Family care prior to the admission of the elderly in a nursing home and continuity in family care: A comparative study of Colombia and Spain.

This study examined the background before admission to a nursing home and the conditions for the continuity of care, of the relatives of older adults of Colombia and Spain. The study sample comprised 546 participants: 278 and 268 from Colombia and Spain, respectively. Structured interviews were conducted with the older adults' relatives. Sociodemographic similarities predominated, although in the Colombian sample there were significantly more unrelated people. Similarities in previous and current care conditions also predominated too. Cluster 1 included all the cases of Colombian low-resource nursing homes, and Cluster 2 included all the relatives of Colombian high-resource nursing homes and all the Spanish centers. The type of nursing home was the variable more important to identify the abovementioned clusters. Conclusions: Family members from Colombia and Spain continue to care for the elderly admitted to geriatric homes. The type of geriatric center is what establishes the differences in the users.

Introduction

Geriatric institutionalization is one of the oldest resources used as a solution to caring for older adults with partial or total loss of autonomy. Despite of all the inconveniences that admission to a nursing home may cause, it is the most supportive care resource in demand, particularly for older adults with dementia (Van Holten et al., 2019).

While it is true that a considerable percentage of older adults with no family ties (singles, childless widowers/widows, etc.) are usually admitted to nursing homes in Latin America (Ruiz et al., 2016) and that family is one of the main resources in preventing or postponing admission to nursing homes, it is also true that many older adults that live in nursing homes have families. Hence, knowing their family ties represents a key issue (Pérez et al., 2020).

In Western societies, around 90% of older adults with dementia will be admitted to a nursing home (Pritty et al., 2020). As rightly stated by Zolotow (2011), in Latin America, a popular myth prevails about older adults who end their lives in “asylums,” although the numbers indicate that less than 2% of the population over 60 years has this option; moreover, in the Latin American context, the model of care for dependent older adults has been characterized by the fact that families themselves assume the care of older adults completely or almost exclusively.

Popularly, the admission of an older adult to a nursing home may have connotations of abandonment (Westergren et al., 2020). In this sense, caring for older adults at home continues to be the preferred option both for the older adult and the caregiving relatives (Clos and Grossi, 2016; Huenchuan et al., 2014). In fact, transcultural research conducted in multicultural countries, such as the U.S., has consistently revealed that Hispanics are far more likely to delay the institutionalization of the older adults than Caucasians (Gallagher et al., 2011).

Today, nursing homes for seniors are considered places that provide support capable of responding to several and the heterogeneous needs of seniors when community life fails to satisfy them (Bayter and Ramos, 2016). However, from a historical standpoint, the option of residential care emerges from the concept of asylum. Barenys (1993) stated that asylum institutions were projected in the backdrop of traditional assistance, assumed by the primary family group, a duty that was partially taken over by these institutions, while trying to ease the social problems that derived from poverty.

With the increased need to provide care to dependent individuals, mainly older adults with dementia and severe limitations in basic daily activities, these institutions also became an option to relieve the families that needed to care for older adults with severe disabilities. This way, other nonsubsidized institutions emerged along with the asylum-based residential facility, which may imply a high economic cost to users and their families. Currently, these different modalities coexist in countries such as Mexico, Brazil, and Colombia (Araújo et al., 2010; Zolotow, 2011).

In Colombia, long-term stay institutions that care for older adults are called social protection centers or nursing homes. In these places, they temporarily or permanently receive social welfare services, accommodation, and comprehensive care. Although information on nursing homes in Colombia is limited, it is estimated that currently 38% are not-for-profit entities and 62% are small private nursing homes, living off limited financial funds, and are an option to relieve families who need to care for older adults with a severe disability (Vargas and Pineda, 2020). According to Cuadros (2020), in 2020, the Office of Social Promotion of the Ministry of Health (MINSALUD) registered 1,216 social protection centers throughout the country, which today look after 35,438 older adults. However, it is calculated that there are about 500 non-registered or clandestine institutions. Most registered institutions have a capacity of accommodating 10–15 older adults; however, there are institutions with over 300 residents.

In addition, the residential care sector in Spain is highly diverse and heterogeneous, and it is not easy to provide exact data on the number of facilities, partially because of the disparity of definitions in the autonomous communities. The preferred term to refer to these institutions is “residential facilities” (Riquelme-Marín et al., 2010). The Institute of Social Services and Seniors (Instituto de Mayores y Servicios Sociales – IMSERSO, 2019) defines residential centers as “social facilities that provide accommodation and specialized care to seniors who, given their family, economic and social situation, as well as their limitations in personal autonomy, cannot be looked after at home.” According to a report from the Spanish Council for Scientific Research (Consejo Superior de Investigaciones Científicas, CSIC) (Del Pino et al., 2020), in Spain, there are about 5,457 residential facilities for older adults, 4,063 (74.5%) of which are privately owned and 1,394 (25.5%) are public. This amounts to a total of 381,158 vacancies, representing a coverage index of 4.21% (which significantly varies between 7.6% in Castilla y León and 1.42% in Murcia). Moreover, 70.4% women use such facilities, out of which 81.8% are over 80 years old. Although most centers are privately owned, most vacancies, almost 6 out of 10, are financed with public funds (59.8%); in this sense, there are also notable differences between the autonomous communities.

We only found one comparative study of nursing homes between Colombia and Spain (Bayter and Ramos, 2016, p. 32), which was conducted from the economic perspective and includes interesting cultural information. According to the authors, “it is clear that in Colombia, there is a long way to go in the context of care services, including residential facilities for older adults, compared to the Spanish expertise as reference…”

There is a consensus that family care does not end with admission to the nursing home (Frahm et al., 2010). Many studies agree that, in general, the decision to admit an older adult to a nursing home was made after an extended period of home-based care and during a time of crisis. Most caregivers experienced mixed feelings about admitting their senior relative to a nursing home because of the feelings of relief of the burden along with the feelings of guilt of not being able to continue to fulfill their “duty of care” (Teng et al., 2020; Vaismoradi et al., 2016). This emotional conflict does not end automatically with admitting the older adult to a nursing home; occasionally, it may increase, generating significant detriments to mental health and affecting the relationship between the relative, the senior resident, and the institution staff (Koppitz et al., 2017).

Today, it is considered essential that professionals working at nursing homes (nurses, geriatricians, social workers, psychologists, and nursing aides) know the needs of the relatives and the challenges they face during institutionalization and formulate interventions focused on the older adult's family. The participation of the family after admission to a nursing home has proven to be beneficial for relatives and for older adults and their well-being (Buhr et al., 2006; Molero et al., 2015; Silva et al., 2014). However, while there is a consensus on the importance of the implication and adaptation of the relative (Crawford et al., 2015), research on the subject has been scarce in the Latin American context, and we have not found any study conducted from a transcultural approach. Villanueva-Lumbreras et al. (2015) published a systematic review that identified effective interventions to help families during the institutionalization process at a nursing home. It indicated that there are limited quality articles presenting the results of research on the older adult's family in the Spanish context.

In Latin America, publications on this subject are scarce and difficult to find. For example, a search on the Scopus database with the keywords “family and geriatric and home,” a several publications from the U.S., the U.K., and Canada were found. Limiting the search to Latin American countries, only 33 publications appeared, 27 of which were from Brazil. In the case of Colombia, although the older adults’ institutionalization issue is addressed, no study about family adaptation was found.

With respect to Spain, we did find some work about the relatives of older adults, with the pioneer work of Padierna (1994) on the relationship between nursing home staff and relatives. However, these publications have been sporadic and related to isolated issues.

This bibliographic scarcity may be due to the prejudice that with the institutionalization of an older adult, the family is no longer important, given that the team of professionals assumes care functions and/or the generalized myth that the institutionalized seniors are neglected or even abandoned by their families (Gans, 2013).

This study seeks to reduce the lack of information about the families of older adults admitted to long-term stay centers in Colombia and Spain. Issues such as the influence of the culture of origin are part of this information gap (Trask, 2009). Knowing the similarities and differences will help design interventions aimed at improving the adaptation of families and older adults who, for diverse reasons, are admitted to nursing homes from a culturally adapted approach.

The objective of the present study was to compare the samples of both countries regarding the conditions for the care of the elderly that the family had before their admission to the geriatric home; and the current conditions for continuity of family care.

In the present study, the term “conditions” encompases the sex, age and level of functional deterioration of the admitted elderly person; the sociodemographic characteristics of the caregiver; the degree of kinship between the caregiver and the admitted elderly person including previous cohabitation, the role of the caregiver, and the reasons for admission.

The current conditions for care that were evaluated were: type of nursing home, time that the elderly person has been admitted to the residence, distance from the caregiver's home, and frequency and satisfaction with the visits.

In this work, “relative” refers to any person, irrespective of the degree of kinship, who had assumed some type of care prior to admitting the older adult to a nursing home and continues to be connected to the older adult after admission, thereby adopting a similar approach to that of several authors who have studied this area (Crawford, 2015; Graneheim et al., 2014; Pritty et al., 2020).

Additionally, information was collected regarding sociodemographic variables, cognitive deterioration, and time spent at the nursing home. The relatives of older adults were interviewed based on the premise that older adults, their families, and communities are closely intertwined and must be examined a whole.

Methodology

This was a quantitative, exploratory, descriptive, and correlational study.

Participants

In both countries, this study used a non-probabilistic sample, selected based on the opportunity to collect information.

The inclusion criteria included: 1) Nursing homes located in Colombia (Caribbean region) and Spain (Murcia) that authorized the collection of information on older adults and agreed to collaborate with the study by providing the contact information of the residents’ relatives; 2) the relatives who provided their informed consent to participate in the study; 3) the older adults admitted to nursing homes, whose families were interviewed; in this case, the older adults themselves provided their informed consent to participate in the study, if legally capable, and if not, the relative was responsible for this authorization.

The study sample comprised 546 individuals, 273 of which were older adults admitted to nursing homes and 273 were their relatives. The Colombian study sample consisted of 278 participants, divided into 139 family units (that is, 139 older adults with their respective relatives). The Spanish study sample consisted of 268 individuals, 134 of whom were relatives, and the rest were their older adults residing in a nursing home.

In the case of Spain, participants from three nursing homes in the Murcia region were included. These residential facilities are privately owned, and admission of older adults is financed by their families. These three nursing homes are located near the capital of Murcia. Access to these residential facilities was achieved thanks to the personal relationship of the researchers of the Spanish team with the directors of the nursing homes. These three residential facilities possess adequate structural conditions and have sufficient qualified staff to care of the senior residents. The older adults can use the electrical appliances, hairdressing, and nursing services.

Access to the Colombian study sample was achieved by means of an official request to the directors of the nursing homes, who were informed of the purpose of the study and of the opportunity to establish an agreement with the university to develop activities of mutual interest. Notably, 12 centers were contacted, but collaboration was only possible with 6 nursing homes. These facilities are located in four cities in the Caribbean region of Colombia, on the country's northern coast. Three nursing homes were located in the capital district and three in its municipalities. Two of the nursing homes located in the capital district are for people possessing high economic resources who can finance the older adult's admission (hereinafter referred to as high-resource nursing home, HRNH), while the remaining facilities accommodate seniors without livelihoods or paying a low-cost fee (hereinafter referred to as low-resource nursing home, LRNH).

Although all LRNHs comply with the minimum structural requirements set out by MINSALUD, conditions are not optimal for people with severe disabilities, there are deficits related to basic sanitary conditions, and there is a lack of resources for proper maintenance of infrastructure, as well as little privacy. Additionally, the professional qualification of the staff only fulfills the minimum qualifications required by MINSALUD, and it is necessary to turn to other institutions or organizations to provide additional services. In all, 49.6% of the Colombian study sample comes from these nursing homes.

Conversely, HRNHs, as well as the Spanish residential facilities, comply with both structural requirements and number and qualification requirements of the nursing staff. Older adults have greater privacy, as they have their own room, as well as overall easy access to the use of electrical appliances, hairdressing, and nursing services. In total, 50.4% of the Colombian study sample was collected from HRNHs.

Instruments

A structured interview was used with the relatives to get to know their sociodemographic characteristics, the type of relationship with the institutionalized older adult, background of the relationship prior to the older adult's admission to the nursing home, and the current conditions of care.

The evaluation of senior residents considered the information recorded in their medical history, such as time spent at the institution, sex, age, and marital status, as well as the degree of cognitive deterioration, as per the evaluation by the nursing home's medical staff based on the Global Deterioration Scale (GDS) (Reisberg et al., 1982). This information can be seen summarized in Table 1.

Table 1

Summary of variables.

Variable	Category	Code
Sociodemographic characteristics	Country	ColombiaSpain
	Sex	FemaleMale
	Age	Years of age
	Level of education	PrimarySecondaryHigher
	Relationship status	With a partner (married or cohabitating)Without a partner (single, widow/widower, or separated)
	Employment	Work outside the homeUnemployedWork from home
Type of relationship between the interviewed relative and the institutionalized older adult	Kinship	Son/daughterSpouseOther relative (blood relation, such as siblings, grandchildren, and cousins or family-in-law relationship, such as, daughters/sons-in-law and brothers/sisters-in-law)Other relationship (friends, neighbors, caregivers, employees, employers, etc.)
Background of care	Cohabitation prior to admission	• The relative lived in the older adult's home. • The older adult lived in the interviewed relative's home. • The older adult lived elsewhere. (other relative's home, hospital, another nursing home). • The older adult lived alone.
	Caregiving role	• Main caregiver • Occasional caregiver • Not a caregiver
Reason for admission	Worsening of the older adult's health	• Not relevant • Very relevant
	Caregiver's health problem	• Not relevant • Very relevant
	Interference in family dynamics	• Not relevant • Very relevant
	Older adult's will	• Not relevant • Very relevant
	Work reasons	• Not relevant • Very relevant
Current conditions of care	Type of center	• Low-resource nursing home • High-resource nursing home
	Distance from the relative's home to the nursing home	• Near • Far
	Frequency of visits	• Very frequent: at least once a week • Sporadic: at least once a month
	Satisfaction with visits	• Satisfied • Indifferent • Unsatisfied
Characteristics of the institutionalized older adult	Level of cognitive deterioration: To facilitate the statistical analyses, this variable was encoded into four levels.	• No cognitive deterioration or little cognitive decline (subjective): Levels 1 and 2 of the Global Deterioration Scale (GDS) • Mild decline: Level 3 GDS • Moderate decline: Levels 4 and 5 • Severe decline: Levels 6 and 7
	Time spent in the nursing home	In months (estimated)
	Sex of the older adult	FemaleMale
	Age of the older adult	Years of age

Table 1 shows a summary of the variables with their respective categories and codes.

Procedure

Data were derived from a broader research study aimed at assessing the family's adaptation upon the admission of the older adult to a nursing home. Information was obtained between 2018 and 2019.

In both countries, interviews were conducted by students close to graduation and/or recently graduated as psychologists, who were previously trained by the researchers. To standardize and facilitate the collection of data, a manual was prepared to explain the preparation of interviews, with information about ethical aspects to be considered during the entire process, the selection of institutions and participants, interviewers’ instructions on how to relate to the interviewees, the content of the interview and the criteria to record answers, as well as data management, describing the procedures related to the management, storage, audit, and entry of data (Fernández-Daza and Martín-Carbonell, 2019).

The interview with the relative was conducted individually, at the nursing homes during the relative's time of visit, or at the relative's home, at the request of the interviewed. In some cases, more than one encounter was necessary to complete the process. Senior residents' medical histories were reviewed at each nursing home.

All participants joined the study confidentially, anonymously, and voluntarily. The study was based on the ethical principles and recommendations of the Declaration of Helsinki (2000), thus complying with the general principle that the concern for the well-being of the human subject must take precedence over the interests of science. The study in Spain also considered Royal Decree 1720/2007 of December 21, which approves the regulations for the development of Organic Law 15/1999 of December 13, on the protection of personal data. The study in Colombia was governed by Law 1090, by which the Deontological and Bioethical Code for the Practice of Psychology in Colombia is issued, and other provisions.

Data analysis

Analyses were executed by means of the Statistical Package of Social Sciences, Version 26, using the Universidad Cooperativa de Colombia's license.

Descriptive statistics were obtained, and the χ2 statistic was employed to assess the significance of the frequency distributions of categorical variables; the t-test was used for scale variables. The level of significance was .05. Cramer's V was used to examine the effect size of the differences detected in the case of nominal variables, considering that from 0 to 0.10, there is no effect; from 0.10 to 0.30, there is little effect; from 0.30 to 0.50, there is medium or moderate effect; and there is a great effect over .50 (Cohen and Nee, 1984).

To analyze the relationship between variables the in depth, a two-step cluster analysis was conducted to identify whether it was possible to establish typologies of relatives. The two-step cluster method is an exploratory tool designed to discover the natural clusters (or cluster) of the data sets, thus being able to create cluster models based both on categorical and continuous variables (Kaufman and Rousseeuw, 1990). Scientific evidence has revealed that this procedure is fairly robust, notwithstanding the distribution of categorical variables and the use of small samples (Rubio and Vilá-Baños, 2017; Tkaczynski, 2017). This analysis included sociodemographic variables (country, age, employment, etc.), background on admission (family tie, role of the caregiver prior to admission, reason for admission, etc.), and current conditions of care (type of nursing home, LRNH or HRNH; time spent in the residential home; frequency of visits; and level of cognitive deterioration of the senior resident). The selection of these variables was based on theoretical criteria, as well as in the prior verification of independence of variables, as recommended by Rubio-Hurtado et al. (2017).

Log-likelihood was used as a distance measurement between clusters, given the mixed nature of the data (qualitative and quantitative), and the system determined the number of necessary clusters. Model adjustment was assessed based on the silhouette coefficient, which is a cluster cohesion and separation measurement to indicate poor, correct, or good results (Rubio and Vilá-Baños, 2017). To control atypical values, the noise treatment was established for 25%. The cases were randomly ordered, and different solutions were tested with different randomly ordered cases to check the stability of the determined solution.

Results

Characteristics of the institutionalized older adults

No significant differences were found between countries with respect to sex or the age of the older adults: women were the majority in both countries (64.3% in the Colombian study sample and 72.5% in the Spanish study sample). Their average age (M) of the Colombian seniors was 82.04 years, with a SD of 10.682, whereas in the Spanish study sample, the average age (M) was of 82.38 years, with a SD of 7.009.

Older adults with severe impairments were in the majority in both countries’ nursing homes, thus showing differences with respect to the degree of cognitive deterioration of the senior residents, with a greater amount of older adults with mild and moderate cognitive deterioration in the Colombian institutions, and a higher number of seniors in Spanish residential facilities [χ2 (3) = 30.10, p = .000]. The comparison of these data can be seen in Table 2.

Table 2

Level of cognitive deterioration of the senior residents.

			Decline
			No decline	Mild	Moderate	Severe
Country	Colombia	Count	6	20	13	72
		Percentage within the country	5,4%	18,0%	11,7%	64,9%
		Percentage of impairments	40,0%	33,3%	23,2%	63,7%
	Spain	Count	9	40	43	41
		Percentage within the country	6,8%	30,1%	32,3%	30,8%
		Percentage of impairments	60,0%	66,7%	76,8%	36,3%

Source: Prepared by the authors.

Sociodemographic characteristics of the seniors’ relatives

Women were the majority in both countries (69.8% in the Colombian study sample and 65.7% in the Spanish study sample). The average age was 51.78 years for Colombia (SD = 12.65) and 54.4 for Spain (SD = 11.83), with similar trends (46 in Colombia and 47 in Spain). No significant differences were thus observed.

Although in both countries, the individuals working outside home were a majority (53.5% of the total number), a higher amount was found in the Colombian study sample (59.7% of Colombians vs. 49.2% of Spaniards). In addition, the number of Spaniards not working (33.6%) were double the Colombian percentage (16.1%) [χ2 (2) = 9.23, p = .01].

In addition, in both countries, more participants had a medium–high level of education. Statistically significant differences were observed with individuals with a high level of education prevailing in the Colombian study sample (76.5%), followed by the medium level (17.6%), while relatives with a medium level of education were a majority in Spain (40.9%), followed by primary education (37.6%) [χ2 (3) = 50.506, p = .01].

With respect to their civil status, individuals who were married or cohabitating with their partners were the majority in both the study samples; however, the percentage of Spaniards in this category was found to be higher (60.4% of Colombians vs. 80.6% of Spaniards), thus making this a statistically significant difference (χ2 = 13.67, gl = 3).

Type of relationship between the interviewed relative and the institutionalized older adult

Individuals with a certain degree of kinship by blood and marriage (81.4%) were a majority in the total sample; they represented 91.8% of cases in the Spanish study sample, whereas they were just 70% of the Colombian study sample. Sons/daughters were a majority over the remaining blood relationships; in the Spanish study sample, this value was almost double the Colombian value, as can be seen in Table 2. Although two items showed an expected frequency lower than 5, the minimum expected frequency was 3.76, and hence, the analysis providing values of 34.449 for χ2, with gl = 3 and Cramer's V = .369, is regarded as valid. Only eight spouses participated in the Spanish study sample, while none of them were present in the Colombian study sample. For more detailed information on the type of relationship between the interviewees and the elderly in both samples, Table 3 can be seen.

Table 3

Type of relationship with institutionalized older adults.

			Type of relationship
			Spouse	Son/daughter	Other relative	Other relationship
Country	Colombia	Count	0	53	30	36
		Percentage within the country	0,0%	44,5%	25,2%	30,3%
		Percentage of the type of relationship	0,0%	35,8%	60,0%	76,6%
	Spain	Count	8	95	20	11
		Percentage within the country	6,0%	70,9%	14,9%	8,2%
		% of type of relationship	100,0%	64,2%	40,0%	23,4%

Source: Prepared by the authors.

Background of the care: role as caregiver, prior cohabitation, and reasons for the older Adult's admission to a nursing home

With respect to the caregiver's responsibilities assumed prior to the older adult's admission to the nursing home, no significant differences were observed between both the study samples. The majority were individuals who have had any responsibility for the older adult's care (84.9% in Colombia and 89.6% in Spain), with 43.2% and 42.9% having taken on the responsibility as main caregiver in Colombia and Spain, respectively.

In both countries, the majority were older adults who were living in their own homes with the interviewed relative prior to their admission to the nursing home (40.3% of Colombians and 54.5% of Spaniards) or those living with the interviewee at their homes (33.8% for Colombia and 27.6% for Spain). In total, 9.4% of Colombian seniors lived with a relative other than the interviewee; 13.4% of Spaniards and 11.5% of Colombians were living in a different retirement home; 2.2% of Colombians and 1.5% of Spaniards were hospitalized, and finally, 2.9% of Colombians and 3% of Spaniards were living elsewhere (unspecified in the interview).

As for the reasons for the older adult's admission to the nursing home, both in Colombia and Spain, the most common reason that was reported by interviewees was disease and the least common reason that was reported was detriments to mental health experienced by the caregiver. However, significant differences were found between both the study samples in the importance given to the older adult's disease (χ2 = 29.85, gl = 1, Cramer's V = .33), with greater prevalence in the Spanish study sample. No differences were observed with respect to the remaining reasons. Table 4 shows the detailed information regarding the reasons for admission in the elderly of both countries.

Table 4

Reasons for admission per country.

		Colombia		Spain
		Frequency	Percentage	Frequency	Percentage
Reason:Older adult's disease	Not relevant	25	18	20	14,9
	Very relevant	111	79,9	113	84,3
Reason:Older adult's own will	Not relevant	51	36,7	62	46,3
	Very relevant	82	59	71	53
Reason:Caregiver's health	Not relevant	72	51,8	76	56,7
	Very relevant	61	43,9	57	42,5
Reason:Work	Not relevant	52	37,4	74	55,2
	Very relevant	81	58,3	59	44
Reason:Family dynamics	Not relevant	77	55,4	83	61,9
	Very relevant	56	40,3	50	37,3

Source: Prepared by the authors.

Time spent at the nursing home, frequency of visits, distance from their houses to the nursing home and satisfaction with visits

Regarding the frequency of visits, older adults were visited more than once per week in both countries (76.1% and 85.6% in Colombia and Spain, respectively). As for satisfaction with visits, no differences were found between countries, satisfaction being the majority in both of them (94.8% in Colombia and 96.3% in Spain).

As for distance from their houses to the nursing home, there were significant differences between countries, with a greater percentage of Colombians stating that they lived far from the residence (51.1%), whereas in Spain, this represented 17.6% of interviewees [χ2(1) = 33.39, p < .05].

In relation to the time spent by older adults in the nursing home, no statistically significant differences were found either, with Colombia obtaining the highest scores, with an M = 42.90, SD = 56.475 (F = 3.747, gl = 270) and Spanish seniors residents having an M of 33.09 and a SD of 43.519.

Relationship between the sociodemographic variables, background, and conditions for continuity of care

In the two-step cluster analysis, a silhouette coefficient of .04 was obtained, which can be regarded as “sufficient,” suggesting that the data fairly demonstrate this cluster structure (Rubio-Hurtado and Vilá-Baños, 2017).

It was possible to identify two clusters: Cluster 1, which was smaller (30.3% of the total study sample), included all LRNHs, whereas Cluster 2 was composed of HRNHs from Colombia and every Spanish case (69.7% of the total study sample). The variable that obtained the highest value to distinguish clusters was the type of nursing home.

Childless families (41.7%) and other visitors who were not relatives of the older adult (33.3%) were the majority in Cluster 1, in addition to more sporadic visits (34.5% of those claiming to visit the older adult at least once a month, and 100% of those who reported visiting them at least once a year), while only 20% of the said group considered the older adult's health to be an extremely important reason for admission. This group also included older adults who have been living in the nursing home for longer (M = 63.98), and individuals who did not serve as main caregiver prior to admission were the majority (68.4% of the cluster's members).

Cluster 2 contained all Colombian HRNHs and all Spanish cases. It involved a higher number of sons/daughters (75.4% of the cluster's members); 74.4% of the total study sample's main caregivers were contained in this cluster. In all, 87% of the members of the cluster reported visiting their relative at least once a week; 79% of them stated that the “older adult's health” was very important for them to decide on admission to the nursing home, while the average stay of the older adult in the residential facility was 31.35 months.

Discussion

Our study provided evidence that there are few differences attributable to nationality, as the relatives of the senior residents living in long-term care facilities in Spain and Colombia are more similar than different, both from the sociodemographic perspective and in terms of background and the conditions of the older adults’ continuity of care after their admission to the facility. Most of the differences found had to do with amounts, and we agree with Fisher and Portinga (2018) that one of the methodological errors of cross-cultural research is usually the overestimation of the “statistical significance of differences,” which in this case may be attributed to the peculiarities of the data collection process; however, this issue remains a subject of investigation.

We are convinced that similarities reflect the fact that both countries have a similar cultural heritage, as Colombia used to be a Spanish colony and they share the same language, religion, and many traditions. Therborn (2007) distinguished five key contemporary family systems, referring to one of them as the “American Creole family Model,” a typical of Latin America, which coexists with the “Christian family Model,” a characteristic of Spain.

We also find that the similarities may be attributed to the demands and singularities of the family's care for the older adult in a situation of dependency. Caregiving has been traditionally understood as a female activity, usually unpaid and based on emotional ties that supported the family structure (Aguirre, 2005). Today, these characteristics can be identified in the sample that, just as reported in studies conducted in other countries (Puurveen et al., 2018), women who are at least 50 years old were the majority among the relatives visiting the older adult in the nursing home (Jin et al., 2017).

In both countries, people who worked outside the home, were married, had a medium–high level of education were also the majority. Aguirre (2005) suggested that in Latin America, the rising trend in women's higher educational background and the widespread increase of their economic activity has been persistent, somewhat similar to what is occurring in Spain (Escuredo, 2007). According to Pérez-Ramos et al. (2020), the work–family reconciliation involves a difficult balance in which women are twice as overburdened, as men are less involved in domestic chores and caregiving and parenting tasks.

As for kinship, blood relatives were the majority in both samples, which is in line with the fact that in these countries, the responsibility that should be assumed by the health and state systems in senior care is less acknowledged, thus placing more emphasis on the family responsibility (Bazo, 1991; Cobeñas-Velasquez, 2018; Guevara and Yépez, 2014; Huenchuan et al., 2014; Poches and Meza, 2017). This aspect is also consistent with the fact that in old age, social networks are reduced and largely consolidated in the family (Riquelme-Marín et al., 2010), as well as with that reported regarding the composition of the social networks of senior residents at HRNHs, both in Spain and Colombia (Zumalde, 1994). Evidence showed that older adults living in this type of retirement home seem to have sufficient family support networks (Clos and Grossi, 2016; Molero et al., 2015).

Another similarity established in the samples of both countries states that of all relatives, sons/daughters represent the largest proportion, which indicates that they are the main source of support for senior living in nursing homes, and this seems to be common in other cultures as well (Dorado et al., 2015; Molero et al., 2015; Sansoni et al., 2013; Silva et al., 2014).

No spouse could be identified in the Colombian sample, only eight were identified among Spaniards. It should be pointed out that no studies have been found that report the degree of kinship of the interviewed caregiver in the Ibero-American context since, as noted earlier, research is scarce. Some possible explanations include that the senior's partners are also older adults who may also need to receive care (Curtin et al., 2017), or the death of their spouses, who used to take on the caregiving tasks, may have triggered their admission to a nursing home (Gallagher et al., 2011; Luppa et al., 2008). In fact, evidence establishes that married older adults are approximately half as likely to be admitted to a residential facility (Gaugler, 2007). No prior studies in Colombian or Spanish populations have been found to support these assumptions, so this topic certainly deserves further research.

With regard to their background of care, the majority of the older adults from both countries lived at their own homes or used to live with the interviewee prior to their admission to the nursing home. These findings are in line with what has been reported by Sansoni et al. (2013).

As for the reasons for admission to a nursing home, the older adult's disease was the most frequently reported reason, and the caregiver's health the least common, which is consistent with studies that indicate that one of the reasons for older adults' admission to nursing homes is the decline in their health, mental impairments, and dementia (Joling et al., 2012; Pedroza et al., 2018).

In addition to disease, Sansoni, et al. (2013) state that this decision was influenced by older adults’ behavioral problems and the damaged relationship between them and their caregiver, while other studies indicate that sociocultural factors, such as work balance, are aspects which trigger the institutionalization of male seniors, rather than their disease (De Lima and Alides, 2006).

A study conducted in 39 social protection centers from Medellín, Colombia, by Cardona et al. (Cardona-Arango et al., 2010) revealed that loneliness was the reason why the older adult was admitted to the nursing home, followed by health and financial problems, in both men and women. These data was collected from interviews with older adults rather than their relatives, which may suggest that the perspectives concerning the decision to admit them to nursing homes are not always the same, an issue for future research to explore.

With regard to the current conditions, both countries showed a larger number of interviewees visiting the older adult on a weekly basis, although this group is smaller in the Colombian sample, which may be due to the fact that a high proportion of Colombians live far from the residential facility, which is similar to the information reported by Pérez et al. (2015). It should be noted that the Colombian sample is more heterogeneous and includes individuals from different cities and municipalities from the northern Colombian region, unlike the Spanish sample, which focused on the capital city of the region of Murcia.

Furthermore, the interviewees' high satisfaction with visits in both countries stands out. According to Molero et al. (2015) and Westergren et al. (2020), this contributes to improving both senior residents and their relative's well-being.

This research has demonstrated that the type of nursing home is what makes the difference in these facilities’ users, both for resident seniors and their relatives, rather than the country. In this regard, significant differences were found in the type of relationship of the interviewees with the seniors living in HRNHs and LRNHs, with a larger proportion of nonrelatives among those individuals interviewed in LRNHs.

According to data obtained from the SABE study (Borda et al., 2016), 85.6% of Colombian seniors reported living with other individuals of varying degrees of kinship by blood and marriage, as well as unrelated individuals such as tenants, companions, or caregivers, which may suggest the presence of different family typologies. As a matter of fact, evidence showed that LRNHs are home to a large number of seniors that were never visited by close relatives; however, this information was not collected for statistical analyses purposes.

The cluster analysis made clear that the type of nursing home variable had greater capacity to classify two groups of relatives, which correspond to the differences found with regard to the type of senior admitted. This way, to summarize the results obtained, it can be said that, regardless the country, in HRNHs, the “most frequent” relative was daughters, who acted as main caregivers prior to the older adult's admission to the nursing home and who visited the senior resident (to a greater extent, their mothers) suffering from moderate to severe dementia. This “profile” is partially consistent with the findings of other cultures, in which admission to a residential facility has been shown to be a valid option for seniors suffering from dementia (Van Holten et al., 2019; Westergren et al., 2020). This aspect also coincides with the remarks made by several Colombian authors, who claim that seniors living in HRNHs and LRNHs were less supported by their families than those admitted to private residential facilities, particularly by their sons/daughters (Cardona-Arango, 2010).

This way, LRNHs have a larger number of male residents than those from HRNHs, a fact that has an impact on the results obtained in other previous studies (Borda, 2013). This circumstance has been occasionally attributed to the fact that relatives claimed to prefer taking care of their mothers at home, unlike the case of their fathers because they thought placing them in an out-of-home care facility would facilitate their daily activities (Bayter and Ramos, 2016). However, this aspect could also be explained by the breakdown of families from low-income populations (Suárez-Landazábal and Araque-Barboza, 2020) and the affected family dynamics and relationships as a result of the armed conflict suffered by Colombia for over 40 years (Hernández, 2012).

In addition, the seniors under study living in LRNHs had been admitted a long time ago and showed signs of more mild cognitive deterioration, which is consistent with the fact that in Colombia, one of the admission specifications of many LRNHs providing healthcare to insolvent older adults, is that seniors should be capable of taking care of themselves because there is no sufficient personnel to look after individuals who require assistance to meet their daily basic needs. Conversely, in HRNHs, virtually, all seniors who suffered from severe impairments, just as described in other cultures, consider admission to a nursing home as a valid option for senior care for those suffering from severe cognitive deterioration (Van Holten et al., 2019; Westergren et al., 2020).

Limitations, implications, and future directions

Transcultural research faces a number of challenges (Fischer and Poortinga, 2018), and this study has been no exception, including difficulties in distinguishing valid differences and biases in data, complications arising from the fact that culture is addressed at individual and population levels from a psychological perspective, and the need to define what is understood by “culture” in a given study and how this factor becomes evident in selected and sample populations.

In view of the foregoing, the scope of the results of this research is limited by the following aspects:

This study is considered to be transcultural because it involves two countries, although the cultural dimensions that may hypothetically account for their similarities and differences have not been defined beforehand. This transnational–transcultural overlapping has been acknowledged by various authors and is a current issue for transcultural research. As a consequence, we delved into other variables of social/cultural characters, such as the level of education, civil status or professional ties that may also give rise to “cultural” differences.

The strategies adopted for case selection and data collection purposes in each country depended on the resources and opportunities of every research group, and hence, they should not be regarded as representative, and care should be taken when generalizing inferences. In this sense, what Fisher and Portinga (2018) call “researcher degrees of freedom” becomes relevant, thus increasing in the studies of limited resources in which close monitoring of procedures for data collection is impossible. This factor can lead to a higher risk of the presence of external variables of explanatory power, not initially included in research, such as the case of this study with the type of nursing home variable, which could only be applied to the Colombian study sample because the Spanish study sample turned out to be homogeneous as a result of the procedure followed to recruit participants.

Despite the abovementioned limitations, we believe that this study makes several important contributions. First, it reveals the existence of a typology of relatives of institutionalized seniors with the typical characteristics of the Hispanic culture. Despite its use as reference in many studies comparing Latin Americans with other cultures (Beyene et al., 2002; Curtin et al., 2017; Mahoney et al., 2005; Ruiz et al., 2016; Wallace et al., 1994; Wallace et al., 1995), this aspect needs to be further studied and validated.

The second contribution is demonstrating how this “typology” is mediated by the type of nursing home, as although long-stay centers are legally defined as homogeneous, both in Spain and Colombia, heterogeneity in its sources of funding establish important differences between the beneficiaries, either between senior residents or their relatives. The said differences should be considered when designing intervention strategies aimed at improving the quality of life of older adults and their relatives, as well as in the programs whose objective is to prevent senior neglect and abuse.

The results of this study reflect the importance of the continuity of family care after the admission of the older adult to the nursing home. Furthermore, the information under study is unfortunately gaining relevance now as a result of the impact of the novel coronavirus disease 2019 (COVID-19) in the health condition of seniors and the radical changes made to protocols to engage with older adults in their residential life, with respect to matters as basic as access to the facility and visit schedules and methodology.

Notably, between March and August 2020 alone, at least half of those who died of COVID-19 or matching symptoms in Spain were living at these nursing homes. Information in this regard has not been found for Colombia, although there is an increased call for dignified care for seniors and their families (Cuadros, 2020; Robledo, 2020; Vargas and Pineda, 2020).

Conclusions

In the analysis carried out on the relationship between sociodemographic variables of the family and the history of the elderly in respect to continuity of care, no significant differences were observed between the samples from Colombia and Spain. In this sense, it should be noted that in both samples the following circumstances occur:

Children (mainly daughters) are the greatest source of family support.

Health problems of the elderly were the main reason for admission.

In most cases, the elderly previously lived either at home, assisted by family caregivers, or housed by a family caregiver.

The main difference in relation to post-admission family care has been a greater frequency of visits in the case of relatives in the Spanish sample. This difference may be related to a greater distance between the institution and the relative's home in the Colombian sample. However, no significant differences were found in terms of satisfaction regarding the visits to the elderly.

Important differences were found regarding post-admission family care, not depending on the country, but in relation to the type of geriatric institution. In this way, it is worth pointing out a lower frequency rate in the visits received by the elderly in nursing homes (LRNH) with respect to residences (HRNH). The facts that in the first type of institutions there is a greater number of elderly people who do not have close relatives such as children or a partner, as well as longer-stay institutionalization, have been proved to be related to a lower frequency rate of visits. In addition to this, it is important to observe that the elderly who live in nursing homes also have fewer economic resources and that these centres had a greater physical distance from the urban nucleus as well as less provision at the infrastructure level in general.

Declarations

Author contribution statement

Antonio Riquelme-Marín & Marta Martín-Carbonell: Conceived and designed the experiments; Performed the experiments; Analyzed and interpreted the data; Wrote the paper.

Juan M. Ortigosa-Quiles: Conceived and designed the experiments; Performed the experiments; Contributed reagents, materials, analysis tools or data.

Marta Fernández-Daza: Performed the experiments; Contributed reagents, materials, analysis tools or data; Wrote the paper.

Inmaculada Méndez: Conceived and designed the experiments; Performed the experiments; Contributed reagents, materials, analysis tools or data.

Funding statement

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Data availability statement

The data that has been used is confidential.

Declaration of interest's statement

The authors declare no conflict of interest.