Filial responsibility: what are the attitudes of adult child caregivers on the institutionalization of aged parents?

Abstract

OBJECTIVE

To analyze attitudes of filial responsibility about the institutionalization of aged parents.

METHODS

A qualitative descriptive study with intentional sample of 100 caregivers of aged people from two Primary Health Care Units of Porto Alegre/Brazil. The information was collected in 2014, through a semi-structured interview. Thematic analysis was carried out. The NVIVO® software version 10 was used.

RESULTS

Two categories were elaborated according to the protocol questions: the possibility of institutionalization of the aged parents and expectation of care.

FINAL CONSIDERATIONS

Most adult child caregivers did not consider the institutionalization of aged parents in the reason of a duty they felt to take care of their parents, and the institutionalization was considered as abandonment. Most of the adult child caregivers had an expectation to be cared by their children and perceived the institutionalization as an alternative of receiving this care. The results of the study contribute to the strengthening of the formal and informal network for the aged and their adult child caregiver.

Keywords:
Caregivers; Institutionalization; Attitude; Aged

Resumo

OBJETIVO

Analisar as atitudes de responsabilidade filial sobre a institucionalização dos pais idosos.

MÉTODOS

Estudo qualitativo com amostra intencional de 100 filhos cuidadores de idosos de duas Unidades de Saúde de Porto Alegre/RS. As informações foram coletadas em 2014, por meio de entrevista semiestruturada. A análise baseou-se na análise temática. Foi utilizado o software NVIVO® versão 10.

RESULTADOS

Elaboraram-se duas categorias de acordo com as questões do protocolo: possibilidade de institucionalização dos pais idosos e expectativa de cuidado.

CONSIDERAÇÕES FINAIS

A maioria dos filhos cuidadores não considerou a institucionalização dos pais idosos, por julgarem ser um dever deles o cuidado aos pais, e considerarem a institucionalização como abandono. A maioria dos filhos cuidadores possuía expectativa de ser cuidada pelos filhos e percebeu a institucionalização como forma de receber este cuidado. Os resultados do estudo contribuem para o fortalecimento da rede formal e informal ao idoso e seu filho cuidador.

Palavras-chave:
Cuidadores; Institucionalização; Atitude; Idoso

Resumen

OBJETIVO

Analizar las actitudes de responsabilidad filial sobre la institucionalización de los padres mayores.

MÉTODOS

Estudio cualitativo con muestra intencional de 100 hijos cuidadores de personas mayores de dos Unidades de Salud de Porto Alegre/RS. Las informaciones se recolectaron en 2014, por medio de entrevista semiestructurada. El análisis se basó en el análisis temático. Se utilizó el software NVIVO®, versión 10.

RESULTADOS

Se elaboraron dos categorías, según las cuestiones del protocolo: posibilidad de institucionalización de los padres mayores y expectativa del cuidado.

CONSIDERACIONES FINALES

La mayoría de los hijos cuidadores no consideró la institucionalización de los padres ancianos, por juzgar ser un deber de ellos el cuidado de los padres, y por considerar la institucionalización como abandono. La mayoría de los hijos cuidadores tenía la expectativa de ser cuidada por los hijos y pasó a ver a la institucionalización como una forma de recibir este cuidado. Los resultados del estudio contribuyen al fortalecimiento de la red formal e informal al anciano y su hijo cuidador.

Palabras clave:
Cuidadores; Institucionalización; Actitud; Anciano

Introduction

The aged population has shown high rates of growth. In 2017, the aged represented 962 million people in the world (13%), and projections indicate that they will represent 2.1 billion people (22%) by 2050¹. In Brazil, in this same period, the aged will represent 33% of the population². Faced with this scenario, taking care of parents during the aging process is an increasingly frequent experience. The responsibility of the adult child in the care of the aged parents, or filial responsibility, an expression used in the international context, is conceptualized as a cultural and social norm represented by the behaviors of the adult child in relation to the process of care with the parents³ and involves the individual and collective scope. At the individual level, it comprises the interpretation and dynamics of the family in caring for the aged, and in the collective it is related to the social standards and models of public policies instituted³.

The filial responsibility can be evaluated through attitudes and behavior of care⁴. Attitudes refer to a personal assessment of an object that may be related to a person or to a situation⁴. The term “behavior”, in the perspective of care, is understood as an individual conduct to provide support to the aged parents and may be related to the history of family interaction and to be influenced by the attitudes of the adult child and, consequently, of social and cultural norms⁵.

In Brazil, in addition to the cultural and moral tradition of care for the aged, the attributions of the adult child caregiver in relation to the care of the aged parents are legally established. The Brazilian Federal Constitution in articles 229 and 230, establishes that the eldest adult child have the duty to help and support their parents in the process of aging or illness. As for public policies, the National Policy on the Health of the Aged establishes the prioritization of care for the aged by their own family, to the detriment of their institutionalization⁶.

The family, as informal support, has been the main source of support for the aged and their caregiver⁷. On the other hand, social changes, such as the increasing participation of women in the labor market, the reduction of the number of children and changes in the pattern of nuptiality, have been transforming family structures and forms of care⁸. Given this context of longer longevity and reduction of the informal support network, the formal support network (Long-Stay Institutions for the Aged - LSIA, day centers, day hospitals and formal home care) would need to be better structured to support aged and their families².

In addition, it is important to emphasize that in the Brazilian reality, there are different support needs, such as physical/instrumental aspects (aid in the execution of tasks), financial aspects (to provide financial help) or emotional (involves expressions of affection, love, visits, company)⁹. It should be noted that, the context of Brazilian social inequality makes it impossible for many families to consider the option of institutionalization, since in most circumstances it is a paid alternative, not constituting a right. Thus, even institutionalization being a desire of the aged and their family, the low purchasing power makes it unfeasible¹⁰. Another important aspect to consider in the Brazilian reality is that many aged people are the main source of financial support for the family².

To date, no national studies on filial responsibility and institutionalization have been identified from the perspective of adult child caregiver. In this scenario, this study is justified by the need to understand the attitudes of adult child caregivers in relation to the institutionalization of their aged parents in the Brazilian reality. For nursing, it can contribute in the way of analyzing, organizing and advocating for the care of the aged and their adult child caregiver in the aging process. Likewise, this study may assist in the planning and management of care, as well as in the elaboration of health policies. Thus, the present study aims to analyze the attitudes of filial responsibility of adult child caregivers on the institutionalization of aged parents.

Methods

Study with descriptive qualitative approach. Integrates a larger research carried out in partnership with the researchers of the School of Nursing of the Universidade Federal do Rio Grande do Sul and the Center for the Study of Aging at the University of Victoria, Canada, entitled “Filial Responsibility in Different Contexts: A Comparison of Filial Attitudes and Behaviors in the Care of The Elderly”^11-13.

The field of study were two Basic Health Units of the city of Porto Alegre/Brazil - Modelo and Santa Cecília, located in the Centro Sanitary District. In addition to having the largest proportion of aged in the municipality (20.96%), both units develop care activities for the aged and their caregivers¹⁴.

The Brazilian investigation had an intentional sample of 100 adult child caregivers based on the Canadian study^12-13. The inclusion criteria were: being a caregiver of an aged father/mother, enrolled in said health care units, for at least three months, with parental care activities involving the child for at least three hours a week, whether instrumental, financial or emotional. The exclusion criteria were: child caregivers aged less than 18 years, or children whose parents had died in the time interval between the registration of the unit and the collection of data.

Data collection took place at the caregiver's home or in a place defined by him, between 2014 and 2015. The data were collected by four trained researchers, through a semi-structured interview, with an average duration of one hour, recorded in MP5 device and later transcribed in full to guarantee the reliability of the speeches. For the collection, the protocol “Filial Responsibility Across Cultures”, adapted and validated for use in Brazil^4,11. A mixed study involving seven scales and open and closed questions was carried out, one of which refers to institutionalization and one to the expectation of care.

Based on the adaptation study of the protocol¹¹, two categories were elaborated: Possibility of institutionalization of aged parents and Expectation of care. The first one was elaborated from the question: “Under what circumstances, if any, would you consider admitting your parent and/or mother to a long-term institution or nursing home?” This question was applied, individually, to the children who lived with their parents and caregivers but lived in their own home. And the Care Expectancy category originated from the question: “As you yourself age, what do you expect from your own children, in terms of care?”

Of the 100 participating adult child caregivers, the first question was applied to 95 children whose parents were not institutionalized and the second to only 68 caregivers who had children. The first question was not applied to children whose parents were already institutionalized, according to the guidelines of the research protocol mentioned above.

The information organization and exploitation process was carried out in the software NVIVO®, version 10. Thematic analysis was performed, following the steps: pre-analysis, material exploration with double categorization, treatment of the results obtained and interpretation.

The major study was approved by the Research Ethics Committee of Hospital de Clínicas de Porto Alegre under number 536.662

Results

It was verified that 74% of the caregivers were women, with a mean age of 54.04±10.17 years old and mean educational level of 13.96±4.87 years of study. 42% were married or had a partner, 58% had formal employment, and 63% of the participants were the main caregivers, assuming full-time care. Out of the participants, 63% were daughters caring for their mothers and 61% lived with the aged parents. Among the adult child caregivers, 68% had children.

There were two thematic categories and two subcategories: the possibility of institutionalization of aged parents (with subcategories: under no circumstances, and in some circumstances considered) and expectation of care (with the subcategories: expect to receive care, and do not expect to receive care). During the process of analysis and categorization of the speeches, the inter-relationship between the thematic categories was identified, since often the attitude of the child on the institutionalization of the parents also reflected the answers about what he wished for himself in his care, besides the influence of what he lived in this process, as in the case of the integral care and overload that many did not want their children.

Possibility of Institutionalization of Aged Parents

This category emerged from the questioning of adult child caregivers whose parents were not institutionalized, under which circumstances they would consider the possibility of admitting their parents to a LTII.

They did not consider under any circumstances

When questioned, 61 adult child caregivers (64%) did not consider any possibility for such, as evidenced in the following statements:

I do not want [...] I want to take care of her..., unless I cannot do it, I do not accept (F5).

In fact, I would not think. The most we would tolerate would be a necessary hospitalization, of course, but putting her in a clinic [...] would not think about it [...] (F29).

No way (F30).

Among the justifications for non-institutionalization, 27 caregivers reported a preference for family care, keeping their parents in their environment:

We do not evaluate this, the family does not evaluate it [...], we have always opted to keep her in her house [...] (F8).

None, first because I would not walk away from her and I do not think I would have a reason and I would not have a reason for her to leave the house from where she has all the attention [...] because, however good it is, it's not her house, and so it really never crossed my mind and did not even think (F26).

I do not think [...] that from the moment you take a person home, unless she has a total dementia, the person dies. If one takes her life, if takes it out of her space. [...] (F83).

There were also talks about previous negative experiences with the institutionalization of other family members, and institutionalization as a form of helplessness:

Oh, not at all [...] because I already had my father in a nursing home and he was very mistreated, and very poorly taken care of (F17).

No, I think, this I think without cogitation, this is a kind of abandonment (F10).

Ah, I do not admit [...] I think they, I worked at geriatrics home. I think they lose a lot of reference [...] they get very lost (F16).

Another reason would be the difficult coexistence, because they believed that the parents would find difficulties in a collective environment, besides the non-acceptance of the institutionalization by the parents:

For her. She thinks she could not live in any collective environment. [...] She is a very determined, very determined, very stubborn person (F57).

No, but I know that my father does not admit to living in the clinic [...] I promised them that if I had to, I would set up a mini-hospital in the house [...] (F61).

Because he does not want to. He is an extremely lucid person, one has already talked a lot about it [...] not put in a clinic, because I know he does not want it (F64).

Feelings of responsibility and duty to care for aged parents were reported by the adult child caregivers. The speeches show the care to the parents as a form of retribution for the care received in childhood:

None, [...] because I think it's my duty even as a daughter to take care of her (F49).

After all, they've taken care of us since we were born, so when they get old, they do not even have children and we must take care of them. Obligation (F58).

No, I would not consider [...]. He's already taken care of us, looked after his grandson, even has a great grandson now, and we would not put him down. The obligation is ours to take care of (F80).

They considered in some circumstances

Of the 95 adult child caregivers, 34 (36%) considered the institutionalization of their parents in some circumstances, although often the speech was accompanied by the denial of institutionalization. The admission of the aged to a LSIA was pointed out in circumstances in which the caregiver and other family members were no longer able to provide the necessary care at home, either due to worsening of the aged or caregiver's health condition due to changes in family structure, others:

This is a very difficult decision [...] I think the day that I really cannot take care of her anymore, for physical or financial reasons, I cannot do it anymore (F7).

Circumstances that I can no longer watch, of course, must have more specific care, kind of nursing, must take a serum, a medication, something more complicated so we do not know at home, right.

Unless it is something that fades, for example, that he becomes very weak in the cognitive deficit, for example, or that he is no longer able to communicate his needs, he needs a special treatment, while we do not have it (F35).

Respondents also considered institutionalization if one of their parents died, since they could not maintain the necessary organization for care, or because of the difficult coexistence:

[...] she does not want me to even talk about it, but if one of them dies, I certainly cannot live with my mother in my house too, my mother is very difficult (F54).

In the last case I would put [...] would be placing her in a clinic for a loss of the father, and I do not really have the conditions of physical space inside my house to take care of her (F55).

Some adult child caregivers thought about the possibility of institutionalization if it were financially accessible or other forms of support, such as some place where the aged could spend a day or period. They also pointed out the difficulties in having a hired caregiver:

Oh, if I could, it would have been the day before yesterday [...] I have been with her in this situation for 26 years, and for five years she stopped walking […] I do not have financial conditions.

[...] it is, I even thought about it once, but because the value was very high, I gave up, because sometimes it is a burden, and I am alone [...] Look if it was a more accessible thing, I do not say drop there, but a period or the day (F40).

I've been thinking about it, right. Because I have a caregiver [...] who is hospitalized, so she probably will not come back to me [...] for finding a trustworthy person (F51).

Participants also reported positive aspects related to institutionalization, such as greater social network for the aged, better care and lesser burden on caregivers:

Well, there are places like this that are very good, that they even communicate and have a much better life than at home sometimes, without people of the same age to talk, to knit, I do not know, for anything [...] (F11).

It has wonderful clinics, I have some friends, I have already visited [...] (F90).

Expectation of Care

Participants who had children (68) were asked about their expectation of care for their children during aging. Two thematic subcategories emerged which are presented below.

They expected to be cared of

When questioned, most caregivers (68%) reported expecting to be cared for by their children in their old age. Many respondents hoped to receive this care in a spontaneous way, due to the care they had with the children and example they took care of their parents:

[...] because each one is one way, right, so I've always tried to protect [...] I hope they do exactly what I'm doing for them (parents) (F36).

Yes [...] not because I'm doing it for her, but if I need to, I think it's the natural law of life. The love you give your children that they may one day do it for you, when you need it (F55).

Let them do the same thing to me. Let them take care of me the same (F92).

Some adult child caregivers expected care in their old age, but this could be through attention and affection, considering the case of their institutionalization:

Well, I expect his presence. Not necessarily how I am doing it, because I think it involves a lot of things. [...] I hope he's present, maybe I'm in a geriatrics, you see, that does not mean he has to do the same thing (F18).

Let her be careful with me, but let her not sacrifice herself like this, let her be present, but if she thinks it is best to leave me in a nursing home, that's all right.

It was evidenced in the speeches that the participants did not want to demand care for their children, and hoped they did not need care:

I do not want to get into my old age without a structure [...] I want them to have affection, but do not have to take care of me, because it is too much (F21).

I hope I am not a burden [...] And I always said like this: I hope that, the day that I need, I have you by my side. My children, we need our children very much (F96).

Participants reported that care should not be looked upon by children as a duty, but they expected the presence of their children during their aging.

I put them in the world, I have the obligation. They did not put me in the world, so I think, if they want or if they have time [...] that's okay, take care of the old mother [...] (F11).

Oh, I hope you do not have to take care of me. But this way, I do not charge of son this thing of: Oh, you're going to have to take care of me. Because I think about it a lot: children were not prepared to take care of their parents [...] (F70).

They did not expect to be cared of

The lack of expectation of care was evidenced in the speech of some participants (32%). Of these, a large part evidenced that she did not expect to be cared for by her children, considering her admission to a LSIA as a means of receiving the necessary care in her aging process:

I do not expect anything from anyone, I'm already getting ready to go to a geriatrics, I do not want to depend on anyone [...] everyone has their life, son, family, everything (F46).

No. My daughter is going to put me in a clinic. And I prefer it! (F63).

I do not think they have the function to take care of me. Because each one has his life. I would have thought, however, if I could afford it, to stay in a clinic (F75).

Among the reasons, a change in values and principles over generations has been reported, distancing their children from the role of caregivers.

Look, frankly, I do not expect anything. I expect nothing from this generation. I'm already scheduled, I am going to a clinic, I want to go (F10).

No […] because life today is different, right, we do not want to occupy them like that, they have their lives, right? (F44).

I think we raise children not to take care of people, I think we raise our children for life [...] I do not have that idea of the old generations [...] they created a lot of children for their old age, to me that's... selfishness, you know? (F91).

The separation of the parents, resulting in distancing the children was one of the factors cited by respondents who did not expect care in their old age from their children:

I do not expect much, no [...] because they were raised too far from me and, I do not know, I do not think so. In my old age I do not think so (F1).

I do not expect much, because I almost have no contact with her, understand? [...] there is not that one, you know? That son bond, so I do not expect too much (F67).

Some respondents mentioned that they did not expect to receive care from their children because they were male:

I want to go to a clinic. I want to go [...] they are three men and her, my daughter, is the only daughter and she has her life, her problems, she will not have conditions [...] (F17).

Look, I have two sons and a girl, a woman [...] The boys will be more difficult because it is with daughter-in-law, [...] But I'm going to tell her that if one day I cannot do something or bother her, she can put me in a clinic [...] (F100).

Discussion

Attitudes of filial responsibility were evidenced in the speeches of caregiver children who denied institutionalization and those who considered it in some circumstances. Among the negative ones for institutionalization, the preference for home care was pointed out to their aged parents. In an earlier study conducted by the researchers on this subject¹¹, the preference for home care was also identified, justified by the possibility of preserving social networks and family life, preserving their environmental ties and affective bonds. These findings corroborate with what is recommended by the Brazilian legislation, which guides that care for the aged should preferably be carried out at home, to the detriment of institutionalization⁶.

For the older Brazilian generations, LSIAs still carry brands, as they acted more as a social support for the aged without financial conditions and family support⁸. However, in the Brazilian reality, LSIAs have been modified in order to provide qualified care, which often cannot be offered at home².

Another justification for non-institutionalization was the understanding that this action would represent the helplessness of the aged parent. This finding is like that found in a qualitative study carried out with adult child caregivers of aged Chinese parents, who sought to analyze family dynamics in the institutionalization process. Institutionalization was seen by parents as abandonment and disrespect of their children, even though the country has government-funded institutions with quality care and with more accessible values¹⁵. These findings may also be related to the moral and legal issues of care for aged parents present in both countries.

It has also been reported by adult child caregivers that parental care is a form of retribution for the care they have previously received. These results refer to the concept of delayed reciprocity proposed by Funk, in which the care given to the aged parents would be a way for the caregiver children to reciprocate the care received during childhood¹⁶. In the Canadian study, this concept was rejected as a view of simple caregiving, which would place care of aged parents as an obligation, and study participants preferred to see reciprocity as a return of love and affection to aged parents. It should be emphasized that care for the aged in Canada is, as a matter of priority, considered as State responsibility, unlike the Brazilian reality.

The non-institutionalization of the parents was considered by some adult child caregivers due to negative experiences in the institutionalization of other relatives. This finding refers to the need to qualify care in these services. On the other hand, it was evidenced a study in which the aged themselves opted for institutionalization after having contact with positive experiences of family and friends, but that was done in another context¹⁵.

Regarding the possibility of institutionalization, the adult child caregivers reported the worsening of the health of the aged and their dependence to perform activities of daily living as limiting the care at home. This finding corroborates other national and international studies in which the aged with physical disabilities, dependence to perform basic activities of daily living and presence of chronic diseases were more likely to be institutionalized^17-19. In addition to the intensity of care, the home structure was reported by the adult child caregivers as a factor that hinders care, making them consider the institutionalization of their parents, also identified in another study¹⁸. However, in Brazil, institutionalization as formal support is still not the main source of support chosen⁷.

Related to the limitations of daily life, adult child caregivers also reported, as a reason for institutionalization, the occurrence of diseases that impair the cognitive ability of their parents, among which highlighted diseases such as Alzheimer's, Parkinson's and others. This finding is like that found in national and international studies, which identified that the cognitive impairment of the aged is associated with their institutionalization^17,19.

Institutionalization was also considered in the case of the death of one of the parents, which is in line with what was identified in other studies: a higher proportion of aged without a partner in the institutionalized group in relation to the group of aged people living in the household^16,18. Faced with such findings, one can infer that changes in family structure are quite pronounced and have altered the way of planning care, to a certain extent, reducing children's obligations to aged parents.

The high value for maintaining an aged person in a LSIA was a factor pointed out by the respondents that limited the institutionalization. The same justification was identified in an investigation carried out in a municipality of the State of Rio Grande do Sul/Brazil, where the authors verified that the proportion of aged people with income greater than three minimum wages was higher in the group of institutionalized aged than those living in the household¹⁹. It is inferred that, in addition to the attitudes of caregiver children, financial limitation is a strong determinant for non-institutionalization, with care centered on the family because there are no other possibilities.

Controversially, a study showed that expenses with the maintenance of caregivers at home, especially in the higher dependency levels of the aged, where more than one caregiver is necessary to maintain care in an uninterrupted manner, are generally higher than expenses with a LSIA¹⁸. In these cases of financial unavailability to institutionalize or provide formal care at home, the informal caregiver is overloaded, who has no one to share the task of caring for. In addition, in Brazil the formal support network for long-term care is still incipient in the Unified Health System, which is more organized in the private network.

In addition to the high value to maintain the care routine, discussed previously, it was mentioned the difficulty in hiring and maintaining formal caregivers at home. In this regard, similarity was found with study results that identified that difficulties related to the hiring of good caregivers, maintenance of full-time care, management of absenteeism, as well as taking care of the caregiver's lack of care are factors that influence institutionalization¹⁸.

The positive aspects of institutionalization were also remembered by the participants. In a Chinese study, cited previously, about half of the children believed that institutionalization could help increase the social interactions of aged parents¹⁵. In addition, in research with professionals and the aged of a LSIA, greater sociability and a higher level of activities were reported for the aged, who previously could be deprived of this coexistence at home¹⁸. Such findings may be related to the fact that the family and the aged are not exposed to the impact generated in the daily life, in addition to preserving the quality of life of both.

In the responses regarding the expectation of care in their aging process, it was evidenced that the adult child caregiver expected to receive this care in a natural way, due to the care they had with their own children and the example they took care of their parents. This finding recalls the delayed reciprocity cited previously. Funk's study also addresses the concept of preparatory reciprocity as a way of demonstrating and modeling the expected care of their children in old age¹⁶.

Adult child caregivers expected greater retribution of affection and other forms of care, such as visits and emotional support. This withdrawal from the activities of daily living may reflect their experience, as they were going through this parenting situation and, most of the time, were overwhelmed by being the primary caregivers. In a Chinese study cited previously, institutionalized aged parents were satisfied with the possibility of receiving care from their children in the form of visits or by the proximity of the LSIA in relation to their children's residence¹⁵. This departure from daily activities still reflects that they did not want the same burden for their children, also predicting the limitation of the care network that should be accentuated due to the demographic transition.

As for those who did not expect to receive care from their children, institutionalization was pointed out as a way of receiving care that they would need in the aging process. This was also verified in a study with institutionalized aged people, in which the majority had children and the fact did not constitute a protective factor for institutionalization, which was mostly performed as a treatment and care option that families would not be able to perform¹⁸.

In the report of these children, another reason for not expecting care is the change in the values of the current generation, which takes children away from the role of caregivers. A study carried out in the state of Bahia/Brazil also found that in the care of the aged, sometimes conflicts arise because the aged has experienced other cultural contexts, with their beliefs that differ from the younger generations²⁰. In this sense, Brazil has been undergoing several social changes, impacting directly on culture, in the sense of dealing with situations.

In addition, it was reported that they did not expect their children's care because they had male children. Similarly, Chinese research investigated the motivation of older people who opted for institutionalization. Among the reasons, it was mentioned the relationship with the daughter-in-law, who was the major caregiver¹⁵. Although it is known that this is a cultural characteristic of that country, in which the wives of the eldest children are obliged to take care of their parents-in-law and not of their own parents, in our context, the predominant role of the woman as caregiver.

Other sources of formal care and support were not reported in the adult child's caregiver statements. One respondent suggested that if there was a place where the aged could spend a day or a period, it would already be of help to the adult child caretakers. The expansion of the care network for the aged, such as day care centers, might be able to respond to this demand. Alongside this, we note the immense responsibility of children in providing these care, and the low complementarity and responsibility of the State in supporting them, such as providing long-term care, among others.

Filial responsibility emphasizes the role of adult child caregivers in supporting their parents but neglects the role of formal government support to help the family. Although valued by Brazilian culture, it has been changing to give meaning to new relationships in the world today. This new standard affirms the responsibility of the adult child caregivers to respect and support their parents but emphasizes the importance of the State for the economic support and care of the aged and the importance of mutual respect between the generations.

Final Considerations

Knowing the attitudes of filial responsibility of adult child caregivers in relation to the institutionalization of aged parents is important as it bases and directs the practice of health professionals, who work in the care of the aged and their adult child caregiver, in the search for interventions, mainly those focused on educational strategies. These are aimed at qualifying care directed at this population, reducing care overload and strengthening the informal network. Moreover, they can be directed to generate reflections and possible cultural changes, regarding intergenerational relations, the negative/stigma of institutionalization, and gender differences.

In addition, the study has implications for public policies related to long-term care as a necessary demand in the face of changes in family structure. Although moral and legal care prevails in Brazilian culture, such changes incite the need to think along with families new forms of care, as well as to demystify the concept of institutionalization as abandonment, but as a form of care needed to support informal care network.

Regarding the formal support network, it is necessary to seek the organization of public services focused on the health needs of the aged population and their families, promoting the integration of actions and health services with provision of continuous, integral and quality care. In this perspective, the Best Home Program established by the Ministry of Health, and articulated to Family Health, is an important strategy that should be prioritized to ensure comprehensive care for the aged, family and caregivers at home. It is also worth noting the shortage of other services of the formal support network, such as day centers, which would enable the aged to attend during a period, reducing the caregiver's overload, and promoting the maintenance of the aged at home.

For nursing practice, this study will contribute to the organization of the formal network through health actions aimed at promoting the quality of life in aging and preparation for assistance to the aged and caregiver in the aging process, aiming at greater support for adult child caregivers and your parents. Also, the data presented here can be used for the purposes of management, planning and elaboration of public policies directed to this population.

As limitations of the study, it is identified that the investigation was carried out only with the adult child caregivers, not analyzing the attitudes of filial responsibility between the generations. Other studies that compare intergenerational attitudes may reveal new knowledge about the subject.

Referências

• ¹
  United Nations (US). Department of Economic and Social Affairs. Population Division. World population prospects: the 2017 revision: key findings and advance tables. New York: UN; 2017 [citado 2019 Jan 21]. Disponível em: https://esa.un.org/unpd/wpp/Publications/Files/WPP2017_KeyFindings.pdf.
  » https://esa.un.org/unpd/wpp/Publications/Files/WPP2017_KeyFindings.pdf.
• ²
  Camarano AA, Barbosa P. Instituições de longa permanência para idosos no Brasil: do que se está falando? In: Alcântara AO, Camarano AA, Giacomin KC, organizadores. Política nacional do idoso: velhas e novas questões. Rio de Janeiro: IPEA; 2016 [citado 2018 mai 2]. p. 479-514. Disponível em: http://www.ipea.gov.br/agencia/images/stories/PDFs/livros/livros/161006_livro_politica_nacional_idosos_capitulo20.pdf.
• ³
  Funk L. The interpretive dynamics of filial and collective responsibility for elderly people. Can Rev Sociol. 2010;47(1):71-92. doi: https://doi.org/10.1111/j.1755-618X.2010.01223.x
  » https://doi.org/10.1111/j.1755-618X.2010.01223.x
• ⁴
  Chappell NL, Funk LM. Filial caregivers: diasporic Chinese compared with homeland and hostland caregivers. J Cross Cult Gerontol. 2011;26(4):315-29. doi: https://doi.org/10.1007/s10823-011-9154-x
  » https://doi.org/10.1007/s10823-011-9154-x
• ⁵
  Gans D, Silverstein M. Norms of filial responsibility for aging parents across time and generations. J Marriage Fam. 2006;68(4):961-76. doi: https://doi.org/10.1111/j.1741-3737.2006.00307.x
  » https://doi.org/10.1111/j.1741-3737.2006.00307.x
• ⁶
  Ministério da Saúde (BR). Portaria nº 2.528, de 19 de outubro de 2006. Aprova a Política Nacional de Saúde da Pessoa Idosa. Brasília, DF; 2006 [citado 2018 mai 5]. Disponível em: http://bvsms.saude.gov.br/bvs/saudelegis/gm/2006/prt2528_19_10_2006.html.
• ⁷
  Lima-Costa MF, Peixoto SV, Malta DC, Szwarcwald CL, Mambrini JVM. Informal and paid care for Brazilian older adults (National Health Survey, 2013). Rev Saúde Pública. 2017;51 Supl 1:6s. doi: https://doi.org/10.1590/s1518-8787.2017051000013
  » https://doi.org/10.1590/s1518-8787.2017051000013
• ⁸
  Silva A, Dal Prá KR. Envelhecimento populacional no Brasil: o lugar das famílias na proteção aos idosos. Argumentum. 2014 [citado 2018 jun 15];6(1):99-115. Disponível em: http://www.redalyc.org/articulo.oa?id=475547142008
  » http://www.redalyc.org/articulo.oa?id=475547142008
• ⁹
  Guedes MBOG, Lima KC, Caldas CP, Veras RP. [Social support and comprehensive health care for the elderly]. Physis. 2017;27(4):1185-204. Portuguese. doi: https://doi.org/10.1590/s0103-73312017000400017.
  » https://doi.org/10.1590/s0103-73312017000400017.
• ¹⁰
  Pinheiro NCG, Holanda VCD, Melo LA, Medeiros AKB, Lima KC. Inequality in the characteristics of the institutionalized elderly in the city of Natal, Brazil. Ciênc Saúde Coletiva. 2016;21(11):3399-405. doi: https://doi.org/10.1590/1413-812320152111.19472015
  » https://doi.org/10.1590/1413-812320152111.19472015
• ¹¹
  Aires M, Weissheimer A-M, Rosset I, Oliveira FA, Morais EP, Paskulin LMG. Transcultural adaptation of the filial responsibility interview schedule for Brazil. Int Nurs Rev. 2012;59(2):266-73. doi: https://doi.org/10.1111/j.1466-7657.2011.00940.x
  » https://doi.org/10.1111/j.1466-7657.2011.00940.x
• ¹²
  Chappell NL, Funk L. Filial responsibility: does it matter for care-giving behaviours? Ageing Soc. 2012;32(7):1128-46. doi: https://doi.org/10.1017/s0144686x11000821
  » https://doi.org/10.1017/s0144686x11000821
• ¹³
  Aires M. Responsabilidade filial no cuidado aos pais idosos e a repercussão no bem-estar dos cuidadores no sul do Brasil [tese]. Porto Alegre (RS): Escola de Enfermagem, Universidade Federal do Rio Grande do Sul; 2016.
• ¹⁴
  Secretaria Municipal da Saúde de Porto Alegre (BR) [Internet]. Porto Alegre: SMS; c2019 [citado 2019 fev 12]. Dados demográficos IBGE 2010 [aprox. 1 tela]. Disponível em: http://www2.portoalegre.rs.gov.br/sms/default.php?p_secao=918
  » http://www2.portoalegre.rs.gov.br/sms/default.php?p_secao=918
• ¹⁵
  Chen L. Power and ambivalence in intergenerational communication: Deciding to institutionalize in Shanghai. J Aging Stud. 2017;41:44-51. doi: https://doi.org/10.1016/j.jaging.2017.03.004
  » https://doi.org/10.1016/j.jaging.2017.03.004
• ¹⁶
  Funk LM. 'Returning the love', not 'balancing the books': talk about delayed reciprocity in supporting ageing parents. Ageing Soc. 2012;32(4):634-54. doi: https://doi.org/10.1017/s0144686x11000523
  » https://doi.org/10.1017/s0144686x11000523
• ¹⁷
  Hajek A, Brettschneider C, Lange C, Posselt T, Wiese B, Steinmann S, et al. Longitudinal predictors of institutionalization in old age. PLoS One. 2015;10(12):e0144203. doi: https://doi.org/10.1371/journal.pone.0144203
  » https://doi.org/10.1371/journal.pone.0144203
• ¹⁸
  Malheiro AD, Nunes PRR. Institucionalização de idosos em Porto Alegre, RS. Unoesc & Ciênc - ACHS. 2015 [citado 2018 set 15];6(2):187-94. Disponível em: https://portalperiodicos.unoesc.edu.br/index.php/achs/article/view/7729/5168
  » https://portalperiodicos.unoesc.edu.br/index.php/achs/article/view/7729/5168
• ¹⁹
  Lini EV, Portella MR, Doring M. Factors associated with the institutionalization of the elderly: a case-control study. Rev Bras Geriatr Gerontol. 2016;19(6):1004-14. doi: https://doi.org/10.1590/1981-22562016019.160043
  » https://doi.org/10.1590/1981-22562016019.160043
• ²⁰
  Silva DM, Vilela ABA, Nery AA, Duarte, ACS, Alves MR, Meira SS. Dynamics of intergenerational family relationships from the viewpoint of elderly residents in the city of Jequié (Bahia), Brazil. Ciênc Saúde Colet. 2015;20(7):2183-91. doi: https://doi.org/10.1590/1413-81232015207.17972014
  » https://doi.org/10.1590/1413-81232015207.17972014

• Funding

  The present study was supported by the following institutions: Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES), the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), the Fundo de Incentivo à Pesquisa e Eventos do Hospital de Clínicas de Porto Alegre (FIPE/HCPA) and the Fundação de Amparo à Pesquisa do Estado do Rio Grande do Sul (FAPERGS).

Publication Dates

• Publication in this collection
  10 June 2019
• Date of issue
  2019

History

• Received
  08 Sept 2018
• Accepted
  30 Jan 2019