Preparation for Future Care Needs by West and East German Older ...

Journal of Gerontology: SOCIAL SCIENCES 2000, Vol. 55B, No. 6, S357–S367

Copyright 2000 by The Gerontological Society of America

Preparation for Future Care Needs by West and East German Older Adults Silvia Sörensen1 and Martin Pinquart2 1Utah 2Friedrich

State University, Logan. Schiller University of Jena, Germany.

Objectives. We evaluated a model of the process of preparation for future care needs. This model predicted that less concrete preparation activities (e.g., becoming aware and gathering information) would predict more concrete ones (e.g., deciding on preferences and making concrete plans), and that attitudes (expectations of needing care and negative beliefs about the usefulness of planning) would mediate the effect of vulnerability (age, ADL/IADL deficits) and resources (socioeconomic status, social network) on preparation activities. Methods. The Preparation for Future Care Needs Measure was used to assess two attitudes toward preparation (Cronbach’s ␣ range: .66–.86), four planning processes (Cronbach’s ␣ range: .75–.86), and the content of planning for future care needs. In addition, demographic variables, social network, and ADL/IADL limitations were assessed. Using path analysis, the model was first developed on a West German sample (n ⫽ 280), and then validated on an East German sample (n ⫽ 294). Results. The best-fitting path models suggested that more concrete preparation activities were predicted by less concrete ones, but not always in the expected sequence. Gathering information, deciding on preferences, and age predicted concrete planning. Indicators of vulnerability were mediated by expectations of needing care in the future and several preparation activities, especially becoming aware and gathering information. Negative beliefs about the usefulness of planning inhibited gathering information and concrete planning. Discussion. The results suggest that preparation for future care needs may be conceptualized as a successive process. Some individuals, however, may skip steps in the preparation process. For example, relatives may offer to provide care before the older adult has to decide among her or his options.

HE aged population (65⫹) is estimated to make up 12.8% of the U.S. population (U.S. Bureau of the Census, 1999). In Germany, this percentage has already reached 15.9% (Statistisches Bundesamt, 1999). Because the need for help or care tends to increase with old age (Hobbs & Damon, 1996; Jette, 1996; Schneekloth, 1996), there is increasing concern both in Germany and the United States about future care arrangements for older adults. While the majority of older adults have thought about future care needs or discussed them with family members, only 8–15% have actually made concrete plans for care (e.g., in Germany: Schmitz-Scherzer, Schick, Kühn, Plageman, & Krauthoff, 1977; in the United States: Kulys & Tobin, 1980; Sörensen & Zarit, 1996). Investigating preparation for future care in nations such as Germany, whose present population structures resemble those expected in the United States, can be quite useful in understanding emerging behavioral trends in the aging population. The proactive coping model suggests that mobilizing resources in advance of a stressful event, as well as considering and preparing for possible problems before the onset of a stressor, may prevent that stressor or may help cope with it and may improve well-being at the time of the event (Aspinwall & Taylor, 1997). Empirical applications of this model suggest that individuals who have made concrete plans are more likely to be satisfied with the level of discussion and planning in their family (Sörensen & Zarit, 1996),

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are less likely to suffer health problems due to loss of control over care arrangements (Brechling & Schneider, 1993; Reinardy, 1992), and are less likely to end up “scrambling” to find new living arrangements after they have experienced a crisis (Maloney, Finn, Bloom, & Andresen, 1996). The present study has two objectives: The first is to understand the interrelationships between preparation activities that lead to a final plan, which may be more or less concrete. The second objective is to identify the predictors of concrete planning and to uncover pathways to having concrete plans for the future. Path analysis was chosen in order to investigate the process of preparation in conjunction with specific predictors. The model is tested for a West German and an East German sample, which are culturally quite similar (e.g., valuing social welfare programs, saving for the future), but differ somewhat in the extent to which financial, informational, and structural resources are available. The resulting joint model is suggested as a conceptualization of preparation for future care needs that is valid across the two contexts. This study extends our previous work on preparation for future care (Sörensen & Pinquart, 2000) by applying a measure of preparation process, rather than merely the concreteness of planning content, and by using different samples. The German Social and Cultural Context The German and the U.S. care contexts are different in two respects. First, Germany has universal health care covS357

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erage, which provides government-funded health and care services to people at all levels of income, based on the individual’s level of physical need. Health insurance, family benefits, and social service programs are an intrinsic part of the German social welfare system (Gelfand, 1988). In addition, a new government long-term care insurance (Pflegeversicherung), funded through a special income tax, covers nursing care for frail individuals (Chappell, 1996). Because the German long-term care insurance covers a substantially higher proportion of physical care needs than does Medicare, older Germans need to plan somewhat less for the financial aspects of their care than older U.S. citizens—and recent research shows that in fact they do plan less (Sörensen & Pinquart, 2000). The second difference is the recent instability in the German health care system, which has resulted from the graying of society and from German unification (Scharf, 1999). Germans have recently experienced cuts in health care expenditures (e.g., a reduction in procedures for which medical doctors can be reimbursed; Scharf, 1999) and a change to the abovementioned system of long-term care provision. In the 1990s, Eastern Germans experienced additional disruptions when the East German health care system was taken over by the West German system after reunification. Health care systems in transition may confuse older adults because the government resources older adults plan to use in the future may no longer be available at the time they are needed. Confusion about available resources is likely to inhibit planning (Pinquart & Sörensen, in press). Despite these differences, substantial similarities also exist between Germany and the United States that make an understanding of the German experience relevant for Americans. First, both systems have the same options for receiving care (e.g., family, home health care, assisted living, nursing home), although there may be regional differences in access to these services. Second, although government-mandated insurance is not available in the United States, rapid growth in the long-term care insurance industry and newly legislated insurance-related tax breaks (Langdon, 1996) suggest that the use of long-term care insurance is increasing in the United States. Third, while the United States is not presently facing the same level of instability as is Germany, discussions about the solvency of Medicare and Social Security, as well as simple lack of information about care options, may well leave older Americans as confused as older Germans. Fourth, the factors that predict whether older adults make plans for future care are also similar. In both countries, activities of daily living/instrumental ADL deficits and age are associated with more concrete preparation (Sörensen & Pinquart, 2000). Finally, concern for the welfare of one’s children and reluctance to burden them with care are common to both cultures (McCullogh, Wilson, Teasdale, Kolpakchi, & Skelly, 1993; Thomae, 1987). Understanding the Process of Preparation for Care Scholnick and Friedman (1993) suggest that both the process (i.e., which steps are involved in planning) and the content of plans (i.e., which options are chosen and what level of detail in planning has been accomplished) are important

to understanding planning and problem solving. Explanations of the processes involved in planning have been described in theories of reasoned action (Heckhausen, 1989; Kuhl, 1981), planning in everyday situations (Scholnick & Friedman, 1993), and anticipatory coping (Aspinwall & Taylor, 1997). These theoretical approaches largely agree that planning involves a series of steps, including (a) gathering information about the present situation, (b) gathering information about future goal states, (c) evaluating various options for reaching these goals, (d) making and choosing specific plans regarding how to reach the goal, and (e) implementing these plans. However, one can not assume that every individual follows these steps exactly or even makes rational or mindful decisions. Langer (1994), for example, argues that because there is no natural endpoint to the decision-making process, people often commit to a particular alternative for nonrational reasons and then simply stop considering other possibilities. Janis and Mann (1977) also acknowledge that some individuals may prefer to choose the first available option when they are under stress or may rely on others to make decisions for them. Although “nonrational” approaches may be common (Langer, 1994), the assumption underlying the present study is consistent with Janis and Mann’s assertion that an ordered decision-making process that involves gathering information, generating alternatives, and then committing to options is more likely to lead to well-thought-out decisions that fit the individual’s true preferences. For important life decisions, such as where to obtain care, most practitioners would agree that having sufficient information is crucial to making an informed and well-fitting decision (Maloney et al., 1996). Several studies have identified styles or levels of preparation for future care in older adults or their adult children (Bromley & Blieszner, 1997; Hansson et al., 1990; Maloney et al., 1996). Based on the concept of anticipatory coping, a model and measure of preparation for future care proposed by Pinquart and Sörensen (2000a) suggests a series of components of making care plans: becoming aware of future care needs or avoiding them, gathering information about services, deciding on preferences, and making concrete plans. Because the majority of studies have not focused on the full range of components of preparation (e.g., Kulys & Tobin, 1980; Sörensen & Pinquart, 2000), or have not used samples large enough to test multivariate effects (e.g., Maloney et al., 1996; Sörensen, 1998), the first objective of the present study is to explore the process of preparation for future care needs. Although cross-sectional data do not allow an analysis of the order of steps in the care-planning process, they do allow a statistical estimate of the extent to which steps predict each other, because, according to Sobel (1995), an asymmetrical regression relationship between two variables suggests plausible directions of influence. To meet the first research objective, paths that represent the suggested process of preparation were specified. These are shown in Figure 1, where direct positive paths were hypothesized from the least concrete to the more concrete preparation activities, that is, from becoming aware to gathering information, from gathering information to deciding on preferences, and from deciding on preferences to concrete planning. Because this theoretical succession does not

A PATH MODEL OF PREPARATION FOR CARE

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Figure 1. Hypothesized path model for process and predictors of preparation for future care needs.

take into account the fact that some individuals may not plan in an incremental fashion (e.g., individuals whose relatives offer care before decision making is initiated), we also specified direct positive paths that skipped steps, for example, from becoming aware to concrete planning. Contributors to Preparation for Care Numerous background factors may affect the likelihood with which the different steps of preparation are executed. According to Aspinwall and Taylor (1997), factors that draw attention to or sensitize an individual to an impending stressor, such as an acute need for assistance with everyday tasks, might trigger proactive coping. In addition, access to resources that are helpful in ordinary reactive coping may also foster anticipatory coping. Thus, individuals who are more vulnerable to requiring help or care in the near future, as well as individuals who have the greatest access to resources that enable preparation, would be most likely to plan. Attitudes.—According to Aspinwall and Taylor (1997), the detection of a potential stressor is important in triggering the process of proactive coping, and people are more likely to plan to prevent a stressful future event if they expect it to have serious, stressful consequences (Berg, Strough, Calderone, Meegan, & Sansone, 1997). Thus, expecting to need care in the future should sensitize older

adults to their level of need and, thus, make them more aware of the need for planning. Also, a direct positive path between expectations of needing care and making concrete plans is hypothesized, because individuals who do not expect to need care are unlikely to make concrete plans even if they are confronted with care options or have ideas about which options they would not want. People generally only plan when they consider planning useful and beneficial for accomplishing their goals (Scholnick & Friedman, 1993). In an unpredictable environment (Berg et al., 1997; Pinquart & Sörensen, in press) or with severely limited planning resources (Goodnow, 1987), planning may not be viewed as useful. As is the case for expectations about care, beliefs about the usefulness of planning also are likely to affect preparation, just as agency beliefs are likely to facilitate control-enhancing behaviors (Skinner, 1997). Therefore, the attitude that planning is not useful is hypothesized to be negatively related to each of the three preparation variables. A relationship between expectations about care and beliefs about the usefulness of care planning is not specified because expecting an event can exist separately from the belief that one can control that event. Vulnerability due to ADL/IADL limitations.— Several larger studies, both in the United States and Germany, report that the ADL deficits and health limitations of indepen-

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dently living older adults predict their propensity to plan for care or expect nursing home use (Holden, McBride, & Perozek, 1997; Sörensen & Pinquart, 2000). Our theoretical model states that ADL/IADL limitations should affect preparation most strongly through creating greater expectations of needing care, rather than acting on preparation variables directly. Therefore, a positive path from ADL/IADL deficits to expectations for needing care in the future is specified. Vulnerability due to age.—The risk of needing help and care increases with age (Deeg, Kardaun, & Fozard, 1996). In addition, being older is likely to lead to greater expectations that one might need care in the future; older adults often observe an increasing number of peers who require care, discuss their future care with adult children (Sörensen, 1998), and expect that their advanced age will be linked to loss of competence (Harris and Associates, Inc., 1975). Because individuals are likely to feel more vulnerable with increasing age, it is hypothesized that with increasing age, beliefs in the usefulness of planning increase. Gender differences in preparation.—Gender is a third source of vulnerability. Because women tend to live longer than men, they are also more likely to require help with ADLs at some point (Schneekloth, 1996). Resources: social support.—Social support, especially from family, provides individuals with more options for planning, because closeness to family members is linked to more helping (Arber & Gilbert, 1989), more anticipation and planning for future care needs (Kulys & Tobin,1980), and more concrete planning content (Sörensen & Pinquart, 2000). However, because our theoretical premise is that the effects of resources and vulnerabilities are channeled primarily through their effects on attitudes, social support is expected to be negatively related to the belief that planning is useless. In addition, individuals who have more contact with family (Stoller, 1982) or have a larger social network may have more impetus and opportunity to discuss future care options with others. Thus, they may be more inclined to gather and consider information. As a result, a direct relationship from social support to gathering information is specified. Resources: socioeconomic status.—Two paths are hypothesized for socioeconomic status (SES). First, given the literature on the relation of SES on health and well-being (Lichtenstein, Harris, Pedersen, & McClearn, 1993; Pinquart & Sörensen, 2000b), as well as on health maintenance and prevention (Pill, Peters, & Robling, 1995), there will be a direct, negative path from SES to ADL/IADL deficits. In addition, people with ample financial resources and higher education are more likely to have access to expensive care options and greater knowledge about the formal support systems available to them (Chapleski, 1989; Wister, 1992). Thus, higher SES is likely to be related to lower levels of perceived uselessness of planning.

METHODS Samples and Procedures Sample 1.—A sample of 600 community-dwelling senior citizens, drawn randomly from official population registries of two large cities (⬎100,000 inhabitants) and rural areas in the state of Baden-Württemberg, Western Germany, was sent a mail-out questionnaire. The sample was stratified by rural/urban residence and gender. Because registries were largely outdated, 150 individuals were deceased, could not be located, or already required care. These persons were replaced by randomly drawn older adults. The replacements were not counted as additional mail-outs because they replaced individuals who had not actually received the questionnaire or were ineligible. Also, 150 additional questionnaires were mailed out in order to obtain a similar N for both samples. After reminder letters were sent to nonresponders, we received a total of 299 out of 750 questionnaires. The effective return rate, not including the replacements of deceased, relocated, or ineligible persons was 39.9%. Eleven of the returned questionnaires were eliminated because respondents were already receiving long-term care and eight because of missing data; thus, 280 (37.3%) questionnaires were analyzed. The respondents were 65–93 years old (M ⫽ 74.0 years, SD ⫽ 6.4 years). Forty-seven percent of this sample were female; 62% were married, 26.8% widowed, 5.3% divorced, and 6% never married. Participants had an average of 1.9 living children (SD ⫽ 1.3); 14.4% were childless. The older adults had an average of 9.4 years (SD ⫽ 2.0) of school-based education (equivalent to 10th grade in a U. S. high school vocational track); their median income was 2000 German Marks (about $1,180). Sample 2.—The same questionnaire was sent to 600 community-dwelling older adults drawn randomly from official population registries of two large cities (⬎100,000 inhabitants) and rural areas in the state of Thuringia, Eastern Germany. The sample was stratified by rural/urban residence and gender. Twenty-five respondents who were deceased, who could not be located, or were ineligible were replaced with new respondents. After reminder letters were sent to nonresponders, we received a total of 308 out of 600 questionnaires. The effective response rate, not including replacements for deceased, relocated, or ineligible individuals, was 51.3%. Fourteen of the returned questionnaires had to be eliminated because they required care or had missing data, leaving 294 (49%) respondents for analysis. The participants were 65–90 years old (M ⫽ 73.0, SD ⫽ 5.8 years). Almost half of the respondents were female (48.6%); most were married (64.5%); 27% were widowed, 5.1% divorced, and 3.4% never married. Respondents had an average of 1.9 living children (SD ⫽ 1.4); 13.9% of the participants were childless. Average schooling was 8.9 years (SD ⫽ 1.5; equivalent to 9th grade in a high school vocational track); median income was 1750 German Marks ($1,030). The West German respondents were on average one year older than the East Germans (t ⫽ 2.01, p ⬍ .05) which reflects the higher life expectancy in West than in East Ger-


many (Statistisches Bundesamt, 1999). In addition, the differences in income were significant (t ⫽ 3.35, p ⬍ .001), favoring West Germans, which reflects existing differences in social security pensions between the regions, not a sampling bias. The two samples do not differ significantly with respect to gender, number of children, and percentage of married respondents. Because we needed to use slightly different sampling frames, we were wary of the potential for these differences to influence our results. For example, our samples might have been nonrepresentative of the particular country or region from which we sampled, which might have led to selection bias on specific variables. Comparisons of the samples to the target population statistics of Western and Eastern Germany showed that with respect to the age distribution, as well as distribution of income and marital status, both samples are largely representative (Statistisches Bundesamt, 1999). In the West German sample, however, individuals with lower education are underrepresented

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slightly. The differences between the two samples, thus, are unlikely to have stemmed from sampling differences. Measures Table 1 contains the measures used in the study. The “Preparation for Future Care Needs” measure (Pinquart & Sörensen, 2000a) assesses subjective views of contributors to planning, aspects of preparation for future care needs, and care preferences. The following subscales were included: perceived usefulness of planning for future care needs (e.g., believing that planning is not useful); expectation of needing future help or care (e.g., believing that there is a good chance that one will need care); becoming aware (e.g., thinking about the future, comparing one’s health with those of other people, attending to information in the media about future health care needs of elderly people, talking to others); gathering information for future health care (e.g., by talking with friends or health care professionals about care options, observing or participating in the care of other people); de-

Table 1. Mean, Standard Deviation, Internal Consistency, and Retest Reliability of Attitudes About Planning, Process of Preparation for Future Care Needs, and Demographic Variables for West and East German Older Adults

Scale Attitudes Low usefulness of planning

Expectation of care Process Becoming aware

Number of Items 7

5

6

Gathering information

7

Deciding on preferences

6

Concrete planning

7

ADL/IADL limitations

13

Social network

Age

4

West (n ⫽ 280)

East (n ⫽ 294)

Cronbach’s Alpha

M

SD

West

East

Stability (3 Months)

6.9

23.5

6.6

.78

.73

.68

14.7

4.7

14.6

4.7

.66

.86

.75

17.3

5.7

17.5

5.8

.80

.83

.68

19.4

5.7

17.5

5.8

.86

.82

.67

15.8

5.5

14.9

5.5

.76

.77

.62

14.2

5.9

13.0

5.6

.75

.77

.70

14.5

3.6

14.3

2.8

.93

.89

.73

12.29

2.53

12.18

2.5

n/a

n/a

n/a

74.1

6.3

73.0

5.8

n/a

n/a

n/a

Sample Items and Coding Algorithm

M

It is impossible to plan for future care – you must take life one day at a time. 1 ⫽ disagree completely 5 ⫽ agree completely At my age there is a good chance that I will need care in the future.

20.7

Talking to other people has made me think about whether I might need help or care in the future. 1 ⫽ not true of me 5 ⫽ completely true of me I have been following the public discussion in the media to learn more about care options. 1 ⫽ not at all true of me 5 ⫽ completely true of me I have compared different options of obtaining help or care in the future and have decided which would work for me and which would not. 1 ⫽ not at all true of me 5 ⫽ completely true of me I have identified how I want to be cared for and taken concrete steps to ensure that those options are available (e.g., arranged to live with a relative). 1 ⫽ not at all true of me 5 ⫽ completely true of me 1 ⫽ need no help, 2 ⫽ need some help, 3 ⫽ can’t do at all Frequency of contact with family, friends, number of persons to confide in, and number of adult children

SD

Note: M ⫽ scale mean; SD ⫽ standard deviation; ADL ⫽ activities of daily living; IADL ⫽ instrumental activities of daily living.

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ciding on preferences (general preferences about which forms of help or care the respondent would take into consideration or would not consider at all); making concrete plans (activities to make future health care plans come true, e.g., saving money or explaining the care preferences to close others). These scales have acceptable internal consistency (Cronbach’s alpha) and stability (assessed by sending the same questionnaires to 110 of the respondents after 3 months and calculating the correlation of T1 and T2 scores for the 103 returned questionnaires). A second group of variables focused on objective influences on preparations for future care needs. ADL/IADL limitations were measured using a 13-item list of ADLs taken from Mahoney and Barthel (1965) and IADLs taken from Lawton and Brody (1969). Respondents indicated whether they could do them alone, do them with assistance, or not do them at all. Three items were used to assess SES: number of years of schooling, postsecondary or vocational training, and net income. Because factor analysis (available on request) showed that all three items loaded on the same factor, the factor scores (calculated separately for the two samples) are used in the following analyses. Social network.—A four-item measure was used to assess the respondents’ social network. The items included were the number of adult children, the frequency of contact with family members, the frequency of contact with friends and acquaintances, and the number of persons the respondent could talk with about personal problems. As recommended by Bollen and Lennox (1991), internal consistency was not computed for this measure because the frequencies of social contact with family members and with friends are not assumed to correlate positively, although both do measure social resources. Finally, age and gender (1 ⫽ male, 2 ⫽ female) were also assessed. Results The initial path analysis that was computed for the West German sample using LISREL 8.03 (Jöreskog & Sörbom, 1998) resulted in a poor model fit (␹230 ⫽ 52.02, p ⬍ .08, GFI ⫽ .96). The modification indices suggested adding three new paths: from gender to deciding on preferences, from age to concrete planning, and from ADL/IADL deficits to concrete planning. Adding these paths resulted in significant improvement of the model fit (␹24 ⫽ 32.7, p ⬍ .001), a good fit of the final model (␹226 ⫽ 19.32, p ⫽ .82, GFI ⫽ .98), and an increase in the explained variance of concrete plans from 38% to 48%. This adjusted model was used to estimate the paths for the East German sample. No further paths were suggested by the modification indices. The adjusted model fit the East German data less well (␹226 ⫽ 36.54, p ⫽ .08, GFI ⫽ .98), though it was still acceptable. It explained 41% of the variance in the concrete planning variable. The path diagram depicting the model that resulted from the path analysis is presented in Figure 2. The path coefficients shown first are standardized partial regression coefficients for the West German sample, followed by the path coefficients, in parentheses, for the East German sample. Some of the hypothesized paths were not significant in the final model. Only those paths that were significant at the 5% level

in at least one sample are depicted in Figure 2. In the following, individual paths will be discussed. Interrelations Between Preparation Variables As hypothesized, direct, positive paths were present in both samples—from becoming aware to gathering information about care options, from gathering information to deciding on preferences, and from deciding on preferences to concrete planning. However, one path that “skips” variables, from gathering information to concrete planning, was also significant. Follow-up analyses revealed that, in the East German sample (though not in the West), the direct path from gathering information to concrete planning was significantly stronger than the indirect path through deciding on preferences. However, the indirect paths from becoming aware to concrete planning were significantly stronger than the direct paths for both samples. In order to check whether a competing, nonincremental decision-making model (Langer, 1994) might apply, the direction of the paths from deciding preferences to gathering information and from concrete planning to gathering information were reversed and the model was recalculated. In this alternate model the reverse paths were significant, but the fit of the model was not as good (East: ␹226 ⫽ 41.16, p ⫽ .03; West: ␹226 ⫽ 25.60, p ⫽ .49). Because both models had the same degrees of freedom, it was not possible to test whether differences in the model fit were significant. Thus, while the present data fit our hypothesized model well, alternative models can not be ruled out. Interrelations Between Attitudes and Process Variables As hypothesized, the older adults’ expectation that they will one day need care predicted activities to monitor their health (becoming aware). Because it was conceivable that becoming aware may have caused higher expectations of needing care in the future, the path model was recalculated with the direction of the arrow between the two variables reversed. This change resulted in a poor model fit (West: ␹222 ⫽ 189.74, p ⬍ .001; East: ␹222 ⫽ 44.73, p ⬍ .003). Comparisons to the previous model showed that the modified model fit was significantly worse for the West Germans (comparison of model fit ␹24 ⫽ 163.74, p ⬍ .001) and marginally worse for the East Germans (␹24 ⫽ 8.19, p ⬍ .10). Direct effects had been hypothesized for negative beliefs about the usefulness of planning on gathering information, on deciding preferences, and on concrete planning. The positive paths involving gathering information and concrete planning were significant in both samples, but the path involving deciding on preferences was not. The importance of beliefs about the usefulness of planning is supported by the fact that the direct path from believing that planning is not useful to concrete planning is significantly stronger than any indirect paths between these variables, although this is true only for the West German sample. Expectations for care were not correlated with beliefs about usefulness of planning. Relationship of Vulnerability and Resources to Planning Variables Hypotheses regarding direct effects of vulnerability and resource variables were also only partially confirmed. Con-


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Figure 2. Path model for process and predictors of preparation for future care needs, including new paths.

sistent with our expectations, ADL/IADL deficits and higher age were positively related to greater expectations for future care need. In the West German sample, age had a significant, direct, and positive relationship to concrete planning. Contrary to our predictions, age was not related to beliefs about the usefulness of planning. Women made more decisions on preferences, but only in the West German sample. With regard to resources, SES was neither related to beliefs about the usefulness of planning nor expectations of need. However, consistent with our hypotheses, more social support predicted less negative beliefs about the usefulness of planning for East Germans and more information gathering for West Germans. With regard to the interrelationships between measures of vulnerability, several were significant, as hypothesized. Age was positively related to ADL/IADL deficits, but the path from being female to ADL/IADL deficits was not significant in either sample. The hypothesized negative relationship of SES to ADL/IADL deficits was significant for West Germans only. Finally, the sum of direct and indirect effects on concrete planning was computed. As shown in Table 2, concrete planning was primarily a function of direct and indirect effects of having gathered information, believing that plan-

ning is useful, becoming aware, deciding on preferences, expecting care in the future, being older, having greater ADL/IADL deficits, and having a larger social network. In addition, being female was related to planning in the East German sample. SES was the only variable that was not related to concrete planning by a summed direct and indirect path. East–West Differences East–West differences were small. The associations of gender and age on preparation variables were significant for West Germans only. In contrast, social network was related to beliefs about planning for East Germans only. However, 95% confidence intervals showed that none of the differences between the path coefficients were significant at p ⬍ .05. As our model was tested on two samples, we retested the model using a Bonferroni correction. The effect was marginal, with all but one path (from social network to beliefs about planning, which changed from p ⬍ .05 to p ⬍ .06) remaining significant. DISCUSSION The first objective of this study was to understand the interrelationship between preparation activities that lead to a final plan. The second objective was to identify the predictors of concrete planning, such as vulnerability and access to re-

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Table 2. Sum of Direct and Indirect Effects of Background Variables, Attitudes, and Preparation Processes on Making Concrete Plans Among West and East German Older Adults

ADL/IADL deficits Age Gender (female) SES Social network Expect care Belief planning is not useful Becoming aware Gathering information Deciding on preferences

Sample 1 (West Germans) (n ⫽ 280)

Sample 2 (East Germans) (n ⫽ 294)

.20*** .28*** .01 ⫺.01 .11*** .26*** ⫺.33*** .31*** .46*** .20**

.16** .18*** .03* .00 .09** .13* ⫺.35*** .25*** .50*** .19***

Note: ADL ⫽ activities of daily living; IADL ⫽ instrumental activities of daily living; SES ⫽ socioeconomic status. *p ⬍ .05; **p ⬍ .01; ***p ⬍ .001.

sources, and to uncover likely pathways to having concrete plans for the future. The main contribution of this study is that it presents a model of the process of preparation for future care needs, which has been rarely discussed in the literature to date. Moreover, existing studies have been mostly qualitative or have involved small samples (Maloney et al., 1996; Sörensen, 1998). The model presented here was tested using sizable samples and is valid—with some variation—for two samples in the German cultural context. Whether this model also holds true in other countries must be addressed in future research. Our research supports the general proposition that preparation activities that are less concrete predict preparation activities that are more concrete, that is, becoming aware of future care needs predicts gathering information about care options. Gathering information in turn predicts deciding on preferences for future care; and deciding on preferences for future care predicts concrete planning. The findings also suggest that not all older adults follow the hypothesized path from becoming aware to gathering information, via deciding on preferences to concrete planning. For example, some individuals may use a “hypervigilant” decision style (Janis & Mann, 1977), which is suggested by the direct positive path from gathering information to concrete plans. Because thinking about future care needs may provoke negative feelings, these individuals may hastily decide to pursue one option without previously comparing and weighing the different possibilities for obtaining care. In addition, when older adults discuss future care needs with others (e.g., while gathering information), their family members or health providers may offer ideas for care options and thus trigger or even take over planning. Individuals using this preparation strategy risk that the option they choose may not adequately meet their needs. An alternate explanation for these results may be that some older adults report having made plans, without deciding on one specific option, because they make general plans that can be modified as needed (Pinquart & Sörensen, in press; Scholnick & Friedman, 1993).

Gathering information plays a central role in the preparation process—it mediates the relationship between being aware of future care needs and making concrete plans. This is evident in the absence of direct paths from being aware to deciding on preferences and to concrete planning. Also, the fact that the sum of direct and indirect paths between awareness and concrete planning is larger than the simple direct effect in our data supports this mediator hypothesis. This conclusion is, therefore, consistent with previous theory (e.g., Janis & Mann, 1977) and research, which indicate that lack of information about available service options is a serious barrier to judging the appropriateness of certain care arrangements (Maloney et al., 1996; Weaver, Ross, Chapman, O’Brien, & Elstein, 1994). Another contribution of this study is clarification of the pivotal role that attitudes and beliefs play in predicting the formation of care plans. Consistent with the hypothesized model, higher expectations of needing care predict more activities to monitor one’s health (becoming aware). Although it is plausible that expecting to need care may trigger an immediate planning process without involving some of the intervening variables, expectations for care needs do not predict concrete planning directly in our data. Thus, Langer’s (1994) suggestion that individuals plan nonrationally, for example, by deciding on an option without previously collecting information, is not consistent with our findings for care planning. Another important finding is that the negative beliefs about planning predict less information gathering and less concrete planning, whereas they have no detectable effect on deciding about preferences. Individuals who believe that planning is not useful may not waste their energy on active preparation activities (Berg et al., 1997; Scholnick & Friedman, 1993), such as talking to others or reading in order to gather information, but they still may have preferences for or against specific care options. For example, some older adults may simply state that they expect their adult children to care for them, even though they have not researched other types of care. In the original model the influence of vulnerability and resources was mainly mediated by expectations that one may need care in the future and by attitudes regarding the usefulness (or uselessness) of planning. These mediator effects are present for ADL/IADL deficits, age, and social network, but not for SES. This result is consistent with a previous study on influences on the concreteness of plans, where SES was found to influence care planning in American older adults but not in East Germans (Sörensen & Pinquart, 2000). The lack of influence of SES may reflect the particulars of the German system of care for elders, where a mandatory insurance for long-term care needs (Pflegeversicherung) covers most of the in-home and nursing home care needs. Also, Cockerham, Kunz, Leuschen, and Spaeth (1986) suggest that SES is not related to more health prevention activities for Germans (as opposed to Americans) because the variability of income and education is smaller in Germany than in the United States. In addition to indirect paths to concrete planning for future care needs, some direct effects of vulnerability on preparation activities are present. First, there is a direct effect of


age on concrete planning for West but not East Germans, although differences in the path coefficients are not significant. The direct effect of age, but not ADL/IADL deficits, may be due to the fact that relatives are more likely to provide plans for older adults of more advanced age (Hansson et al., 1990; Sörensen, 1998), but they may not be as aware of ADL/IADL deficits, if they do not see the older adult on a regular basis. Since many younger East Germans have lost their jobs and moved, their ability to suggest plans for their aging parents may be reduced compared to West Germans. Another direct effect on preparation is that women are more likely to have decided on their care preferences. Because in most families women are the primary caregivers (Schneekloth & Potthoff, 1994; Stone, Cafferata, & Sangl, 1987), they may have developed more concrete preferences for their own care needs while caring for other persons. In addition, women are more likely to outlive their husband, whereas men are likely to rely on their wife for care (Stone et al., 1987). Because men cannot be certain that their wife will be able to care for them, but are also not exposed to other care options, deciding on preferences is more restricted for them. Thus, when working with older adults, different strategies may be necessary in helping men and women with developing realistic plans. The East–West difference for this path may be due to the fact that a much higher proportion of older East German women were in the workforce and, therefore, less likely to be exposed to the same types of caregiving experiences as the West German women. While some East–West differences were found in this study, the path coefficients were not significantly different from each other. Moreover, there are far more similarities than differences between the two regions. This supports the validity of our proposed model because the majority of the paths are not sample-specific. This is the case despite the differences in response rate, which might magnify the differences between the samples. Thus, an important contribution of this study is to provide a model that may be generalized to some degree across two social structures that are different with respect to the availability of resources and recently experienced social change. Future research might replicate this model with samples from other cultural contexts. Two limitations of this study should be kept in mind. First, because of the low overall response rate, both samples are most likely biased toward older adults who are healthier than average, who have higher education (only for West Germans), who are willing to think about future care needs, and who are more likely to respond to questionnaires. Unfortunately, analyses of nonresponders were not possible in this study because we did not have additional information about the nonresponders. This limits the generalizability of the study. However, the samples are largely representative of the populations with regard to the other demographic characteristics (gender distribution, income, age). The sample’s higher education levels probably do not significantly affect the relationships between variables uncovered in the path analysis because the effect of SES on preparation for care is primarily due to income rather than education (Sörensen & Pinquart, 2000). Greater representativeness with

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regard to education would probably also not affect mean levels of preparation, because SES has no direct effect on levels of preparation in this and other German samples (Sörensen & Pinquart, 2000), and even the indirect effect through ADL limitations is not significant in the present sample. The fact that the sample is healthier than the general population is due to the fact that we screened out individuals already receiving care because our goal was to assess plans before care needs were present. It is conceivable that, for individuals in poorer health, preparation for future care needs would be more likely to follow the “skipped steps” pattern mentioned above. For example, older adults in poor health may already require some assistance. Therefore, choices are more likely to be made for them by others. A primary limitation of our process model, therefore, is that it applies primarily to relatively healthy older adults with fewer than two ADL limitations. The response rate is also affected by the fact that older adults who are “avoiders” are much more likely to discard a questionnaire about planning or to send it back unanswered and, therefore, to be underrepresented in our sample. This source of bias might have caused us to find higher mean levels of planning than are common in the general population. However, the focus of this study is on the interrelationships of preparation processes and their predictors. Because the path analysis results are quite similar for the two samples, despite small differences in response rates and mean levels of planning, it is less likely that the findings regarding the process of preparation are sample-specific. Nevertheless, it is important for future research to measure preparation less directly or to find ways to motivate avoiders to participate in such research so that their patterns of preparation may be compared to these results. Second, the present study is cross-sectional. Thus, the direction of some of the paths can not be determined unequivocally. For example, it is possible that the path from expecting future care needs to becoming aware of care needs may be reversed in a longitudinal study, indicating that older adults who become aware of their future care needs are also more likely to expect to need care in the future. To truly assess the effect of expectations on awareness—and some of the other variables—over time, a longitudinal design would be necessary. However, while our analyses do not rule out reverse effects for some paths, logic precludes reverse effects for many of the relationships we found. For example, it is unlikely that there would be a path from expecting care to age or even from concrete planning to deciding preferences. We did test models involving reverse directions on some of the paths and found that the model fit was poorer than for the hypothesized model. Thus, while longitudinal studies are definitely necessary to obtain unequivocal support for our model, our analyses present initial supportive evidence. Despite these limitations, the hypothesized order of the preparation process variables from least to most concrete, as well as the role of attitudes, vulnerabilities, and resources, appears to be largely supported by our analyses, though more strongly for some relationships than others. The clearest pathways appear to involve the effects of indicators of

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vulnerability through the mediator of expectations for future care needs to preparation activities. In this pattern, gathering information plays a particularly salient role. This is important because many older adults are not aware of the care services available to them (Wister, 1992) and may be reluctant to think about care because they imagine it to mean nursing home care only (Pinquart & Sörensen, in press). Providing individuals with more information about care options may significantly assist them in planning efforts. However, based on the data presented here, this information may need to be coupled with a convincing argument that care could be needed, since the expectation of needing care appears to mediate the effects of vulnerability on becoming aware of care needs and, ultimately, on planning. The findings on expectations and beliefs suggest that to encourage individuals to consider and plan for future care, it might be necessary to first modify their beliefs. Practitioners and educators working with older adults might be well advised to structure programs around strengthening the belief in planning, for example, by modifying people’s control beliefs (Rodin & Timko, 1991) or by teaching the rescaling of goals to accommodate losses (Brandstädter & Rothermund, 1994). With respect to the direct effects of indicators of vulnerability and resources on components of preparation, the results are somewhat less conclusive. For West Germans, they suggest that being older and being female may make individuals more receptive to decision making and concrete planning, and, for East Germans, that having social resources encourages gathering information. Because social resources also are related to positive beliefs about planning for some individuals, efforts at enhancing the anticipation of care needs might include involving older adults’ existing social networks by targeting potential caregivers and providing them with planning tips. Although some important differences in the health care system between Germany and the United States exist, we have no reason to believe that the interrelationships between the preparation for care variables would differ substantially between the two countries. The concept of preparation for future care needs is based on more general theories of planning and decision-making processes, which are not thought to change in different policy contexts. Thus, one would expect Americans to pursue similar strategies for decision making as Germans, even if they may draw on different resources to cover their care. However, national and cultural differences are likely to affect the mean levels of observed preparation, because different sociocultural contexts may affect the perceived usefulness of planning, and differences in government funding of long-term care may affect the necessity to plan financially. Also, selected predictors of preparation may play a greater role in the United States. Acknowledgments 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, and a Field Research Grant from the Friedrich Schiller University of Jena, Germany. The authors thank Philipp Mayring at the Paedagogische Hochschule Ludwigsburg for assistance with access to the West German sample and

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Received August 24, 1999 Accepted May 23, 2000