appreciation, a pack of biscuits is prepared for your participation.

Complaints may be directed to the Ethics Secretariat, The University of New South Wales, SYDNEY 2052 AUSTRALIA (phone (02) 9385 4234, fax (02) 9385 6648, email [email protected]). Any complaint you make will be investigated promptly and you will be informed of the outcome.

441 [Feedback to Participants] A one-page summary of research findings will be prepared upon completion of this research project. If you wish to receive a copy, please provide your postal or email address in the signature page.

[Your Consent] Your decision whether or not to participate will not prejudice your future relations with UNSW and (name of support organisation). If you decide to participate, you are free to withdraw your consent and to discontinue participation at any time without prejudice. A stamped envelope is provided for your return of the revocation of consent slip.

If you have any questions, please feel free to ask me. If you have any additional questions later, Professor Richard Hugman (phone +61 (2) 9XXXXXXX) will be happy to answer them.

You will be given a copy of this form to keep.

442 THE UNIVERSITY OF NEW SOUTH WALES and (Name of Support Organisation)

PARTICIPANT INFORMATION STATEMENT AND CONSENT FORM (continued)

Communities of Care and Community Care: Perspectives of Older Australian and Singaporean Service Users

You are making a decision whether or not to participate. Your signature indicates that, having read the information provided above, you have decided to participate and consent to the following:

☐ My participation in the research project: Communities of Care and Community Care: Perspectives of Older Australian and Singaporean Service Users.

☐ I give consent to having my interview digitally voice-recorded.

☐ I give consent for the use of anonymous quotes from what I say in this interview.

…………………………………………………… .……………………………………………………. Signature of Research Participant Signature of Witness

…………………………………………………… .……………………………………………………. (Please PRINT Name) (Please PRINT Name)

…………………………………………………… .……………………………………………………. Date Nature of Witness

Postal / email address: ______

REVOCATION OF CONSENT

Communities of Care and Community Care: Perspectives of Older Australian and Singaporean Service Users.

I hereby wish to WITHDRAW my consent to participate in the research proposal described above and understand that such withdrawal WILL NOT jeopardise any treatment or my relationship with The University of New South Wales and (name of support organisation).

…………………………………………………… .……………………………………………………. Signature Date

…………………………………………………… (Please PRINT Name)

The section for Revocation of Consent should be forwarded to Professor Richard Hugman at postal address: Room XXX, Morven Brown Building, Kensington Campus, The University of New South Wales, Sydney, NSW 2052, Australia. A stamped envelope is provided for the return of this revocation slip.

443 Appendix I: Participant Information Statement and Consent Form (Chinese)

批准文号 (14 072)

新南威尔士大学 UNSW

Communities of Care and Community Care: Perspectives of Older Australian and Singaporean Service Users.

是林德发，现读于新南威尔士大学的一社会科学博士生。的督师是 Richard Hugman 教授 Katrina Moore 博士。

[Participant Selection and Purpose of Study] 您邀请参本研究的原因由此: 年龄 65 岁及以新坡民或永久居民在过去五年居住 在一个社区积极参邻里，社交，基层活社区乐龄护理使用者。

[Description of Study and Risks] 这是一个一次性的访问。需长达半到一小时。在录音之前将会征得您的意。

采访内容注于社区护理和邻里之间的系。会寻求您对社区护理，邻里活的看法和验。 回答这些问题可能需要透露一些私人知了或家庭情况。如有请您尽早让知道。

采访中获得的信息将可能增们对社区护理及邻里运行的了解于知识。希望这能间接益社区 护理使用者和服机构。但们敢保真本研究会对您个人有任何帮。

[Confidentiality and Disclosure of Information] 任何可以识别您身份的资料将予保密除非有您的许可或是法律规定需要透露。在此请您应许本研 究使用您的引用句表达学要点。这项研究的结果将会学术论文及在学者期刊和会社里传播。 无论如何发表，您的身份将予保密。

[Recompense to Participants] 感谢您的参，准备了一精制的饼干。

如有满， 您可向道德秘书处投诉。 地址是The University of New South Wales, SYDNEY 2052，AUSTRALIA 电话 +61(2) 93854234，传真 +61(2) 93856648， 电子邮件 [email protected])。任何投诉将立即进行调查而您将收到调查结果。

[Feedback to Participants] 研究完当儿您可收到一份单页总结。请在签页提供您的住址或电子邮件地址。

[Your Consent] 您的参或推出将会照利的影响会损害你和 UNSW 以及 (name of support organisation) 未来的系。您可随时推出而损害。在此您提供了贴邮票的信封方便您寄 出推出字条。

如有疑问，可向发问或联系 Richard Hugman 教授 电话+61(2) 9XXXXXXX)。

您可保留这份文件.

444 THE UNIVERSITY OF NEW SOUTH WALES and (Name of Support Organisation)

参者资料声明和意表格续

Communities of Care and Community Care: Perspectives of Older Australian and Singaporean Service Users.

您将在此表示参。您的签字代表您已阅览资料声明并意以几项

☐ 参本研究: Communities of Care and Community Care: Perspectives of Older Australian and Singaporean Service Users.

☐ 进行录音

☐ 使用引用句

…………………………………………………… .……………………………………………………. 参者签 证着签

…………………………………………………… .……………………………………………………. 全 全

…………………………………………………… .……………………………………………………. 日期 证着性质

住址／电子邮件地址: ______

推出字条

Communities of Care and Community Care: Perspectives of Older Australian and Singaporean Service Users.

在此撤回意参以述研究及了解此决定会对照利的影响会损害和 UNSW 以 及 ______的系。

…………………………………………………… .……………………………………………………. 签 日期

…………………………………………………… 全

推出字条必须寄给 Richard Hugman 教授。地址: Room XXX, Morven Brown Building, Kensington Campus, The University of New South Wales, Sydney, NSW 2052, Australia. 您可 使用您提供的贴邮票的信封。

445 Appendix J: Interview Checklist

Interview Checklist

Demographic Information Interview Schedule Name: Date: / / Gender / Age: Start: : AM/PM Ethnicity: End: : AM/PM LOS in Com: Venue: Housing Type: Housing Size: P/No Main Source of Income: Marital Status:

Consent Form Checking for Discomfort

Participation: Any Discomfort? YES / NO

Voice-recording: When participant become distressed:

Use of Quotes: 1. Stop interview immediately

Postal / Email Address 2. Ask whether participant wish to speak Provided? to someone Copy for Participant: 3. Leave contacts / refer if appropriate

Research Questions Nominatio of Caregiver Family / Support Network Name: Gender / Age: Service Usage / Relation: Accessibility Contact: Social & Community Participation Independent Living Concluding Gift / Checking on Allergies Ageing in place Stamped Return Envelope / Sense of Community Revocation Chance Meeting Community Care

Community Support

446 Appendix K: Briefing Outline

Briefing Outline (Staff and Volunteers)

1. Purpose of Research

2. Selection Criteria: a. Older person aged 65 and over; b. An Australian when interviewed in Australia (vice-versa for Singapore); c. Living in this area for at least five years; d. Active participant in community-based social and recreation activities; and / or e. Service user of community aged care services.

3. Exclusion Criteria: a. Grief and loss – recently in the past six months and / or unresolved b. Mental health – poor history and / or recent onset c. Stressful family or social situation – for example: recent estrangement

4. Information to Disseminate: a. Purpose of research b. Participation is purely voluntary c. Participants can decide on: i. Time and venue of interview ii. Presence or absence of staff / volunteers / family members iii. Voice-recording d. No repercussions to not participate and withdraw at any stage e. Reply directly to researcher through mobile phone contact or reply slip at the bottom portion of the flyer with stamped return envelope provided.

447 Appendix L: Summary of Recruitment Sites

Site Model Daily Managed By Funding Groupings (number of Attendance Sources days in bracket) A1 Day centre / 40-60 Local Council HACC & Multicultural main groups closed Local Council (4), multicultural men-only group (1), three ethnic- specific groups (1 each)

A2 Day centre / 60-80 Ethnic-based HACC & Ethnic-specific main closed organisation parent groups (5); with men and ethnic-based women-only tables and organisation language considerations.

A3 Community 40-150 Public Local Council Serves all tenants; 85% of centre / housing and public the tenants in the estate open tenants donations are aged 65 and over.

S1 Day centre / 40-50 Religious MOH and Multicultural main groups closed Charity parent (5) with gender-based religious table grouping during organisation meals.

S2 SAC / open 40-60 FSC MSF and Serves older tenants in public the target block where the donations SAC is located; at least 60% of public housing tenants are aged 60 and over. Exceptions are made for younger people with disabilities and nearby residents of purchased housing.

S3 SAC / open 40-60 Religious Parent Serves older residents in charity religious the same housing estate organisation with exceptions for and public referrals made by regular donations service users for friends and relatives who live further away.

448