factors that promote and prevent preparation for future care needs

Health Care for Women International , 23:729–741, 2002 Copyright © 2002 Taylor & Francis 0739-9332 /02 $12.00 + .00 DOI: 10.1080 /0739933029010746 7

FACTORS THAT PROMOTE AND PREVENT PREPARATION FOR FUTURE CARE NEEDS: PERCEPTIONS OF OLDER CANADIAN, GERMAN, AND U.S. WOMEN Martin Pinquart, PhD Friedrich Schiller University of Jena, Jena, Germany

Silvia Sörensen, Ph.D University of Rochester, Rochester, New York, USA

The risk of needing help with household tasks or of requiring care in old age increases. Using semi-structured, qualitative interviews, beliefs about the usefulness versus uselessness of planning ahead for future care needs (FCN) were investigated in 23 East German, 10 U.S., and 10 Canadian elderly-communit y dwelling women (¸ 65 years). Primary reasons in favor of planning for FCN were: gaining a feeling of security regarding the future, avoiding being a burden to potential helpers, and coping with one’s present health conditions. Factors that prevent planning for FCN were: the dif culty foreseeing FCN, the lack of resources to plan, and low levels of perceived vulnerability. The women dealt with the contradictions between these factors that promote and prevent preparation by making general plans which could be adapted in the case of needing help by developing alternative plans or by avoidance of thinking about possible future health crises.

Getting old is associated with the increased risk of needing help or care. This has been documented in several industrialized countries, for example, in the United States (Hobbs & Damon, 1996), in Germany (Schneekloth, 1996), and in Canada

Received October 1999; accepted April 2001. Special thanks to Kelevelyn Hurley, Sharon Koehn, and Catherine Roberts for help with data collection in Canada, and Brad Benson, Lisa Boyce, and Michelle Lewandowski for help with qualitative data collection and analysis in Utah. This study was supported by grants from the German-American Academic Council Foundation (Transcoop Program 1997/I), the Vice President for Research at Utah State University, a Field Research Grant from the Friedrich Schiller University of Jena, and the Centre on Aging at the University of Victoria. Address correspondence to Martin Pinquart, Department of Developmental Psychology, Friedrich Schiller University, Am Steiger 3 Haus 1, 07743 Jena, Germany. E-mail: [email protected]

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(Elliott, Hunt & Hutchinson, 1996). Recent research suggests that preparing for the eventuality of needing help or care (i.e. by making plans about how and where to obtain such care) may enable seniors to cope more effectively with increasing frailty (Groger, 1994; Sörensen, Pinquart, & Benson, 2000). Individuals tend to plan more, however, when they believe that planning will bene t them in some way (Scholnick & Friedman, 1993). Little is known about the extent to which individuals perceive such bene ts and how these perceptions might vary with social/environmental conditions, such as the structure of the social and health care systems through which care is provided. In the present study, we explore preparation for future care needs (FCN) in older adults in three countries that differ in their social and health care systems: Germany, the United States, and Canada. Speci cally, we focus on perceived factors that promote and prevent preparation for older women in connection with whether they live in regions that are resource-rich or resource-poor and whether they have experienced a great deal of recent change and upheaval in their respective health care systems. We focus on older women because they are at higher risk for needing care than older men in all three countries (Elliot et al., 1996; Hobbs & Damon, 1996; Schneekloth, 1996). Also, they have access to fewer sources of care. Among women 65 years and above, about 50% are widowed. This percentage is about three times as high as for men (Elliot et al., 1996; Hobbs & Damon, 1996; Statistisches Bundesamt, 1998). Because older women are more likely to live in poverty than older men (Arber & Ginn, 1991), paid help is less available to them than for older men, except if they are eligible for welfare-based programs such as Medicaid.

Advantages and Disadvantages of Preparation for FCN Theories on role transitions such as anticipatory socialization (Hagestad & Burton, 1986) and proactive coping (Aspinwall & Taylor, 1997) suggest that preparing for a stressful event before it occurs may help prevent serious consequences and enhance coping at the time of the event. We conclude from this that preparing for FCN may be useful for older adults. However, most of the research on anticipatory socialization and proactive coping has been done on events that have a high probability of occurring in the near future. Whether one will need help or care in the future and which speci c types of support will be needed are, however, more dif cult to foresee for the individual, even though several risk-factors for illness and disability may be identi ed (Deeg, Kardaun & Fozard, 1996). Kulys and Tobin (1980) distinguished two kinds of uncertainty with regard to future crises: event uncertainty (uncertainty that a speci c crisis will occur) and time uncertainty (uncertainty of when the event will occur). Based on the uncertainty of future events, it is not obvious whether planning ahead for future health care needs is worthwhile. There is, however, some evidence that supports the usefulness of planning ahead. For example, studies on care decisions show that the need for care may appear suddenly (e.g., because of falls or strokes). In these situations, relatives are often charged with making decisions for the senior without his or her full input (Abramson, 1988; Brechling & Schneider, 1993). This is because, after a traumatic event, the older person may not be able to function at full capacity. In addition, such care decisions may have to be made under the pressure of time (Maloney, Finn, Bloom & Andresen, 1996; van Meter & Johnson, 1985). Communicating one’s preferences to family members, or arrang-

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ing in advance for one’s preferred care options, may, therefore, be very bene cial (Groger, 1994). However, there are situations in which preparing for FCN may have some disadvantages. For example, a plan may be obsolete if older people never end up needing care (because of sudden death), or it may become unrealistic given changes in personal circumstances or social context. In addition, previous research suggests that some aspects of dealing with the risk of needing care in the future, namely worrying about and anticipating the many dif culties and risks that lie ahead, are related to greater overall anxiety (Kulys & Tobin, 1980). Thus, some individuals may prefer not to dwell on possible future health problems or care needs, and may even actively avoid care planning altogether (Kulys & Tobin, 1980). In fact, several studies showed that only a minority of older adults has concrete plans for FCN. While about two thirds of seniors report that they have thought about possible future need for help or care (Schmitz-Scherzer, Schick, Kühn, Plageman, & Krauthoff, 1977; Sörensen & Zarit, 1996), only about 8%–15% have actually made concrete plans for such an event (Kulys & Tobin, 1980; Sörensen & Zarit, 1996), although the latter percentage may be higher when using qualitative interviews (Stoller, 1982).

Contextual In uences on Preparation for FCN Planning is frequently affected by individual, contextual, and cultural factors (Berg, Strough, Calderone, Meegan & Sansone, 1997). Contextual factors may include the social welfare and health care system under which the individual lives, as well as the extent to which the individual’s social-structural milieu and access to resources enhance or prevent effective planning (Mayer & Müller, 1986). Planning for FCN may be easier when one has enough individua l resources with which to plan ahead (e.g., nancial means), when the society is resource-rich with respect to options for care, and when future care options are easy to foresee (e.g., because the societal health care system is stable). Compared to residents of many Western countries, Eastern Germany can be considered resource-poor for two reasons. First, incomes are relatively low in Eastern Germany because of the wage structure of workers and because workers lost savings during the currency reform in 1990 (Schwitzer & Winkler, 1993). Second, German reuni cation has also led to a high level of instability, due to the process of restructuring the Eastern German health care system to match the West German system (Scharf, 1999). For example, the cost of nursing home placement in Eastern Germany has multiplied more than 10 times in eight years, and government funded long-term care assistance is now available only to those who meet particular criteria of incapacity. In contrast, the American system of health care has been quite stable for the last 10 years. The region of northern Utah, in particular can be considered resource-rich because of the high number of home health agencies, assisted living facilities, and nursing homes available in the area, as well as the additional community resources of close family ties and church assistance through volunteers offered by the Church of Jesus Christ of Latter-Day Saints (Mormon) church. The Canadian health care system provides universal health care that pays for a range of services which allow seniors to stay in their own homes, even when their income is low. Thus, the Western Canadian region we studied can be considered

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resource-rich. However, in 1995, during the period of our study, Canadian seniors experienced cuts in bene ts (which limited their assistance through home health care agencies to medical care and excluded home maker services. This development has been described as a threat to the government’s maxim of “aging in place” by policy experts (Chappell, 1994).

Research Questions Because so little is known about what makes older adults plan or avoid planning for FCN, we combined an exploratory, qualitative study of older, single (widowed, divorced, and never married) women with quantitative analyses of their responses. We selected a sample of non-married women because, when compared to men, women have a higher risk of requiring care, and single women have, on average, fewer resources ( nances, available helpers). Thus, they are more likely to bene t from planning ahead for FCN, but may also nd it more dif cult to prepare for these needs. Our rst research question focused on reasons why older adults plan for FCN. Based on Kulys and Tobin (1980), we expected that feeling safe (not vulnerable) at present and feeling uncertain regarding future care needs would be mentioned as arguments against planning for FCN. We expected that trying to avoid making care decisions under stress (van Meter & Johnson, 1985) would be a motive to plan ahead for FCN. In our second research question, we analyzed whether individual access to resources and the stability of the health care system in uence planning for FCN. Based on differences in the access to resources and in the stability of the health care system between our samples, we expected that Eastern German women would report more reasons against planning for FCN than women in Utah and Canada. We did not expect that one group of older adults would perceive only reasons that speak for preparation for FCN and another only reasons that speak against it. On the contrary, perceived factors that promote and prevent planning ahead for FCN may coexist in many respondents. For the case that respondents mention both reasons that speak for and against preparation for FCN, our third research question was how older women cope with these contradictions.

METHODS Sample Of the 45 elderly women who participated in our study, 23 lived in Eastern Germany, 10 in the United States, and 12 in Western Canada. They were recruited through newspaper ads, senior centers, and church groups in and around three university towns (Jena, Eastern Germany; Logan, Utah; and Victoria, British Columbia). They had a mean age of 76.2 years (65–86 years; SD D 5:0). Criteria for participation in the study were 1) that the respondent is living independently without reportedly needing assistance with activities of daily living (ADLs), 2) that she is over 65, and 3) that she never married, or is now widowed or divorced. We also tried to include individuals with both low and high income and education. The majority of participants were widowed, with an average of 2–3 children. Eight were divorced. About a third never married. Education levels ranged from 8 to 20 years of schooling. German women were found to have less education than the other two groups.


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Data Collection We conducted semi-structured interviews lasting between two and three hours each. The interviews were taped and relevant sections transcribed. Interview guidelines consisted of a series of questions that could be asked in varying order, depending on the ow of the conversation. We asked open-ended questions to explore the context, subjective meanings, antecedents, and consequences of preparation for FCN. Respondents were questioned about the values and dif culties they perceived in thinking, talking, and making decisions about FCN. In addition, we asked questions about age, number of children, education, and income. Objective health was measured by asking about serious health conditions. The respondents were coded as having good physical health if they mentioned no serious health conditions, fair health if they reported illness without serious in uences in daily life (e.g., having well-controlled diabetes), and poor health if their illness interfered with daily life (e.g., severe arthritis).

Data Analysis The qualitative analysis of these data was largely based on the method of modi ed analytic induction (Bogdan & Biklen, 1992). In the modi ed analytic induction approach, the researcher has general hypotheses prior to data collection, which are then con rmed or refuted as new themes and concepts emerge from the data. In the rst step of our analysis, we did a cross-case analysis (Huberman & Miles, 1994) of (1) the stated reasons and perceived advantages of preparing for FCN, and (2) the perceived reasons that speak against preparing for FCN. We developed initial categories describing the reasons respondents gave for and against preparation for FCN based on the ndings of previous studies (Kulys & Tobin, 1980; Sörensen & Zarit, 1996). Using interview transcripts and summaries as well as re ective notes generated during data collection and analysis (Huberman & Miles, 1994), we modi ed these categories and developed additional categories. In the next step, we coded whether these reasons were mentioned by the respondents. The frequency of each reason was calculated by summing up the responses across the respondents. Similarly, we developed categories on how the respondents coped with contradictions between reasons for and against preparation for FCN. Unlike the original analytic induction approach, we did not use negative case analysis to refute the emerging hypotheses; rather, we strove to describe more fully the variety of patterns. Once speci c reasons for and against preparation for FCN were found, we compared their frequency in the 3 subsamples through supplementary quantitative analysis in concordance with our 2nd research question. Combining qualitative and quantitative approaches has been suggested as an accurate method of testing and interpreting group differences that have been detected in qualitative research (Tashakkori & Teddlie, 1998; deVries, Weijts, Dijkstra, & Kok, 1992).

RESULTS In the rst part of this section, we discuss perceived reasons that speak for and against preparations for future care needs. Five factors that inhibit or prevent older women from preparation for FCN and three factors that promote such preparation were identi ed in the data. Because we found more factors that inhibit rather than promote preparation, we begin with the inhibiting factors.

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Reasons that Speak Against Preparation for Future Care Needs The respondents recognized that future care needs are dif cult to predict and that they may lack resources to plan for future care needs. Country (U–01–U–10 D United States, G–01–G–23 D Germany, C–01–C–12 D Canada), age, and marital status (nm D never married, w D widowed, d D divorced) are provided after each interview excerpt.

1. FCN and Future Resources can not be Predicted (N D 28)

Seniors in all three countries emphasized that a person can not know when and how much help she might need in the future. For example, a 79-year-old Canadian widow said: You don’t know what might happen—there are so many things. You can break your hip or you can get a stroke, or you can have some other things—a heart attack or whatever, and it’s impossible to know what condition you will be in. So, it is also impossible to know what I would want to do at the time. (C–09, 79, w)

While the majority of comments in this category focused on the dif culty of predicting care needs, a signi cant minority commented that the health care system is changing so quickly that one cannot predict what options will be available in the future and under what conditions. This theme was mentioned more often by the German women than by the U.S. and Canadian respondents: “But today everything is constantly changing. You always have to consider that : : : the nursing homes will raise their prices to such astronomical heights that you have to take it out of your plan, as well” (G–11, 70, nm). In addition to societal changes, potential changes in social context—for example, changes in the availability of potential helpers—were also named as a barrier to planning.

2. Planning Would Endanger Present Well-being (N D 13)

The second most frequent reason against planning for FCN that emerged from the interviews was the belief that thinking about future health care risks would reduce the present subjective well-being. This belief was often justi ed by having good health. For example, a 72-year-old American woman said: So far, I’ve been very fortunate and I’m in good health. So, I haven’t needed any special attention: : : : I guess, I don’t really want to think about it [needing care in the future]. I think if you dwell on something like that it gets worse. I’d rather keep going as I can, and when the day comes when I can’t, then I’ll worry about it. I just live from day to day. (U–10, 72, w)

A 71-year-old woman who never married tried not to think about the risk of becoming frail because such thoughts might make her depressed. Although she reported symptoms of depression after retirement because she was not prepared to be idle for eight hours a day, she again avoided preparation in order to protect her present psychological well-being: The older you get, the more things can go wrong, and then you start taking care of those things as they come up. But, I think to dwell on them is to say you’re there already: : : : It makes it morbid, sort of. But I think that until I have some of these frailties, why, I’m not going to really worry about them now: : : : I think you would go into a depression . (U–9, 71, nm)


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3. Perceived Low Vulnerability of Needing Care in the Future (N D 10)

A number of respondents felt that planning for FCN is not necessary (yet) because they are too young, too healthy, or because family members died without becoming so sick that they needed care over a longer period. For example, an 81-year-old Canadian widow did not want to plan for FCN as long as she could manage her household: “I just put it behind me because the rst inkling I will have that I really have got to start and think of it seriously is, as I told you, I won’t be able to manage the house” (C–10, 81, w). A 73-year-old German widow thought that she would have to plan for FCN only upon reaching the age of 80. Her optimism of not needing care in the next few years was based on the fact that her husband and her parents died unexpectedly without needing long-term care: You always push it ahead of yourself, you know: : : : When I’m 80, then things will become serious: : : : I wish that I can be healthy for a long time and then a quick death, not lying in bed for a long time, not withering away for years. That’s no good. I lost my husband within half an hour: : : : He fell down the stairs and didn’t get up: : : : My father had an accident when his lung was damaged and died after 6 weeks. (G–5, 73, w)

4. Resources are Insuf cient to Plan (N D 8)

The respondents considered a lack of nancial resources and relatives for whom they could turn as a good reason not to plan for FCN: “I always thought I could go into a nursing home. But now it is like this, my pension is not very large. Then my kids would have to pay. And I don’t really want that” (G–12, 71, d). Another women said: Some of us are going around and looking at these places, nding what’s availabl e and what you might have to do, and one time I thought: Well, if I had all kinds of money I’d like to buy an apartment, say across the hall, and have somebody live there that could just come over and help me when I needed it. But that’s sort of a pipe dream. (C–4, 78, w)

5. Relying on Plans of Others (N D 7)

A small group of respondents explained their lack of planning with the fact that others would be able to make better (more reliable) plans. These respondents expected to rely on the plans of their doctors or their adult children. The plan to rely on a physician’s decision was, in part, based on the fact that a medical decision would be needed to receive some kind of support (e.g., by the German long-term health insurance). For example, a German divorcée reported: You can’t plan to move into a nursing home like in past times. A doctor would have to give his professiona l opinion. Because there are no availabl e places in nursing homes, the doctor would have to decide if you can move in. (G–4, 67, d)

Respondents who relied on care decisions by family members said that their adult children had brought up the topic. For example, an American widow who had not made plans for future care mentioned that her daughters began discussing her FCN: “My daughters have both mentioned to come live with them. One asks all the time now: ‘Can I help?’ Who would make decisions for me? I hope it would be my daughter” (U–2, 77, w).

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Reasons in Favor of Preparation for Future Care Needs Three reasons were named in favor of preparing/planning for the future. These reasons re ected the desire to use present knowledge and experience to shape the future.

1. Planning Helps to Cope with the Insecurity of the Future (N D 12)

Respondents who mentioned this theme thought that planning would help them to be better prepared for future health care needs and take charge of their lives. For example: “I can steer my life in the right direction, instead of sitting around, getting down, complaining, and waiting until someone comes from the outside” (G–01, 76, w). Another women reported: “And I, you just, it’s just a matter of common sense to look into the future and try to see your future needs. Because once a house starts burning, it’s too late to wish you had smoke alarms” (U–07, 65, w).

2. Planning for the FCN will Bene t Potential Helpers (N D 10)

Several respondents thought that one can avoid being a burden on helpers and prevent con icts by planning: Well, I guess it’s a realism, knowing that changes happen, and that you need to be aware of that in so far as you’re able at the time; you’re thinking about it, to do what you can to make it easier both for yourself and others, other people. (C–05, 75, nm)

3. Planning for Future Health Care Needs Helps Cope with Present Health Problems (N D 5)

Several women felt that having a plan for future frailty would help them cope with the challenges and worries of their present health problems. An example of this was a respondent whose planning for future needs was a reaction to her increasing frailty and the fact that her son lived close by but was disabled. I’m in the process of reorganizin g my life, since I am very ill. I’ve had three real heart attacks and the other two were probably angina pectoris. And I only have 22% of my bone substanc e left. And so I will move to Fürth into an assisted living facility. (G–03, 81, w)

In uences on the Perceived Reasons that Promote or Prevent Preparation for FCN In our second research question, we analyzed whether the perceived reasons that promoted and prevented preparation for FCN differ between older women from East Germany, Utah, and Canada. We used analysis of variance with post-hoc contrasts (ANOVAs) with LSD contrasts to test for group differences. There was a signi cant between-group difference regarding the perceived lack of resources (F .2; 42/ D 3:72, p < :05). East German women were more likely to say that lack of resources caused them not to plan for FCN (35%) than Canadian women (8%, p < :05) and women from Utah (10%, p < :10). Furthermore, we found a marginal betweengroup difference in the number of perceived reasons that promote planning for FCN (F .2; 42/ D 3:17, p < :10). German women reported, on average, fewer reasons that promote planning for FCN than Canadians (p < :05) and women from Utah (p < :10). In addition, we analyzed associations between perceived factors that promote and prevent preparation for FCN and age, the number of adult children, education,


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income, and health using point biserial correlational coef cients. Despite the small sample size, women with lower income were more likely to report that others could make better plans than themselves (r D ¡:35, p < :05) and, that fewer resources would prevent them from planning for FCN (r D ¡:29, p < :10). The women with the worse objective health were more likely to say that planning for FCN would help them cope with present health problems (r D :72, p < :001). Age, number of adult children, and education did not correlate with perceived factors that promote and prevent preparation.

Resolving Contradictions Between Reasons that Promote and Prevent Preparation for FCN In our nal research question, we looked at ways in which the women dealt with the contradiction between the wish to plan and the limitations on “planability”. One third of our respondents reported both reasons that promote and inhibit preparation for FCN. Contradictions between wanting to plan and not being able to were resolved by making very general plans (forming preferences) that could be adjusted according to actual FCN (N D 24). Several of the respondents did not speak of planning in this context, but rather used the expressions “developing ideas” or “make provisions.” While as researchers we would code these provisions as general plans, the respondents often did not consider this “making plans.” For example, one respondent reported: “Yes, I agree with planning and thinking of what might be, but that these plans aren’t concrete. They are something which would have to be looked into” (C–06, 75, nm). Another woman said: You can’t plan directly. You plan, but you can’t say that it will happen exactly that way. You can only say when you plan: I want to have it like this and that, if possible. But you can’t plan 100%. Fate often takes you down a very different path. (G–01, 76, w)

A smaller number of respondents also developed various alternative plans from which they could choose the best one later. For example, a 70-year-old German woman who never married lived with her sister and planned to stay in their shared home as long as possible by using home health care, if needed. In case of her sister’s death, she planned to move to a smaller apartment. She included nursing home care in her plans as a last option: I’m quite aware of what possibilitie s I have, and there are not many of them, and I know them all now. And when the decision really comes up, I just have to list all of these possibilitie s and then the decision has to be made. (G–11, 70, nm)

A number of respondents also resolved the contradiction between advantages and disadvantages of preparation for FCN by avoiding thoughts about the future, altogether (N D 8). Those seniors were marginally less likely to perceive reasons that promote preparation for FCN (r D ¡:27, p < :10) and more likely to perceive reasons that inhibit preparation (r D :29, p < :05). For example a German divorcée reported: You shouldn’t even think about that, that I could become such a case. Certain things you just push ahead of yourself: : : : If I think about this now, I would probably only burden myself unnecessaril y with problem s that are not yet relevant (G–23, 75, d).

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DISCUSSION In our rst research question, we were interested in beliefs regarding the usefulness of planning for FCN. Second, we analyzed in uences on planning beliefs, speci cally whether differences in individua l and societal resources and in the stability of the health care systems of Eastern Germany, the United States, and Canada would in uence the way older women reason about planning. Third, we investigated how older women coped with the contradictions inherent in planning for the future, especially for a very unpredictable event such as FCN. With regard to our rst research question, more reasons that prevent than promote preparation for FCN were mentioned. In concordance with Kulys and Tobin (1980), the dif culty of predicting FCN was a prevalent argument against planning ahead. While Kulys and Tobin focus on event uncertainty (in our study, whether FCN would come up and what kind of support would be needed) and uncertainty regarding time of occurrence (time uncertainty), our respondents reported a third aspect of uncertainty, namely, what resources would be available in case they needed care, which we call “resource uncertainty.” The belief that thinking about FCN would endanger one’s present well-being was the second prevalent disadvantage of planning ahead. In fact, many worries of older adults are focused on the worsening of health and loss of independence (Skarborn & Nicki, 1996). Thus, by avoiding the thought of future care needs, the respondents avoided worrying, thereby protecting their present well-being. Because the belief that preparing for FCN would endanger subjective well-being was not related to age and health, it may more strongly re ect a general style of coping than an objective estimation of one’s vulnerability (Kulys & Tobin, 1980). However, because of our small sample size, more research is needed to con rm this result. We also found that having fewer resources prevented long-term planning. Thus, when attractive options for receiving support are not available (e.g., money to pay for an assisted living facility or relatives who would provide care), there may be no alternatives left that make planning worthwhile. The most frequent belief in the usefulness of planning for FCN focused on reduction of uncertainty regarding the future and feeling prepared for future crises that may come up. Future planning can be seen as attempt to exert primary control over one’s life, which has been described as a primary mode of coping with developmental demands (Heckhausen, 1999). In fact, planning ahead for FCN may prevent the need to make care decisions under the pressure of time, or having no in uence over the decisions of one’s care (Abramson, 1988). Some respondents mentioned that planning for FCN helped them cope with a present health crisis. Because many health problems in old age worsen over time (Deeg et al., 1996), selecting a future care arrangement promotes an immediate feeling of security that one will be well cared for in the future. We interpret the tendency of respondents to plan ahead for their own care needs in order to avoid burdening others (especially adult children) as an expression of their parental role. For example, Thomae (1987) suggested that identifying with the fate of one’s children is a common coping style in old age. The in uences of resources and the stability of the health care system on preparations for FCN was our 2nd topic. The nding that East German women were more likely to perceive a lack of resources as a barrier of planning for FCN, and are less likely to mention advantages of planning for FCN, suggests that social-structural


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factors are at play. It is interpreted, rst, as a re ection of their relatively low level of income and savings (Schwitzer & Winkler, 1993), which restricts available options for future care. Second, because important aspects of their biography had been controlled and predetermined by the German Democratic Republic (GDR) government (e.g., choice of occupation), these women may not have learned to plan for themselves. In fact, several German women mentioned that this biographical experience shaped their attitude toward planning. The dramatic change in the community and in government-sponsore d care services created another barrier to preparing for FCN in East Germans. First, many long-term care plans were based originally on the previous societal system and are now no longer realistic. Second, future societal resources and care options are dif cult to foresee. For example, under the previous G.D.R. government, it had been possible to put one’s name on a waiting list for a retirement/nursing home. Since the introduction of universal long-term care insurance, acceptance into a nursing home and receipt of long-term care bene ts depends on whether one is classi ed as needing a high level of care. These changes and the resulting unpredictability cause many to state that planning is not very useful. East German women are not only more likely to mention inhibitors to preparation for FCN, but they are also less likely to name reasons in favor of preparation (e.g., that it provides more control over one’s future) than Canadian and U.S. women. There is some evidence that North American values and attitudes emphasize self-reliance— more so than German values. Also, because the German government support system is much more extensive than in North America, less individua l planning is required (Gelfand, 1988). Thus, taking control over one’s life and satisfying one’s needs for self-reliance by planning for FCN appears to have a larger value for women in North America than for women in Germany. The women in our study coped with the unpredictability of future care needs and resources by either not making plans or making general plans which could be made more concrete in the case of acute care needs. Because planning for future care reduces worry with the assurance that one will be taken care of (Salamon & Lockhart, 1980), making general plans appears to help protect well-being in the case of an unpredictable future. Making general plans that can be adapted to more concrete needs at a later date gives older adults a feeling of being prepared and of control over their lives. In addition, they make it possible to react exibly to the exact nature of future care needs and reduce the risk that plans for FCN may become unrealistic or obsolete. This exibility of goal adjustment is described by Brandtstädter and Greve (1994) as an important mode of coping for older adults. Our ndings support this notion while extending it speci cally to care plans.

CONCLUSIONS Because our study was exploratory and based on a relative small sample size, future studies with larger samples that include married respondents and males are recommended to generalize our results. Despite this caveat, three conclusions can be drawn. First, the dif culties of accurately assessing FCN and lack of resources are substantial barriers to planning. Second, making exible plans is a creative way of coping with the contradictions between the wish to control one’s life and the dif culty of predicting the future. Third, interventions may focus on low resources and perceived low vulnerability as barriers to planning ahead. Enhancing resources

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(e.g., by early planning for nancial needs in retirement) and enhancing knowledge about available resources may reduce barriers to planning for future care needs. Because individuals may not recognize their vulnerability to needing care, doctors treating common health problems are good sources of information to help older adults understand their health risks and to provide information with which to plan ahead.

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