Preparation for future care needs - Springer Link

Journal of Cross-Cultural Gerontology 15: 349–381, 2000. © 2000 Kluwer Academic Publishers. Printed in the Netherlands.

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Preparation for future care needs: Styles of preparation used by older Eastern German, United States, and Canadian women SILVIA SÖRENSEN1 & MARTIN PINQUART2 1 University of Rochester Medical Center; 2 Friedrich Schiller University of Jena

Abstract. Many older persons have chronic conditions and limitations in their everyday functioning. While some individuals prepare for their future care needs, many others do not. Using semi-structured, qualitative interviews, discourse about dealing with the risk for needing help or care in the future was investigated in 23 East German, 10 U.S., and 12 Canadian elderly community-dwelling women (>65 years). Eighty percent had thought about future care needs; 64% had made general plans for their future care. Four preparation styles were identified in the three social-structural contexts: Avoidance of preparation, thinking without planning, short-term planning, and long-term planning. Individuals using these styles differed in their subjective assessment of preparation as well as in objective personal conditions. More similarities than differences were found between German, U.S. and Canadian women in the use of these styles. Results suggest that limited resources, system instability, and personal characteristics contribute to the choice of planning style. Keywords: Anticipation, Care planning, Elderly, Planning styles, Qualitative research, Women

The majority of older persons in industrialized countries have at least one chronic disease and many have several chronic conditions leading to limitations in everyday functioning (Hobbs & Damon 1996; Schneekloth 1996). However, while numerous behavioral factors (Deeg, Kardaun & Fozard 1996) and social risk factors (George 1996) for illness and disability have been identified for elder persons, it is impossible to predict for particular individuals whether they will actually require care in the future. In fact, the need for personal care often appears unexpectedly as a result of an acute event (e.g., falls, strokes). Thus, decisions about care often have to be made either under time pressure or in situations in which the older person is no longer able to make appropriate decisions (van Meter & Johnson 1985). It is in this context, that senior’s own future plans, made in advance of the need for care, could be crucial in making appropriate care arrangements. Several theoretical approaches to role transitions (e.g., Hagestad & Burton 1986; Merton 1966) and to proactive coping (Aspinwall & Taylor 1997) suggest that preparing for problems and decisions in advance of a stressful event is likely to improve later coping efforts. Whereas the ways

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in which individuals prepare for their future care needs has been investigated retrospectively (Maloney, Finn, Bloom & Andresen 1996) or in relation to the family caregivers’ plans (Bromley & Blieszner 1997; Hansson et al. 1990), little is known about the processes by which older adults prepare for their future care needs. Thus, the first objective of this paper is to explore qualitatively the existing styles of preparation for future care among seniors and to compare how the individuals who use each of these styles differ from one another. Planning is influenced by individual factors (Sörensen 1998) as well as by contextual factors (Berg, Strough, Calderone, Meegan & Sansone 1997) and the interaction of individual and contextual factors (Maloney et al. 1996). Individual factors include an individual’s vulnerability to needing care soon as well as his or her personality. For example, Sörensen and Pinquart (2000) found that larger ADL-deficits and higher age were associated with more concrete preparation, whereas Sörensen (1998) reported that internal locus of control was associated with more anticipation of future care needs. No previous studies have investigated the role of such individual factors in relation to particular styles or levels of preparation, especially with regard to respondents’ perceptions of the importance of these factors. Thus the second objective of this study is to compare styles of preparation with respect to individual differences between respondents, including their own subjective views of what are important determinants of their planning for future care. Contextual factors that can contribute to preparation for future care 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 enhances or prevents effective planning (Mayer & Müller 1986). No previous studies have compared preparation for future care in several socio-cultural contexts that vary in the degree of resources available and the degree of recent social change. The third objective of the present study, therefore, is to identify aspects of three social and health care systems that may contribute to the use of particular styles of preparation. In particular, the focus will be on how women in three countries – Eastern Germany, Western U.S., and Western Canada – go about preparing for their future care needs. The interaction of individual and contextual factors becomes particularly apparent with respect to gender. Older women tend to require more care than men (Hobbs & Damon 1996), they are about three times as likely as men to be widowed (Hobbs & Damon 1996; Statistisches Bundesamt 1998), and paid help is less available to them because they are more likely to live in poverty or near-poverty than older men (Arber & Ginn 1991). Because, due to these circumstances, women tend to be the most vulnerable to the effects of social

PREPARATION FOR CARE IN THREE COUNTRIES

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change, single older women only, rather than gender differences, are the focus of this cross-national study.

Preparation for care Whereas some individuals prepare for their own future care needs by thinking about them, talking to relatives about them, or planning for how to obtain assistance, many others do not. 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), but only 8–15% have actually made concrete plans for such an event (Kulys & Tobin 1980; Sörensen & Zarit 1996). Preparation for future care appears to be of greatest value to older individuals when it involves concrete activities, such as decision-making or concrete planning for care (Groger 1994). For example, decision-making may involve developing preferences for specific care arrangements and concrete planning for care might involve informing other family members of these preferences, knowing whether these options are funded by the health coverage system, or saving in order to be able to afford them. In contrast, less concrete aspects of preparation, such as worrying about or anticipating the many difficulties and risks that lie ahead are related to greater overall anxiety (Kulys 1983). Thus, since most seniors worry about loss of independence and health limitations (Scarborn & Nicki 1996), preparing for future care needs may also have disadvantages for them. Additional disadvantages of preparation might also include that planning for future care may be obsolete or unrealistic with changes in circumstances. Preparing for future care in three economic and socio-cultural contexts As mentioned above, planning may not only be a function of individual characteristics, but it may also be affected by the larger contexts and an individual’s representation of the context in which planning occurs (Berg et al. 1997). In fact, different social welfare and health care systems (and the associated levels of availability of services and payment for services under these systems) may have differential impacts on individuals’ perception of their life course, choices and actions as well as the consequences of those choices (e.g., Mayer & Müller 1986; Sørensen 1986). Systems in transition, may provide more options, but also be more confusing to seniors. In addition, individuals in social systems with fewer governmental support services might be less able to plan because they lack the options to choose from, even though they might benefit more from planning for future care.

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In the present study we are interested in exploring the preparation for future care needs in three distinct regions: Eastern Germany, Northern Utah (U.S.), and Western Canada. These regions have different health and social care systems and vary in the degree of resources available to older adults and of recent societal change. For reasons listed below, Eastern Germany at the time of the data collection (Summer of 1996) was “resource-poor” and highly unstable, Northern Utah was “resource-rich” and very stable, and Western Canada was “resource-rich” but somewhat unstable. Thus, one might expect these social contexts to affect the preparation for care of older adults in these three social contexts. Given the limitations of our small and directed sample, we are not focusing on a broad comparison of populations, but on exploring what factors inherent to each social system may relate to preparation. For this reason, the characteristics of each social system will be described in more detail below. The East German context. Our Eastern German sample was most affected by social changes due to reunification, which occurred seven years before data collection. As a result of reunification, seniors in Eastern Germany have fewer savings than seniors in Western Germany or other industrialized countries, in part because of the wage structure during their working years and in part because they lost savings during the currency reform in 1990 (Schwitzer & Winkler 1993). Also, because of the high rate of unemployment in Eastern Germany many adult children have moved to Western Germany, which has reduced the availability of help by family members for the elderly. Between 1989 and 1997, for example, about 750,000 (5%) of East German inhabitants moved to West Germany (Statistisches Bundesamt 1998). Thus, financial and family resources are quite limited for the East German older adults. Reunification 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. This restructuring has led to considerable changes (both good and bad) in the available options for long-term care in Eastern Germany. For example, as before reunification, the East Germans continue have universal health care coverage, which provides health and care services to people at all levels of income, based on their level of physical need. In addition, due to the increasing need for long-term care for the growing aging population a new government long term care insurance (Pflegeversicherung) has been instated, which is paid for through a special tax levied on everyone’s income (including seniors’ pensions). However, drastic cuts in health care expenditures have taken their toll as well: the government is reimbursing medical doctors for fewer procedures, is limiting their allowed prescriptions, and is requiring individuals to pay a larger share of their health care costs


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(Chappell 1996). In addition, the cost of nursing home placement in Eastern Germany has multiplied more than 10-fold in eight years, and government funded long-term care assistance is now available only to those who meet particular criteria of incapacity. While in the area we studied, the number of private home health services has multiplied rapidly and the new long-term care insurance is touted as providing more security for long term care coverage, these massive changes have left seniors in Eastern Germany quite confused about how and where to obtain care, thereby limiting their access to services (Schwitzer & Winkler 1993). This constellation of circumstances suggests that the social context in the Eastern German region we studied can be classified as both “resource-poor” and highly unstable. The United States context. In contrast, whereas the health and social care system for the older adults in the U.S. had been somewhat under fire and its long-term viability has been questioned for some years (Quadagno 1996), the system was comparatively stable at the time of the study. Most problems associated with it were due to lack of information or lack of funds on the part of individuals, not to rampant restructuring. For example, whereas general medical care is covered by Medicare, older U.S. citizens are often surprised to find that their long-term care needs are not covered by Medicare or even supplemental health insurance. In fact, coverage for medical home health care through the Medicare system is limited in the amount of time and the types of circumstances for which it is available. Thus, while services are available, they can often be accessed only by those who have enough funds to pay for them or by those who are destitute, in which case Medicaid pays for the services (Wiener & Illston 1996). With respect to resources, however, the circumstances of the respondents questioned in the present study may be somewhat atypical. For example, while many rural and semi-rural areas in the Western U.S. do not have abundant health and social resources (such as home health services), the region of the Northern Utah that we studied has many home health agencies, assisted living facilities and nursing homes available, making it a “resource-rich” region. In addition, the predominant L.D.S. (Mormon) subculture adds an additional community resource of close family ties and church assistance through volunteers that bolster the help available to older adults. The Canadian context. The Canadian sample’s context was defined both by the national Canadian health insurance system administered by the province of British Columbia, and by a “resource-rich” local context (Southern Vancouver Island). The combined National and Provincial health care system provides universal health care to all citizens and reimburses a range of

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services that allow seniors to stay in their own homes, even those with low incomes. With regard to the local characteristics, most respondents lived on Southern Vancouver Island, an area deemed the “Florida of Canada,” where a well-developed urban and rural network of resources and services for the aged exists, including a dense network of senior centers, a relatively large number of home health agencies, senior housing complexes, assisted living centers, and nursing homes. In fact, several of the respondents lived in special senior housing, despite the fact that they had no need for physical care at the time. Those who did not have senior services nearby, for example, those living on smaller islands, often had a close-knit community that organized informal support among the population. However, during the period of the study, Canadian seniors were experiencing cuts in benefits. Because of the exponential growth of health care costs, especially of home care costs, the national funding mechanisms changed in 1996, so that assistance previously available at low cost through home health care agencies was to be limited to medical care and no longer to include home maker services. This development was seen as a danger to the Federal and Provincial governments’ maxim of “aging in place” both by researchers (Chappell 1994) and by the seniors themselves. In recent years, however, the policy directions have reversed and further expansion of home health care and community based services are now recognized as being central to lowering the inpatient and nursing home expenditures (“Canada’s Health Care System” 2000). We expected both similarities in the older women’s process for preparing for future care needs across all three countries as well as differences. The similarities are likely to be due to three reasons: First, there is a comparable health care risk for women in all three countries; second, the motivation to stay independent as long as possible is important to seniors in most industrialized countries (Gibson 1984); third, family caregiving occurs with similar frequency in countries that have similar proportions of the older adults in their population (Kosberg 1992). These similarities are likely to be reflected in the intensity of preparation and the temporal aspects of plans, as well as the respondents’ emotional responses to the topic of preparation for care. The national differences in preparation for future care needs we expected were based on the variation between countries in the availability of personal resources and access to care services and national differences in the speed and intensity of social change, which interferes with the predictability of future help and care options. However, we purposely do not focus on broad cultural differences in the present study, since they cannot be disentangled from the social forces at play, nor from the impact of resource availability; furthermore, the groups we interviewed may have subcultural attributes (Eastern German, Utah – Mormon subculture). In addition, since aging is a differ-


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ential process and not all older persons will cope with developmental tasks in the same manner (e.g., Lehr & Thomae 1991), we expect that there will be variability also within each country regarding the discourse about future health care needs.

Research questions This paper presents an in-depth conceptual understanding of preparation for future care needs in three countries arrived at through qualitative data analysis. In the present paper we investigate three questions: 1. What are the patterns of preparation in which these women engage and how are they related to the temporal aspects of planning for care, as well as the level of detail or concreteness of plans? 2. What are the subjective views of planning for care and the emotional responses to preparing for care in a particular environment that are associated with each planning style? What patterns of objective individual conditions (health, income, social resources), of which respondents themselves may not be aware, distinguish each planning style? 3. How do the styles of preparation most prevalent in each national context relate to social change and economic structure within these contexts? While some quantitative analyses are presented to illustrate the differences between subgroups in this study, particularly with regard to differences in objective conditions between the styles, these numerical results should be treated with great caution due to the small sample and limited representativeness of the respondents. Rather than using these results to make inferences or generalizations about national groups as a whole, we present them as further support for the qualitative differences in respondents’ living conditions and to suggest inter-relations of contextual factors of which respondents may not themselves be aware. Thus the comparison of objective contextual conditions is a reflection of more latent influences on respondents’ planning style, rather than manifest connections that can be elicited from respondents directly.

Methods Sample Participants were older women who lived in Eastern Germany (N = 23), the Western U.S. (N = 10) and Western Canada (N = 12). They were recruited through newspaper ads, senior centers, and church groups in and around three university towns (Jena, Eastern Germany; Logan, Utah; and Victoria,

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British Columbia). Participant ages ranged between 65 and 86. Criteria for participation in the study were (1) that the respondent is living independently without reportedly needing assistance with ADLs, (2) that she is over 65, (3) that she is never married, 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 (1 Canadian, 7 Germans) and about a third were never-married and thus (with a few exceptions) unlikely to have children. Subjective health was measured with two items, one asking the respondents to evaluate their physical health and the other to evaluate their mental health; response options ranged from 1 (excellent) to 5 (very poor). Health ratings ranged between excellent and fair for the entire sample. Objective health was measured by asking for 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 influences on their everyday life (e.g., having well-controlled diabetes), and poor health if their illness interfered with everyday life (e.g., severe arthritis). Education levels ranged from 8 years of schooling (completion of German grammar school) to 20 years (advanced degrees). Significant differences (tested with non-parametric statistics, because of the size of sample) among the groups were found for level of education and subjective health, with the German women having lower education and worse health. Data collection Forty-five semi-structured interviews were conducted, lasting between two and three hours each. Interviews were taped and transcribed.1 Interview guides consisted of a series of questions that could be asked in varying order, depending on the flow of the conversation. Questions were based on previous studies (Sörensen & Zarit 1996), which had suggested four primary levels of preparation for future care needs and caregiving (i.e., Anticipation, including thinking and talking about future care, Decisionmaking, Concrete Planning, and Role Socialization). We formulated questions related to the first three levels in the interview outline since the fourth was more relevant to individuals already providing or receiving care. For example, respondents were asked whether they had ever thought about future care needs, what their past thoughts about this topic had been, what triggered these thoughts, etc. Then they were asked if they had ever discussed their care needs with anyone, how it felt to talk about them, and what the outcomes of these discussions were. Questions on whether they had made decisions about preferences and whether they had made concrete plans or arrangements were handled in a similar fashion. We asked additional open-ended questions to


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explore the context, subjective meanings, antecedents, and consequences of each of these levels of preparation. For example, if someone said they had talked to others about their future care, we asked what had instigated them to have these discussions, what having such discussions meant to them, and what happened as a result of the discussions. Respondents were also questioned about what value and what difficulties they saw to thinking, talking, making decisions about, and making concrete plans for future care needs. Data analysis The approach used to analyze these data was largely based on the method of modified analytic induction (Bogdan & Biklen 1992). In the modified analytic induction approach, the researcher has general hypotheses prior to data collection, which are confirmed or disconfirmed as new themes and concepts emerge from the data. Unlike the original analytic induction approach, however, we did not use negative case analysis to disconfirm the emerging hypotheses; rather, we strove to describe more fully the variety of patterns, using interview transcripts and summaries as well as reflective notes generated during data collection and analysis (Huberman & Miles 1994). Consistent with Gilgun’s (1995) recommendations, our aim in using this approach was not to test specific hypotheses, but rather to use guiding hypotheses and questions to elaborate and refine Sörensen and Zarit’s (1996) conceptual outline of preparation for future care, thereby uncovering new patterns and developing a more detailed theory of preparation. With regard to our first guiding question, we investigated whether respondents would prepare for future care along the levels of preparation suggested by Sörensen and Zarit (e.g., thinking and talking about care, making decisions, and making concrete plans). Consequently, in the first step of our analysis, we did a cross-case analysis (Huberman & Miles 1994) of (1) the extent or level of preparation for future care, (2) the content of plans, (3) the stated antecedents, triggers, and reasons for preparing, (4) the perceived consequences of preparing, (5) the role of other individuals involved in the respondents’ preparation, and (6) the social structural context of preparation and planning, by looking for themes in each of these broad categories. For example, we collected all statements related to the level of preparation and then looked for commonalities between respondents regarding these levels. Also, the inter-relations of levels of preparation with the other aspects (content of plans, reasons for preparing) were coded. For example, we coded whether the levels of preparation were related to the specific expected planning outcomes (e.g., move to a nursing home) that respondents mentioned or whether they were related to greater financial resources, or uncertainty about the future. Statements were coded as reflecting thinking and talking

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about care if respondents related thoughts or conversations about the topic, but did not mention having particular solutions in mind. Respondents were coded as having made decisions about care needs when they stated particular preferences for care. Concrete planning was defined as having preferences and having devised a strategy of how to make these preferences a reality, or having realistic strategies for later decision-making in place. During coding it became necessary to distinguish planning for the short and the long-term. Short-term planning was defined as planning for either a limited time or a limited amount of care. Long-term planning involved considering care spanning months to years with increasing levels of need. The cross-case analysis and coding of planning temporality and content allowed us to assign respondents to preliminary categories corresponding to the Sörensen and Zarit’s (1996) levels of preparation. However, as the patterns were investigated more closely and related to distinct patterns of personal and contextual influence, new styles of preparation emerged. With regard to the second research question, we analyzed whether individual perspectives as well as objective contextual characteristics would affect individual types or levels of preparation. Thus, we compared the types and patterns of preparation that emerged from the data using qualitative description as well as quantifiable variables. Specifically, we looked more closely at the subjective factors expressed by the respondents in each style category (e.g., perceived usefulness of preparation). As well, we compared and contrasted the emerging styles with regard to a number of objective circumstances (e.g., age, income, health), which, although not explicitly listed by respondents as factors in their planning, nevertheless played a role. These differences are discussed under each style heading below. In answer to research question three, we hypothesized that social service structure would have an impact on the extent and process of preparation so that different types of preparation might be preferred by respondents from different countries. Thus, we related the preparation styles that emerged in the first step of data analysis to the general economic and political context of each respondent by comparing whether some styles were more prevalent than others across the three national groups. We did this by coding the respondents’ reasoning for using certain styles of preparation particularly with regard to their comments about social structure and resource availability.

Results Before answering the research questions, we assessed the overall frequency of thinking about future need for help or care. This was quite similar in the three samples. Seventy eight percent of the German women, 80% of the U.S.


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respondents, and 83% of the Canadian women said that they had thought about the possibility of needing help or care in the future. Styles of preparation for future care needs Our first research question dealt with the process by which older women prepare for future care needs. From the comparison of levels of preparation across cases, we found four predominant styles of dealing with the unknown risk of needing care in the future. The styles that emerged reflected primarily the level of concreteness and detail of the plans as well as the temporality (long-term vs. short-term) of respondents’ preparation for future care. Particular styles were also linked to certain subjective attitudes and emotional responses toward preparation or opinions about the usefulness of planning. As well, the styles were associated with unique combinations of financial and educational status, family relationships, and health. These connections were not necessarily manifest in the interviews, but rather emerged from the comparison of groups by the researchers. The four emerging styles are A: Avoidance of Planning, B: Thinking without Planning, C: Short-term or Limited Care Planning, and D: Longterm Planning. Each style is described below in some detail, along with the subjective and objective conditions that were associated with it.2 While we separate those conditions in the following discussion, the reader should be aware that they are often intertwined and dependent on one another. Style A. Avoidance of preparation (N = 9) The women who used this planning style did not have any long or short-term plans. In fact, they tried not to think about future health risks in any detail because they felt it would be unpleasant. They wanted to deal with care needs when they came up, not in advance. Some were optimistic that they would have sufficient time in this event, and that they would be able to plan, others thought that external forces would determine their fate regardless of any planning. Women who initially claimed to have “never thought about future care” were often included in this style if, when probed, they consistently showed resistance to thinking about the topic. Subjective conditions contributing to this style. Most avoiders felt they had too few financial or social resources to plan. In addition, respondents in this group tended to believe or hope that they would not require help or care (almost half), or that one cannot predict the future enough to make plans (78%). The following response was given by a 68-year old widow who felt that since life was so uncertain, there was no point in making plans:

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When you get older, you are already thinking: My God, what do we have to expect? But we don’t know what to expect. I can’t think about what will become of me, when I don’t know at all what will become of me. I could have a heart attack this evening and be gone. I can’t consider: what will happen if you lie there for weeks. Something has to happen. The doctor has to say, or the Red Cross or whatever. And I have to cope with that, since I’m alone. (G-06, 68, w)3 Respondents who avoided preparation tended to perceive more disadvantages than advantages to planning. A third of the respondents in this group suggested that thinking about negative future events was not good for one’s well-being. For them, the thought of needing long-term care was so unpleasant that it was avoided altogether. This is exemplified in the 80-year old Canadian woman, who stated a great reluctance to think about the future. Reflecting on the difficulties of planning, she said: You can dwell on things, you can make yourself sick by how you think. (C-11, 80, w) Similarly, a 75 year old healthy German woman felt that thinking about care would be a burden to her: 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 unnecessarily with problems that are not yet relevant. (G-23, 75, d) About three quarters of the respondents in this group felt that events were determined by outside forces, more than by their own planning efforts. These forces included doctors, agencies, or family members who would decide where they would be placed, but some respondents also believed that they would be taken care of by God’s providence. For example, an 82-year old Canadian women emphasized her faith in God, but then also showed great trust in her children’s abilities to decide for her: I really take the advice of my children maybe over my own sometimes because [. . .] they’re outgoing and they’ve had experience and are all university graduates. (C-2, 82, w) The avoiders’ reluctance to plan for care was especially apparent in the comments of respondents regarding nursing homes. East German respondents appeared to be paralyzed by the unexpected ten-fold increase in nursing home costs. A 70-year-old widowed avoider in Eastern Germany insisted that people were being exploited by nursing homes (G-15, 70, d). The perceived


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lack of other options had an almost paralyzing effect on these women. For example, a 75-year-old widow said: Ever since the nursing home is out of the question [for financial reasons], I don’t want to think about needing care in the future any more. Whenever the thought wanted to come up, I said: It will happen the way it’s meant to. You are probably just expecting the worst it could possibly be. You can’t know how it’s going to be. And then I stop those thoughts altogether. (G-23, 75, w) In the U.S. avoiders, the thought of going a nursing home appeared to generate a great deal of anxiety in the women and prevented more extensive planning. If they said I had to go to a nursing home, I don’t know what I’d do. Definitely would speak up to children about it. I would just refuse to go and then it would be their problem what to do with me. (U-10, 72, w) These responses illustrate that the reluctance to plan for seniors is often related to the undesirability of nursing home care, lack of information regarding alternative arrangements, as well as to the economic limitations of the individual with regard to rising nursing home expenses. For Eastern German seniors, going to a nursing home had been an affordable, though dreaded last resort before reunification, in part because alternative services were unavailable. Since the East German health system had changed to match West German regulations, however, a number of East German respondents found that nursing home care was unaffordable unless they were completely bed-ridden or dependent. In addition, because they lacked information about alternatives, these respondents were unable to develop new plans. Thus, they may have chosen not to think about the unpleasant topic of needing nursing care without being able to afford it, rather than allow these thoughts to hamper their well-being. For the East German respondents, being classified as an avoider was therefore related, in part, to the unique circumstances that rapid social changes brought about. In contrast, for United States and Canadian respondents, nursing homes were also a last resort, but they were more aware of alternative care arrangements. Thus, developing plans was more feasible and less threatening to them. Avoiders, and especially those in the American and Canadian subgroup, were also more likely to assign low importance to planning in situations not related to care – they felt that life should be taken “day by day” rather than planned. This was less often the case in the other three planning styles, who were more likely to endorse planning for other occasions in life (see below).

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Objective conditions contributing to this preparation style. Consistent with their subjective assessment avoiders had fewer resources with which to plan. Compared to those who had planned for future health care needs, avoiders were less educated (p < 0.05), had lower income (p < 0.05), and had the fewest children (ns). These numbers confirm the impression gained from the qualitative analyses that lack of financial, educational/informational, and social resources may have hampered their planning. However, there were no apparent differences between avoiders and thinkers or planners regarding age and health. Style B. Thinking about future care needs without planning (N = 7) Individuals who used this planning style thought intensively about future care needs without finding a solution. For the East German respondents, who made up the majority of this preparation style, thinking about future care needs was characterized by much worry and rambling discussion of possibilities. However, this same level of worry was not present for the U.S. American thinkers/non-planners. None of the Canadians were classified in this group. An example of this style was provided by a 75-year-old never-married German woman who felt that older adults in general could not rely on the younger generation, and felt this was particularly the case for her since she had no children: You go through this in your mind: What if the eye operation doesn’t work and I were to go blind? Or if you get Alzheimer’s [. . .] It’s one of my biggest problems, that you think: Who could help me one day? Because the younger generation is missing for this [. . .] I see no solution. (G-10, 75, nm) Subjective conditions contributing to this style. Unlike the avoiders, thinkers/non-planners did not attribute their lack of planning to lack of financial resources. Rather, they focused on lack of social resources – the unavailability of family. Respondents who thought, but did not plan, reported more ambivalent or conflicted family relationships than the avoiders. Five out of the seven respondents in this group felt that family members were not available or not trustworthy, or they mentioned relationship problems in the family. The attitude of thinkers/non-planners on the usefulness of planning for future health-care needs was very similar to that of the avoiders. For example, the view that future care needs can not be predicted was associated with this style of planning – four of the seven respondents in this group mentioned this as a reason for not planning. The same divorced woman mentioned above insisted that preparing for the future was not useful or effective:


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You can’t really make good decisions in old age. Because you don’t know what will be tomorrow. You really have to wait to see what happens tomorrow. (G-04, 67, d) About three quarters of this group wished or hoped they would never need care and more than half of these respondents also had a sense that forces beyond their control would eventually determine where they end up. They had little trust in the effectiveness of planning for facing future crises. References to biographical experiences that had affected their perceptions of the usefulness of planning stood out in this group. Three out of seven respondents in this group (all East Germans) mentioned biographical experiences that had discouraged them from making detailed plans. Some of the experiences that inhibited later planning included that the war and subsequent compulsory relocation (displacement) completely obliterated any plans that had been made for the future. For example, many German women of certain cohorts could not finish their education because of the war and many could not marry because few men of their generation were still alive after the war. In addition, the political system in the GDR limited freedom to plan for many of the East German women. Important aspects of biography, such as, choice of occupation, had been controlled and predetermined by the GDR government. Overall, it appeared that women who saw their lives so far as unplanned or uncontrollable were less likely to plan for the future. For example, a 75year old woman who had worked for church organizations and had thus been discriminated by the state for getting a new apartment with a bathroom said: I have gotten out of the habit of planning. When I look at my life starting with my youth, with profession, being a refugee, and in jail . . . and life plans that I had. Where you noticed: not one of those plans was fulfilled. It was always different, but life always went on [. . .] Every time it turned out different than planned [. . . and] you didn’t need to plan. They planned for you. (G-10, 75, nm) Regarding obtaining care she said: You cannot plan for people because you can’t control their lives [. . .] so I would say, I can easily live day to day. [Because you don’t get into nursing homes until you have certain limitations] It is completely useless, since you cannot plan. I’m afraid that if you become a case for full-time personal care, that you can’t decide much. It will be done by the doctors and the agencies. (G-10, 75, nm) Thus, a number of our respondents across the sample, especially among the East Germans, had learned not to plan and many of these were represented

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in the “thinking-but-not-planning” preparation style. For those older adults in this category who were not from East Germany, however, planning was not explicitly related to their biography – it was simply not a salient way to cope with possible difficulties. These respondents had considered some of their options, but had not acted on their preferences. The following Utah respondent, for example, had clear preferences for what she wanted (stay at home for as long as possible), but no clear idea of how to achieve this or what would come next. In response to questions about her plans, she said: I just live more or less day to day. And today will take care of itself and tomorrow will take care of it when it happens. I make my own decisions. [I] never had any big decisions to make [. . .] If there comes a decision and I have to decide on it, well then I do . . . [What makes people plan for the future?] Well, it’s a good idea, and maybe fear, you know. ‘Oh, I don’t want to be alone’. I guess there’s all sorts of things you could think about it, if you just sat down and dwelled on it. You would be foolish not to think about the future, you have to do that, to a certain extent. But there’s no use in it, there’s not much use in worrying about it or anything. (U-02, 77, w) Objective conditions contributing to this style. The individuals in this group had, compared to older adults with long-term care plans, lower income (p < 0.05), but a larger number of children (p < 0.05), despite their perception of family unavailability. Compared to older adults with plans for short- and long-term care needs, members of this group had less education (p < 0.001 and p < 0.05 respectively). For respondents in this group, making concrete plans may have been hampered by their socio-economic disadvantage and the resulting limited access to care and planning resources. However, the perception of too few financial resources was less prevalent in this group than among the avoiders: Only two out of seven “thinkers” mentioned this as a reason for not planning. It is also possible that the lack of planning was the result of limitations in problem-solving ability due to limited educationbased cognitive training or ability. This issue, however, was not addressed by the respondents directly. The thinkers/nonplanners did not differ from the other groups regarding age and objective health. However, the women in this group were the most likely of all others to evaluate both their physical and mental health negatively (quantitative rating) compared to older adults with plans for short-term and long-term care needs (p < 0.05). While the respondents who used the other styles of preparation had similar levels of satisfaction, those seniors who wanted to plan, but – because of lack of resources, like potential helpers – were unable to develop a feasible plan


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often mentioned lower satisfaction with their preparation and lower subjective well-being than other respondents. A divorced 67-year-old German woman, for example, who had no contact with her only daughter and was not wellinformed about professional care services, said: The thought comes up often, daily, hourly, one could say. There is that fear, the great fear. There is no one. If something happens during the day, no one is there who would even notice. That somebody is up there completely alone. [. . . Thinking about my future] means a lot of sadness to me. And you get depressed. If you have to think about the future and don’t know how it will go on. You’re just afraid. That’s the worst part. (G-04, 67, d) Thus, having the desire to plan, but not being able to make detailed or concrete plans appeared to be related to lower satisfaction, more frustration, and a negative emotional response to the topic of planning, but this was mostly the case for the Eastern German respondents, whereas the Americans in this category were generally satisfied with not having plans in place. In part, this may have been due to their increased access to family resources, about which they expressed less ambivalence than the East German women. Style C. Making plans for short-term or limited care needs (N = 11)4 Respondents in this category made plans for temporary or limited need for help. These plans often developed in reaction to an identifiable trigger: a concrete health crisis or noticeable decrements in everyday competence. The plans were then extended to future short-term health care needs – but they were not adjusted to meet more serious future need. It was difficult for the respondents in this style to contemplate such levels of disability, but thinking about a limited need for help (e.g., household help) was more manageable. For example, a 71-year old German woman who had a number of difficulties due to osteoporosis was able to imagine needing help with cooking and household tasks, but not able or willing to think beyond this. I have arranged my apartment so that it is aging appropriate or at least aging-friendly. In the case that I need help? Then I would maybe try to use other sources of help, if I’m not too sick or disabled. Whether that is home health care, a daily two-hour helper or something. (G-09, 71, w) As was the case with several others in this category, this respondent focused on a need that may not exceed requiring 2 hours of help at home. She would not comment on what might happen if this were not enough, if she were to need 24-h care or many months of increasing assistance. When prompted, she replied,

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You can’t change anything anyway. And to worry in advance, I don’t want that. It’s enough [to think about it] when the time comes – that you have to consider it. I have already thought about it by remodeling my apartment to be aging-appropriate. (G-09, 71, w) Short-term/limited care planners were more likely than others to focus on particular types of help rather than consider many possible types of need or forms of help, as did long-term planners. For example, in the U.S., short-term planners often mentioned having saved money as their primary planning strategy. Subjective conditions contributing to this style. Short-term planners were more likely to see preparation as helpful in maintaining their subjective wellbeing. Almost half the respondents in this group mentioned that planning helps them feel better about the future or feel prepared. In general, planning for future events was more salient as a positive proactive coping strategy or even as an enjoyable activity, as illustrated by a 78-year-old Canadian widow: I’ve always planned ahead because I enjoy planning, because I think this is part of the enjoyment you get out of things, whether it’s a trip you’re going on or whatever, it’s, you enjoy some of it ahead of time and you learn a little in the process as a rule, so I like to plan ahead. In fact, it’s sort of disconcerting sometimes if you have no time to plan. (C-12, 78, w) However, one third also mentioned the difficulty of predicting the future as a reason for them not to plan beyond the short-term future. The contradiction between wanting to plan and not being able to foresee what might occur in the future was a salient feature of respondents’ discourse in this category. This was also reflected in their use of their own biography as an explanation both for planning and for not planning: One short-term planner said she had always planned, another three said that their experiences had shown that you can’t plan. Respondents’ urge to make at least some plans was also propelled by their awareness of family members’ work-family stresses and by their own ambivalence about desiring family care but not wanting to burden family members. For example, focusing on available services, like home care services, allowed respondents to plan for reduced involvement of their busy family members. Among the short-term planners, there were also individuals who had originally made plans, but for whom changing circumstances required a drastic revision of plans. As a result, they preferred to make short-term plans only. This was particularly evident in the German sample, for whom the cost of nursing homes had risen dramatically after reunification. A 71-year old


divorced woman, for example, original plan to enter a nursing her children with her care. She advantage of home health care, find a solution.

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experienced this change as destroying her home. She now had to consider burdening was able to plan for the short-term to take but for the long run felt that she could not

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) Objective conditions contributing to this style. In our study, short-term planners had the highest education. They were, as mentioned above, significantly better educated than avoiders and thinkers/nonplanners. There were no differences to other groups in age, income, number of children, and objective health. Style D. Making plans for long-term care needs (N = 18) The women using this final style planned for chronic care needs either by making financial arrangements that would cover in-home or nursing care, or by making agreements with family members willing to take on their care. A 78-year old Utah woman, who had never married, for example, made financial plans that would cover nursing home care later in life. I have told my family that as long as I can continue to function in this house I plan to function here [. . .] I have enough money to take care of me as long as I am on this earth. I have savings which I hope will supplement my retirement. I have nursing home insurance that will take care of me for a year so that I don’t burden a family member to come and take care of me. (U-01, 78, nm) Long-term planners were not immune to the contradictions inherent in trying to plan for an uncertain future. Contradictions between wanting to plan and not being able to were resolved by many respondents by making very general plans (forming preferences), which could be adjusted according to actual future care needs. 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 probably code these provisions as general plans, many of these respondents, when asked directly if they had made plans, actually said that they had not planned. Sample statements from this group included: 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

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this and that, if possible. But you can’t plan one hundred percent. Fate often takes you down a very different path. (G-01, 76, w) 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) A smaller group of respondents also developed various alternative plans from which they could choose the best one later. For example, a never-married 70-year old German woman who lived with her sister planned to stay in their shared home as long as possible by using home health care, if needed. In the case of the death of her sister, she planned to move to a smaller apartment. She included nursing home care in her plans as well, as a last option: I’m quite aware of what possibilities I have, and there are not many of them, and I know them all now. And when the decisions really comes up, I just have to list all of these possibilities and then the decision has to be made. (G-11,70, nm) Subjective conditions contributing to long-term planning. The respondents in this category saw planning as potentially more useful than any of the other groups. They were more likely to give reasons in favor of rather than against planning. They felt that planning helps to cope with the insecurity of the future and that one can avoid being a burden on potential helpers and prevent conflicts with them by planning. In addition the long-term planners appeared more aware of their present state of health and how it might affect their future. Planning for future health care needs was seen as a way to cope with present health problems. An example of this was a German respondent whose planning for future needs was a reaction to her increasing frailty and the fact that her son lived close, but was disabled. I’m in the process of reorganizing 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 substance left. And [. . .] so I will move to Fuerth into an assisted living facility. (G-03, 81, w) Long-term planners also struggled with the drawbacks of preparation for future care: Considering that she might be dependent in the future, a Utah respondent, for example, had set up a trust fund to take care of her nursing home expenses “as a last resort.” She dealt with the unpleasant feelings associated with preparation by quickly making a plan and then no longer thinking about the issue:


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I think to dwell on them [care issues] is to say you’re there already or something [. . .] It makes it morbid, [. . .] I think you go into a depression.” (U-9, 71, nm) A substantial number of long-term planners mentioned that they were financially stable or that they had a clear idea of which services they could get covered by private (U.S.) or government (Germany, Canada) health and long-term care insurance. However, financial factors were not generally named as reasons for planning; rather, they were mentioned in passing, as an enabling factor. Objective conditions contributing to long-term planning. Despite their peripheral attention to their own financial situation, the respondents in this group had the highest income, which was significantly different from avoiders and thinkers/nonplanners (both p < 0.05). Long-term planners had higher education than thinkers/nonplanners. Compared to the other groups, long-term planners were slightly older and had slightly more serious health problems, although both differences were not statistically significant. Long-term planners and short-term planners did not differ significantly in the variables under consideration. National similarities and differences in planning styles Our combined qualitative and quantitative analyses by nationality highlighted (1) that there were more similarities than differences between the three national groups, (2) that some differences prevail, however, and (3) that individual differences within national groups were also present. With regard to national differences in planning styles, avoidance was about equally common in all three national groups: 17% of the Canadian women, 20% of respondents in the U.S. sample, and 22% of those in Germany were in this category. Short-term planning was also quite similar across all three groups: Between 20% (U.S.) and 33% (Canada) used this planning style. Long-term care plans were more common among the Canadian women (50%) than among the Eastern German women (35%), with the U.S. women, ranking in between at 40%. The greatest difference was found for thinking without planning. This style was used by 20% of the U.S. women and 22% of the German respondents, but none of the Canadians. When combining short- and longterm planners and avoiders with thinkers, the differences between Canadians (83% planners) versus Eastern Germans and U.S. Americans (56% and 60% planners) becomes particularly apparent. Although none of these differences were statistically significant (not surprising, given the small sample sizes),

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they suggest the need to further investigate differences between countries in the salience of different styles. In fact, we found in our qualitative analysis that certain issues were mentioned more often in one of the three countries than the others. For example, a major issue that differed across nationalities was the level of instability in the history of the nation and the present social structure. The issue of instability was clearly the most pervasive in the East German sample due to changes in the social structure associated with reunification. As mentioned above, Eastern Germans had experienced the most uncontrollability both in recent social changes, in their personal history, and in personal economic circumstances, all of which contributed to a different outlook regarding the usefulness of planning. These circumstances led them to be the least likely to plan for the future. A seventy year-old never-married East German woman stated the impact of changes in the health care system on the individual’s ability to plan most succinctly, But today everything is constantly changing. You always have to consider that they will change the currency on us and that we have nothing left. Or 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) Surprisingly, the Canadian women, even though they were also experiencing changes in health care and home care coverage, were not affected as strongly in their preparation as many of the East Germans. Even those Canadians who did not plan did not complain about the quality or instability of government services. This may be because both the recent changes and the historical events they had experienced were much less drastic than those experienced by the East Germans. In addition, the Canadian women in our study were among those with the highest relative income and education. Since lack of resources was a reason for not planning, especially by avoiders, the greater access to resources enjoyed by Canadians may have been one of the primary factors enabling effective planning for this group, despite changes in social services. Several Canadians also mentioned the importance of education in determining why people plan. Thus national differences were probably confounded with resource differences for Canadians. In contrast to the Germans and Canadians, the U.S. non-planners focused mostly on their negative beliefs about planning. These beliefs were not unique to the U.S. sample, but in the absence of some of the other themes, they appeared particularly strong in explaining the planning styles of this group. Despite the national differences outlined above, the similarity of the national groups was quite remarkable, given the differences between the social and health care systems and the difference with regard to recent social


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change. The qualitative analyses suggested that this was, due first, to the fact that seniors in all three national groups had comparable everyday competence (none were in need of significant assistance with activities of daily living), despite the slightly worse health among the German respondents. A second reason for the similarity among the national groups, and a common theme that emerged, was that respondents’ goal in all three groups was primarily to stay independent as long as possible. Third, the relationship of lack of financial or social resources to the ability to plan was a theme common to all three groups. Even among the Canadians, whose financial resources were sufficient, those who did not plan or who had only short-term plans had no available family members to turn to. Finally, a substantial percentage of seniors in all three countries also felt that a person can not know when and how much help she might need in the future. This sense of the difficulty in foreseeing future care was shared across the national groups and contributed to the considerable similarity between them. In the search for national differences and similarities, we also came across some individual differences in the women’s responses to their contextual conditions. For example, among East German interviewees, social instability and biography was cited by planners as a reason for becoming a planner and by non-planners as a reason for not planning. A 76-year old widow who moved from West Germany back to East Germany after reunification in order to be closer to relatives put it like this: I’ll tell you where that came from. My parents were living here and then the recession [came] around 1930, 29 the bank collapse etc. And my father had money invested in a firm for which he was working and the firm went bankrupt suddenly. He lost everything. And I observed this at 10 years old. And at that point I thought, well that should not happen to us. So I always tried to make sure that that cannot happen to us, that there is some security somewhere. I actually always thought about the future. When I think of how the war came to an end and the Russians came here and so on, I always thought about the future. I said ‘I’m not staying here!’ (G-01, 76, w) This finding suggests that individual differences, as are reflected in respondents’ personality dispositions, beliefs about the importance and usefulness of planning, or even the willingness to confront difficult topics may have played a role in affecting preparation for care as well. In support of the latter point, one East German respondent said regarding planning: I don’t know if it’s worth it, but it’s the right thing to do. But not specifically for old people, but in general. Old people should think about their

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future. I mean, I don’t enjoy thinking about it, it forces itself on me, I think about it daily, [also] about the future of the children, about the news, the future of the country. [. . .] I started with others’ [care issues]. Because I am involved with the church, I observe this all the time. The old people . . . most of them are in that situation, and you experience that with them. And I am often called [. . .] and people tell me about their worries and problems, etc. This [thinking about dependency] is not a problem for me, I don’t block any of it out. (G-02, 80, w)

Discussion In this study, we were interested in preparations that older women make for future health care needs in three industrialized countries. Based on the concepts of anticipatory socialization (Merton 1966) and proactive coping (Aspinwall & Taylor 1997), we made the assumption that for the elderly it would be useful to plan for future health needs. Because these theoretical concepts have been applied primarily to events that are fairly predictable, we wanted to know whether and how preparing for the much less predictable event of future need for help and care occurs. Three questions were the focus of our investigation. First we were interested in the extent to which levels of preparation found in previous research would emerge. Second, in order to understand individual and societal factors affecting style of preparation we compared subjective views and responses to personal and societal conditions and objective conditions associated with each style. Finally, we were interested in the impact of social-systems contexts on preparation and, therefore, investigated whether German, U.S., and Canadian women would differ in their planning styles and in how they viewed the influences on their preparation for care. How seniors prepare for future care In previous studies, different types of preparation were not differentiated, that is, planning was either assessed as a total score of different activities (Kulys & Tobin 1980) or by single item indicators that did not separate long-term and short-term plans (e.g, Gurin, Veroff & Field 1960; Heyman & Jeffers 1965). The first unique contribution of this study is the finding that respondents’ discourse reflects different styles of planning. However, these styles do not correspond directly to Sörensen & Zarit’s (1996) proposed framework for understanding preparation for future care. As suggested by those authors, thinking and talking about future care needs often appear together, but do


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not necessarily lead directly to the formulation of concrete plans. In contrast to Sörensen & Zarit’s framework, decision-making in our data appears not to be easily separated from concrete planning because most individuals plan at a moderate level of concreteness and only specify their plans when actual need for help is experienced. A second contribution of this study is the finding that some respondents made long-term and others made short-term plans. This important distinction between preparing for the short-term vs. the long-term future has rarely been addressed in the literature to date. Our analyses also suggest that some respondents actively avoid planning. Maloney et al.’s (1996) retrospective study of older adults who had recently made a change in their living arrangements suggests that avoidance of planning may lead to hasty decision-making when long-term care must be found. Maloney et al. suggested that there are “scramblers,” whose long-term care decisions are made in response to a crisis and “reluctant consenters,” who have to be convinced by a relative or health care professional to make decisions. These individuals are comparable to our “avoiders”, since in our prospective study, they have not yet made care-related adjustments in their living arrangements and they report reluctance to make preparations in advance of needing care. Maloney et al. (1996) also identified individuals for whom a “wake-up call,” triggered a change in their living arrangements, and people who were clearly “advance planners.” These latter types might be likened to our shortterm planners and long-term planners, respectively. Especially among our short-term planners, certain triggers (e.g., personal illness) had brought about an attempt to plan. However, in our study, short-term planners considered only lower levels of need for care, whereas long-term planners also made provisions for more extensive and longer lasting care. These patterns probably reflect (1) that the objective risk of needing short-term care or limited help for a long time is higher than the risk of chronic care needs or high levels of care (e.g., Schneekloth 1996), and (2) that it is easier to plan for limited and predictable short-term needs than for less predictable long-term care needs, particularly when one already requires limited help with household tasks. Differences between planning styles We found significant differences between the four styles with respect to individual subjective and objective conditions experienced by the women we interviewed. Differences in subjective circumstances included (1) the perceived availability of social and material resources for planning and for receiving help, (2) the extent to which life and particularly care needs

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appeared planable to the respondents, and (3) the importance that planning in general had in the life of respondents, and (4) individual differences in personality or individual style. In addition, people who used different planning styles differed in terms of objective criteria: planners had higher education and income than non-planners, but no differences in age or health were found. Perceived and actual availability of resources with which to plan (e.g., financial resources, educational/informational resources, available options) affected preparation for care in several ways. For example, especially the German women’s planning was clearly hindered or made more difficult by the consequences of recent social change on their financial resources. The dramatic increase in the cost of nursing home care (which had been part of several women’s plans before the reforms) combined with lack of information left these women with the perception that there were no options to choose from, and, thus, no reason to plan. These findings are consistent with the literature on consumer decision-making. For example, Shiv & Fedorikhin (1999) report that individuals who have more processing resources (e.g, information about choices) are more likely to make decisions based on the consequences of their choice, whereas when processing resources are low, they tend to rely more on their affect to make decisions. Respondents in our study were especially likely not to plan when they had the least access to information, either due to contextual circumstances, or, as is supported by the differences in schooling between planners and non-planners, if their access to information or the ability to process this information extensively was limited by less education. In addition, the lack of social resources resulting from children’s high occupational stress and from conflicts or ambivalent relationships with family members inhibited planning for future care needs. A second subjective factor that played a role in determining preparation style was the extent to which life was experienced as planable or non-planable and the extent to which planning was seen as useful or not. One source of the perception of planability was the individual’s biography. Women who had encountered repeated instances of sudden change that rendered their plans useless, such as wartime losses, or a social system (like the GDR) that did not allow them to make life choices, were more likely to see their lives as non-planable. As a result, they either avoided planning, or they emphasized the impossibility of making any useful plans, but suffered from their inability to do so. However, we also found that there were buffers to the effects of these experiences of rapid change. Among Canadians, greater access to resources and greater trust in the system was one such buffer; among the Germans, personal style appeared to play a role as well.


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Authors in the economics literature, such as, Lindemann (1993) and Lopes (1993) suggest that there are risk-aversive (or security-minded) and riskseeking (potential-minded) orientations that may affect how people mentally represent a decision-situation and cause them to make decisions that are incompatible with expected utility theories (Starmer 2000). In the present study, most older individuals favored the former strategy of ensuring lower risk by planning for the eventualities, but those who chose an avoidant planning style may be characterized as more potential-minded, since they often hoped that they themselves would not need to receive care in the future. The third area in which the planning styles varied was in the extent to which respondents felt that planning was important. Individuals who stated that they lived day by day and did not believe in the importance of planning were more common among the avoiders and thinkers/non-planners. This was less common among those who prepared for care – they always were able to report other areas in which they had planned as well. Those who didn’t plan were also more likely to feel that thinking about the prospect of future dependency was a threat to their present well-being. While we would not suggest that planning is a stable trait, it is quite possible that some individuals are more likely to deal with problems in a planful manner (Frese, Stewart & Hannover 1987) than others and that this would be most strongly expressed for problems involving many uncertainties. Finally, planning styles may also be related to individual differences, such as personality, locus of control, or coping style. Consistent with Sörensen’s (1998) result that thinking and talking about future care is predicted by high internal locus of control, many of the non-planners/avoiders in our study felt that events were predetermined or determined by outside forces, including powerful others, and not by their own planning efforts. The patterns of avoiders with regard to considering concrete long-term care options also suggested that the process of negative emotional arousal, outlined by Aspinwall & Taylor (1997) may play a role. Negative emotional arousal occurs when a potential stressor is appraised as highly threatening. Such arousal must be regulated efficiently for the individual to continue assessing and coping with (e.g. planning for) a potential stressor (Aspinwall & Taylor 1997). For example, our avoidant participants, responded to their anxiety about the inability to pay for home care by shunning planning, rather than considering reasonable alternatives. Future studies might investigate the relation of preparation styles to personality factors and to coping strategies, such as, active and avoidant coping (e.g, Suls & Fletcher 1985), or problemfocused vs. emotion-focused coping (Monat & Lazarus 1985).

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National differences and similarities in preparation for care A third unique contribution of this study is the investigation of both differences and similarities between countries to help us better understand the impact of both social policy and individual differences on planning styles. Although – due to the small samples – none of the numerical comparisons were statistically significant, planners appeared more likely to be Canadian than German or American, and German and U.S. women were more likely to think, but not plan for future care than Canadians. As indicated above, variations in social conditions between the countries, especially national differences in the uncertainty of the social systems, emerged as contributors that distinguished the three countries. Unfortunately, because the selection of our small, non-random samples did not allow us to control for education, income, and health, and the Germans in the sample did differ from the other national groups on two of these variables, it was impossible for us to determine whether the qualitative differences between the national groups were solely related to social policy or rather to these other differences. Also, social instability did not to have as severe effects for Canadians, probably due to their superior individual and societal resources. A further source of differences that we did not assess in our study, but that might have played a role in national differences could be national variations in value orientations. It has been suggested that Americans’ attitudes emphasize individualism, self-reliance, and initiative – views rooted in the history of settlement in America. In contrast, high levels of self-reliance were historically not needed in Germany because of lower mobility, closely integrated communities, and a broad system of societal welfare programs (Cockerham, Kunz, Leuschen & Spaeth 1986; Gelfand 1988). Also, Americans have higher levels of internal locus of control and lower levels of externality (e.g., with regard to health Cockerham et al. 1986; Staudinger, Fleeson & Baltes 1999). Evidence from Canada suggests that Canadians value self-reliance and privacy (Wister & Burch 1989), but they also expect that government health insurance will assist the individual to remain in his or her natural setting (Vezina & Roy 1996). Although we did not assess the attitudes toward self-reliance in our study, these differences in orientation are likely to affect the planning evidenced by the citizens of these three countries. The surprising similarities between the three samples support the notion that some factors are common across contexts. Lack of financial or social resources and the difficulty of foreseeing future care needs were common factors mentioned as inhibitors to planning in all three samples. Also, the desire to remain independent, which played a role in shaping the content of plans for individuals in all three contexts to plan was a common theme. However, within-country variation also suggested that individual differences


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in how people deal with culturally-specific biographic experience and with social structure may influence preparation almost as strongly as national, cultural, and economic contexts. Limitations In this research we were seeking to understand the patterns and processes of preparation that seniors engage in, in response to specific social structure, personal circumstances, and the personal meaning of planning. The fact that distinct styles of preparation emerged across three national contexts and individuals using those styles differed in subjective interpretations and objective characteristics of planning situations lends credibility to our findings. However, clearly the study’s design and limited sample size should be considered when interpreting the results. In the present study, we limited the sample to a single interview with each participant and we excluded married women and men. Therefore, we do not claim to have developed a comprehensive or “sufficiently detailed” theory (Strauss & Corbin 1990) that is applicable to all seniors. Because perceptions of the availability of future care options and styles of responding to social-structural and individual circumstances may vary with gender, marital status, and ethnicity, it is important to replicate these findings with more diverse samples, so that we can compare men and women, married and single seniors, and different ethnic groups. In fact, the lack of representativeness of these small, qualitative samples should preclude any broader statements about how Germans, Canadians, or U.S. Americans in general might plan. In addition, given the speed and intensity of change in Eastern Germany, seniors from both East and West Germany should be compared in order to gain more insight into the extent of regional differences. Building on such comparisons, future research should also deal with the effects of earlier plans on later well-being. Using longitudinal studies, the conceptual linkages between processes of preparation, their contextual and biographical antecedents, and their outcomes should be validated and explored. Finally, based on the small size of the sample, it is also quite plausible that rarer influences on care planning styles as well as smaller national differences remained undiscovered. As we come to a more refined understanding of the process of preparation, larger scale quantitative studies may provide additional insight in to differences between the national groups regarding the predictors of more extensive preparation for future care needs.

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Conclusions Despite the limitations of this study, three main conclusions emerge. First, we can conclude that preparation for future care may be carried out through variety of strategies, ranging from thinking over future health risks without making any plans to detailed planning for the long-term future. These preparation styles are influenced by individuals’ perception about the usefulness of planning and their biographical experiences, as well as by the extent to which their particular context (financial, social, political) allows for effective planning. A second conclusion is that the difficulties of accurately assessing future care needs as well as of living in a rapidly changing resource environment are substantial barriers to planning, which is reflected in the tendency toward making flexible plans. Finally, we can conclude that thwarted efforts at planning or excessive worry without taking concrete action are likely to be a source of distress. These findings suggest that in times of social change, assistance with planning and preparation for future care may be useful to older adults, but only if it is accompanied by more tangible support that will allow feasible plans to be developed. Such support could include, for example, extensive orientation to the new system as well as improved access to the new care resources and options available under the changing system.

Acknowledgments We would like to thank Brad Benson, Lisa Boyce, Kelevelyn Hurley, Sharon Koehn, Michelle Lewandowski, and Catherine Roberts for help with qualitative data collection and/or analysis, and Kathy Piercy, Jim McAuley, and one anonymous reviewer for comments on earlier drafts of this paper. 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.

Notes 1. Due to limitations in resources a number of interviews were only transcribed in part. However, the sections transcribed in full for all interviews included the stated preparation activities and content of plans (even when mentioned later in the interview), attitudes, thoughts, and stated feelings regarding future care, the influences on planning, biographical experiences with life-planning as well as with giving/receiving care, and specific


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reasons given for and against planning. Furthermore, any statement regarding the governments role in assisting older adults and attitudes toward changes in health care systems and services were transcribed as well. 2. We compared the individuals in the four planning styles to each other regarding their age, number of children, education, income, and objective health. We used Analysis of Variance with post-hoc LSD-contrasts. Given the small sample size, the primary reason was to validate the perceived differences, not to make statements about populations. National differences were analyzed in the same fashion. 3. Country (U-01–U-10 = U.S., G-01–G-23 = Germany, C-01–C-12 = Canada), age, and marital status (nm = never married, w = widowed, d = divorced) are provided after each interview excerpt. 4. An option was coded as a short-term plan when the respondent stated the intention to take advantage of a specific type of short-term help or care. In contrast, we did not code as a plan if no concrete source of help or care was mentioned (e.g., “I would have to find someone to help me”), or it was stated only that one then should (would have to) request help from a particular person or service, but that this is not desired.

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