Social Networks, Family, and Care Giving Among Older Adults in India

Lisa F. Berkman; T.V. Sekher; Benjamin Capistrant; Yuhui Zheng

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National Research Council (US) Panel on Policy Research and Data Needs to Meet the Challenge of Aging in Asia; Smith JP, Majmundar M, editors. Aging in Asia: Findings From New and Emerging Data Initiatives. Washington (DC): National Academies Press (US); 2012.

Aging in Asia: Findings From New and Emerging Data Initiatives.

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11Social Networks, Family, and Care Giving Among Older Adults in India

Lisa F. Berkman, T.V. Sekher, Benjamin Capistrant, and Yuhui Zheng.

Social networks and family ties are among the core institutions providing support and opportunities for engagement to older adults around the world (Berkman, 2000; Bloom et al., 2010; Bongaarts and Zimmer, 2002; Wachter, 1997). Social networks are defined by the web of associations and the structure of ties that surround a person (Berkman and Glass, 2000; McPherson, Smith-Lovin, and Cook, 2001; Wellman and Berkowitz, 1988). The network has several functions including the provision of emotional, instrumental, appraisal, and financial support. At the same time, it is important to acknowledge that social networks may involve both negative and positive interactions, with resulting health impacts (Berkman, 2009; Berkman and Glass, 2000; Seeman et al., 2001). Furthermore, the contribution of support provided by older adults to their families and communities is important and often not well recognized. As societies undergo demographic transitions with rising life expectancy and decreases in fertility, societies as a whole “age” (Kirk, 1996). India, while early in this transition, has started to experience the growing pains associated not only with population growth but also an aging society. Over the next decades, the demographic and health transition will challenge core institutions to adapt and to develop innovative approaches to work, family life, caregiving, and education across the life course (Lee, 2003; Lloyd-Sherlock, 2010). Globally, somewhere around 2020, there will be more people aged 65 and older than children under 5. In India, this crossover will happen later, but not so much later. Furthermore as women continue to join the paid labor force, integrating care needs of older and younger family members while remaining in the labor force will pose challenges to both women and men in most societies (Budlender, 2008; Das et al., 2010; Sabates-Wheeler and Roelen, 2011). The changing older dependency ratios for world regions for 2000, 2020, and 2040 suggest that in Asia (excluding the Near East), the number of people aged 65 and older for every 100 people 20–64 will grow from 11 to 28 in this time period (United Nations, 2008). In this regard, India is no exception. Thus, it is critical that data regarding the family and network dynamics of older people in India be understood so that both formal and informal sectors can develop and plan effectively to maintain health, well-being, and productivity in the growing population of older adults and their families.

As in many countries, the family is a cherished institution in India and often provides important nonformal social security for the older population (Bloom et al., 2010). Most older men and women in India live with their families, and it is the most preferred living arrangement of older people (Gupta, 2009). Families continue to be the central organizing unit for economic support and for providing care for those physically unable to care for themselves (Kozel and Parker, 2000; Samuel and Thyloth, 2002). In the absence of institutions that provide social insurance (Barrientos, Gorman, and Heslop, 2003; Lloyd-Sherlock, 2002), we suspect that India’s older populations will continue to rely on the family and social networks (Gupta, 2009; Gupta, Rowe, and Pillai, 2009). Social networks comprised of both family and friends are an important resource in the older person’s life (Cohen and Wills, 1985; Shanas, 1973, 1979), although there is little evidence in India of the impacts of social networks on physical and mental well-being. As the nature of family, intergenerational relationships, and the role of women in the family are changing, these transitions may well impact the care and welfare of older people (Lloyd-Sherlock, 2000, 2002). In some instances, the family in the 21st century may be unable to meet the needs of the aged, thereby creating a need to look for other support services. India’s National Policy on Older Persons (Government of India, 1999) emphasizes that programs will be developed to promote family values and sensitize the young to the necessity and desirability of intergenerational bonding and continuity.

The aim of this chapter is to provide a description of family and network ties among older men and women in India and to illustrate the dynamic interplay between caregiving and receiving among older people. In this chapter, we present findings from the Longitudinal Aging Study in India (LASI) pilot study, a cross-sectional survey of men and women over the age of 45 and their spouses in four states in India. In all our analysis, we will only include participants aged 45 and older: spouses younger than 45 were excluded because they were a representative sample of the population of their ages.

METHODS

Sample

LASI is a panel survey representing persons at least 45 years of age in India. Its pilot study is funded by the National Institute on Aging and samples individuals in four states (Karnataka, Kerala, Punjab, and Rajasthan). The survey instrument has been designed to collect information that is conceptually comparable to the U.S. Health and Retirement Study (HRS) and its sister surveys in Asia, and includes variables on demographics; family structure and social network; health and health behaviors; health care utilization; work and pension; housing and environment; and income, assets, debts, and consumption. The LASI survey instrument captures local characteristics of India. To capture regional variation, we will include two northern states (Punjab and Rajasthan) and two southern states ( Karnataka and Kerala). Karnataka and Rajasthan were included in the Study on Global AGEing and Adult Health (SAGE), which will enable us to compare our findings with the SAGE data. The inclusion of Kerala and Punjab will demonstrate our ability to obtain a broader representation of India, where geographic variations accompanied by socioeconomic and cultural differences call for careful study and deliberation, especially when preparing for the nationally representative sampling for the subsequent baseline study. Punjab is an example of an economically developed state, while Rajasthan is relatively poor. Rajasthan is also one of the states with the highest ratio of males to females and is the capital of the practice of sati; thus, the well-being of widows may be particularly low in this state. Kerala, which is known for its relatively efficient healthcare system, has undergone rapid social development and is included as a potential harbinger of how the situation might evolve in other Indian states. The sampling frame for LASI is drawn from the 2001 Census Primary Census Abstract. We use listing directories of villages and towns to select sample areas within each state for the pilot project. The primary sampling units (PSUs) are the randomly selected villages in rural areas and census enumeration blocks in urban areas that typically consist of 100–150 households. Basic distributions by gender are shown in Tables 11-1A and 11-1B.

TABLE 11-1A

Distribution of Outcomes by Gender (in percentage).

TABLE 11-1B

Distributions of Demographic and Socioeconomic Variables by Gender (in percentage).

Three Measures of Family and Social Networks

Social networks are comprised of multiple ties with family, friends, and links to more formal and informal social institutions. These ties form a web that provides resources to its members, often in the form of social support. Social support itself takes a number of forms, including emotional, instrumental, appraisal, and financial support. Social ties need not be positive but can also lead to negative outcomes including conflict and abuse. In this section, we explore some of the basic kinds of ties with spouse or partner, friends, and social activities often involving weaker ties and their social patterning in terms of social, economic, and demographic characteristics. We start with an exploration of three different aspects of social networks: ties with spouse, ties with close friends, and participation in social activities. These ties range from the most intimate and close ties with a partner to more extended and weaker ties with those who engage in social activities. There is little information currently available on these types of ties in India so basic information is essential.

We examined three measures of family and social networks. The first measure is closeness with spouse. The question asks “How close is your relationship with your spouse or partner?” The response categories include “Very close/Quite close/Not very close/Not at all close.” We generated a binary variable about closeness with spouse, which takes a value of 1 if reporting “Very close” and 0 for reporting other categories.

The second measure is related to ties outside of the household. It indicates whether a respondent reported having any close friends. This measure was generated based on two questions in LASI. The first was “Do you have any friends?” If the answer is yes, then a second question was: “How many of these friends would you say you have a close relationship with?” If a respondent reported having any friend, and had a close relationship with one or more friends, then the measure of “having any close friend” takes the value of 1. Otherwise, it is 0.

The third measure is related to participation in social activities. LASI asks about how frequently a person participates in each of the following seven activities: (1) Go to the cinema, (2) eat out of the house, (3) go to a park/beach, (4) play cards or games, (5) visit relatives/friends, (6) attend cultural performances/shows, and (7) attend religious functions/events (outside home). The response categories are as follows: Twice a month or more/About once a month/Every few months/About once or twice a year/Less than once a year. Since activity 7, attending religious events, is strongly correlated with religion, we decided to exclude this activity for the measure of participation in social activities. The measure takes the value of 1 if for one or more of the other six activities, a person reported participating “Twice a month or more” or “About once a month.”

Analysis

Since all three outcomes are binary, we applied a logit model to examine how social ties are associated with various sociodemographic characteristics and economic positions. Demographic characteristics include age group, gender, living in urban area, marital status, and living with a child or not. Economic positions are measured by education and per capita consumption. Per capita consumption is preferred over income for low-income regions and rural areas. LASI collected detailed data on household consumption. We used the variable of per capita consumption on Organisation for Economic Co-operation and Development equivalence, which takes into account not only number of household members, but also different consumption burden by age. The household adult was assigned a weight of 1, additional adults each were assigned a weight of 0.5, and each child was assigned a weight of 0.3. The per capita consumption measure was generated by adding all weights of the household members, and dividing the total household consumption by this summed value. Since LASI provides imputed data for missing values using a hot deck method, we control for imputed consumption in the models to adjust for any systematic bias due to missing data for some components of household consumption. We recoded the per capita consumption measure into terciles: low, middle, and high. The cutoff values for the terciles were 31,100 (RPs) and 57,033 (RPs). Finally, we control for region, caste, and state.

RESULTS

Sociodemographic Characteristics of LASI Participants

Sample characteristics of LASI are shown in Tables 11-1A and 11-1B. The pilot survey was done in selected states including Karnataka, Kerala, Punjab, and Rajasthan. Table 11-1A shows the distribution of the three social tie measures of interest, and Table 11-1B shows the other demographic conditions. Seventy-one percent of women and 75% of men lived in rural areas. Women were much less likely to be currently married: 65% versus 91% among men. This is not due to differences in age structure in our sample: Table 11-1B shows that for female participants, 61% were aged between 45–59, 30% aged between 60–74, and 9% were 75 and older. The corresponding percentages for male participants were 58%, 33%, and 9%, respectively.

In LASI, 32% of women are currently widowed. There is a growing concern about the increasing proportion of widows among older persons. The two main reasons for the significant gender disparity in widowhood are the longer life span of women compared to men and the general tendency in India for women to marry men older than themselves. Adjustment to widowhood can be difficult for women in all societies, particularly in India. Widows often face restrictions and social stigma. Lack of inheritance rights and property, and insufficient incomes and earnings expose elderly widows to deprivation and social isolation. As has been noted, “Widowhood is more than the loss of a husband—it may mean the loss of a separate identity” (United Nations Population Fund, 1998, p. 42).

Living arrangements are an important component of analysis of welfare of elderly. In other words, the care and support experienced by the elderly are commonly linked to the place of their residence. Table 11-1B shows that among women, 51% were living with spouse and children, 12% living with spouse only, 28% living with children only, and 8% living with neither spouse nor child. For men, 77% were living with both spouse and child, 13% were living with spouse only, 6% were living with spouse only, and 4% were living with neither spouse nor child. However, the large numbers of women surviving their spouses as compared to men may create increasing economic vulnerability of older Indians. One of the main social effects of extension of life is the extended period of widowhood for many women. According to the 2001 Census of India, 51% of the women aged 60 years and older are widowed, compared to only 15% among men. Men commonly have wives to care for them into older ages, but spouses may not be the major source of care for the majority of older women in India. Finally, in LASI, we have created a measure of economic status of the households by categorizing into them into five wealth quintiles: The lowest quintile constitutes the poorest households, and the highest quintile represents the richest households.

Distribution of Outcome Measures

Table 11-1A shows the distributions of the three outcome measures by gender. Men and women reported similar level of closeness to spouses, if married: 78% among men and 80% among women. However, women were less likely to participate in any social activities: 60% among women versus 67% among men. Finally, only 34% of women reported having any close friend, while 56% of men did. The gender distributions across the four regions in LASI are very similar.

Regression Analysis

Closeness with Spouse

We first assess the relationship quality between the spouse and the participant in LASI. A set of questions was included in the survey to measure the extent of satisfaction with life and current situations. One question is about a respondent’s relationship with a spouse. The responses were categorized into three levels: completely/very satisfied, somewhat satisfied, and not satisfied. Table 11-2 shows the odds ratios for “feeling very close to your spouse” among men and women who were married in LASI. Respondents who are somewhat satisfied or not satisfied are contrasted with those who are completely or very satisfied.

TABLE 11-2

Odds Ratios of Logistic Regression for the Outcome of “Very Close to Spouse,” if Married.

The results of this analysis suggest that there is little difference in marital satisfaction with age. While those aged 60 and older are slightly less likely to report being close to their partners, these results are not significant. Gender differences are also not substantial in these analyses once we control for covariates. Those living in urban areas were likely to be close to their spouses but the association was not significant (OR 0.77, 95% CI 0.45–1.30). When comparing educational levels with terciles of consumption, some important differences emerge. Within educational levels, relative to the illiterate group, those with any education, primary, secondary, or high school and above were twice or more likely to report being close to their spouses. In contrast, those in the middle and high tercile of consumption were more likely to report being close to a spouse, but the associations were not significant. Those with imputed consumption values were more likely to report being close to spouses. Finally, religion, caste, and state were not associated with closeness to spouse.

Ties with Close Friends

Ties with close friends are a potential source of support, friendship, and intimacy. Even in countries where close ties are often kinship based, close friends turn out to have a critical role in social networks. Table 11-3 shows the association of close friendships with the same set of social and demographic characteristics we examined previously in a multiple logistic analysis looking at the independent association of each variable.

TABLE 11-3

Odds Ratios of Logistic Regression for the Outcome of “Any Close Friend”.

The results of this analysis contrast in some significant ways with those related to spousal relationships. Age, for instance, is strongly associated with friendship patterns, with older men and women much less likely to have close friends. Younger respondents are more than three times as likely to have close friends compared to older people. Surprisingly, since women are often thought of as caregivers and social “connectors,” in this analysis, they are much less likely to report close friends than are men (OR .35, 95% CI .24–.51). There is a hint, though not statistically significant, that widowed, divorced, and single respondents are more likely to have close friends than their married counterparts, suggestive of some level of substitution among types of ties. These odds ratios, however, are relatively small. Finally, increasing education and consumption were associated with an increasing likelihood of having close friends. Respondents living in Kerala were more likely to report having close friends than those living in other regions.

Social Activities and Social Participation

The LASI pilot survey included questions about social participation. Specifically, a question asked about social activities including going to the cinema, eating out of the house, going to the park/beach, playing cards or games, visiting relatives/friends, attending cultural performances/shows, and attending religious functions/events (outside home). In a multivariate logistic regression analysis, we examined the associations between demographic and economic conditions and participation in social activities. Table 11-4 shows the results of the analysis with odds ratios and 95% confidence intervals.

TABLE 11-4

Odds Ratios of Logistic Regression for the Outcome of “Any Social Activities”.

The results from this analysis indicate the participation in social activities is substantially lower among those aged 75 and older than those at younger ages. Women are less likely to engage in social activities than are men. The strongest associations, however, are in relation to socioeconomic position. Both men and women with high levels of education and in middle and high consumption terciles are more likely to engage in social activities. In these analyses, respondents living in Rajasthan were much less likely to participate in social activities than those in other regions.

Positive and Negative Aspects of Social Relationships

Social networks may be positive and enriching as well as negative and conflict-laden. While a deep analysis of these dimensions is beyond the scope of this chapter, here we present some preliminary findings with regard to the quality of different types of social ties. Our aim was to explore both positive and negative aspects of ties, including ill treatment of older men and women, patterns of communication among friends, and patterns of financial support in terms of support both given and received by participants. We describe these findings in the text. The data are available from the authors upon request.

Ill Treatment of Elderly within the Family

Elder abuse and neglect are increasingly acknowledged as a social problem internationally (Acierno et al., 2010; Cooper, Selwood, and Livingston, 2008; Dong et al., 2009), and India is no exception. The responsibility of caring for the elderly in India is traditionally borne by the immediate family (Gupta, 2009). However, with a changing trend toward nuclear family set-ups, the vulnerability of the elderly is considerably increasing. The intersection of high care demands and competing time-use priorities can result in low-quality care and high caregiver burden (Boggatz et al., 2007; Dias and Patel, 2009; Navaie-Waliser, Spriggs, and Feldman, 2002), which may manifest in continued unmet needs/neglect and, in the most extreme cases, even direct abuse. Even though there is a general perception about the mistreatment perpetrated on older adults (Cooper et al., 2008; Newman, 2006), the exact magnitude and nature of abuse is still unknown in India. A recent study (Sebastian and Sekher, 2010) observed that female elderly, especially widows, those in the oldest-old age group (80+ years), and the physically immobile, are more vulnerable to abuse than others. Not only the poor, but also the rich are susceptible to neglect and abuse in many families. Chokkanathan and Lee (2005) found that the prevalence of mistreatment was 14% among older adults in an urban setting in India. The mistreatment of elderly is multidimensional and multilayered, emerging from differences in gender, economic position, and physical condition (Selwood, Cooper, and Livingston, 2007; World Health Organizagiton, 2008). The general perception that families are the safest place for the aged in India has been questioned by micro-level studies in recent years (Chokkanathan and Lee, 2005; Selwood, Cooper, and Livingston, 2007; Srinivasan, 2009).

The question “How often do you feel ill-treated within your family?” was posed to all respondents in the LASI pilot survey. This question is not an explicit question about abuse but taps a more general domain related to perceptions of being treated poorly. About 7% stated “often” and 19% responded by stating “some of the time.” However, no significant difference was observed between males and females and also between rural and urban areas. It is also important to note that about three-fourth of respondents stated that they never/hardly ever felt ill-treated within the family. Reporting being ill-treated often is higher among lower-income groups and also among the less educated. The findings of this survey are in tune with prevalence estimates of earlier studies (Chokkanathan and Lee, 2005).

Communication with Friends

Frequency of communication is often identified as an indicator of closeness among social ties. In LASI, if the respondent has friends, the question was asked, “On average, how often do you do each of the following (meet up, speak on phone) with any of your friends?” This section describes how often the older respondents maintain close relationships with their friends through meeting with them or speaking over the phone. The responses given were grouped into three categories: frequently, sometimes, and rarely. Nearly 85% of elderly meet up with a friend frequently. Only 7% responded “rarely.” Meeting with a friend frequently is relatively less common among urban residents and among females. Nearly half of the older respondents (47%) talk with their friends over the phone frequently. Among the older population, speaking over the phone is not as frequent as meeting their friends. Half of the males and 42% of the females speak with their friends frequently. Speaking frequently over the phone is more common among higher economic groups and those with better education.

Financial Support Given to or Received from Family and Friends

LASI asked questions about household financial help given to or received from family members and friends. Financial help includes giving money, helping pay bills, covering the cost of medical care or insurance, schooling, marriages, religious events, rent for housing, and other expenses. Only 5.5% of respondents (N = 81) received any financial help from family; and only 7.4% (N = 110) gave any financial help to family. While financial help is a relatively rare occurrence in this cohort, it is of interest to note that support was given about as much as it was received among older men and women and their families.

CONCLUSIONS

Social networks, family dynamics, and both positive and negative aspects of these relationships are central to the well-being and functioning of men and women across the globe. In this chapter, we have described the basic relationships of older Indian men and women across four states from the LASI pilot study. In this study, the vast majority of both men and women are well connected both in terms of their intimate family ties as well as to more extended, weaker social networks. While 4% of men and 8% of women lived with neither spouse nor children, about 32% of women were widowed. As India continues to experience demographic and health transitions, it will be critical to monitor the ways in which informal social networks from both family and friends will continue to support Indians well into old age.

Another important aspect of these analyses points out that older men and women both give and receive support. In our present analyses, this is particularly true with regard to financial support. One critical aspect of an aging society is the recognition that with increases in life expectancy and healthier functioning into older ages, older men and women will be able to contribute to the well-being of their families and communities (Hughes et al., 2007; Verbugge and Chan, 2008). Older men and women are not only on the receiving end of support, but also contribute to the dynamic and interdependent aspects of social institutions (Cong and Silverstein, 2011; Silverstein et al., 2002). This bidirectional force is often less recognized as societies begin to have larger older populations with a resultant undue emphasis on the burden of older people in rapidly evolving societies such as India.

Socioeconomic conditions, as well as rural versus urban geography, may also shape patterns of social networks and perceptions about the quality of social relations (Pinquart and Sörensen, 2000; Yen and Syme, 1999). In the LASI data, increasing education and income are associated with a greater likelihood of social participation and having close friends. This pattern is often found in Western industrialized countries, particularly the United States (Berkman and Glass, 2000). In other studies, participation in religious activities and ties with close family are not socioeconomically stratified as much as other types of contacts (Berkman and Glass, 2000). Among both indicators on socioeconomic position, those who are most disadvantaged are least likely to be satisfied with their spouses. Within educational levels, those with primary-level education are most likely to be satisfied with the relationship with their spouse. Interestingly, rural residents are about twice as likely as urban residents to report being satisfied with their spousal relationships. These differences suggest more subtle processes of either experience or evaluation of social relationships (Gerstel, Riessman, and Rosenfield, 1985; Goldman, Korenman, and Weinstein, 1995; Julien and Markman, 1991). It is important to note, of course, that this is a cross-sectional study and that the relationship between social networks and socioeconomic and geographic locale is likely to be bidirectional with selection processes going in both senses: that is, that social ties shape both socioeconomic opportunities and geographic mobility.

Our initial analyses are descriptive; however, the next phases of analyses will be aimed at gaining a more nuanced understanding of the social networks of older men and women in India and the social and economic forces that shape them. With more longitudinal data, we will be able to understand the ways in which such social ties and the positive and negative aspects of these ties shape health outcomes and are, in turn, shaped by them.

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Bookshelf ID: NBK109207

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