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The Connections between Attitudes towards Nursing Home Placement, Intergenerational Solidarity, and the Conflict between Tradition and Modernity among Three Generations of Arab Muslim Families in Israel

The Connections between Attitudes towards Nursing Home Placement, Intergenerational Solidarity,... Hindawi Journal of Aging Research Volume 2021, Article ID 6148980, 11 pages https://doi.org/10.1155/2021/6148980 Review Article The Connections between Attitudes towards Nursing Home Placement, Intergenerational Solidarity, and the Conflict between Tradition and Modernity among Three Generations of Arab Muslim Families in Israel Pnina Ron School of Social Work, University of Haifa, Haifa, Israel Correspondence should be addressed to Pnina Ron; pitzyron@research.haifa.ac.il Received 18 January 2020; Revised 18 July 2021; Accepted 10 August 2021; Published 23 August 2021 Academic Editor: He´lio J. Coelho-Ju´nior Copyright © 2021 Pnina Ron. (is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. (e goal of this study was to examine three generations of Arab Muslims in Israel, to investigate the relationships between their attitudes regarding the placement of an older relative in a nursing home, intergenerational solidarity, and to ultimately proceed with the nursing home placement. (e backdrop to this examination was the increasing sociocultural tension between mod- ernization tendencies and the long-established traditions and norms in the Arab Muslim society in Israel. (e sample included a total of 126 university students, as well as one parent and one grandparent of each student. All participants completed identical questionnaires examining the attitudes towards the nursing home placement of an elder relative. (e findings of the study indicate a strong objection among the youngest generation, whose attitudes were more similar to those of their grandparents than to those of their parents. Psychosocial mechanisms in the Arab Muslim population, such as intergenerational solidarity, has been the subject of increased scrutiny and debate over recent years, given the intensive pace of modern developments, which has called into question the familiar norms, thus constituting a threat to the tradition that has guided the population throughout numerous centuries and generations. consequently, the informal support network in the Arab 1. Introduction sector is remarkably strong. Data regarding support Nursing home placement became an official part of the patterns indicate that the degree of support granted to old welfare services available to older individuals in the Arab people in the Arab population is much higher than that sector in Israel approximately 30 years ago [1]. (is granted to old people in the Jewish population. Fur- phenomenon evolved at the same time that the Arab thermore, findings have shown that adult Arab children society in Israel was undergoing changes in several fields, who observe the tradition find it rewarding to care for including, society, economy, education, proprietorship, as their aging parents, whereas the youngest and less tra- well as the distribution of authority roles within the family ditional generation attributes less importance to family [2]. According to the Arab tradition, aging people’s main solidarity [5–7]. Consequently, placing an older parent in support network is the family, and typically, reliance on a nursing home is perceived as shaming the family, and the assistance provided to the community by official those who opt to avail themselves of such services are services is either minimal or nonexistent. Arab society viewed as having betrayed their parents [8]. accords a great deal of significance to maintaining family In recent years, however, there has been a shift in the way solidarity and particularly honoring one’s parents and that the nursing home is perceived among the Arab pop- elders [3, 4]. According to this tradition, the family is ulation, a shift which is related to the changing attitude in responsible for caring for the older relative, and Arab society towards the trends of modernization. 2 Journal of Aging Research (5) Functional solidarity concerns the degree of assis- (e first nursing home for the Arab sector was estab- lished in 1992 by the ESHEL organization in the village of tance and instrumental support between generations and the reciprocity of such support Dabburieh. Currently, there are a substantial number of nursing homes for the Arab sector in Israel; most of them are (6) Normative solidarity the degree of commitment to located in northern Israel, where the largest concentration of family roles and norms Arab Moslems resides. In the past decade, there has been a (e researchers [13] described the findings from the significant increase in the percentage of older people in Israeli portion of a broad (Oasis) survey that examined Israel. In the Jewish sector, older adults constitute 11% of the intergenerational relationships and transmission in several population, compared with 3% in the Arab sector. (e Arab countries (Israel, Norway, England, Germany, and Spain) population, in general, is younger than the Jewish pop- using the intergenerational solidarity model [14]. (ey ulation in Israel, with the number of people older than 65 found that the majority of participants from all countries years totaling 70,350. Furthermore, among the Arab pop- reported a high level of normative solidarity, although the ulation of age 65 years or older, 35% are older than 75 years, solidarity level reported among Israeli participants was compared with 47% in the elder Jewish population [9]. (e higher than that reported by participants in Spain or Ger- rate of disabilities among the elder Arab population is many. According to these researchers, the explanation is relatively high, whereas the rate of nursing home institu- based on the fact that in Israel, there is a greater emphasis on tionalization is low, as manifested in the relatively small family solidarity and a stronger commitment to supporting number of official institutions available to this sector, such as aging parents than in other countries and that this finding is nursing homes, activity centers, and senior citizen centers particularly related to input from Arab families in Israel. [2]. (e percentage of older Arab adults living in nursing In the current study, only four (affectual/emotional, homes is 0.9%, compared with 6% in the Jewish sector, and functional, normative, and structural solidarity) of the six of these, approximately half resides in northern Israel where dimensions of the model were used to examine and gain a they constitute 30% of all of the aging population, regardless better understanding of the essence of the intergenerational of sector affiliation [9]. (e paucity of professional literature relationships and family bonds as perceived by aging in- regarding older adults in the Arab sector, their families, and dividuals, their children, and their grandchildren in the their placement in nursing homes is evident; moreover, the framework of the Arab Muslim family and especially to gain focus of studies conducted in this field to date has been on insight into the attitudes of the three generations in the Arab Arab society as a whole, without examining attitudes within family towards nursing home institutionalization of an aging the Arab sector or within the Arab family unit. family member. 1.1. Intergenerational Solidarity. (e intergenerational sol- 1.2. e Phenomenon of Nursing Home Placement among the idarity model is based on the exchange theory [10, 11] and is Older Adults in the Arab Society. Despite the generally used by numerous researchers to examine intergenerational negative attitudes among the Arab population regarding solidarity, and especially intergenerational relationships of nursing home institutionalization, the approach of older reciprocity, and the phenomenon of transmission between people and their relatives towards the formal services aging parents and their children [10, 12]. (e model, which available suggests a mixture of traditional and modern introduces a new point of view for the exchange theory, is perspectives [15]. In a study that examined the attitudes of intended to provide a comprehensive explanation of the Arab families that decide to place an aging family member in relationships among generations in a single family, by a nursing home, findings indicated that participants found it assessing the quality and characteristics of these relation- easier to see an aging relative in an institute such as a ships. In this model, intergenerational solidarity is perceived hospital, as it demonstrates to their society that this is a as a multidimensional phenomenon, which includes six temporary arrangement for the purpose of receiving components that reflect the reciprocal relationships in a emergency care, so that the aging relative can be brought family [10, 11, 13]. back into the home [16]. A different study that sought to gain (1) Structural solidarity refers to residential patterns, the insight into the reasons for the high rate at which nursing geographical distance between generations and the home residents in Dabburieh were leaving the nursing home number of generations in the family found that the cause was mostly the need to abide by social norms of caring for older family members, due to a sense of (2) Associational solidarity is about the number and shame, and social pressure [8]. As a result of the attitude of patterns of intergenerational interactions the Arab society towards nursing homes, in many cases, families consider the option only after it is too late, as the (3) Affectual (emotional) solidarity describes the quality older relative experiences health complications and reduced of the intergenerational bond, expressions of love, functionality to such an extent that the family can no longer affection, and emotional support cope with the increasing problems and needs [17]. Placing an (4) Consensual solidarity reflects the degree to which aging relative in a nursing home is likened to consumption generations in the family agree on issues of social and by necessity and the fact that numerous people who reside in nursing homes are so averse to it as to leave even after a political values Journal of Aging Research 3 relatively long stay suggests that this institution is not well 2.1. Population and Sampling. (e study population con- accepted. Such a negative attitude is characteristic of Arab sisted of three generations of Muslim Arabs living in the society, as is a lack of awareness of its advantages [17]. northern region of Israel: an elderly family member Researchers have found that the existence of a nursing home (grandparent generation), his or her adult child (parent that is adapted to fit the social and cultural needs of the Arab generation), and members of the youngest generation, Muslim population increases awareness and the family’s specifically 126 undergraduate students attending Haifa willingness to be assisted by this system. (us, once they University (grandchild generation). (e population was become familiar with the system, the typically negative at- recruited using the convenience sampling method. titude of Arab family members tends to change: the system is seen as a positive option, families wish to let their aging 2.2. Data Collection. Each student was given three identical relative reside in a nursing home for a prolonged period, questionnaires, one to be completed by the student and the while continuing to maintain an active role in the life of their other two for a parent and a grandparent of the same gender relative [18]. as theirs. After the goals of the research were explained, all of Attitudes towards a particular behavior are a function of the participants in the sample signed an informed consent the personal component, i.e., the individual’s positive or form, indicating their willingness to participate in the re- negative assessment of the relevant behavior in relation to a search voluntarily. given set of circumstances; in this case, we are considering Table 1 includes demographic data regarding partici- the behavior of placing an aging relative in a nursing home. pants’ characteristics. (e students demonstrated enthusi- (e familial and cultural Muslim norms in Arab society asm at the opportunity to examine the issue of attitudes regarding this particular behavior inevitably influence the within their families. Nonetheless, it was not always possible individual’s perception of the issue. (e theoretical frame- for them to recruit family members of the same gender as work for the current study is based on the theory of reasoned theirs. As a result, it was decided that rather than conducting action [19]. (is theory constitutes the framing model for intrafamilial statistical analyses, a generational cross-sec- assessing the relationship between beliefs, their underlying tional analysis of the data would be conducted. A total of 140 assumptions and the individual’s attitude, and whether this triads of questionnaires were distributed; of these, 14 triads relationship can serve to predict social behavior. were rejected, for the most part, due to incomplete ques- (e focus of the current study when examining family tionnaires pertaining to one of the generations in a family. members’ attitudes regarding nursing home institutionali- An examination of the data presented in Table 1 indi- zation of an aging relative was on three generations in a cates that the majority of participants (63%) were women, family: the aging person, the middle generation, and the the grandparent generation had the largest number of grandchildren’s generation. (is examination took into children (5.84, SD � 2.27) and that the lowest level of ed- account the extensive changes that the Arab society is un- ucation among all three generations was 6.02 years of study dergoing in terms of its familial and social structures. (SD � 5.05). Based on the information reviewed herein, two major study hypotheses emerged: 2.3. Instruments. (e instrument used in this study was a (1) (e attitudes of the three generations of family structured questionnaire, which had been translated from members regarding nursing home institutionaliza- Hebrew into spoken Arabic by a professional translator and tion of an aging parent or grandparent will vary by then back translated into Hebrew by two bilingual re- age, such that the younger the participants are, the searchers. (e questionnaire consisted of four parts, as stronger will be their support in favor of this move. follows. (2) A negative correlation will be found between the (1) A Demographic Questionnaire collected informa- quality (relative strength or weakness) of intergen- tion about background variables of each participant. erational solidarity and the attitudes of the three (is section was designed specifically for the pur- generations of family members regarding the poses of the current study. placement of an aging parent or grandparent in a (2) An Attitudes Questionnaire was intended to ex- nursing home; specifically, the younger family amine participants’ general attitudes regarding members will exhibit a weaker solidarity and a more nursing home placement. (is variable was mea- positive attitude towards the placement of an aging sured according to the instrument designed by parent or grandparent in a nursing home, whereas Tzivoni [20], which addresses two dimensions: (a) members of the older generations will exhibit attitudes that favor nursing home placement and (b) stronger solidarity and less positive attitudes towards attitudes against nursing home placement. (is such placement of an aging family member. section of the questionnaire was selected based on studies that indicate the existence of a positive re- lationship between attitudes and actual actions taken 2. Methods and the ability to predict actions based on attitudes. Participants indicated their responses to statements (e study was approved by the Ethics Committee of Haifa University. using a Likert-like scale, ranging from 1 � completely 4 Journal of Aging Research Table 1: Background characteristics (N � 378). Generation Variable N % Grandparents 126 33.3 Parents Number of participants 126 33.3 Grandchildren 126 33.3 Gender Entire sample Male 102 37.0 Female 276 63.0 Family status Entire sample Married/living with a spouse 299 79.1 Unmarried/live alone 77 20.9 Level of religiosity Orthodox 102 27.0 Entire sample Conservative 165 43.6 Secular 111 29.4 M SD Grandparents 76.48 6.71 Age Parents 49.86 5.78 Grandchildren 23.29 3.45 Grandparents 6.02 5.05 Parents Years of education 11.18 4.4 Grandchildren 14.55 2.39 Grandparents 5.84 2.27 Parents Number of children 3.47 1.39 Grandchildren 0.89 0.5 Grandparents 3.89 .48 Parents Attitudes towards nursing homes 3.52 .54 Grandchildren 3.05 .60 Grandparents 2.75 .51 Parents Attitudes against nursing homes 3.37 .88 Grandchildren 4.10 1.13 Grandparents 5.42 1.15 Parents Intergenerational solidarity 3.69 1.39 Grandchildren 3.51 1.61 Grandparents 3.37 1.95 Parents Predicting the intent to place a relative in a nursing home 4.93 1.26 Grandchildren 2.58 1.87 items. Participants indicated their degree of agree- agree to 7 � completely disagree. Of the 38 state- ments in this section, approximately half represent ment with each item using a seven-point Likert-like attitudes in favor of nursing home placement and scale, ranging from 1 � completely agree to half represent attitudes against it. Reliability mea- 7 � completely disagree. sures were as follows: for attitudes in favor of nursing (4) (e reliability measures found for each dimension of home placement, Cronbach’s alpha � .63; for atti- the Solidarity Questionnaire ranged from .61 to .91, tudes against nursing home placement, Cronbach’s Cronbach’s alpha. In the current study, the average alpha � 61. score for all solidarity types is presented as a single variable, referred to as “the quality of intergenera- (3) (e Intergenerational Solidarity Questionnaire is tional solidarity,” whereby a low score indicates weak based on Bengtson and Schrader’s [21] instrument solidarity and a high score indicates strong solidarity. for measuring intergenerational solidarity and conflict. (e original instrument includes 72 state- (5) Predicting Social Behavior (PSB) Questionnaire was ments intended for parents and children. In this based on the instrument designed by and Ajzen and current study, solidarity was measured in terms of Fishbein [22] and was adapted for the specific the following four dimensions: (a) affectual (emo- purposes of the current study, namely, predicting the tional), (b) functional, (c) normative, and (d) intent to place a relative in a nursing home. Par- structural solidarity and included 58 statements. (e ticipants indicated their agreement to 27 statements instrument was translated into Hebrew and adapted using a Likert-like scale, ranging from 1 � completely to the needs of the Oasis study, which was conducted agree to 5 � completely disagree. (e statements in by a collaborative team of senior researchers from this questionnaire were related to three dimensions: (a) what nursing home placement means to the five different countries [13]. For the purposes of the current study, the questionnaire was shortened to 54 respondent (nine statements); (b) willingness to Journal of Aging Research 5 in a nursing home due to loss of functional autonomy place a relative in a nursing home in the case of the relative’s loss of functional autonomy (nine state- (r � .63, p< .01). To examine the relationship between the variable of ments); and (c) willingness to place a relative in a nursing home in order to ease the family’s burden of family status and the attitudes regarding nursing home care (nine statements). In the course of the statistical placement among the three generations, Chi square values analysis, it was found that the three dimensions were were calculated. No significant correlation was found be- interrelated and demonstrated a high reliability tween family status and attitudes for or against nursing score, both for the entire sample and for each of the home placement. In contrast, strong and significant corre- generations separately. Consequently, it was decided lations were found between the level of religiosity and at- to consider the entire instrument as a single variable, titudes against nursing home placement, both among the instead of measuring each dimension separately. (e generation of grandchildren (χ � 53.17; p< .01, rc � 0.8; (34) reliability of the entire instrument was Cronbach’s p< .01) and the generation of grandparents (χ � 50.03; (33) alpha � .69. From here on, this behavior that this p< .01, rc � 0.7; p< 0.01). questionnaire was meant to predict will be referred At this stage, and to examine the research hypotheses, to as “the intent to place a relative in a nursing several two-way ANOVA procedures were conducted. For home.” the purpose of statistical analysis, relevant variables were grouped into one of two categories, either above or below the mean score value for each variable. Findings of these cal- 3. Results culations indicated the following. (e current study examined the relationship between per- (a) (e generation variable had a significant effect on the sonal variables (attitudes regarding nursing home placement mean score for attitudes against nursing home and the intent to place an aging relative in a nursing home), placement (F � 5.36, p< .01). To examine the (2,162) interpersonal variables (intergenerational solidarity), and source of this effect, a Scheffe test was conducted, demographic variables (e.g., age, education, religiosity). which revealed that the mean score for attitude In the first stage of the analysis, distributions, means and opposing nursing home placement was higher standard deviations were calculated for all of the variables among the grandchild generation than it was among related to nursing home placement per each generation (see the grandparent generation. On the attitude variable Table 1). A review of the data in Table 1 indicates that the of opposition to nursing home placement, no sig- highest scores were assigned by the grandparent generation, nificant difference was found on the intent variable indicating a positive attitude towards nursing home place- between the grandparent and the parent generations ment (M � 3.89, SD � .48) and the intent to move into a or between the parent and the grandchild nursing home (M � 3.37; SD � 0.54). In other words, the generations. positive attitude regarding nursing home placement was strongest among the grandparent generation, and this (b) (e generation variable had a significant effect on the generation also indicated the strongest intent to place a mean score for intent to place an aging relative in a relative in a nursing home in the context of “loss of func- nursing home (F � 12.9, p< .01). To examine (1,162) tional autonomy”. the source of this effect, a Scheffe test was conducted, To examine the internal connections among the nursing which revealed that the mean score for intent to home placement variables, a total score was calculated based place an aging relative in a nursing home was higher on the mean score for each of the research variables. In among the parent generation than among the addition, Spearman’s tests and Pearson’s tests were con- grandchild generation. No significant difference was ducted to examine these connections. (ese analyses were found on this variable between the grandparents and conducted using the entire sample. (ere is room to examine the parent generations or between the grandparent whether there is a connection when generational division is and the grandchild generation. not taken into account. (c) (e generation variable was found to have a sig- (e data presented in Table 2 indicate that no significant nificant effect on the intergenerational solidarity positive correlation was found between the variable of ed- variable (F � 11.58, p< .01). A Scheffe test (2,162) ucation and any of the other relevant study variables. revealed that the mean score for intergenerational Findings of the study indicate no significant relationship solidarity was higher among the grandparent gen- between participants’ education level and either their atti- eration than among the parent generation. No sig- tudes towards nursing home placement or their intent to nificant difference was found between the mean place a relative in a nursing home. scores on intergenerational solidarity between the (e variable of religiosity correlated negatively with the grandparent generation and the grandchild gener- attitude favoring nursing home placement (r � −.34, p< .05) ation or between the parent and grandchild and with the intent to place an aging relative in a nursing generation. home in case of loss of functional autonomy (r � −.22, p< .05). Furthermore, a strong positive correlation was Up to this point, findings of the current study indicated that some of the variables were related to positive attitudes found between the variable “arguments favoring nursing home placement” and the variable of intent to place a relative regarding nursing home placement, as well as to opposition 6 Journal of Aging Research Table 2: (e connections between the research variables . 1 2 3 4 5 (1) Education — — — — — (2) Level of religiosity −.050 — — — — (3) Attitudes towards nursing homes .016 −.34 — — — ∗∗ (4) Attitudes against nursing homes −.024 .69 −0.04 — — (5) Intergenerational solidarity −.050 .47 −0.15 0.27 — ∗ ∗∗ ∗ (6) Predicting the intent to place a relative in a nursing home −.033 −.22 0.63 −0.48 −.30 ∗ ∗∗ For the religiosity variable, a Spearman’s correlation was conducted. For the other variables, a Pearson’s correlation was conducted. p< .05; p< .01. to placing a relative in a nursing home. To summarize the By contrast, as regards negative attitudes regarding findings and examine the first research hypothesis, a mul- nursing home placement in each of the generations, it was tiple regression analysis was conducted. Findings of this found that variable of intergenerational solidarity explained analysis are presented in Table 3. the negative attitude among both the grandchild and the An examination of the data in Table 3 reveals that in the parent generations. As regards the grandchild generation, case of a positive attitude towards nursing home placement the variable of intergenerational solidarity had a negative among the grandparent generation, the remaining variables effect on the negative attitude regarding nursing home explained 32% of the variance, but only the variable of placement, whereas the variable of intent to place a relative religiosity significantly predicted positive attitudes towards in a nursing home had a positive effect on the negative nursing home placement, and this regression model was attitude. found to be significant (F � 3, p< .05). In the case of a (7,45) negative attitude regarding nursing home placement, it was 4. Discussion found that among the grandparent generation, the variables of the model explained 8% of the variance; however, the (e goal of the current study was to examine and compare the regression model did not render a significant outcome attitudes of three generations (grandparents, parents, and (F � 0.58, n. s.). grandchildren) in the Arab Muslim family in Israel regarding (7,45) Focusing on the parent generation, it was found that the placement of an aging parent or grandparent in a nursing when the dependent variable was positive attitudes towards home. According to the Arab tradition, the family that nursing home placement, 16% of the variance was explained constitutes the major support network for older adults re- by the other study variables, but the regression model did frains from accepting the assistance of formal services offered not render a significant outcome (F � 1.25, n. s.). by the state, such as nursing home placement for an aging (7,45) However, when the dependent variable was a negative at- relative. However, as the processes of change and moderni- titude towards nursing home placement, 29% of the variance zation begin to affect the Arab society, they leave their mark was explained by a single variable, namely, intergenerational on social values as well. (e current study and its findings give solidarity, and the model rendered a significant outcome rise to two major issues that merit discussion: the first is (F � 2.64, p< .05). related to the nursing home placement of aging relatives in (7,45) An examination of the grandchild generation found that Muslim society and the second is the issue of collectivism when the dependent variable was positive attitudes towards versus individualism in the Arab Muslim society. It is im- portant to emphasize that this society is undergoing two nursing home placement, the variable of religiosity predicted 48% of the variance, and the regression model was signif- processes simultaneously: change and modernization on the icant (F � 4.37, p< .01). (e regression model was one hand, and a return to tradition, on the other hand. (7,45) significant also when the dependent variable was negative A detailed study that reviews nursing home placement of attitudes regarding nursing home placement (F � 5.32, Muslim older adults in the United States claimed the fol- (7,45) p< 0.01). Both the variable of intergenerational solidarity lowing: “With Islam placing a strong emphasis on caring for (β � 0.38, p< .05) and the variable of intent to place a relative one’s parents in the home, along with cultural barriers, in a nursing home (β � −.60, p< .01) significantly predicted Medicaid and Medicare’s focus on nursing homes is not a attitudes against nursing home placement, with the latter viable option for Muslim Americans” ([23]; p. 1). (e author offered several possible causes that might explain why variable being the more significant among the two. To summarize, the findings of the regression analysis Muslim older adults living in the United States do not opt for nursing home placement, chief among them, the issue of indicated that the variable of religiosity significantly pre- dicted a positive attitude regarding nursing home placement religion. (e Koran, which is revered as the word of God, among the grandparent and the grandchild generations; states the following. none of the variables predicted a positive attitude among the parent generation. In other words, the higher the level of Your lord has decreed that you worship none but Him, religiosity was, the less positive were the attitudes regarding and that you be kind to parents. Whether one or both of nursing home placement, such that higher orthodoxy was them attain old age in your life, say not to them a word of negatively associated with favorable attitude regarding contempt, nor repel them, but address them in terms of nursing home placement. honor. Journal of Aging Research 7 Table 3: Multiple regression analysis measuring the contribution of the research variables attitude for or against nursing home placement. Grandparents Parents Grandchildren Generation/attitude Variable For Against For Against For Against Gender 0.04 −0.2 0.17 −0.06 0.2 −0.4 Family status −0.23 0.05 −0.15 0.11 −0.3 0.26 Education −0.01 −0.28 0.34 −0.19 −0.54 0.3 ∗ ∗∗ Religiosity −0.09 0.24 −0.16 0.13 −0.68 0.45 ∗ ∗ Intergenerational solidarity 0.13 0.25 −0.27 0.28 −0.19 0.38 Predicting the intent to place a relative in a nursing ∗∗ 0.18 −0.27 0.19 −0.21 −0.53 −0.60 home Multiple R 0.32 0.08 0.16 0.29 0.48 0.58 ∗ ∗ ∗∗ ∗∗ F F � 3 F � 0.58 F � 1.25 F � 2.64 F � 4.37 F 2.89 (7,45) (7,45) (7,45) (7,45) (7,45) (7,45) � ∗ ∗∗ p< 0.05; p< 0.01. modernity and tradition is not without problems [25]. (e (us, the more religiously conservative the family is, the more likely it is to interpret the command to honor one’s Arab population that now resides in the state of Israel was parents to mean providing unmediated care in one’s own under the Turkish rule when modernization began, and later home for aging parents and relatives [24]. (e researcher under British rule, until 1948 when the state of Israel was indicated that placing an aging Muslim parent in a nursing established. Israel has followed the Western philosophy and home is considered a type of elderly abuse. In her study, Al- its behavior patterns and, as the world of computers and Heeti [23] noted the discretion required in Muslim families digitalization and the notion of the global village are in- creasingly becoming the norm, Arab families, and especially when a relative requires medical attention or treatment, so that the family can avoid public shame or humiliation, which Muslim Arabs, have found themselves faced with the choice of either adapting to the new world or withdraw and isolate stem from the social norm that views the family—rather than the public services—as responsible for caring for an themselves from the surrounding society. Consequently, aging relative. As the author explains, it is important that the psychosocial mechanisms, such as intergenerational soli- family appear to be the one taking care of the aging relative, darity and transmission, have been used in recent decades as and it is crucial to maintain discretion whenever a member a way of coping with the new and evolving reality, which is of the Arab Muslim family in the United States requires increasingly affecting aspects of life that for generation upon treatment outside the home. A further complication stems generation were the accepted and familiar norms [8, 26]. from the fact that an aging Muslim man might reject treatment from a female healthcare professional, while an 4.1. Discussion regarding Hypothesis 1. (e current study, aging Muslim woman might be apprehensive or feel un- examined the attitudes of 126 university students, one of comfortable being left alone to be cared by a male healthcare their parents and one of their grandparents, thus reviewing professional. (ese issues are familiar in Israel as well, yet three generations of Arab Muslim families. (e goal of the they have never been directly studied. (is is because, given Israel’s small geographic area and the particularly the study was to gain insight into the participants’ attitudes regarding nursing home placement and to compare these geographic concentration of Arab Muslim populations in Israel, Muslims of any generation would be reluctant to attitudes among the three different generations. Two hy- potheses guided this study: the first was that the three divulge collaborate with researchers by divulging informa- tion on such sensitive issues. generations would differ in their attitudes regarding nursing home placement of an aging parent, such that the younger (e transition from a traditional society to a modern one is referred to in the professional literature as social mobi- the participants are, the stronger will be their support in favor of this move. (is hypothesis was not confirmed; on lization [7]; a concept that conveys a transition from a the contrary, findings indicated that the younger the par- generations-old patterns of belief and behavior to newer ticipants’ age, the greater the opposition to placing a parent ones. In recent years, their tradition has been subjected to or grandparent in a nursing home. (is was perhaps the abrupt changes. (e modern Western philosophy has led traditional societies to be characterized as different, “exotic most surprising of the findings of the study, as the grand- child generation’s attitudes against nursing home placement and also as reflecting lower stages of evolutionary ad- vancement”. As a result of this social perception, traditional were stronger than those of the other two generations. Furthermore, they reported a low level of intent to place an societies in the United States, India, Iran, and other coun- tries have opted to adjust and adapt to the Western phi- aging relative in a nursing home, particularly if the older relative has lost some degree of functional autonomy. Al- losophy, which conveniently dictates behavior patterns but though the education level of the youngest generation was does not interfere with beliefs or ideologies. A lot of it is also the highest, and the expectation was that the education related to the quality of life offered to the elderly and how variable would have the strongest effect on favoring nursing much their children are satisfied from it. Nonetheless, the home placement, this expectation was not confirmed. encounter between these two worlds creates an ideological Moreover, reports from the youngest generation indicated a crisis, and the need to cope with the conflict between 8 Journal of Aging Research Rijnaard et al. [34] suggested that family closeness and higher level of religiosity. It is possible that this indicates a desire to hold on to a tradition that is fading. (e attitudes of involvement before the initialization will have a major impact on the attitudes, willingness, and involvement in the the youngest generation were more similar to those of the grandparent generation than to their parents’ generation, process of nursing home placement of an elderly family’s which suggests that the intergenerational transmission did member. not play a role in this sample. (e current study’s findings indirectly indicate the A study that examined filial responsibility among three breaking of this psychosocial pattern. None of the findings of generations of Arab Muslim families [27] found positive this study—whether related to the effects of demographic attitudes and perceptions among all three generations to- variables (education, religiosity), to participants’ attitudes, to the intent to place a relative in a nursing home in the case of wards the notion of filial responsibility and assisting aging parents, with the youngest generation’s positive attitudes loss of autonomy, or to the variable of intergenerational solidarity—indicated any form of consecutive intergenera- ranking higher than those of their parents or grandparents. Findings also demonstrated that in all three generations, tional transmission. As regards the education variable, there is a simple explanation for the absence of intergenerational women’s attitudes were more positive than those of men, and the attitudes of religious participants were more positive transmission, namely, the fact that in contemporary ad- than those of their secular counterparts. A study that ex- vanced societies, members of the youngest generation are amined the experiences of Muslim families who have a relatively more educated than either their grandparents or family member in a nursing home found that psychological their parents, and this is also true in traditional Arab so- attitudes and sociocultural norms are two challenging issues cieties and is particularly noticeable among the women in affecting families both in the decision making about nursing the Arab society. (e finding that the highest level of religiosity was re- homes stage and living with this decision after making it [28]. ported by the youngest generation contradicts the known patterns of intergenerational transmission. As previously A possible explanation for the attitude among the youngest generation, as found in the current as well as in the mentioned, a possible reason for this may be the global phenomenon of increased religiosity among the youth of all aforementioned study, may stem from the tendency to as- sociate increased religious practice with the strengthening of three monotheistic religions. Furthermore, observing and traditional social norms. An increasing inclination towards adopting the role of caregiver to one’s aging relatives is conservative religiosity has been noted in the Arab world in considered the result of learned behavior [35]; hence, the general and among Muslims in particular. Not surprisingly, clan-like lifestyle shared by all of the generations in the Arab this trend has emerged also among Muslims in Israel and is family could serve to explain the similarity of attitudes and noticed among the youngest generation [23, 28, 29]. intent regarding nursing home placement between the grandparents’ and the grandchildren’s generations. In the current study, the assumption was that inter- generational transmission would be the psychosocial Notwithstanding, members of the youngest generation in Arab Muslim families in Israel move out of the family mechanism by which traditional cultural and religious norms were inculcated to younger members of the family home to pursue advanced studies, and occasionally, they unit. Intergenerational transmission is a concept that in- even move overseas. Due to the rate of unemployment in dicates the finding of similarities between consecutive Israel, some of them leave their homes located in rural areas generations in terms of attitudes and behavioral patterns, and move to major cities, where the chances for finding which seemingly are passed down from generation to employment are much better. Despite the observation made generation. Some researchers [30, 31] have used the term by the author [36], it may be surmised that a high level of behavioral genetics. People are generally affected directly by opposition among the youngest generation to the placing of the familial model within which they were raised, whereas an aging family member in a nursing home indicates the grandchildren’s inability to understand the functional and the models provided by previous generations have an in- direct and subconscious effect. Consequently, traditions, health-related needs of their grandparents. Members of the grandchildren generation view their grandparents in terms behaviors, beliefs, and rules are passed from generation to generation [32, 33]. (e researchers claimed that the family of the significant role they have in the extended family, unit exerts horizontal and vertical pressures on its members; rather than as older adults who need round-the-clock at- the vertical pressures, which are passed from one generation tention to a greater or lesser degree. In other words, their to the next, include general approaches and ways of func- attitudes are based on emotions rather than on rational tioning and solving emotional problems. (us, vertical considerations. pressures may be related to adult children’s sense of re- sponsibility and commitment to care for their aging parents, and they also account for the parents’ expectation that in due 4.2. Discussion regarding Hypothesis 2. (e second hy- pothesis was that a negative correlation would be found time and according to the tradition, they too will be cared for by their children. (us, these vertical pressures provide a between the strength of intergenerational solidarity and the positive attitudes of members of the three generations re- possible explanation not only for the current study’s finding of pervasively negative attitudes regarding nursing home garding nursing home placement. (is hypothesis was based placement among all participants but also for the excep- on the assumption that the youngest generation would be tionally strong opposition among the youngest generation. more open to the idea of nursing home placement than the Journal of Aging Research 9 As regards the grandchildren’s generation, much like oldest generation, and hence, the youngest generation would represent the greatest change in terms of accepting modern the perspective of the grandparent generation, the quality of their relationship with their grandparents was not behavior patterns. Such greater openness could be assumed, given that modern Arab society in Israel clearly understands related to their degree of agreement with an attitude fa- that demonstrating concern for an aging family member but voring nursing home placement. Rather, their attitude confining care and support to the family framework do not against nursing home placement was related to the degree go hand in hand. Not only is such an approach liable to be to which they reported receiving financial and emotional detrimental to the health maintenance of the aging relative, it assistance from their grandparents and the degree to would also hinder the ability of the young Arab family to which they felt obligated to give back something in return for said assistance. Grandchildren also reported that the advance and develop in today’s modern competitive and capitalist world [37, 38]. However, the second hypothesis better their relationship with the grandparent was, the less inclined they were to place him or her in a nursing home was not confirmed, and as in the case of the first hypothesis, the hypothesis was contradicted by the findings. in the case of loss of autonomy. (e grandchildren at- tributed less significance to the advantages associated with In the current study, it was found that the generation of grandparents assigned higher scores and thus indicated a nursing home placement (such as lightening the family stronger agreement with the notion of nursing home burden, availability of medical services, relative inde- placement compared with the grandchildren’s generation. pendence for the aging grandparent, and more compre- (ey also indicated a higher degree of intent to move into a hensive support available) and greater significance to the nursing home if they suffer a loss of autonomy. (is un- cultural norm, which views nursing home placement as expected gap may express the grandparents’ realistic un- unacceptable. It appears that the intergenerational loyalty and commitment that even the grandchildren expressed derstanding that the organized healthcare system is better equipped to provide significant medical assistance, moni- towards the oldest generation led them to believe that they could fulfill all of the necessary functions and thus avoid toring their dietary and activity needs on a regular basis as is the practice in nursing homes. Another possible explanation nursing home placement. (e strong emotional bond was created by the fact of living in a joint residence, and thus for this unexpected finding, which was found to be related to the level of intergenerational solidarity, maybe the grand- spending a great deal of time with the grandparents is a parents’ effort to avoid becoming a burden on the younger likely explanation for the grandchildren’s sense of com- family members, particularly on the women, who in recent mitment towards the grandparents. In the current sample, years have ventured beyond the home and found suitable a large percentage of the grandchildren indicated that they employment [35]. were living or had lived with a grandparent, in most cases As regards the middle generation, it appears that the with a widowed grandmother who feared living alone or who could not be accommodated in her sons’ homes. It more the members of this generation reported having an affectionate relationship with their parents, meeting with may be surmised that the grandchildren’s sense of re- sponsibility and commitment towards their grandparents them, calling them, and providing emotional support, the more likely they were to display attitudes and claims in consisted mostly of emotional and less of functional favor of nursing home placement. By contrast, when the support, which alone is not sufficient to ensure that the members of the middle generation reported providing aging grandparent receives appropriate care in the long essential functional care for their parents, in terms of fi- term. nancial assistance, shopping, and housekeeping, all of which necessitated living in close proximity to their par- 4.3. Limitations of the Study. (e main limitation of the ents, the less likely they were to display attitudes favoring current study is related to sample and sampling. nursing home placement. (e findings of the study dem- Recruiting members from three different generations of onstrate the devotion of the children and their commit- Arab Muslim families constitutes a rather complex lo- ment to care for their parents. Indeed, this is the norm in gistical challenge. (e willingness of university students to the Arab family, where all the generations live in close engage in this study and to learn about their families was a geographic proximity and the large number of children and grandchildren ensures that there is always someone facilitating factor, but it constituted a methodological limitation. available to care for the aging family members, visit them, address their needs, or live with them in the same Future studies should continue this line of investigation by conducting cross-sectional research of the Arab Muslim household. In addition, this high degree of devotion may reflect the religious and cultural values that characterize the population in Israel, so as to characterize populations in various geographical regions, differentiating between the desired filial behavior of children towards their aging rural villages and major Arab cities, as well as between the parents. (us, it is possible that these findings indicate, to population in the major cities and the Bedouin communities some degree, that the devotion of the middle generation living in unrecognized villages (known as P’zura, meaning, towards their parents is limited, in the sense that they scattered dwellings). (is type of differentiation will make it understand that should intensive long-term treatment possible to determine the degree to which each group is become necessary, reliance on the available formal re- sources for assistance would not necessarily be considered a exposed to the various healthcare options available to aging family members. betrayal of their filial commitment. 10 Journal of Aging Research [5] H. Litwin and S. Zoabi, “Modernization and elder abuse in an 5. Summary Arab-Israeli context,” Research on Aging, vol. 25, no. 3, pp. 224–246, 2003. A review of the current study should take into account [6] H. Litwin and S. Zoabi, “A multivariate examination of ex- global trends related to longevity and quality of life. (e age planations for the occurrence of elder abuse,” Social Work at which individuals choose to move to a nursing home is Research, vol. 28, no. 3, pp. 133–142, 2004. constantly rising, both in Israel and throughout the world. [7] R. Khalaila and H. Litwin, “Modernisation and filial piety Improved quality of life during old age postpones the among traditional family care-givers: a study of Arab-Israelis decision and delays the actual move, which in turn means in cultural transition,” Ageing and Society, vol. 32, no. 5, that in the Western world, a smaller percentage of the aging pp. 769–789, 2012. population opts to live in nursing homes. In Israel, this [8] K. Suleiman and A. Walter-Ginzburg, “A nursing home in delay is related also to the tight family structure that Arab-Israeli society: targeting utilization in a changing social characterizes Israeli society in general. Hence, compared and economic environment,” Journal of the American Geri- with other Western countries, there was never a sudden atrics Society, vol. 53, no. 1, pp. 152–157, 2005. upsurge in the number of people moving into nursing [9] Israel’s Central Bureau of Statistics, Chapter 11: e Elderly Population in Israel, Israel’s Central Bureau of Statistics, homes, and even to this day, the trend is rising only Jerusalem, Israel, 2013. gradually, and the decision is typically postponed for later [10] V. Bengtson and D. Mangen, D. Mangen, V. Bengtson, and years. P. Landry, “Family intergenerational solidarity revised: sug- In addition to the global and local trends, also the gestions for future management,” in Measurement of Inter- particular characteristics of older adults in the Arab society generational Relations, pp. 222–238, Sage, Beverly Hills, CA, in Israel should be examined, as these tend to differ com- USA, 1991. pared with the Jewish population. (us, for example, in the [11] V. L. Bengtson and R. E. L. Roberts, “Intergenerational sol- Arab society, the average age of the older adult population is idarity in aging families: an example of formal theory con- typically younger than that in the Jewish society, and a struction,” Journal of Marriage and the Family, vol. 53, no. 4, higher percentage of the aging population in the Arab so- pp. 856–870, 1991. ciety requires medical care (30%) compared with the older [12] M. Tzivoni, “Reciprocal intergenerational solidarity between adult population in the Jewish society (14%), often because older people and their children,” Gerontology, vol. 75, pp. 19–30, 1995, in Hebrew. of disabilities that require daily attention. [13] A. Lowenstein, R. Katz, D. Mehlhusen-Hasson, and Despite the changes that the Arab society in Israel is D. Priluzky, “A comparative cross-national perspective on undergoing, there is still an emphasis on the importance of intergenerational solidarity and impact on elders’ life satis- taking responsibility for caring for aging family members faction,” Retraite et Soci´et´e, vol. 38, pp. 52–79, 2003. and on treating them—as much as possible—with the re- [14] A. Lowenstein, “Solidarity-conflict and ambivalence: testing spect they are due. two conceptual frameworks and their impact on quality of life for older family members,” Journal of Gerontology: Social Sciences, vol. 62B, pp. 100–107, 2007. Data Availability [15] F. Azaiza and J. Brodsky, “(e aging of Israel’s Arab pop- ulation: needs, existing responses, and dilemmas in the de- (e data will be available within a year/a year and a half upon velopment of services for a society in transition,” e Israel request to corresponding author. Medical Association Journal: IMAJ, vol. 5, no. 5, pp. 383–386, [16] K. Suleiman, “Institutionalization of older Arab people in Conflicts of Interest Israel: employees and observations at the Dabburieh nursing home following a decade of activity,” inProceedingsofthe15th (e authors declare that they have no conflicts of interest. Biannual Conference of the Israel Gerontology Association, Israel Gerontology Association, Tel Aviv, Israel, December References [17] K. Suleiman, N. Massalha, A. Massalha, and A. Azaiza, “(e [1] F. Azaiza and J. Brodsky, “Changes in the Arab family and attitudes of Arab families regarding nursing homes before and development of services for Arab elderly in Israel during the after the institutionalization of an older relative, and their last decade,” Journal of Gerontological Social Work, vol. 27, involvement in the decision to institutionalize,” Gerontology, no. 1-2, pp. 37–53, 1996. vol. 32, no. 1, pp. 123–132, 2005, in Hebrew. [2] F. Azaiza, A. Lowenstein, and J. Brodsky, “Institutionalization [18] A. Lowenstein and R. 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The Connections between Attitudes towards Nursing Home Placement, Intergenerational Solidarity, and the Conflict between Tradition and Modernity among Three Generations of Arab Muslim Families in Israel

Journal of Aging Research , Volume 2021 – Aug 23, 2021

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Copyright © 2021 Pnina Ron. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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10.1155/2021/6148980
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Hindawi Journal of Aging Research Volume 2021, Article ID 6148980, 11 pages https://doi.org/10.1155/2021/6148980 Review Article The Connections between Attitudes towards Nursing Home Placement, Intergenerational Solidarity, and the Conflict between Tradition and Modernity among Three Generations of Arab Muslim Families in Israel Pnina Ron School of Social Work, University of Haifa, Haifa, Israel Correspondence should be addressed to Pnina Ron; pitzyron@research.haifa.ac.il Received 18 January 2020; Revised 18 July 2021; Accepted 10 August 2021; Published 23 August 2021 Academic Editor: He´lio J. Coelho-Ju´nior Copyright © 2021 Pnina Ron. (is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. (e goal of this study was to examine three generations of Arab Muslims in Israel, to investigate the relationships between their attitudes regarding the placement of an older relative in a nursing home, intergenerational solidarity, and to ultimately proceed with the nursing home placement. (e backdrop to this examination was the increasing sociocultural tension between mod- ernization tendencies and the long-established traditions and norms in the Arab Muslim society in Israel. (e sample included a total of 126 university students, as well as one parent and one grandparent of each student. All participants completed identical questionnaires examining the attitudes towards the nursing home placement of an elder relative. (e findings of the study indicate a strong objection among the youngest generation, whose attitudes were more similar to those of their grandparents than to those of their parents. Psychosocial mechanisms in the Arab Muslim population, such as intergenerational solidarity, has been the subject of increased scrutiny and debate over recent years, given the intensive pace of modern developments, which has called into question the familiar norms, thus constituting a threat to the tradition that has guided the population throughout numerous centuries and generations. consequently, the informal support network in the Arab 1. Introduction sector is remarkably strong. Data regarding support Nursing home placement became an official part of the patterns indicate that the degree of support granted to old welfare services available to older individuals in the Arab people in the Arab population is much higher than that sector in Israel approximately 30 years ago [1]. (is granted to old people in the Jewish population. Fur- phenomenon evolved at the same time that the Arab thermore, findings have shown that adult Arab children society in Israel was undergoing changes in several fields, who observe the tradition find it rewarding to care for including, society, economy, education, proprietorship, as their aging parents, whereas the youngest and less tra- well as the distribution of authority roles within the family ditional generation attributes less importance to family [2]. According to the Arab tradition, aging people’s main solidarity [5–7]. Consequently, placing an older parent in support network is the family, and typically, reliance on a nursing home is perceived as shaming the family, and the assistance provided to the community by official those who opt to avail themselves of such services are services is either minimal or nonexistent. Arab society viewed as having betrayed their parents [8]. accords a great deal of significance to maintaining family In recent years, however, there has been a shift in the way solidarity and particularly honoring one’s parents and that the nursing home is perceived among the Arab pop- elders [3, 4]. According to this tradition, the family is ulation, a shift which is related to the changing attitude in responsible for caring for the older relative, and Arab society towards the trends of modernization. 2 Journal of Aging Research (5) Functional solidarity concerns the degree of assis- (e first nursing home for the Arab sector was estab- lished in 1992 by the ESHEL organization in the village of tance and instrumental support between generations and the reciprocity of such support Dabburieh. Currently, there are a substantial number of nursing homes for the Arab sector in Israel; most of them are (6) Normative solidarity the degree of commitment to located in northern Israel, where the largest concentration of family roles and norms Arab Moslems resides. In the past decade, there has been a (e researchers [13] described the findings from the significant increase in the percentage of older people in Israeli portion of a broad (Oasis) survey that examined Israel. In the Jewish sector, older adults constitute 11% of the intergenerational relationships and transmission in several population, compared with 3% in the Arab sector. (e Arab countries (Israel, Norway, England, Germany, and Spain) population, in general, is younger than the Jewish pop- using the intergenerational solidarity model [14]. (ey ulation in Israel, with the number of people older than 65 found that the majority of participants from all countries years totaling 70,350. Furthermore, among the Arab pop- reported a high level of normative solidarity, although the ulation of age 65 years or older, 35% are older than 75 years, solidarity level reported among Israeli participants was compared with 47% in the elder Jewish population [9]. (e higher than that reported by participants in Spain or Ger- rate of disabilities among the elder Arab population is many. According to these researchers, the explanation is relatively high, whereas the rate of nursing home institu- based on the fact that in Israel, there is a greater emphasis on tionalization is low, as manifested in the relatively small family solidarity and a stronger commitment to supporting number of official institutions available to this sector, such as aging parents than in other countries and that this finding is nursing homes, activity centers, and senior citizen centers particularly related to input from Arab families in Israel. [2]. (e percentage of older Arab adults living in nursing In the current study, only four (affectual/emotional, homes is 0.9%, compared with 6% in the Jewish sector, and functional, normative, and structural solidarity) of the six of these, approximately half resides in northern Israel where dimensions of the model were used to examine and gain a they constitute 30% of all of the aging population, regardless better understanding of the essence of the intergenerational of sector affiliation [9]. (e paucity of professional literature relationships and family bonds as perceived by aging in- regarding older adults in the Arab sector, their families, and dividuals, their children, and their grandchildren in the their placement in nursing homes is evident; moreover, the framework of the Arab Muslim family and especially to gain focus of studies conducted in this field to date has been on insight into the attitudes of the three generations in the Arab Arab society as a whole, without examining attitudes within family towards nursing home institutionalization of an aging the Arab sector or within the Arab family unit. family member. 1.1. Intergenerational Solidarity. (e intergenerational sol- 1.2. e Phenomenon of Nursing Home Placement among the idarity model is based on the exchange theory [10, 11] and is Older Adults in the Arab Society. Despite the generally used by numerous researchers to examine intergenerational negative attitudes among the Arab population regarding solidarity, and especially intergenerational relationships of nursing home institutionalization, the approach of older reciprocity, and the phenomenon of transmission between people and their relatives towards the formal services aging parents and their children [10, 12]. (e model, which available suggests a mixture of traditional and modern introduces a new point of view for the exchange theory, is perspectives [15]. In a study that examined the attitudes of intended to provide a comprehensive explanation of the Arab families that decide to place an aging family member in relationships among generations in a single family, by a nursing home, findings indicated that participants found it assessing the quality and characteristics of these relation- easier to see an aging relative in an institute such as a ships. In this model, intergenerational solidarity is perceived hospital, as it demonstrates to their society that this is a as a multidimensional phenomenon, which includes six temporary arrangement for the purpose of receiving components that reflect the reciprocal relationships in a emergency care, so that the aging relative can be brought family [10, 11, 13]. back into the home [16]. A different study that sought to gain (1) Structural solidarity refers to residential patterns, the insight into the reasons for the high rate at which nursing geographical distance between generations and the home residents in Dabburieh were leaving the nursing home number of generations in the family found that the cause was mostly the need to abide by social norms of caring for older family members, due to a sense of (2) Associational solidarity is about the number and shame, and social pressure [8]. As a result of the attitude of patterns of intergenerational interactions the Arab society towards nursing homes, in many cases, families consider the option only after it is too late, as the (3) Affectual (emotional) solidarity describes the quality older relative experiences health complications and reduced of the intergenerational bond, expressions of love, functionality to such an extent that the family can no longer affection, and emotional support cope with the increasing problems and needs [17]. Placing an (4) Consensual solidarity reflects the degree to which aging relative in a nursing home is likened to consumption generations in the family agree on issues of social and by necessity and the fact that numerous people who reside in nursing homes are so averse to it as to leave even after a political values Journal of Aging Research 3 relatively long stay suggests that this institution is not well 2.1. Population and Sampling. (e study population con- accepted. Such a negative attitude is characteristic of Arab sisted of three generations of Muslim Arabs living in the society, as is a lack of awareness of its advantages [17]. northern region of Israel: an elderly family member Researchers have found that the existence of a nursing home (grandparent generation), his or her adult child (parent that is adapted to fit the social and cultural needs of the Arab generation), and members of the youngest generation, Muslim population increases awareness and the family’s specifically 126 undergraduate students attending Haifa willingness to be assisted by this system. (us, once they University (grandchild generation). (e population was become familiar with the system, the typically negative at- recruited using the convenience sampling method. titude of Arab family members tends to change: the system is seen as a positive option, families wish to let their aging 2.2. Data Collection. Each student was given three identical relative reside in a nursing home for a prolonged period, questionnaires, one to be completed by the student and the while continuing to maintain an active role in the life of their other two for a parent and a grandparent of the same gender relative [18]. as theirs. After the goals of the research were explained, all of Attitudes towards a particular behavior are a function of the participants in the sample signed an informed consent the personal component, i.e., the individual’s positive or form, indicating their willingness to participate in the re- negative assessment of the relevant behavior in relation to a search voluntarily. given set of circumstances; in this case, we are considering Table 1 includes demographic data regarding partici- the behavior of placing an aging relative in a nursing home. pants’ characteristics. (e students demonstrated enthusi- (e familial and cultural Muslim norms in Arab society asm at the opportunity to examine the issue of attitudes regarding this particular behavior inevitably influence the within their families. Nonetheless, it was not always possible individual’s perception of the issue. (e theoretical frame- for them to recruit family members of the same gender as work for the current study is based on the theory of reasoned theirs. As a result, it was decided that rather than conducting action [19]. (is theory constitutes the framing model for intrafamilial statistical analyses, a generational cross-sec- assessing the relationship between beliefs, their underlying tional analysis of the data would be conducted. A total of 140 assumptions and the individual’s attitude, and whether this triads of questionnaires were distributed; of these, 14 triads relationship can serve to predict social behavior. were rejected, for the most part, due to incomplete ques- (e focus of the current study when examining family tionnaires pertaining to one of the generations in a family. members’ attitudes regarding nursing home institutionali- An examination of the data presented in Table 1 indi- zation of an aging relative was on three generations in a cates that the majority of participants (63%) were women, family: the aging person, the middle generation, and the the grandparent generation had the largest number of grandchildren’s generation. (is examination took into children (5.84, SD � 2.27) and that the lowest level of ed- account the extensive changes that the Arab society is un- ucation among all three generations was 6.02 years of study dergoing in terms of its familial and social structures. (SD � 5.05). Based on the information reviewed herein, two major study hypotheses emerged: 2.3. Instruments. (e instrument used in this study was a (1) (e attitudes of the three generations of family structured questionnaire, which had been translated from members regarding nursing home institutionaliza- Hebrew into spoken Arabic by a professional translator and tion of an aging parent or grandparent will vary by then back translated into Hebrew by two bilingual re- age, such that the younger the participants are, the searchers. (e questionnaire consisted of four parts, as stronger will be their support in favor of this move. follows. (2) A negative correlation will be found between the (1) A Demographic Questionnaire collected informa- quality (relative strength or weakness) of intergen- tion about background variables of each participant. erational solidarity and the attitudes of the three (is section was designed specifically for the pur- generations of family members regarding the poses of the current study. placement of an aging parent or grandparent in a (2) An Attitudes Questionnaire was intended to ex- nursing home; specifically, the younger family amine participants’ general attitudes regarding members will exhibit a weaker solidarity and a more nursing home placement. (is variable was mea- positive attitude towards the placement of an aging sured according to the instrument designed by parent or grandparent in a nursing home, whereas Tzivoni [20], which addresses two dimensions: (a) members of the older generations will exhibit attitudes that favor nursing home placement and (b) stronger solidarity and less positive attitudes towards attitudes against nursing home placement. (is such placement of an aging family member. section of the questionnaire was selected based on studies that indicate the existence of a positive re- lationship between attitudes and actual actions taken 2. Methods and the ability to predict actions based on attitudes. Participants indicated their responses to statements (e study was approved by the Ethics Committee of Haifa University. using a Likert-like scale, ranging from 1 � completely 4 Journal of Aging Research Table 1: Background characteristics (N � 378). Generation Variable N % Grandparents 126 33.3 Parents Number of participants 126 33.3 Grandchildren 126 33.3 Gender Entire sample Male 102 37.0 Female 276 63.0 Family status Entire sample Married/living with a spouse 299 79.1 Unmarried/live alone 77 20.9 Level of religiosity Orthodox 102 27.0 Entire sample Conservative 165 43.6 Secular 111 29.4 M SD Grandparents 76.48 6.71 Age Parents 49.86 5.78 Grandchildren 23.29 3.45 Grandparents 6.02 5.05 Parents Years of education 11.18 4.4 Grandchildren 14.55 2.39 Grandparents 5.84 2.27 Parents Number of children 3.47 1.39 Grandchildren 0.89 0.5 Grandparents 3.89 .48 Parents Attitudes towards nursing homes 3.52 .54 Grandchildren 3.05 .60 Grandparents 2.75 .51 Parents Attitudes against nursing homes 3.37 .88 Grandchildren 4.10 1.13 Grandparents 5.42 1.15 Parents Intergenerational solidarity 3.69 1.39 Grandchildren 3.51 1.61 Grandparents 3.37 1.95 Parents Predicting the intent to place a relative in a nursing home 4.93 1.26 Grandchildren 2.58 1.87 items. Participants indicated their degree of agree- agree to 7 � completely disagree. Of the 38 state- ments in this section, approximately half represent ment with each item using a seven-point Likert-like attitudes in favor of nursing home placement and scale, ranging from 1 � completely agree to half represent attitudes against it. Reliability mea- 7 � completely disagree. sures were as follows: for attitudes in favor of nursing (4) (e reliability measures found for each dimension of home placement, Cronbach’s alpha � .63; for atti- the Solidarity Questionnaire ranged from .61 to .91, tudes against nursing home placement, Cronbach’s Cronbach’s alpha. In the current study, the average alpha � 61. score for all solidarity types is presented as a single variable, referred to as “the quality of intergenera- (3) (e Intergenerational Solidarity Questionnaire is tional solidarity,” whereby a low score indicates weak based on Bengtson and Schrader’s [21] instrument solidarity and a high score indicates strong solidarity. for measuring intergenerational solidarity and conflict. (e original instrument includes 72 state- (5) Predicting Social Behavior (PSB) Questionnaire was ments intended for parents and children. In this based on the instrument designed by and Ajzen and current study, solidarity was measured in terms of Fishbein [22] and was adapted for the specific the following four dimensions: (a) affectual (emo- purposes of the current study, namely, predicting the tional), (b) functional, (c) normative, and (d) intent to place a relative in a nursing home. Par- structural solidarity and included 58 statements. (e ticipants indicated their agreement to 27 statements instrument was translated into Hebrew and adapted using a Likert-like scale, ranging from 1 � completely to the needs of the Oasis study, which was conducted agree to 5 � completely disagree. (e statements in by a collaborative team of senior researchers from this questionnaire were related to three dimensions: (a) what nursing home placement means to the five different countries [13]. For the purposes of the current study, the questionnaire was shortened to 54 respondent (nine statements); (b) willingness to Journal of Aging Research 5 in a nursing home due to loss of functional autonomy place a relative in a nursing home in the case of the relative’s loss of functional autonomy (nine state- (r � .63, p< .01). To examine the relationship between the variable of ments); and (c) willingness to place a relative in a nursing home in order to ease the family’s burden of family status and the attitudes regarding nursing home care (nine statements). In the course of the statistical placement among the three generations, Chi square values analysis, it was found that the three dimensions were were calculated. No significant correlation was found be- interrelated and demonstrated a high reliability tween family status and attitudes for or against nursing score, both for the entire sample and for each of the home placement. In contrast, strong and significant corre- generations separately. Consequently, it was decided lations were found between the level of religiosity and at- to consider the entire instrument as a single variable, titudes against nursing home placement, both among the instead of measuring each dimension separately. (e generation of grandchildren (χ � 53.17; p< .01, rc � 0.8; (34) reliability of the entire instrument was Cronbach’s p< .01) and the generation of grandparents (χ � 50.03; (33) alpha � .69. From here on, this behavior that this p< .01, rc � 0.7; p< 0.01). questionnaire was meant to predict will be referred At this stage, and to examine the research hypotheses, to as “the intent to place a relative in a nursing several two-way ANOVA procedures were conducted. For home.” the purpose of statistical analysis, relevant variables were grouped into one of two categories, either above or below the mean score value for each variable. Findings of these cal- 3. Results culations indicated the following. (e current study examined the relationship between per- (a) (e generation variable had a significant effect on the sonal variables (attitudes regarding nursing home placement mean score for attitudes against nursing home and the intent to place an aging relative in a nursing home), placement (F � 5.36, p< .01). To examine the (2,162) interpersonal variables (intergenerational solidarity), and source of this effect, a Scheffe test was conducted, demographic variables (e.g., age, education, religiosity). which revealed that the mean score for attitude In the first stage of the analysis, distributions, means and opposing nursing home placement was higher standard deviations were calculated for all of the variables among the grandchild generation than it was among related to nursing home placement per each generation (see the grandparent generation. On the attitude variable Table 1). A review of the data in Table 1 indicates that the of opposition to nursing home placement, no sig- highest scores were assigned by the grandparent generation, nificant difference was found on the intent variable indicating a positive attitude towards nursing home place- between the grandparent and the parent generations ment (M � 3.89, SD � .48) and the intent to move into a or between the parent and the grandchild nursing home (M � 3.37; SD � 0.54). In other words, the generations. positive attitude regarding nursing home placement was strongest among the grandparent generation, and this (b) (e generation variable had a significant effect on the generation also indicated the strongest intent to place a mean score for intent to place an aging relative in a relative in a nursing home in the context of “loss of func- nursing home (F � 12.9, p< .01). To examine (1,162) tional autonomy”. the source of this effect, a Scheffe test was conducted, To examine the internal connections among the nursing which revealed that the mean score for intent to home placement variables, a total score was calculated based place an aging relative in a nursing home was higher on the mean score for each of the research variables. In among the parent generation than among the addition, Spearman’s tests and Pearson’s tests were con- grandchild generation. No significant difference was ducted to examine these connections. (ese analyses were found on this variable between the grandparents and conducted using the entire sample. (ere is room to examine the parent generations or between the grandparent whether there is a connection when generational division is and the grandchild generation. not taken into account. (c) (e generation variable was found to have a sig- (e data presented in Table 2 indicate that no significant nificant effect on the intergenerational solidarity positive correlation was found between the variable of ed- variable (F � 11.58, p< .01). A Scheffe test (2,162) ucation and any of the other relevant study variables. revealed that the mean score for intergenerational Findings of the study indicate no significant relationship solidarity was higher among the grandparent gen- between participants’ education level and either their atti- eration than among the parent generation. No sig- tudes towards nursing home placement or their intent to nificant difference was found between the mean place a relative in a nursing home. scores on intergenerational solidarity between the (e variable of religiosity correlated negatively with the grandparent generation and the grandchild gener- attitude favoring nursing home placement (r � −.34, p< .05) ation or between the parent and grandchild and with the intent to place an aging relative in a nursing generation. home in case of loss of functional autonomy (r � −.22, p< .05). Furthermore, a strong positive correlation was Up to this point, findings of the current study indicated that some of the variables were related to positive attitudes found between the variable “arguments favoring nursing home placement” and the variable of intent to place a relative regarding nursing home placement, as well as to opposition 6 Journal of Aging Research Table 2: (e connections between the research variables . 1 2 3 4 5 (1) Education — — — — — (2) Level of religiosity −.050 — — — — (3) Attitudes towards nursing homes .016 −.34 — — — ∗∗ (4) Attitudes against nursing homes −.024 .69 −0.04 — — (5) Intergenerational solidarity −.050 .47 −0.15 0.27 — ∗ ∗∗ ∗ (6) Predicting the intent to place a relative in a nursing home −.033 −.22 0.63 −0.48 −.30 ∗ ∗∗ For the religiosity variable, a Spearman’s correlation was conducted. For the other variables, a Pearson’s correlation was conducted. p< .05; p< .01. to placing a relative in a nursing home. To summarize the By contrast, as regards negative attitudes regarding findings and examine the first research hypothesis, a mul- nursing home placement in each of the generations, it was tiple regression analysis was conducted. Findings of this found that variable of intergenerational solidarity explained analysis are presented in Table 3. the negative attitude among both the grandchild and the An examination of the data in Table 3 reveals that in the parent generations. As regards the grandchild generation, case of a positive attitude towards nursing home placement the variable of intergenerational solidarity had a negative among the grandparent generation, the remaining variables effect on the negative attitude regarding nursing home explained 32% of the variance, but only the variable of placement, whereas the variable of intent to place a relative religiosity significantly predicted positive attitudes towards in a nursing home had a positive effect on the negative nursing home placement, and this regression model was attitude. found to be significant (F � 3, p< .05). In the case of a (7,45) negative attitude regarding nursing home placement, it was 4. Discussion found that among the grandparent generation, the variables of the model explained 8% of the variance; however, the (e goal of the current study was to examine and compare the regression model did not render a significant outcome attitudes of three generations (grandparents, parents, and (F � 0.58, n. s.). grandchildren) in the Arab Muslim family in Israel regarding (7,45) Focusing on the parent generation, it was found that the placement of an aging parent or grandparent in a nursing when the dependent variable was positive attitudes towards home. According to the Arab tradition, the family that nursing home placement, 16% of the variance was explained constitutes the major support network for older adults re- by the other study variables, but the regression model did frains from accepting the assistance of formal services offered not render a significant outcome (F � 1.25, n. s.). by the state, such as nursing home placement for an aging (7,45) However, when the dependent variable was a negative at- relative. However, as the processes of change and moderni- titude towards nursing home placement, 29% of the variance zation begin to affect the Arab society, they leave their mark was explained by a single variable, namely, intergenerational on social values as well. (e current study and its findings give solidarity, and the model rendered a significant outcome rise to two major issues that merit discussion: the first is (F � 2.64, p< .05). related to the nursing home placement of aging relatives in (7,45) An examination of the grandchild generation found that Muslim society and the second is the issue of collectivism when the dependent variable was positive attitudes towards versus individualism in the Arab Muslim society. It is im- portant to emphasize that this society is undergoing two nursing home placement, the variable of religiosity predicted 48% of the variance, and the regression model was signif- processes simultaneously: change and modernization on the icant (F � 4.37, p< .01). (e regression model was one hand, and a return to tradition, on the other hand. (7,45) significant also when the dependent variable was negative A detailed study that reviews nursing home placement of attitudes regarding nursing home placement (F � 5.32, Muslim older adults in the United States claimed the fol- (7,45) p< 0.01). Both the variable of intergenerational solidarity lowing: “With Islam placing a strong emphasis on caring for (β � 0.38, p< .05) and the variable of intent to place a relative one’s parents in the home, along with cultural barriers, in a nursing home (β � −.60, p< .01) significantly predicted Medicaid and Medicare’s focus on nursing homes is not a attitudes against nursing home placement, with the latter viable option for Muslim Americans” ([23]; p. 1). (e author offered several possible causes that might explain why variable being the more significant among the two. To summarize, the findings of the regression analysis Muslim older adults living in the United States do not opt for nursing home placement, chief among them, the issue of indicated that the variable of religiosity significantly pre- dicted a positive attitude regarding nursing home placement religion. (e Koran, which is revered as the word of God, among the grandparent and the grandchild generations; states the following. none of the variables predicted a positive attitude among the parent generation. In other words, the higher the level of Your lord has decreed that you worship none but Him, religiosity was, the less positive were the attitudes regarding and that you be kind to parents. Whether one or both of nursing home placement, such that higher orthodoxy was them attain old age in your life, say not to them a word of negatively associated with favorable attitude regarding contempt, nor repel them, but address them in terms of nursing home placement. honor. Journal of Aging Research 7 Table 3: Multiple regression analysis measuring the contribution of the research variables attitude for or against nursing home placement. Grandparents Parents Grandchildren Generation/attitude Variable For Against For Against For Against Gender 0.04 −0.2 0.17 −0.06 0.2 −0.4 Family status −0.23 0.05 −0.15 0.11 −0.3 0.26 Education −0.01 −0.28 0.34 −0.19 −0.54 0.3 ∗ ∗∗ Religiosity −0.09 0.24 −0.16 0.13 −0.68 0.45 ∗ ∗ Intergenerational solidarity 0.13 0.25 −0.27 0.28 −0.19 0.38 Predicting the intent to place a relative in a nursing ∗∗ 0.18 −0.27 0.19 −0.21 −0.53 −0.60 home Multiple R 0.32 0.08 0.16 0.29 0.48 0.58 ∗ ∗ ∗∗ ∗∗ F F � 3 F � 0.58 F � 1.25 F � 2.64 F � 4.37 F 2.89 (7,45) (7,45) (7,45) (7,45) (7,45) (7,45) � ∗ ∗∗ p< 0.05; p< 0.01. modernity and tradition is not without problems [25]. (e (us, the more religiously conservative the family is, the more likely it is to interpret the command to honor one’s Arab population that now resides in the state of Israel was parents to mean providing unmediated care in one’s own under the Turkish rule when modernization began, and later home for aging parents and relatives [24]. (e researcher under British rule, until 1948 when the state of Israel was indicated that placing an aging Muslim parent in a nursing established. Israel has followed the Western philosophy and home is considered a type of elderly abuse. In her study, Al- its behavior patterns and, as the world of computers and Heeti [23] noted the discretion required in Muslim families digitalization and the notion of the global village are in- creasingly becoming the norm, Arab families, and especially when a relative requires medical attention or treatment, so that the family can avoid public shame or humiliation, which Muslim Arabs, have found themselves faced with the choice of either adapting to the new world or withdraw and isolate stem from the social norm that views the family—rather than the public services—as responsible for caring for an themselves from the surrounding society. Consequently, aging relative. As the author explains, it is important that the psychosocial mechanisms, such as intergenerational soli- family appear to be the one taking care of the aging relative, darity and transmission, have been used in recent decades as and it is crucial to maintain discretion whenever a member a way of coping with the new and evolving reality, which is of the Arab Muslim family in the United States requires increasingly affecting aspects of life that for generation upon treatment outside the home. A further complication stems generation were the accepted and familiar norms [8, 26]. from the fact that an aging Muslim man might reject treatment from a female healthcare professional, while an 4.1. Discussion regarding Hypothesis 1. (e current study, aging Muslim woman might be apprehensive or feel un- examined the attitudes of 126 university students, one of comfortable being left alone to be cared by a male healthcare their parents and one of their grandparents, thus reviewing professional. (ese issues are familiar in Israel as well, yet three generations of Arab Muslim families. (e goal of the they have never been directly studied. (is is because, given Israel’s small geographic area and the particularly the study was to gain insight into the participants’ attitudes regarding nursing home placement and to compare these geographic concentration of Arab Muslim populations in Israel, Muslims of any generation would be reluctant to attitudes among the three different generations. Two hy- potheses guided this study: the first was that the three divulge collaborate with researchers by divulging informa- tion on such sensitive issues. generations would differ in their attitudes regarding nursing home placement of an aging parent, such that the younger (e transition from a traditional society to a modern one is referred to in the professional literature as social mobi- the participants are, the stronger will be their support in favor of this move. (is hypothesis was not confirmed; on lization [7]; a concept that conveys a transition from a the contrary, findings indicated that the younger the par- generations-old patterns of belief and behavior to newer ticipants’ age, the greater the opposition to placing a parent ones. In recent years, their tradition has been subjected to or grandparent in a nursing home. (is was perhaps the abrupt changes. (e modern Western philosophy has led traditional societies to be characterized as different, “exotic most surprising of the findings of the study, as the grand- child generation’s attitudes against nursing home placement and also as reflecting lower stages of evolutionary ad- vancement”. As a result of this social perception, traditional were stronger than those of the other two generations. Furthermore, they reported a low level of intent to place an societies in the United States, India, Iran, and other coun- tries have opted to adjust and adapt to the Western phi- aging relative in a nursing home, particularly if the older relative has lost some degree of functional autonomy. Al- losophy, which conveniently dictates behavior patterns but though the education level of the youngest generation was does not interfere with beliefs or ideologies. A lot of it is also the highest, and the expectation was that the education related to the quality of life offered to the elderly and how variable would have the strongest effect on favoring nursing much their children are satisfied from it. Nonetheless, the home placement, this expectation was not confirmed. encounter between these two worlds creates an ideological Moreover, reports from the youngest generation indicated a crisis, and the need to cope with the conflict between 8 Journal of Aging Research Rijnaard et al. [34] suggested that family closeness and higher level of religiosity. It is possible that this indicates a desire to hold on to a tradition that is fading. (e attitudes of involvement before the initialization will have a major impact on the attitudes, willingness, and involvement in the the youngest generation were more similar to those of the grandparent generation than to their parents’ generation, process of nursing home placement of an elderly family’s which suggests that the intergenerational transmission did member. not play a role in this sample. (e current study’s findings indirectly indicate the A study that examined filial responsibility among three breaking of this psychosocial pattern. None of the findings of generations of Arab Muslim families [27] found positive this study—whether related to the effects of demographic attitudes and perceptions among all three generations to- variables (education, religiosity), to participants’ attitudes, to the intent to place a relative in a nursing home in the case of wards the notion of filial responsibility and assisting aging parents, with the youngest generation’s positive attitudes loss of autonomy, or to the variable of intergenerational solidarity—indicated any form of consecutive intergenera- ranking higher than those of their parents or grandparents. Findings also demonstrated that in all three generations, tional transmission. As regards the education variable, there is a simple explanation for the absence of intergenerational women’s attitudes were more positive than those of men, and the attitudes of religious participants were more positive transmission, namely, the fact that in contemporary ad- than those of their secular counterparts. A study that ex- vanced societies, members of the youngest generation are amined the experiences of Muslim families who have a relatively more educated than either their grandparents or family member in a nursing home found that psychological their parents, and this is also true in traditional Arab so- attitudes and sociocultural norms are two challenging issues cieties and is particularly noticeable among the women in affecting families both in the decision making about nursing the Arab society. (e finding that the highest level of religiosity was re- homes stage and living with this decision after making it [28]. ported by the youngest generation contradicts the known patterns of intergenerational transmission. As previously A possible explanation for the attitude among the youngest generation, as found in the current as well as in the mentioned, a possible reason for this may be the global phenomenon of increased religiosity among the youth of all aforementioned study, may stem from the tendency to as- sociate increased religious practice with the strengthening of three monotheistic religions. Furthermore, observing and traditional social norms. An increasing inclination towards adopting the role of caregiver to one’s aging relatives is conservative religiosity has been noted in the Arab world in considered the result of learned behavior [35]; hence, the general and among Muslims in particular. Not surprisingly, clan-like lifestyle shared by all of the generations in the Arab this trend has emerged also among Muslims in Israel and is family could serve to explain the similarity of attitudes and noticed among the youngest generation [23, 28, 29]. intent regarding nursing home placement between the grandparents’ and the grandchildren’s generations. In the current study, the assumption was that inter- generational transmission would be the psychosocial Notwithstanding, members of the youngest generation in Arab Muslim families in Israel move out of the family mechanism by which traditional cultural and religious norms were inculcated to younger members of the family home to pursue advanced studies, and occasionally, they unit. Intergenerational transmission is a concept that in- even move overseas. Due to the rate of unemployment in dicates the finding of similarities between consecutive Israel, some of them leave their homes located in rural areas generations in terms of attitudes and behavioral patterns, and move to major cities, where the chances for finding which seemingly are passed down from generation to employment are much better. Despite the observation made generation. Some researchers [30, 31] have used the term by the author [36], it may be surmised that a high level of behavioral genetics. People are generally affected directly by opposition among the youngest generation to the placing of the familial model within which they were raised, whereas an aging family member in a nursing home indicates the grandchildren’s inability to understand the functional and the models provided by previous generations have an in- direct and subconscious effect. Consequently, traditions, health-related needs of their grandparents. Members of the grandchildren generation view their grandparents in terms behaviors, beliefs, and rules are passed from generation to generation [32, 33]. (e researchers claimed that the family of the significant role they have in the extended family, unit exerts horizontal and vertical pressures on its members; rather than as older adults who need round-the-clock at- the vertical pressures, which are passed from one generation tention to a greater or lesser degree. In other words, their to the next, include general approaches and ways of func- attitudes are based on emotions rather than on rational tioning and solving emotional problems. (us, vertical considerations. pressures may be related to adult children’s sense of re- sponsibility and commitment to care for their aging parents, and they also account for the parents’ expectation that in due 4.2. Discussion regarding Hypothesis 2. (e second hy- pothesis was that a negative correlation would be found time and according to the tradition, they too will be cared for by their children. (us, these vertical pressures provide a between the strength of intergenerational solidarity and the positive attitudes of members of the three generations re- possible explanation not only for the current study’s finding of pervasively negative attitudes regarding nursing home garding nursing home placement. (is hypothesis was based placement among all participants but also for the excep- on the assumption that the youngest generation would be tionally strong opposition among the youngest generation. more open to the idea of nursing home placement than the Journal of Aging Research 9 As regards the grandchildren’s generation, much like oldest generation, and hence, the youngest generation would represent the greatest change in terms of accepting modern the perspective of the grandparent generation, the quality of their relationship with their grandparents was not behavior patterns. Such greater openness could be assumed, given that modern Arab society in Israel clearly understands related to their degree of agreement with an attitude fa- that demonstrating concern for an aging family member but voring nursing home placement. Rather, their attitude confining care and support to the family framework do not against nursing home placement was related to the degree go hand in hand. Not only is such an approach liable to be to which they reported receiving financial and emotional detrimental to the health maintenance of the aging relative, it assistance from their grandparents and the degree to would also hinder the ability of the young Arab family to which they felt obligated to give back something in return for said assistance. Grandchildren also reported that the advance and develop in today’s modern competitive and capitalist world [37, 38]. However, the second hypothesis better their relationship with the grandparent was, the less inclined they were to place him or her in a nursing home was not confirmed, and as in the case of the first hypothesis, the hypothesis was contradicted by the findings. in the case of loss of autonomy. (e grandchildren at- tributed less significance to the advantages associated with In the current study, it was found that the generation of grandparents assigned higher scores and thus indicated a nursing home placement (such as lightening the family stronger agreement with the notion of nursing home burden, availability of medical services, relative inde- placement compared with the grandchildren’s generation. pendence for the aging grandparent, and more compre- (ey also indicated a higher degree of intent to move into a hensive support available) and greater significance to the nursing home if they suffer a loss of autonomy. (is un- cultural norm, which views nursing home placement as expected gap may express the grandparents’ realistic un- unacceptable. It appears that the intergenerational loyalty and commitment that even the grandchildren expressed derstanding that the organized healthcare system is better equipped to provide significant medical assistance, moni- towards the oldest generation led them to believe that they could fulfill all of the necessary functions and thus avoid toring their dietary and activity needs on a regular basis as is the practice in nursing homes. Another possible explanation nursing home placement. (e strong emotional bond was created by the fact of living in a joint residence, and thus for this unexpected finding, which was found to be related to the level of intergenerational solidarity, maybe the grand- spending a great deal of time with the grandparents is a parents’ effort to avoid becoming a burden on the younger likely explanation for the grandchildren’s sense of com- family members, particularly on the women, who in recent mitment towards the grandparents. In the current sample, years have ventured beyond the home and found suitable a large percentage of the grandchildren indicated that they employment [35]. were living or had lived with a grandparent, in most cases As regards the middle generation, it appears that the with a widowed grandmother who feared living alone or who could not be accommodated in her sons’ homes. It more the members of this generation reported having an affectionate relationship with their parents, meeting with may be surmised that the grandchildren’s sense of re- sponsibility and commitment towards their grandparents them, calling them, and providing emotional support, the more likely they were to display attitudes and claims in consisted mostly of emotional and less of functional favor of nursing home placement. By contrast, when the support, which alone is not sufficient to ensure that the members of the middle generation reported providing aging grandparent receives appropriate care in the long essential functional care for their parents, in terms of fi- term. nancial assistance, shopping, and housekeeping, all of which necessitated living in close proximity to their par- 4.3. Limitations of the Study. (e main limitation of the ents, the less likely they were to display attitudes favoring current study is related to sample and sampling. nursing home placement. (e findings of the study dem- Recruiting members from three different generations of onstrate the devotion of the children and their commit- Arab Muslim families constitutes a rather complex lo- ment to care for their parents. Indeed, this is the norm in gistical challenge. (e willingness of university students to the Arab family, where all the generations live in close engage in this study and to learn about their families was a geographic proximity and the large number of children and grandchildren ensures that there is always someone facilitating factor, but it constituted a methodological limitation. available to care for the aging family members, visit them, address their needs, or live with them in the same Future studies should continue this line of investigation by conducting cross-sectional research of the Arab Muslim household. In addition, this high degree of devotion may reflect the religious and cultural values that characterize the population in Israel, so as to characterize populations in various geographical regions, differentiating between the desired filial behavior of children towards their aging rural villages and major Arab cities, as well as between the parents. (us, it is possible that these findings indicate, to population in the major cities and the Bedouin communities some degree, that the devotion of the middle generation living in unrecognized villages (known as P’zura, meaning, towards their parents is limited, in the sense that they scattered dwellings). (is type of differentiation will make it understand that should intensive long-term treatment possible to determine the degree to which each group is become necessary, reliance on the available formal re- sources for assistance would not necessarily be considered a exposed to the various healthcare options available to aging family members. betrayal of their filial commitment. 10 Journal of Aging Research [5] H. Litwin and S. Zoabi, “Modernization and elder abuse in an 5. Summary Arab-Israeli context,” Research on Aging, vol. 25, no. 3, pp. 224–246, 2003. A review of the current study should take into account [6] H. Litwin and S. Zoabi, “A multivariate examination of ex- global trends related to longevity and quality of life. (e age planations for the occurrence of elder abuse,” Social Work at which individuals choose to move to a nursing home is Research, vol. 28, no. 3, pp. 133–142, 2004. constantly rising, both in Israel and throughout the world. [7] R. Khalaila and H. Litwin, “Modernisation and filial piety Improved quality of life during old age postpones the among traditional family care-givers: a study of Arab-Israelis decision and delays the actual move, which in turn means in cultural transition,” Ageing and Society, vol. 32, no. 5, that in the Western world, a smaller percentage of the aging pp. 769–789, 2012. population opts to live in nursing homes. In Israel, this [8] K. Suleiman and A. Walter-Ginzburg, “A nursing home in delay is related also to the tight family structure that Arab-Israeli society: targeting utilization in a changing social characterizes Israeli society in general. 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Journal of Aging ResearchHindawi Publishing Corporation

Published: Aug 23, 2021

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