Health Care for Women International

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Systems Perspective: Understanding Care Giving

of the Elderly in India

Rashmi Gupta

To cite this article: Rashmi Gupta (2009) Systems Perspective: Understanding Care
Giving of the Elderly in India, Health Care for Women International, 30:12, 1040-1054, DOI:
10.1080/07399330903199334

To link to this article: https://doi.org/10.1080/07399330903199334

Published online: 04 Nov 2009.

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Health Care for Women International, 30:1040–1054, 2009
Copyright © Taylor & Francis Group, LLC
ISSN: 0739-9332 print / 1096-4665 online
DOI: 10.1080/07399330903199334

Systems Perspective: Understanding Care

Giving of the Elderly in India

RASHMI GUPTA
School of Social Work, San Francisco State University, San Francisco, California, USA

In this article I propose a systems model of elder care giver burden

among Indian care givers. The systems model specifies the effects of
elder characteristics, family structure, and personal characteristics
of the care giver on care giver burden. Sampling was conducted
using a multistage probability method to generate a sample of 259
care givers. The care giver burden questionnaire was translated
from English to Hindi and then back into English and pilot tested
before implementation. The care givers were interviewed via face-to-
face interviews. Regression analysis was used to estimate the effects
of the hypothesized determinants on care giver burden. The r square
explained 46% of the variance in care giver burden. The following
variables were significant from three dimensions: personal charac-
teristics, elder characteristics, and family level. Personal charac-
teristics of the care giver included whether they adhered to Asian
cultural norms, the age of the care giver, and gender. Elder char-
acteristics included behavioral problems of the elder. Family func-
tional variables included number of care giving tasks provided by
the care giver, and level of family income. Social work practice
issues are discussed in the context of this study.

The objective of this study was to test an empirical model based on a

systems theory perspective of care giver burden in Indian families in Alla-
habad, a city located in North India. India has one of the highest proportions
of elderly people in the world. Approximately 81 million people over the age
of 65 live in India, of whom 33% live below the poverty line, 90% are day

Received 16 July 2007; accepted 19 June 2008.

I thank Dr. Gerald Eisman for his support and Ms. Bonnie Hale for her comments. Both are
at the Institute for Civic and Community Engagement (ICCE) at San Francisco State University.
Address correspondence to Rashmi Gupta, Assistant Professor, School of Social Work,
San Francisco State University, 1600 Holloway Avenue, San Francisco, CA 94132, USA. E-mail:
rgupta@sfsu.edu

1040
 Understanding Caregiving of the Elderly in India 1041

laborers from the unorganized sector who do not receive social security, and
73% are illiterate and are, therefore, dependent on physical labor for their
money and survival (Help Age India, 2008). Because of a growing elderly
population and lack of assistance from government programs, the care of the
elderly falls primarily on the family (Chakraborti, 2004; Desai & Raju, 2000;
Gupta, Rowe, & Pillai, 2009).
A family is defined both by its members and by the culture and com-
munity within which it exists. Families provide the opportunity for intimate
social interactions for each of its members. In social work, a family sys-
tems model looks at care giving from the context of the family structure:
characteristics of the care recipient and of the care giver(s), and how the
family functions, which can be used as predictors of burden (Bass, 2002;
Gallagher-Thompson & Powers, 1997; Gupta & Pillai, 2005; Penrod, Kane,
Kane, & Finch, 1995; Yun et al., 2005).
Care giving needs to be understood from a systems perspective since
there is a growing consensus among family therapists that a systems frame-
work defines problems in new ways and calls for innovative intervention
methods (Keith, 1995). The earlier methods of fragmentation, or isolating
an individual and treating the family without any attempt to understand the
social system in which the family is nested, have not proven to be as suc-
cessful as a systems approach. Any attempt to bring about change in the
family has an impact on the interlocking systems and the social institutions
in which the family is embedded. Changes to the family system, such as sup-
porting care givers both monetarily and emotionally, have produced positive
lasting results (Bass, 2002; Penrod et al., 1995). The interaction of all of the
characteristics and their subsystems can produce burden on the care givers.

Conceptual Framework
In India, the elderly couple and their adult children, primarily sons and their
offspring, live in the same household. This “joint family system” in India
evolved over a long period of time. It still exists in most rural and several
urban communities in India. As with any social system, organization is of
prime concern. Family organization is distinguishable from other systems by
its high level of relatedness. Since it is the smallest social and interpersonal
system, there is an intensity of interdependence among its components. In
order to achieve its goal of providing care for all the members in the family
system, the family must secure and conserve energy from within its internal
resources. The members of the family must contribute energy for the fam-
ily system as well as import energy for their individual purposes (Bowen,
1966). For that reason, economists in India have theorized that people in
India had a large number of children as a form of social security in old
age (Cain, 1991; Nugent, 1985). Parents saved money/assets, and transferred
1042 R. Gupta

these resources to their adult children as a form of social security. It was

obligation of these adult children, who lived in the joint household with
their families, to provide care for the elderly parents until they died. The re-
ligious, sociocultural milieu in India dictates that the dharma, or moral duty
of adult children (primarily sons), is to provide care for their older parents
and in-laws. With modernization and advances in medicine and technol-
ogy, older adults now live longer than they did even a decade ago. The
life expectancy in India in the 1960s was 45–50 years and now is 65–70
years. With larger numbers of family members and the high cost of living,
female family members who formerly provided the majority of care giving
to the elderly have increasingly found it necessary to be employed out-
side the home. As a consequence, the family system has had to go through
some reorganization, which likely has created a greater burden on other
family care givers as roles have shifted, by necessity, and become increas-
ingly complex as families struggle to keep up with inflation and the rising
costs of goods and services. Thus, systems theory is a particularly useful
approach in understanding care giving, since it allows us to understand the
situation in Indian families, takes family system variables into account, and
defines characteristics of the elderly and characteristics of their care givers,
and how the care givers function in describing perceived burden of care
giving.

Family Structure
The family system has several components that are necessary for the whole
system to work adequately. In the joint family system in India, several units
function together. The elderly couple and their adult son and his offspring
live in the same household. Several family members may be employed, and
their incomes are pooled for the upkeep of the family system. Earlier studies
on care giver burden show mixed results about the impact of family income
and its relationship to perceived burden (Andersons, Linto, & Stewart-Wynne,
1995; Chiu, Shyu, & Chen, 1997; Chowdhry, 1992; Stommel, Given, & Given,
1993). We hypothesized that if total family income increased, the burden on
care givers would decrease.

Elder Characteristics
In using the systems perspective, we considered a second set of system vari-
ables: characteristics of the elderly care recipient. With the aging process, the
family system undergoes many changes as the health of older adults, both
physical and mental, begins to decline. There have been debates in the aca-
demic community about whether there are fewer incidences of Alzheimer’s
disease in older Indian adults compared with older adults in other countries
 Understanding Caregiving of the Elderly in India 1043

(Cohen, 1998; Leibing & Cohen, 2006). It is unclear whether there has been
a large-scale assessment of dementia in India, or whether the incidence of
dementia gets unreported because it is seen as confusion in old age, which
may be considered part of the aging process. Moreover, research shows that
elderly persons with behavioral problems, such as yelling, screaming, curs-
ing, being verbally abusive, or throwing things, produce greater challenges
for care givers than simply providing routine care giving tasks (Jamuna, 1997,
2003). Hence, a testable hypothesis that emerges is that the more behavioral
problems the elder has, the greater the burden will be on his or her care
giver(s).

Care Giver Characteristics

The final component in system variables is related to characteristics of the
care givers. Worldwide, a majority of families provide care for the elderly
parent and only a small proportion of the elderly are institutionalized (AARP,
2007). Families provide a greater number of care giving tasks, including both
assistance in daily living (ADL), such as bathing, feeding, and getting elders
in and out of bed, and they provide instrumental assistance in daily living
(IADL) tasks, such as shopping, managing money, and providing support
and recreation. Earlier research shows that care givers who perform a greater
number of care giving tasks, such as feeding, bathing, and so on, feel more
burden (Andersons et al., 1995). Thus, we hypothesize that the more tasks
the care giver has to perform, the greater his or her perceived burden will be.
Although there has been ongoing debate in the literature that filial piety
norms are gradually eroding, research shows that families still continue to
provide care for their elders. Previous research showed that care givers who
adhered to the Asian Indian cultural norm of dharma, or moral duty to
provide care for the elderly parent, were less likely to consider it a burden
to provide care for them (Gupta & Pillai, 2002). Thus, we hypothesize that
the greater the adherence to Asian cultural norms is, the less the perceived
burden will be.
The literature is replete with studies that show that demographic char-
acteristics of care givers, such as age and gender, also play a significant role
in their perceptions of burden. Several studies show that female care givers
perceive greater burden when they provide care to the elder compared with
male care givers (Kim, 2001; Wuest, 1997). So we hypothesize that females
perceive greater burden compared with male care givers. Another emerging
factor that we see with increased life expectancy is the age of the care giver.
As care givers age themselves, it becomes increasingly difficult for the care
giver to provide care (Chan, 2005; Park, Phua, McNally, & Sun, 2005). We
hypothesize that the greater the age of the care giver, the greater the perceived
burden.
1044 R. Gupta

In order to test the hypotheses enumerated above, we designed a study

to see which aspects of the systems perspective hold true in the context of
care giver burden in Asian Indian families in India.

METHODOLOGY
Sample Selection
In this study, the term care giver refers to persons 18 years of age or older
who satisfy a number of selection criteria for this study. In order to be
eligible for inclusion in this study, the care giver had to be a male/female
taking care of a parent or parent-in-law, grandparent, or relative who was at
least 60 years of age or older and who had lived in a joint household with the
elderly care recipient for over a year. In joint households, several members
of the family often share care giving tasks and reside in the same household
(Soldo & Myllyluoma, 1983). Among these care givers, the primary care giver
is one who self-identifies as the person who provides at least 4 hours of care
per day and assists the care recipient with at least one ADL or two IADL.
The primary care giver is someone who provides more care to the elderly
compared with other care givers in the family.

SAMPLING PROCEDURE
Allahabad is an Indian city with a population of 1,022,365 people (India
Census, 2001). A large proportion of the population are Hindus, followed by
Muslims, Sikhs, and Christians (Census of India, 2001). A multistage prob-
ability sampling method was used to generate a sample of primary care
givers.
The city of Allahabad consists of 40 wards (districts). Five wards were
chosen randomly from a list of all wards. From the Nagar Mahapalika (gov-
ernment based municipality) we obtained a master map of the city that
shows the boundaries of all the selected wards. Maps of the selected wards,
which showed the layout of residential areas within each of the five selected
wards, were obtained from the City Planning Office. All residential neigh-
borhoods were identified with the help of the ward maps. For the purpose
of this study, a neighborhood was defined as any area used for residential
purposes enclosed by roads on all the sides. A count of all the neighbor-
hoods within each of the wards was obtained. Nearly 104 neighborhoods
containing approximately 125 households were identified. Ten percent of
all the neighborhoods from the five selected wards were randomly chosen.
The distribution of the neighborhoods across the five selected wards was as
follows: Three each from Civil Lines and Daryaganj wards; two from Tagore
town; and one each from Chowk and Katra.
 Understanding Caregiving of the Elderly in India 1045

In order to establish contact with households in which primary care

givers resided, three points of entry into the community were utilized. The
first involved contact with officials from religious organizations such as tem-
ples, mosques, and churches in each of the selected wards. A number of
religious officials were informed about the objectives and design of the
study and were asked for permission to advertise the study through posters
placed in areas outside the buildings where worshippers tended to congre-
gate. Permission also was sought to communicate with worshippers inside
the premises of the religious organizations. Conversations with worshippers
led to the publicity of the study.
A second point of entry was through well-known community leaders.
A number of prominent community leaders were identified in each of the
selected wards. Persons who were elected representatives, either at the mu-
nicipality or ward level, were considered community leaders. A list of all the
community leaders in the selected wards was developed. These leaders were
informed about the study, and cooperation for the study was sought from
them. They provided letters of permission to solicit household interviews
from areas under their political jurisdiction.
A third point of entry into the community was through the media. Two
major newspapers published articles on the principal investigators’ work
on caregiving of the elderly in the United States and invited care givers to
participate in the social survey that had been launched.
The locations of all the selected neighborhoods were obtained from the
wards, and visits were made to each of the selected neighborhoods. The
purpose of the site visit was to become familiar with the layout of houses
in the sample neighborhoods. Upon familiarization with the physical layout
of houses in the neighborhoods, a count of all the houses in each of the
sample neighborhoods was obtained. In all, approximately 1,150 houses
were counted in the selected neighborhoods.
Every second house was included in this study, constituting a sample of
575 households, and their house numbers were noted. Interviewers visited
the selected houses. The household members were informed of the study,
and information with respect to presence of an elderly member and his or
her care giver was sought. If no care giver was present, the next house was
visited and so on. Once a care giver was identified during this process, the
house was identified as one where interviews were needed; then permission
for interviews were sought from the members of those households. Of the
575 households contacted, 354 households had primary care givers. From
these 354 households, 263 agreed to participate in the study. As a result, the
response rate for the study was 73%.
Five doctoral students from the Department of Psychology at the Univer-
sity of Allahabad, who were experienced in data collection, were trained in
the survey techniques. Three of the five interviewers were Hindus, one was a
Muslim, and the other was Sikh; three of the five interviewers were females.
1046 R. Gupta

A questionnaire was created to gather data required for this study. The
interview questionnaire was translated into Hindi, the Indian national lan-
guage and the main language spoken in Allahabad, and then translated back
into English. Even though Muslims speak Urdu, they understand Hindi be-
cause the two languages are very similar. The interviewers made contact with
household members from each of the selected households in this study. In a
structured face-to-face interview with the primary care giver, the interview-
ers first described the study. Informed verbal consent was given for each
interview. Written consent was not required since some of the respondents
were illiterate. Confidentiality was guaranteed to all the participants. Most
of the interviews were conducted during the first meeting. Each interview
lasted approximately 1 to 2 hours.

INSTRUMENTATION

Several variables were included in each of the three subsystems.

Perceived care giver burden scale: The dependent variable is the per-
ceived care giver burden scale, which is a 31-item ordinal scale adapted
from Stommel, Given, and Given (1990). The scale has five subscales and
includes items related to financial burden, alpha value 0.87; abandonment
by extended family, alpha value 0.89; disruption of work schedule, alpha
value 0.90; care giver’s health problems, alpha value 0.73; and feelings of
entrapment, alpha coefficient 0.97. The scale was coded as 1 = strongly
agree; 4 = strongly disagree.

Family Structure
Total number of elder children included a number from one to 10. The
question asked was, “How many living children does the elderly person
have who could assist you sometime when you need it?”
Number of people in the family working and financially contributing for
the care of the elder ranged from one to 10.
Total family income were categories ranging from less than Rs.5,000 per
year to over Rs.100,000. The question asked was, “What is your total family
income in your household per year?”
Elder characteristics included several variables.
Elderly persons confusion was coded as (3 = very confused; 2 = some-
what confused, 1 = not confused), followed by a qualitative question asking
the respondent to list the elderly person’s levels of confusion by asking if the
elder remembers what year it is, name of the President of India, and how
many children they had.
Elderly persons behavior problems was coded as 1 = present; 0 =
not present, followed by asking respondents to list the elderly person’s
 Understanding Caregiving of the Elderly in India 1047

behavioral problems. Some of the responses included lethargy, sadness,

loneliness, and anger outbursts.
Care giver characteristics included several variables related to the de-
mographic and personal characteristics of the care giver.
Number of care giving tasks provided by care giver was a number 1 to
12. The question asked was, “How many care giving tasks do you provide
per day?”
Identification with Asian cultural norms was a 22-item filial piety scale
adapted from Ho and Lee (1974) and was coded as 1 = strongly disagree; 4
= strongly agree. The alpha value for this scale was 0.71.
Gender was coded as 1 = female, 0 = male.
Care giver age was a ratio level variable that ranged from ages 18 to 88
years.

EMPIRICAL ANALYSIS

A multiple regression analysis was conducted, with variables in each sub-

system entered as a group to see the effect of the subsystem on care giver
burden as presented in Table 1.
Table 2 presents the results of regression analysis.

RESULTS

The results from the model indicate that all the three models of the family
system contributed to perceived care giver burden.
The first part of the model was the family structural level variables. In
joint family systems, several family members contribute to the family income.
Out of the three hypotheses that were presented, only one was supported.
The hypothesis that theorized that the greater the family income was, the
less burden there would be was β = −1.31, b = −.39; p < .001. The r square
for family structural variables was 0.21. This means that 21% of the variance
in care giver burden can be explained by total family income.
The hypothesis that was significant for the characteristics of the elder
was that the more behavioral problems the elder had, the greater the level
of perceived burden would be was β = 3.29, b = .18; p < .05. The r square
for elder characteristics was .34. This explains that 34% of the variance in
care giver burden can be explained with factors related to the behavioral
problems of the elderly care recipient.
In the last subsystem, which included characteristics of the care giver,
several variables, such as identification with Asian cultural norms, age, gen-
der, and the number of care giving tasks performed by the care giver, were
significant. The results indicate that the care givers who identified with Asian
cultural norms perceived less burden (β = −.39, b = −2.78, p < .05). The
1048 R. Gupta

TABLE 1 Demographic Characteristics of Care Givers and the Elderly Among Indian Sample,
N = 258

Variable Percent N Variable Percent N

Care giver age 42 yrs. (Range: 18 Min; Elder age 75 yrs

(mean) 88 Max) (mean)
Care giver religion Elder gender
Hindu 60.6 157 Male 38.2 159
Muslim 29.3 76 Female 61.4 99
Christian 8.5 22
Sikh 1.2 3 Elder health
Care giver gender
Male 25.1 65 Yes 85.7 222
Female 74.9 194 No 13.9 36
Family income per month
Median Rs.8000 U.S.$166 No. of people in 6.59
(U.S.$166) the house (mean)
Mean Rs.7000 U.S.$146
Relationship to elder Elder marital
status
Spouse 9.7 25 Married 47.9 124
Daughter 19.7 51 Widowed 48.6 126
Son 18.5 48 Divorced 1.9 5
Daughter-in-law 30.1 78 Single (nm) 1.2 3
Grandchild 13.9 36
Other 8.1 21 # of people 1.85
employed (mean)
Care giver marital status Elder confusion
Married 66.4 172 Very much 14.3 37
Never married single 29.0 75 Sometimes 38.2 99
Divorced 2.7 7 Not at all 47.1 122
Widowed 1.9 5
Education of care giver Care giver health
No school 2.7 7 Excellent 30.1 78
Elementary 1–6 8.5 22 Good 47.9 124
Secondary 7–12 17.4 45 Fair 20.8 54
Some college 13–14 21.2 55 Poor 0.8 2
College 16–18 23.9 62
Postgraduate 25.9 67
Work of head of Elder behavior
household problems
Professional 25.5 66 Very much 18.5 48
Own business 14.7 38 Sometimes 39.8 103
Cleaning/housework 46.7 121 Not at all 41.3 107
Skilled worker 9.7 25
Retired 3.5 9

greater the number of care giving tasks performed by the care giver, the
greater the perceived burden (β = .18, b = .23, p < .0001). Female care
givers perceived greater burden than male care givers (β = −3.66, b =
−2.08, p < .0001). The higher the age of the care giver, the greater the care
giver burden (β = .19, b = 3.33, p < .05). The r square for model was .46,
which explains 46% of the variance in perceived care giver burden. The r
 Understanding Caregiving of the Elderly in India 1049

TABLE 2 Regression Model: Predictors of Care Giver Burden for Care Givers of the Elderly
Indians

Model 1 Model 2 Model 3

Unstandardized b Unstandardized b Unstandardized b

(B) (B) (B)
Characteristics of Family
Total number of elder −.59(−.09) −.61(−.00) −.24(−.04)
children
Total family income −1.48(−.44)∗∗∗∗ −1.33(−.39)∗∗∗∗ −1.31(−.39)∗∗∗∗
# employed family members 1.98(.13)∗ 1.43(.09) 1.66(.12)
Elder Characteristics
Elder behavior problems 5.18(.29)∗∗∗∗ 3.29(.18)∗∗
Elder money −1.48(−.06) −2.61(−1.86)
Elder confusion −1.92(−.10) −1.99(1.66)
Care giver Characteristics
Identification with Asian −.39(−2.78)∗∗
cultural norms
Care giver age .19(3.33)∗∗
Care giver gender −3.66 (−2.08)∗
# of care giving tasks .18(.23)∗∗∗
R square .21 .34 .46
Adjusted R square .20 .32 .44
F 17.35 15.96 15.97
∗∗∗∗ <.000; ∗∗∗ < .01; ∗∗ < .05; ∗ <.10.

square changed from model one to model two was .7, which means that 7%
of the perceived burden was accounted for by the variables related to the
characteristics of the care giver.

DISCUSSION

The results reported above indicate that all the three characteristics con-
tributed to perceived care giver burden. In the Asian Indian family system,
several family members contribute resources to the family so that their fam-
ily system can be maintained, which also includes providing care for the
elderly. Family members are likely to contribute to the family income, which
is likely to reduce the burden experienced by the primary care giver. This
was especially true for those who had several family members working so
that the total family income alleviated some of the burden on the care giver.
This has been cited in earlier studies that multigenerational family mem-
bers contribute and assist one another primarily by pooling their finances
(Chakraborti, 2004; Jamuna, 2003; Kumar, 2003).
The behavioral problems of the elder were another major factor in care
givers’ perceptions of burden. The care givers had difficulty in address-
ing the behavioral problems of their elders for two reasons. First, many care
givers were unaware that behavioral problems could be due to an underlying
1050 R. Gupta

physical ailment or mental health issue from which the elder may be suffer-
ing. Second, the taboo against openly acknowledging that an elderly parent
could be mentally ill, for fear of expressing disrespect and bringing shame
to the family, often leads to a lack of willingness to seek assistive health
and mental health services (Bertrand, Fredman, & Saczynski, 2006; Gupta
& Pillai, 2002; Gupta, Punetha, & Diwan, 2006) even though such services
may be available in the community. Instead, the care givers often use Asian
religious beliefs to cope with the elder’s behavioral problems as “hassles of
daily living” or as “part of aging process,” without attempting to find other
forms of relief from this problem. Thus the elder’s behavioral problems are
never diagnosed, and, therefore, remain untreated.
We found that a large number of Asian Indian care givers adhered to
the Asian cultural norm of dharma to provide care for the elderly, and this
belief thus lessened the perception of burden. This result is consistent with
earlier studies that show that, in many parts of the world, family members
continue to provide all the care for their elderly parents, especially when
they feel it is their duty to do so (Chan, 2005; Milne & Chryssanthopoulou,
2005).
Although family members in a multigenerational family system may
contribute financially, they might not be assisting the primary care giver with
the care giving tasks that are required for the elderly, such as daily living tasks
like bathing, feeding, and toileting. These and other instrumental activities
of daily living, such as recreational and emotional care of the elderly, are
still the work of the primary care giver. Our results show that the greater the
number of care giving tasks provided by the care giver, the greater the level
of burden was perceived to be. Previous studies have shown that care givers
who provided most of the care giving tasks were likely to burn out or feel
depressed (Kim, 2001).
Our findings confirm the relevance of several demographic variables,
such as the age and gender of the care giver. The higher the age of the care
giver, the greater the burden was in providing care for the elderly. Consistent
with other studies, we also found that women care givers experienced greater
burden in comparison with men in India (Gupta & Pillai, 2006; Huang,
2006). This may be a result of women feeling a greater burden as they try to
maintain traditional Indian multigenerational households while also juggling
employment outside the home. The Indian female care givers may feel that
they have no choice but to provide care for their in-laws as that is a normative
custom in India.
To conclude from the above, results showed that female care givers in
India perceive the greater level of burden in providing care to their elders.
The family system remains the most important source of support for elderly
people requiring care, and it is not envisaged that government input will
enhance the care of the elderly in any way within the near future. Although
our findings suggest that the influence of adherence to Asian cultural norms
 Understanding Caregiving of the Elderly in India 1051

remains strong in India, in reality, care giving behaviors are lessening such
that the basic physical needs of the elderly are satisfied without much con-
cern for their emotional well-being. A few recommendations are suggested
for practitioners:

• As long as adult children feel obligated to support their elderly parents and
relatives, their sense of dharma or duty to their parents must be admired
and given public recognition.
• The female care givers who experience the burden of care should be
assessed and their ability to provide care be gauged realistically. In-home
support and cash award incentives from the government should be tailored
to their needs. The optimal solution would be that care would continue to
be provided by the family, but with support from the community, such as
visiting nurses, respite care, and senior centers. In order to build commu-
nities, new ways need to be adopted that mix informal and formal support
services aimed at enhancing the caring functions of the family within the
community.
• Institutional care should not be regarded as a last resort, as it is the most
appropriate form of care for those requiring intensive support, especially
when the behavioral problems of the elderly have been determined to
have an organic basis. The admission of an elderly person into institu-
tional care should in no way be taken as an act of disregard for the
elder.

The proposed recommendations to support the elderly are not meant

to be exhaustive, but rather as a starting point for policy makers in India to
devise an aged care policy for elderly Indian citizens. Each region or state
government in India must, therefore, devise its aged care policy in support of
its frail elderly people, taking into account the existing formal and informal
systems with the unique needs of each family.
There is clearly a need for social workers to provide information to care
givers in the form of accessing several channels of support from within the
community and also from outside. Thus the social worker would provide
educational seminars and link the female care givers to prevention services
for health and mental health assessment of the care recipient. The social
worker would form a coalition of care givers who advocate for the rights
and services for the elderly.
There are a few limitations to this study because it did not take into
account variations in the adjustments care givers make to care giving over
time. Future studies would benefit from in-depth qualitative analysis of in-
terviews of both recipients of care as well as care giver dyads across two or
more points in time, noting specifically the changes in care giving once the
elderly person becomes sick or approaches the end of life.
1052 R. Gupta

REFERENCES

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