1. Introduction
For older people living alone, supporting their ability to age in place, e.g., in their own home [
1], becomes crucial when limitations in their physical functionalities compromise performing the activities of daily living. Thus, community-dwelling older adults, especially those with limited informal and formal care supports, face a high risk of becoming frail [
2], and during the experience of transitioning toward residential care facilities, older people face substantial challenges (e.g., changes life patterns, isolation, loss of autonomy, stress) [
3].
Frailty is “an ageing-related syndrome of physiological decline, multisystem dysfunction, and susceptibility to adverse consequences” [
4] (p. 2), representing a crucial public health challenge affecting population ageing [
5,
6], being a geriatric syndrome that increases vulnerability to adverse health outcomes [
7,
8]. The interaction between older age and chronic diseases can result in increased frailty, which in turn can lead to disability, hospitalization, and also death [
9,
10,
11]. The literature often relates the physical characteristics of frailty to difficulties in performing basic and instrumental Activities of Daily Living (ADLs and IADLs) [
12,
13]. As people age, the level of independence in performing ADLs e IADLs indeed decreases [
14]. The higher level of functional limitations in people aged 80 and over has also been noted [
14,
15]. Several instruments/tools for measuring frailty have been developed, in order to provide a clinical assessment in different settings [
7], but most of them are appropriate for detecting general health outcomes, and not all dimensions of frailty [
16]. The results of a systematic review and meta-analysis, reporting a pooled prevalence of frailty among older people near to 18% in all settings, showed that frailty is a common issue in European countries, even though differences emerged according to settings and definitions of frailty itself [
17]. A systematic review on frailty in nursing homes [
18] indeed estimated a prevalence in the range of 19–76%, whereas other authors [
19] found a prevalence between 4–59% in community-based studies, with a total weighted prevalence of approximately 11% in people older than 65 years. In particular, in high-income countries, frailty is estimated to affect 10% of community-dwellers aged 65 years and over, and 25–50% of those aged 85 and over [
6,
19]. Previous literature [
20] found the lowest levels/prevalence of frailty in the population over 65 years in Austria and Sweden (11% and 9%), and the highest in Spain and Italy (27% and 23%).
In the latter country, where this study was carried out, the proportion of over 65 s was about 24% of the total population as of 1 January 2021 (i.e., the highest value among European countries), with 50% of people living alone aged over 65 years, and 44% of this population group having severe functional limitations and great difficulties in performing ADLs [
21]. In such a context, belonging to a family-based care regime, the long-term care (LTC) system provides services such as home care, residential care, and especially cash benefits. However, in Italy, frail older people receive support mainly from relatives, in particular children/daughters [
22,
23]. Public services remain indeed overall marginal, with only 1% of older people benefiting from home care service (SAD,
Servizio di Assistenza Domiciliare), and only 2% staying in residential care facilities, in 2018. In the same year, conversely, the national disability attendance allowance (IA,
Indennità di accompagnamento), accounted for 12% of older users [
24]. In the European Union (EU 27), the average shares of older people aged 65 years and over receiving institutional care, home care, and cash benefits, were, respectively about 4%, 6%, and 9% [
25]. In Italy, territorial/regional differences also emerged in public care for older people, with overall prevalence of IA in the South, IA and SAD in the Centre, and residential care in the North [
26]. However, as for daily home care for seniors aged 75 years and over living alone, the situation is partly different, with 1.5% of users in the North, 0.3% in the Centre, and 0.7% in the South [
27]. The overall scarce/lacking public care support in Italy, especially concerning home care, is replaced by personal care assistants (PCAs), 44% of whom are from Eastern Europe, and often remunerated (also) with the IA (when available), and hired with verbal agreement/without a regular work contract [
28]. There were a total of 407,000 regular PCAs (i.e., having a formal work contract) in 2019 and about 40% of them were concentrated in three regions (Lombardy and Tuscany in the North, Emilia-Romagna in the Centre) [
29].
Moving on from available supports to seniors’ opinions for housing solutions/preferences, the literature provides evidence that staying at home and ageing in place, with help from family or public services, is preferred to moving to a care/nursing home. This is considered as the last/not wanted option, because it implies the loss of both autonomy and independence [
30,
31,
32,
33]. Other authors suggest that retirees expect to age in place, especially after living in their home for several years [
34]. Nursing homes were preferred by male older people with low health status, whereas women preferred relatives’ homes [
30]. More recent findings [
35,
36,
37] highlight how the decision-making process, regarding moving from home to an alternative housing arrangement, is difficult and complex, with a great diversity of possible preferences. The decision to remain/stay at home or not, and the associated factors leading to the institutionalization of older people, are influenced by chronic health conditions, the physical functionalities level, care/health needs, availability of support from relatives, the context of welfare resources, and attachment to own place. These recent findings confirmed similar previous results regarding the links between poor health and moving to a different environment [
38,
39], and attachment to one’s home/neighbourhood and ageing in place, thus implying affective aspects [
1], the importance of memories [
40], and desires of independence [
41]. Moreover, the low availability of social support networks negatively impacts the decision of older people to age in place, especially of older widowers living alone [
42]. This highlights that older persons in Northern and Western Europe more often choose to live in residential facilities, as compared to Southern European countries such as Italy, where the family is a pillar of caregiving [
43]. In this country, a strong attachment to one’s own home as a place for ageing also emerged [
44].
In relation to seniors’ opinions on caring responsibilities of both family and public services, the cultural assumption that children will take care of their older parents is high in Latin societies, such as Italy, and it seems more a social expectation than a voluntary decision of children themselves [
45]. There is a reliance on traditional family support, since family/children caregiving is considered as a “moral obligation”, particularly a duty of female members, without relying on private/paid help for providing domestic work [
36], even though social, economic and value changes in recent years are eroding the traditional key care role of families. However, there are also seniors who conversely do not consider caring as a family duty and relatives as the elected providers of support, especially in Northern Europe, where welfare systems work well and seniors receive sufficient support from public services, in addition to help from friends and neighbours [
36]. Thus, some seniors consider their home as a “private space”, where traditional caregiving can only be provided by the family, whereas for others it is an “open space”, where public and private support can be combined. Additionally, professionals highlighted that caring responsibility should ideally be transferred from the family to the community, in order to permit older people to remain at home [
36,
46].
In order to explore the opinions of frail older people with physical limitations living alone in Italy related to future housing preferences/solutions, regulatory public/private orientation on care, and current/received care arrangements, this paper aimed to answer the following research questions: (1) What are seniors’ preferred future housing solutions (e.g., ageing in place at home, at home with PCA, in nursing home)? (2) Should caring responsibilities be the main duty of the family and/or of public services? (3) Are there links between these opinions and socio-demographic characteristics of respondents (e.g., gender, living situation, mobility and supports received)? (4) Are there regional differences in this respect? The analysis of these opinions can be of help in order to understand possible links among available care, preferred care, and responsibility of care for frail older people in Italy, with practicable insights for policy makers.
3. Results
3.1. Sample Characteristics
The sample included 120 older participants, who were mainly aged 85 years and over, women, with an elementary level of education, and widowers. Moreover, most participants lived alone, and with a PCA only in 27 cases. Regarding functional status, a greater mobility outside the home with help, and both a mild and very high level of physical limitations emerged. Help for providing the activities of daily living largely derives from the family, especially from children, and less from public services, mainly SAD. At the regional level, in Lombardy, more respondents who were able to go outside their home and living alone were identified, whereas in Calabria a greater number of older people aged 85 years and over, with an elementary level of education, living with a PCA, and with a serious level of physical limitations emerged. Additionally, in this region, more so than in both Lombardy and Marche, families were often found to support relatives needing care, while little help from public services (
Table 2).
The monthly income is concentrated in the bracket 600–1500 EUR, without particular differences among the three regions. On the whole, the sample shows some opposite aspects between North and South, whereas the Centre of Italy, Marche in this case, is an intermediate context. More details on the sample are available in a previous publication [
22].
3.2. Future Housing Solutions for Older People
3.2.1. Different Possibilities
A general request to express oneself in terms of preferred future assistance in older age was formulated, specifically if health problems should emerge/worsen (
Table 3).
The most accredited hypothesis, as a preferred choice, is being able to stay/remain at home (51%), also with the support of a PCA (20%). No one indicated the preference to stay at home with help from public care services, e.g., SAD. It should be noted that among those who express the second option, only 6% already had a PCA, thus mainly those without PCA (14%) underline the importance of ageing in place, with constant help from a private assistant as a needed resource. A minority of 30% also indicated future transferral to a nursing home, but of these just 7% considered it as first choice, and 23% indicated it as a choice in cases without the possibility of an alternative (second/third choice), in particular if health, especially the cognitive aspect, worsens. Some respondents (10%) also underlined the option of cohabitation with children. At the territorial level, the nursing home option was more widely expressed in the Marche region (45%), whereas the “home” option emerged for more than half of the respondents in both the Calabria and Lombardy regions (“at home with a PCA” prevails however in the Marche, 28%). Cohabitation with children was indicated almost exclusively in Calabria and Marche, and housing proximity to children was considered a possibility only by four older people living in the Marche region. It should be noted that in some cases, despite a hypothesis being expressed, a certain overall insecurity in terms of future housing solutions was also expressed, with the need to make such a decision with one’s family.
3.2.2. Home, ‘Sweet Home’ and PCA
The qualitative analysis of the answers confirmed the generalised desire to stay at home for as long as possible. Ageing in place, with one’s own memories and social network, is therefore considered desirable and certainly the best solution for most of the interviewees.
It is better to stay at home, where I have a memory of everything. (MAR_15)
I am too attached to this house (...), I hope my family will leave me here. This is my wish, what I told them. (MAR_10)
For me, staying in this house is the best solution. Where should I go? I do not want to go anywhere, this is my home, my city! (CAL_31)
I want to stay here [at home]. (...) If I go out for a walk, I can talk with persons I know, I can greet them, I can have company. (MAR_8)
Some of those who already have a PCA underlined the desire to stay at home with this personal assistant (cohabiting or not), and to be able to interact with her/him.
For me, to age in this home is the best solution (…). Here I have a PCA, I have all what I want, if I feel bad, I call her. (CAL_39)
In particular, some respondents with a daily or nightly PCA, expressed hope for a future cohabitant solution with the financial help of their children.
Right now, I only need help [of PCA] at night. If I should need more support even during the day, my children will provide it (…). They will help me for having a living in PCA. I want to stay in my home, I do not want to go anywhere else. (CAL_38)
Even in cases where a PCA was not yet hired, some respondents considered constant help from an assistant as a concrete possibility to ensure ageing at home, so as not to place undue stress on their children for caregiving.
Yes, I would prefer to stay in my home, and to find a solution, a support to continue to stay here. PCA is a solution, also to relief children. (MAR_18)
For example, an older woman without a PCA, expressed that a support could be a good solution providing she ages without cognitive problems, and that family members supervise the care work of such assistant.
[To hire] a PCA? (…). If my head fits as I do now, it would be fine too! If I freak out, a relative should always monitor her work. (LOM_32)
Among those who do not have a PCA, some do not consider this assistance a realistic solution since they believe it to be an expensive option.
I cannot afford a PCA, because he/she wants at least 600–700 EUR a month. I take only 1000 EUR. What could I do with 300 EUR left? (CAL_16)
3.2.3. Nursing Home: Absolutely Not!
The nursing home was, by 70% of respondents, perceived as oppositional to ageing in one’s own home; therefore, it was rejected, due to being considered as a place where older persons are not listened to if they need help, but also for economic reasons.
Who takes me in nursing home? Economically I cannot afford it (…). Moreover, I know that in such a place, when one complains, no help is available. (MAR_14)
The option of a nursing home is also rejected and is perceived as leading to a loss of freedom and control over one’s own existence, as a place where strict rules must be followed and where older people run the risk of living a flat life and not doing what they would like.
I will never go to a facility! Oh no, because at home I feel free with everything. There you are forced to eat at a scheduled time. (…). You cannot go out when you want, you cannot smoke a cigarette. (LOM_26)
Some interviewees also fear becoming victim to mistreatment. In fact, newspapers and TV often provide a very negative picture of the assistance provided in this type of facility.
I do not think I will go to the nursing home (...). In TV I see how older people is badly trated there. Eh, no, no, no, I really do not want go there. (MAR_22).
For some, the nursing home even represents an ineluctable path towards death, both physical and emotional, with the risk of losing the will to live.
The nursing home is the death of older people. If one wants to die first, he/she goes there. It is terrible, terrible. There you must leave with strangers you do not know (…). You are immersed in your memories (...), and you turn off. Gradually you turn off. (CAL_7)
3.2.4. Nursing Home: Maybe
As for the nursing home option, the attitude of some older people is less clear-cut. It remains a solution to be generally avoided, and eventually accepted only as a last chance (second/third choice) in the absence of better alternatives and help, when older people are no longer able to carry out any daily activity and take care of themselves. However, this choice is prefigured more as an action suffered than adopted autonomously.
As long as I can, I will stay here at home (…). Then, if I become dependent, I will go to a nursing home (…). I think it is the only solution. If I cannot do anything anymore, I cannot remain at home. (MAR_13)
The nursing home is considered as a last resort even when cognitive impairments occur.
When I no longer understand anything, I think they [children] will put me in a nursing home, but as long as I stay with my head, I remain here in my home. (MAR_5)
3.2.5. Nursing Home: Accepted
In the very few cases in which the nursing home is accepted, and a more positive perception (first choice) of it is reported, this can be linked to particular factors, such as the following: realities of high quality and cost, even operating abroad; the constant presence of medical personnel; and the possibility of relieving family members, especially children, from the burden of care.
I do not know what the future holds for me. Maybe I will go to a facility, but not in Italy. Maybe I should go to Switzerland, where there are many nursing homes of high quality. (CAL_12)
Children have their own interests and commitments (...). I do not want to disturb them, absolutely! (…). I prefer the nursing home. There is always the medical doctor! Then, when it is time, they bring you your medicine (…). (LOM_36)
3.2.6. Cohabitation and Proximity with Children
There are very few cases in which the eventuality of going to live with children was actually contemplated, at least as an alternative to a nursing home, and with the need to sell one’s own home.
If my health deteriorates, of course I should sell my house and I could even retire with someone (…). I would go to live with my daughter. (MAR_5)
Older people expressed a certain reluctance towards cohabitation with children also because it would imply moving elsewhere, where they do not know anyone, and having to give up their freedom, even if they are living with family members.
My son wants keep me with him out of my city [another town in the province]. Here, if I open the door, someone always passes by and greets me. In other places this cannot happen because there nobody knows me. (CAL_35)
In one case, future cohabitation with one of the participant’s daughters was refused, since it was already experienced in the past (due to the need for assistance after a fall and related fracture), and perceived as a negative period.
I had to stay in my daughter’s house for five months [due to a fracture], I could not take it anymore! (MAR_30)
Only four older people (in Marche region) hope for a future geographical proximity with children, who could take care of them.
I cannot live alone. I cannot remain in this home (…). A small apartment, close to my daughters, would be enough for me. (MAR_9)
3.2.7. Further Housing Solutions
There were also two proposals similar to ‘co-housing’ in the Calabria region, which are indicated as further alternatives to the impractical expense of nursing homes. For instance, an old woman would prefer to age with some friends.
The best thing would be to live with some friends in the same house, all together. Eh, but it is not easy to be realised. (CAL_7)
Three older people even contemplated the possibility of transferring directly to the hospital, as this could be both an emergency and definitive housing solution (for health reasons).
Depending on how [health] things are, if I have to go to the hospital or clinic, I go. (CAL_10)
3.2.8. “I Am Unsure”
In some situations, although some hypotheses were put forward, respondents were undecided about their future housing solution, since they were aware that they could not decide/choose independently on this, but conversely it would be necessary also to consult their family, especially in cases where they become seriously ill and require assistance.
If a debilitating disease takes over, we logically cannot decide by ourselves. Then the others [family members] will decide, unfortunately. (MAR_4)
If my health were to deteriorate, I would discuss with my children and make the appropriate decision [for an adeguate housing solution]. When there are decisions of a certain importance, of a certain consistency, I always consult my children. (CAL_9)
3.3. Family or Public Responsibility in Caring for Older People
3.3.1. Different Regulatory Orientations
Besides the opinions on future housing solutions, the interviewees were also asked if caregiving for an older person should be a priority task for families/children, or if greater support should be provided by public services (e.g., home care) (
Table 4).
The majority (42%) believed that, firstly, family members/children should take care of their older loved ones, if of course they can and are available. This is followed by 32% of those who considered collaboration between/co-responsibility of family and public services as better, with public services supporting both older people and family caregivers. There were fewer respondents (22%) who considered assistance to be a priority/exclusive role of the public sector, especially for older people without a family. The respondents in the North, more so than those in the Centre and South, expressed their beliefs that assistance is a family duty (58%). In the Calabria and Marche regions, 60% of older people desired greater support from public services, alone or with the family, compared to 40% in Lombardy.
3.3.2. The Family, If Any, as First Care Provider
The narratives/quotations confirm and complement the quantitative picture. Among those who argue that assistance for older people is primarily a responsibility of the family, some think in particular that this is an old “general axiom”, and it must be followed as such.
When I was young, grandparents were not abandoned and they were assisted by the whole family. This is the rule. (LOM_17)
The family, especially children, if there are any, are therefore the first choice, for emotional/affective reasons, because the family is always considered as the best solution.
The family is always in the frontline, because the family is in the heart. (MAR_19)
Help comes from the family, from children (...). Children should not abandon their parents! (CAL_38)
In particular, some respondents who reported previous personal experience of family caregiving for their parents, considered this the only feasible option, believing it to be a family role by default.
I think that children are the first caregivers, because it is right so. A mother and a father take care of their children. If there is the possibility, it is right that children help [the parents], as I did it towards my parents. It is a duty of children. (CAL_6)
However, when one does not have children, the assistance of kinship in a broad/extended sense seems possible, even though care by children would be better.
As a general rule, it would be nice to be assisted by the family, but in my case, I do not have a family and children of my own (…). I could have support from grandchildren [daughters of sisters/brothers], but I would have preferred more to be assisted by a child. (LOM_29)
The family also helps older people to feel more calm and secure, whereas when care is provided by other persons, by “strangers”, one has to adapt.
I am convinced that older people must be cared for by relatives, because I think it is much better having support from loved ones than from strangers. (MAR_14)
However, some respondents highlight that, in this respect, there are pre-conditions to be considered. The family caregiving can be accepted if there are several available relatives, but without obligations, because most of them work and in turn have their own families. In some cases, it is also a gender issue, e.g., women are considered as better than men as caregivers.
Well, if there is an extended and available family, it is clearly nice that relatives take care of their older loved ones! (CAL_7)
Children are better, but it is clear that they have their jobs, their families and own babies. They help, but I cannot force them. (MAR_10).
I would prefer a niece, a cousin, I do not know exactly. However, a woman in any case (...). I went to the hospital and they made fun of me because I did not want male nurses to clean me. (LOM_1)
In addition, the family must be united/cohesive and capable of caring, otherwise a “stranger” is preferred.
If a family is unable [to assist], is not smart enough to understand which are the needs of the older parents, then it is better to be assisted by other persons out of the family. (LOM_13)
There are those who attributed to the family also a controlling role for PCAs. Conversely, other more intransigent interviewees believed that it is almost a shame to resort to a PCA if there is a family.
[When a PCA is hired] Family members must always be present, because there are good PCAs who assist well and others who do it exclusively for money (…). Family members must be present, and be vigilant. (CAL_18)
I think that older people must be cared for by their families, but unfortunately currently there are many PCAs in this respect. This is not good. Everyone should take care of their own older family members. (CAL_30)
3.3.3. Family First, but with Public Support
Attitudes have changed, and families in Italy are no longer those (extended) of past years, when all members lived together and helped each other.
Once, when families were extended, one could exchange/alternate in supporting older relatives. Now the families are small and it is no longer possible. Treating a sick person alone, without help, is a heavy thing. (MAR_39)
In light of this, a family–public support network could work better. Family would be first, but with the assistance of public support.
The family is primary, but public service is indispensable. (MAR_4)
The care from the family by civil law must exist, but it is also a task of social structures, of public services. (CAL_12)
Furthermore, children often need to help themselves, because they have their own family (spouse, children) and work commitments. Public services must therefore also support the caring family.
Families today are not always available, they have jobs. They need someone from public services who can support/relief them. (MAR_36)
In particular, it would ideally be desirable to have public services for physical/personal support (“hard” care), and family and children for company and affective support (“soft” care). Family should therefore be raised and integrated by public services in the former tasks.
The presence of children is good for what concerns the affective side, the emotional closeness. It is acceptable that children visit parents or hear them on the phone frequently, but it is heavy to support them for the activities of daily living. (MAR_18)
However, for one respondent, the public integration of family assistance should only concern health-related aspects. In another case, it is defined as allowance, e.g., as a provision of IA, even though it does not seem to be enough.
The first support is the family, when needed (…). The public service should intervene for health needs and medical care. (CAL_20)
The family and IA (...). This association could work, even though the latter sometimes is not sufficient for medicines and treatments that are needed. (CAL_27)
This underlines how, at times, previous personal experience of (heavy) caregiving makes one feel the need for public support for their own family members when being cared for, as they cannot manage such a difficult task without assistance.
My children cannot help me (…). I do not want they live the [heavy] caregiving experience I had when supported my aunt, my mother-in-law, my father. (CAL_35)
With public help for the family, perhaps older people themselves would feel less loneliness at home.
Family and public service. The one does not exclude the other. Children work and cannot be always available. When sometimes I stay with my daughter in Rome, she goes out to work at 9.00 am hour in the morning, and comes back at 8.00 pm in the evening. All day I am alone and dumb like a mummy! (CAL_1)
However, not all seniors accept help by someone other than their family.
There are also some seniors who do not want anyone in their home for assistance, other than the family. (MAR_1)
3.3.4. Public Service as Priority or Exclusively
Some respondents think that public services should intervene firstly as a “general rule”, as a priority or with exclusive help, for older people who have no family/children, or for those who have children who cannot assist them.
There must be greater public attention for older people without children, or other relatives, who cannot assist them. (CAL_7)
Public services must help older people, since family members have their own families. (MAR_38)
The role of public services was considered as central even when seniors do not have good relations with their families. In fact, a couple of responses from older people with little contact with their family indirectly suggest the influence of negative or “loose” family relationships on the choice of the public service as a priority care solution, and indicate dissatisfaction in the stereotyped icon of the loving family, as usually constructed by the collective imagination.
Children cannot be relied upon because they abandon their parents in nursing homes. It does not mean anything to have children! So do not tell me the story of the lovely family. The family does not exist! If you have a lot of money, then you may be treated well. This is the law of life. (CAL_15)
3.3.5. Does the Public Service Work?
Regardless of the caring option indicated above, the idea that public service provision is lacking seems to be a common denominator in some situations (data not in the table).
Family members need to assist their relatives because public services do nothing. (CAL_24)
The Italian State just abandoned seniors and does not help them. This is not the case abroad, where the State intervenes. (MAR_31)
3.4. Future Housing Solutions and Other Dimensions
From the examination of the relationship between future housing solutions and other dimensions, some links emerged (
Table 5).
Men, slightly more so than women, want to stay at home, even with a PCA. This combined housing solution was also preferred by those who are currently supported by the family (23%), and those who already have a PCA (26%), especially if they reported a positive experience in this respect.
My children help me, but I have a PCA every day. She’s very good, it’s a positive experience, that I would also recommend. (MAR_24)
The nursing home is preferred above all by those who live alone (33%), especially if they are tired of this situation of loneliness.
At least there [nursing home] there is someone who says goodnight to you. Do you have an idea of what is it like to eat alone every day for years and years and years? Going to bed alone for years and years and years? (LOM_14)
Mobility seems to have little or no influence on future housing choices. However, the level of functional limitations, although it does not greatly affect the choice of nursing home, seems to be more related to the preference for the home when moderate/high, and for a PCA in the home when mild/moderate, but also very high in some cases.
3.5. Family or Public Care Responsibility and Other Dimensions
From the analysis of the relationship between family or public responsibility in the caring for older people, and other dimensions, other links emerged (
Table 6).
Those who are already supported by their relatives, in contrast to those supported by public services, strongly believe that caring is a family responsibility (40%).
I have my sister, if I need something, she is available. If there is a need, it is better to have help from the family. (MAR_13)
Moreover, the family represents the ideal assistance network slightly more for respondents who can move also outside the home, albeit with help, and for those who have less difficulty in carrying out daily activities, as a result of mild and moderate physical limitations. The family–public service dyad prevails instead among seniors with higher limitations (moderate/high), and among those with even higher limitations (high/very high) it emerged that public intervention should be the main actor in caring for older people, so as not to disturb the family.
More public services [should assist seniors]. I do not want to disturb my children, who work a lot, and have their own families too! Why should they take care of my several health problems? This does not suit me on principle. (MAR_22)
The family–public service binomial also prevailed among women (36%) and those with a PCA (37%), whereas the priority role of public services was indicated above all by men (33%), and by those who live alone (23%), especially those without family/children.
In my opinion, the family should help those who have it. I do not have a family, thus the Municipality, the Region, should help me with public services. (MAR_34)
Even those who already received help from public services seemed to indicate the need for priority/greater responsibility in formal support for caring for older people (23%). Additionally, they require more intensive public assistance.
Public services must intervene firstly, and much more. I need so much and what SAD is delivering is too scarce. I would like more help. Four hours a week is not enough. (CAL_8)
3.6. Future Housing Solutions and Family/Public Responsibility of Caring for Older People
Finally, from the examination of the (only quantitative) relationship between preferred future housing solutions and opinions on family/public responsibility of caring for older people, further links emerged (
Table 7).
Respondents who preferred ageing at home, in great part consider taking care of older people a responsibility of the family (52%). Those who preferred ageing at home with a PCA largely attribute this task to public services (42%). Seniors who proposed also ageing in a nursing home, think above all that caregiving is the responsibility of the family, or of the family with the support of public services (33% for both).
5. Conclusions
The exploration of the opinions of frail older people on possible future housing solutions and care responsibilities provides an articulated and interesting picture that can be of help for understanding and elaborating the gap among available care, preferred care, and different regulatory orientations, especially in the light of an ageing population with both an increase in life expectancy and need of support, with a greater preference for community care. The majority of frail older people with physical limitations, living alone without cohabiting relatives in Italy, and especially those currently supported by the family, would prefer ageing at home, at least with the support of a PCA, thus maintaining habits and providing continuity in social relationships. They also indicate the family as primarily responsible for caregiving, at least with public support, despite some territorial differences emerging, e.g., more desire of family in the North and of public services in the South, that is an overall context opposite to the current care situation of seniors in these parts of the country. However, overall, there are several, also opposite, nuances. Respondents who had a previous personal experience of caregiving for their parents, in some cases consider this as a social rule; in other situations, they feel the need for public support for their caring family members. Additionally, the gender perspective emerged throughout the findings, since some respondents expressed a clear preference for ageing in place with the support of a female caregiver, as they are considered as naturally and traditionally inclined for this task.
Moreover, some interviewees consider the nursing home as a place of loneliness, whereas others feel more alone in their own home. The possibility of future cognitive problems drives the choice towards a nursing home, because older residents with such problems are less aware of the disadvantages of such housing, whereas when a PCA is hired, it is better to have a “quite good head” in order to be aware of the assistance received. PCA and nursing homes are both considered costly for some seniors, and both solutions present risk for elder abuse/maltreatment. Caring for older people depends on several factors, including the concrete provision of formal care services in a country [
137]. Additionally, a gap emerged between where older people would “ideally” age, and where they will “realistically” have to age, and in turn between the desire to satisfy their needs “in the family” and the necessity (but not the preference) to seek help “outside the family”, especially if the level of physical limitations is considerable. Thus, insecurity in this respect is referred to in some cases, indicating that it is extremely complex/difficult, for older people to imagine their future situation. In the end, the effective caring possibilities of the family, if any, in addition to the quality of relationships with relatives/children, and the available public services, play a key role, either providing or not providing the intergenerational solidarity. Sometimes, the interviewees, rather than expressing a preference or a theoretical opinion, responded as influenced by their current care situation, that in turn could impact their possible/preferred future care context. The overall analysis thus focuses on how, in later life, older people would prefer to age in place with family close by, and if this is not possible, especially if children are not available, they resign to opting for different supports. A good solution/compromise could be a complementary model in the LTC provision for older people, where formal/public services and informal/family/private care are integrated.
New housing concepts should thus be developed, bridging the distance between ageing in place and in nursing homes, by focusing on interventions based on a deep evaluation of the needs and desires of both seniors and their respective families [
87,
138], in particular by supporting family caregivers and redeveloping residential facilities, with higher performance and management standards, and the promotion of alternative housing measures, e.g., co-housing [
139]. For this purpose, the preferences and reasonings of seniors should be considered, and investigated in depth with further research, paying careful attention to involuntary movers and involuntary stayers from/in their own home [
87], but also to overcome the usual binary position, i.e., ageing at home or in a nursing home, in order to explore possible new directions of moving [
35] and providing useful insights for policy makers. More research is also needed in order to better explore and compare how the gender equality issue is going to be addressed in Europe, especially with regard to the care of older people, in the light of the increasing participation of women in the labour market.
Our findings should be interpreted in the light of some limitations of the study, since a more articulated definition of frailty (also social/environmental aspects) and the inclusion of respondents with severe functional limitations (e.g., bedridden older people) and from metropolitan areas (where nursing homes are more widely available and of a higher quality), could reveal different preferences and opinions in older people. Moreover, the inclusion of more Italian regions in the survey could have led to higher absolute values, thus allowing for a more informed analysis in this respect.