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Abstract
Older Puerto Ricans of the diaspora live with evident health and socioeconomic disparities, heightening their need for support. They also provide a unique transnational case in which to explore the exchange of support. This study aims to understand the informal social support experiences of older Puerto Ricans with disabilities. Data are based on the translated transcripts of 25 interviews with Spanish-speaking, Island-born Puerto Ricans living in Boston. We identify four themes through thematic analysis: (a) making sense of responsibility within valued familial relationships, (b) conceptualizing friends as family, (c) finding resolve and meaning despite isolation, and (d) (not) asking for help. These themes delineate an incongruence between their beliefs and their lived experiences of social support, as well as how this contradiction is sometimes harmonized. Whereas some older Puerto Ricans with disabilities have support to rely on, others are isolated and lack support to address the challenges of functional impairment. Keywords Puerto Ricans, familismo, marianismo, social support, disability, qualitative methods identity of Puerto Ricans on the U.S. mainland is partly based Background on the idea that, despite their U.S. citizenship, Puerto Ricans Puerto Ricans in the United States live with evident health can be considered migrants because of the linguistic, cultural, disparities and physical limitations that can heighten the and geographic differences between the U.S. mainland and need for support. For example, they experience a higher Puerto Rico (Acosta-Belén & Santiago, 2006; Aranda, 2007; prevalence of severe chronic conditions such as obesity, dia- Duany, 2002b, 2011). Moreover, even though the Island does betes, depression, cardiovascular disease, stroke, and arthri- not constitute a separate country, Puerto Ricans maintain a tis than other Latina/o subgroups (Castaneda-Sceppa et al., resilient Puerto Rican national identity (culturally speaking). 2010; Tucker et al., 2010). These conditions are related to In other words, they maintain a clear collective identity while high rates of disability and limitations in conducting daily living on the U.S. mainland, differentiating their U.S. citizen- activities (Castaneda-Sceppa et al., 2010). Social support— ship from their national identity (Duany, 2002b). Puerto be it formal or informal—can buffer some of the effects of Ricans’ transnationalism is also facilitated through bidirec- disability limitations (Chan, Anstey, Windsor, & Luszcz, tional migration between the island and the U.S. mainland, 2011; Cohen & Wills, 1985). Given the value of social sup- which helps maintain social connections to both places. port in the face of functional impairment, this article exam- Nevertheless, many Puerto Ricans on the mainland feel an ines the perception and beliefs regarding informal support affiliation with the United States, in addition to Puerto Rico. exchanges among a group of Puerto Ricans with disabilities living in the Greater Boston area. These exchanges entail California State University, East Bay, CA, USA both the provision and receipt of informal support. Northeastern University, Boston, MA, USA This article addresses a lack of recent qualitative research University of Massachusetts, Lowell, MA, USA on the social support experiences of older Puerto Ricans, spe- Corresponding Author: cifically those with disabilities (Aranda, 2007; Mattei, 1983; Mariana T. Guzzardo, Department of Human Development and Women’s Sanchez-Ayendez, 1988). A novel aspect of this article is that Studies, Meiklejohn Hall 3069, California State University, East Bay, Puerto Ricans’ perceptions of social support are contextual- Hayward, CA 94542, USA. ized within their transnational experiences. The transnational Email: mtguzzardo@gmail.com Creative Commons CC BY: This article is distributed under the terms of the Creative Commons Attribution 4.0 License (http://www.creativecommons.org/licenses/by/4.0/) which permits any use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage). 2 SAGE Open Therefore, when living on the U.S. mainland, their traditional Alegria, & Sribney, 2007), as well as Puerto Ricans specifi- cultural beliefs intermingle with influences of the American cally (Falcón, Todorova, & Tucker, 2009), have shown a host culture (Acosta-Belén & Santiago, 2006; Aranda, 2007; positive relationship between support from family and Duany, 2002b, 2011). In our previous research (Todorova, friends and psychological well-being, even after controlling Guzzardo, Adams, & Falcón, 2015), we discuss how ele- for confounding sociodemographic factors such as income ments of this transnational identity may help explain their and education. The findings of past studies, on the relation- meaning of health and aging. For the purpose of the present ship of social support and health outcomes, provide a basis study, in our discussion of the findings, we consider how a for the present study and the need to further examine social transnational identity may partly inform their social relation- support experiences qualitatively. However, the research ships and the exchange of social support. presented here does not attempt to make inferences on how The sample in this study includes Puerto Ricans who were social support directly affects health. born on the island, moved to the U.S. mainland from Puerto Rico early in their life and have lived on the mainland for at Previous Research on Social Support Among least three decades. Most have plans to continue aging here, Latinas/os while others talk about the possibility of returning to the island. Given that Puerto Ricans are U.S. citizens, there is no When studying support among Latinas/os many studies focus legal barrier for migration to the U.S. mainland. They may on family support, particularly from the perspective of family maintain close ties to their social network in Puerto Rico caregivers (Borrayo, Goldwaser, Vacha-Haase, & Hepburn, (Duany, 2011), which can include immediate family mem- 2007; Cox & Monk, 1996; Flores, Hinton, Barker, Franz, & bers, extended family members, and friendships, while Velasquez, 2009; Lucke, Martinez, Mendez, & Arévalo- developing and acquiring a network in their current place of Flechas, 2013; Ramos, 2004). Research from the perspective residence. Thus, migration plays an important, although not of older adults demonstrates that a greater reliance on family is exclusive, role in how they experience social support on the observed more often among Latinas/os than other ethnic mainland. groups in the United States (Almeida, Molnar, Kawachi, & In the present study, there is also a consideration of cul- Subramanian, 2009; Weiss, Gonzalez, Kabeto, & Langa, tural beliefs and values identified in previous studies among 2005). Almeida and colleagues conclude that the higher reli- Puerto Ricans, in regard to social support experiences, ance on familial social support found among Latina/o immi- including marianismo and familismo, which are discussed grants is related to being foreign-born and retaining cultural below. Understanding Puerto Ricans perception and beliefs values. In addition, Latinas/os in the United States may rely on surrounding social support, as well as contextualizing their family for support more than nonkin (Delgadillo, Sörensen, & perception and beliefs as transnational individuals, can Coster, 2004). In fact, in a nationally representative sample inform future research and how better to address elder Puerto comparing Latinas/os, Asians, and Whites, Latinas/os reported Ricans’ needs through culturally relevant interventions. the lowest level of support from friends (Chang, Chen, & Alegría, 2014). Perceived social support within nonfamilial relationships (including neighbors and friends) can influence Disability, Social Support, and Well-Being health-related factors and subjective well-being among elders An individual’s level of disability is commonly measured by of various ethnic and racial backgrounds (Baxter et al., 1998; her or his ability to perform activities of daily living (ADLs; Nguyen, Chatters, Taylor, & Mouzon, 2016). Furthermore, in Spector & Fleishman, 1998). ADLs mainly comprise self- a qualitative study, Guzzardo and Sheehan (2013) found that care behaviors, such as eating, bathing, dressing, toileting, among Puerto Rican elders in Hartford, Connecticut, who live walking, and transferring from a bed to a chair (Katz, Ford, in senior housing geared toward Latinas/os, and who lacked Moskowitz, Jackson, & Jaffe, 1963). Poor daily functioning family support, neighbors were an important component of or increased functional dependence is strongly associated their network. These individuals were also connected to com- with increased depressive symptoms (Anstey, von, Sanden, munity-based services, possibly facilitated through their Sargent-Cox, & Luszcz, 2007; Barry, Soulos, Murphy, Kasl, friendships and neighbors (serving as pathways to service & Gill, 2013) and social support is an influential mediating use). Nevertheless, in another study that only included Latinas/ variable in the relationship between disability and psycho- os, family support is more important for health when com- logical well-being (Taylor & Lynch, 2004). Furthermore, pared with support from nonkin, showing a statistically sig- there is an abundance of research that empirically estab- nificant protective effect over risk of depressive symptoms lishes a relationship between the availability of a cohesive (Almeida, Subramanian, Kawachi, & Molnar, 2011). supportive network and health outcomes (Kafetsios & For current and future generations of Latina/o elders, Sideridis, 2006; Lakey & Orehek, 2011; O’Donovan & however, family support may be less available because of the Hughes, 2008). Studies focusing on the relationship of diminishing size of families, economic disadvantage, geo- social support and health among the Latina/o population in graphic mobility, acculturation (Kao & Travis, 2005), the general (Angel, Angel, & Henderson, 1997; Mulvaney-Day, decrease in intergenerational co-residence among Latinas/os Guzzardo et al. 3 (De Vos & Arias, 2003), or increasing reluctance from elders social support among Puerto Ricans (Applewhite et al., 2009; to overburden their family (Rosenthal Gelman, 2002). These García-Preto, 2005; Ramos, 2004). Even though familismo and changing dynamics regarding family support, combined with marianismo are well documented among Latinas/os in general social support needs related to a higher incidence of health (Applewhite et al., 2009; Chavez-Korell, Benson-Flórez, problems, underscore the need to focus on older Puerto Delgado Rendón, & Farías, 2014; Katiria Perez & Cruess, Ricans’ experiences concerning social support and how these 2014), it is particularly important that scholars acknowledge are perceived in light of the unique status of Puerto Ricans. the within-group and between-group variation in cultural fac- tors relevant to health and psychological functioning (Betancourt, Flynn, Riggs, & Garberoglio, 2009). Therefore, Puerto Ricans and Social Support this study focuses on Puerto Rican older adults specifically, As mentioned previously, a novel aspect of this study has to given the need to investigate social support and related cultural do with contextualizing the social support experiences within concepts within each Latina/o subgroup, so that differences the transnational lives of Puerto Ricans. There are studies on between subgroups are not concealed or confounded with other the migratory tendencies of Puerto Ricans and the macro- variables. and/or micro-level factors that influence their movement (Acevedo, 2004; Duany, 2002a, 2002b, 2011), as well as Contribution of the Current Study studies focusing on how their transnational lives influence their incorporation on the mainland (Aranda, 2007); how- The purpose of this article is to describe the social support ever, none of these focus on a qualitative study of their social experiences and perceptions of some older Puerto Ricans, of support exchanges. Furthermore, past research on social sup- low socioeconomic status, and who live with physical dis- port or social networks and Puerto Ricans include the influ- abilities. Qualitative research on the experience of social sup- ence of migration on health care service use (Landale & port exchanges can provide an in-depth understanding of the Oropesa, 2001), the relationships between neighborhood nuances and context of social support in people’s lives, which density on physical health (Roy, Hughes, & Yoshikawa, is particularly valuable for older individuals with greater need 2013), the moderating role of migration in the relationship for support as a consequence of functional disabilities. In the between neighborhood density and depressive symptoms sections above, there is a discussion regarding the lack of (Arévalo, Tucker, & Falcón, 2015), and the influence of research in general that presents the perspective of older characteristics surrounding migration and its relationship to Puerto Ricans (as compared with that of adult children or health (Alcantara, Chen, & Alegria, 2014; Angel & Angel, caregivers). In addition, it is essential to study the social sup- 1992; Arevalo, Tucker, & Falcon, 2014). However, what is port experiences of this unique group (e.g., older age, rela- more difficult to find are studies that consider the transna- tively low socioeconomic status, disability, ethnic minority tional context on the perceived experiences of social support status, transnational circumstances). In other words, they are among elder Puerto Ricans living with disabilities. in a particular need of social support given their specific situ- Earlier qualitative research on older Puerto Ricans’ percep- ation. While there is a vast body of literature on social sup- tion of social support is limited to those of elderly women and port, much of it includes quantitative research that focuses on focuses on cultural beliefs surrounding familial relationships the connections between social support and health. Among (Mattei, 1983; Sanchez-Ayendez, 1988). The most relevant the qualitative research that currently exists, few studies focus example to the present study is an ethnography exploring cul- on the perspective of Puerto Rican elderly on their experience tural meanings and patterns of social interaction and exchange of giving and receiving support, and we have not found of support among Puerto Rican elderly women in Boston another study that includes a consideration of level of disabil- (Sanchez-Ayendez, 1988). The author describes various cul- ity and transnational context. While there are studies and tural concepts manifested in the experiences of the individuals analyses regarding Puerto Ricans migration and incorpora- in her study, including marianismo, which entails the idea that tion in the United States, these articles do not necessarily tie women should fulfill traditional roles by providing support as a the transnational lives of Puerto Ricans to their experiences of daughter, mother, and/or spouse (Applewhite, Briggs, & social support, as we do with a qualitative study. This type of Herrera, 2009), while men fulfill the role of “provider” and research helps get at the distinctions in perception and behav- “protector.” Sanchez-Ayendez (1988) also discusses familismo, ior regarding social support, provide a deeper insight and con- which emphasizes family over the individual, the centrality, sideration of subjective motives, attitudes, and needs. and importance of family, as well as the idea that there should be strong reciprocity between generations (Applewhite et al., Method 2009; Sanchez-Ayendez, 1988). Recent research on mainland Puerto Rican children as caregivers of their elderly parents sug- Study Design and Sample gests that cultural norms that emphasize the reciprocity and interdependence related to familismo and marianismo are still Data for this study are drawn from the Boston Puerto Rican apparent and identified as important concepts in understanding Health Study (BPRHS), a National Institutes of Health–funded 4 SAGE Open longitudinal cohort study that aims to explore the high incidence development (GED) and two had some college education or a of health problems experienced by Puerto Ricans on the U.S. bachelor’s degree. mainland (Tucker et al., 2010). The BPRHS has a total sample of 1,500 participants, and the inclusion criteria were as follows: (a) Analysis identifying as Puerto Rican, (b) residing in the greater Boston area, and (c) being of age 45 to 75 at time of entry into the study. All the authors collaborated in the analytical process. We The current study is based on interviews with a randomly analyzed the transcript of each interview based on thematic selected subsample of 50 participants from the baseline sample analysis using a contextualist approach (Braun & Clarke, of the longitudinal cohort study. The Institutional Review Boards 2006). Thematic analysis is used to identify and analyze of Northeastern University reviewed and approved the study. patterns of meaning in the data regarding individuals’ lived Each person in the sample participated in one interview, which experiences of social support, while the contextualist lasted between 1 and 4 hr. Some of the topics addressed included approach suggests that the broader social context influ- reasons for migration, the experience of aging in the United ences meanings. For the present analysis, social support is States, illness and well-being, social support, caregiving, accul- defined as “an interpersonal transaction” (Antonucci, 2001, turation, discrimination, and comparisons between PR and the p. 429), entailing both giving and receiving support. Boston area. There was equal devotion to topics in the interview, Throughout this article, we call these transactions “social which followed a semistructured approach, allowing the partici- support exchanges.” Antonucci and colleagues explain that pant to elaborate on any subject when necessary. The interview- “social support is highly contextualized and depends on ers were trained PhD students of Latina/o origin who conducted roles, expectations and norms that may vary by culture, the interviews in Spanish at the participants’ homes. The inter- gender, age and time” (Antonucci, Birditt, Sherman, & views were digitally recorded and subsequently transcribed ver- Trinh, 2011, p. 1091). Scholars also claim that a consider- batim. From the 50 interviews, 30 were selected for translation ation of “context” requires qualitative methods to improve from Spanish to English, with the aim of achieving heterogeneity our understanding of the meaning and experiences of social in a number of indicators, including gender, age, educational support among diverse groups of people (Williams, Barclay, attainment, and depressive symptomology. We first randomly & Schmied, 2004). selected several men and women aiming for an equal number, The software program ATLAS.ti was used to aid in the who had diverse educational levels, then we checked their level analysis. First, data were coded based on any relevant topic of depressive symptoms from the survey results and adjusted to to social support. Second, these segments of coded data have a sample within representation from the three categories of were collated into descriptive categories. Third, the data depressive symptoms (Center for Epidemiological Studies were then organized into interpretive themes related to the Depression Scale [CES-D] < 15, 16-22, above 22). lived experiences of receiving and/or providing social sup- This article uses data from the transcribed interviews with port. Fourth, data were systematically reviewed after the those individuals who indicated that they experienced prob- themes were defined to refine the themes. The themes we lems with ADLs based on the BPRHS questionnaire data. Of identify in our findings combine semantic content as well the 30 translated interview participants, 25 individuals expe- as more interpretative or latent ideas. Furthermore, while rience some level of difficulty with ADLs. For purposes of we considered the data taking into account some knowl- this study, we include individuals who indicated experienc- edge of preexisting theories, empirical definitions, and pre- ing any level of difficulty. Of the 25 individuals in the sam- vious findings, we remained open to new concepts ple, there are 17 who experience one to five functional encountered in the analysis. Therefore, the themes in this problems, who we label as “some impairment,” and eight study are based on “a dual deductive-inductive and latent- experience six or more functional problems, who we label as manifest” analytical process (Joffe, 2011). Consensus “considerable impairment.” While we do note throughout the regarding codes and themes was achieved through an itera- results which level of impairment each individual experi- tive process of conceptualizing a theme, and subsequently enced, the analysis was conducted across all 25 participants returning to data to check the validity of the theme. The rather than conducting different analyses for the two groups. authors reviewed the transcripts individually, one at a time, At the time of the interviews, the ages of the participants and then met periodically to review and discuss major ranged from 49 to 75 years old (M = 59). They had lived on the codes and themes that stood out in each transcript. After U.S. mainland for an average of 37 years, and in Massachusetts meeting about one transcript at a time, we each combined for an average of 28 years. Eighteen are female, and at the time our findings across transcripts and then met to arrive at a of the interview, seven were married or living as married, consensus about what themes stood out across interviews. while 10 were divorced, four were never married, three were The researchers have different cultural backgrounds, widowed, and one had a spouse who was not in the household. including Puerto Rican, and all have extensive experience Most of the sample, 18 had a ninth-grade education or less with qualitative research and cross-cultural studies. We (including eight with less than a fifth-grade education). Five continued to analyze the interviews and develop themes completed ninth through 12th or had their general educational until we reached a point of data saturation. Guzzardo et al. 5 some impairment, explains that having family to rely on can Findings be comforting, particularly when one sometimes feels iso- The adults in this study frequently had expectations and lated in the United States: beliefs regarding social support that were informed by cul- tural and generational norms and ideals. The way social sup- [The] most important thing in life is the family . . . in [difficult] port is experienced by these Puerto Rican adults is related to moments one can . . . find comfort, talk about ones problems and experiences of disability, changing family dynamics, and how to try to resolve them, so that one can . . . live here [in the geographic and cultural distance from the island. Our themes United States]. highlight how the traditional beliefs as constructed at the time of the interviews do not correspond with their perceived This value placed on family relationships is related to a sense reality. While we did not start out looking for these incongru- of responsibility toward family members. For many, simply ences, a contradiction between beliefs and actual experiences knowing someone is “worried” about you can be a signifi- became evident through our interpretation of the data, and cant sign that one is being remembered and supported. For are explored below in the following four themes: (a) making example, in her definition of what support means, Blanca, sense of responsibility within valued familial relationships, who is 49 years old and experiences some impairment, (b) conceptualizing friends as family, (c) finding resolve and explains that it “means many things for me. It’s like I feel meaning despite isolation, and (d) (not) asking for help. The supported by someone if someone worries about me.” first theme considers the cultural ideals about the importance Moreover, many participants place value on telephone calls of support exchanges within families, as well as the sense of from family members (on island and/or mainland) asking responsibility inherent in these relationships. Experiences about their health. Responsibility is framed as unquestion- that are incongruent with these ideals include situations in able or self-evident, and surfaces most frequently in situa- which participants cannot provide support because of their tions relating to one’s health. disability, situations in which there is a disruption of Some participants who were unable to reciprocate in their exchange within the family, and difficult or problematic informal relationships considered their situation as futile, familial relationships that entail personal sacrifice. The sec- leading them to feel frustrated about not being able to partici- ond theme discusses how participants characterize their pate fully in their relationships. Lourdes, who is 61 years old, friends, who are valuable social connections when family are is not able to provide help and discusses being dependent on not available, in a manner that contradicts principles about others to take her places, or feeling stuck because she does relying primarily on family. These friendships have their not know how to get around using public transit: “I’m here limitations, however, and cannot provide the same level of like a . . . it angers me to be here like this, useless [helpless] support that one expects from family. Finally, the third and person . . . sometimes I feel so useless [helpless] . . .” fourth themes encompass experiences in which individuals Similarly, Blanca, 49 years old and experiencing some lack support. In the third theme on isolation, a lack of sup- impairment, explains that she would like to be in good health port, as well as expectations that support may continue to be to help her grandchildren so that they would not have to be unavailable as one ages, creates a dissonance with strong sent to day care. Consequently, the sense that physical limita- ideals of family caregiving for older members. The final tions leave them with unfulfilled familial responsibilities is a theme discusses participants’ perspectives on whether or not key contributor to a sense of incongruence with their beliefs one can ask for help from others when support is not avail- around expectations of family support. able, contradicting collectivist ideals and the belief that loved In the discourse on exchanges of support within the fam- ones can always be relied on. All themes include examples of ily, elements of marianismo are easily identified among incongruence between traditional or cultural values sur- female participants. Women in the sample provide support rounding familial support that contradict some of their actual by fulfilling traditional gender roles, which can lead to per- experiences. Within the discussion of each theme, there are sonal sacrifice and be particularly difficult given their func- examples of how participants reconcile or harmonize this tional limitations. Elements of marianismo are also present incongruence. in situations where there is a provision of support to a parent who was abusive in the past, or to children who do not recip- rocate. For example, Andrea, who is 53 years and consider- Making Sense of Responsibility Within Valued ably impaired, perceives her maternal role as never-ending Familial Relationships even when her relationship with her daughter is problematic: “She feels that way about me, like I am her enemy, but I help The exchange of support within family relationships is highly her because she is my daughter . . . I am responsible to my valued, particularly as one ages and experiences more needs children until God takes me from this world.” related to functional disabilities. According to Dolores, a The sense of responsibility and purpose in providing sup- 60-year old woman with some impairment, family is “the port to others is present among the men as well. However, center” and that “we support each other but that’s what family there are important differences when compared with how is for.” Moreover, Juan, a 61-year-old man who experiences 6 SAGE Open women discuss the exchange of support. In the first place, with their beliefs regarding familial responsibility, make the male participants discuss the importance of others needing apparent disruption to filial piety particularly distressing. them and their advice because they are men, particularly in Aside from adult children not providing needed support to regard to their adult children. For example, César, who is 52 participants, many participants experience a social network years and experiencing some impairment, is proud that his that is fragmented by distance and, as such, disrupts the children still need him, and explains, “I’m the boss . . . On the exchange of support. Their network is divided between those issues of the home, it is what I say.” In the second place, the who live on the U.S. mainland (either in MA or other states), discourse by men does not include the extent of support pro- and those family members and friends who live in PR, vided to others that is described by women, which sometimes including siblings, parents, adult children, and extended fam- leads to personal sacrifice. For the men in the sample, the ily. Some find that it is possible to exchange support through discourse on support tends to be framed by how they are sup- visits and telephone calls. However, others discuss sorrow or ported by their female spouses or partners (Francisco, a regret when not being able to provide support to family in 72-year-old man with some impairment confidently states: “I PR, or grief over not receiving calls from family in PR and know that I get sick, she will take care of me”), or by the bal- being worried about their health and well-being. With aging, anced reciprocity in the relationship (52-year-old Enrique, experiencing a disruption in the ability to provide family who experiences considerable impairment, explains that he support conflicts with ideals surrounding reliance on family. and his wife help each other get to their doctors’ appoint- However, participants manage to make sense of this incon- ments: “. . . the two of us go together . . . we limp over there gruence by finding a resilient sense of purpose through pro- together.”) However, there is no one-way provision of sup- viding support. This sense of purpose is manifested when port and self-sacrifice inherent in their discussions, as it is for they care for a frail, ill, or impaired spouse, and when they many women in the sample. help adult children with child care responsibilities for their Despite the value placed on patterns of reciprocity and grandchildren. Individuals in the sample remark that by pro- exchange of support among family, many participants expe- viding valuable support they are fulfilling their duty to fam- rience a disruption of the support from family, an experience ily members. Thus, by emphasizing what they can do for that creates dissonance with beliefs surrounding family sup- others (despite functional impairment) and their commitment port. In the interviews, we observed this disjointedness when to family, they reconcile the lack of support they receive or there was an interruption to filial piety among adult children the sacrifice that some relationships may entail. living on the mainland, and in situations in which family members are living in Puerto Rico (PR). Regarding the inter- Conceptualizing Friends as Family ruption to filial piety, an element of familismo, is present even in situations in which children are perceived as unable For many participants, friends and neighbors provide a sub- to, or uninterested in, providing support. Some participants stantial amount of daily support, either through companion- acknowledge understanding their adult children being too ship, or as sources of instrumental support, such as lending busy and dealing with their own challenges or responsibili- money, visiting them at the hospital, or cooking for them. ties. Sofía, who can only rely on one daughter, explains that Despite a discourse on the value of family support, some par- this daughter supports her despite other responsibilities: ticipants experience the reality of relying more on friends for social connections. Consequently, they harmonize their expe- She has three children and she works . . . and doesn’t have time. riences surrounding the presence of support from friends, She goes out of her way to help us. It’s not easy . . . My family with their cultural ideals regarding family support, by redefin- . . . they have their expenses . . . They pay too much rent . . . ing their friends as family. This redefinition of friends makes [They have] bills . . . the reality of their supportive friendships more congruent with their beliefs that family should be providing support. In another example, Andrea, 53 years old and living with Rosario, a 60-year-old woman who experiences considerable considerable impairment, has problematic relationships with impairment, discusses how she relies on her friends and that her adult children, and seems to feel some resentment about these relationships tend to be reciprocal and satisfying: not getting the help that she needs with ADLs. She states, “What can one do? You have to leave it up to God . . . Hijo I do have some friendships that for me it’s as if they were family, fuiste, padre serás y lo que hiciste, así te harán” (similar to as if we were sisters. I have the comadre Marcela that for me is “what comes around goes around”), referring to the fact that like a sister . . . I have many friendships that we visit each other her children will be treated badly by their own children— and that we always spend time together . . . I always have my similar to how they are treating her now. friendships, when one gets sick [ill] one or the other comes. Thus, there is incongruence with expectations of filial piety and familismo that contrast with the lived reality of Her friends provide instrumental support to her as well: adult children’s inability to provide support to participants. “because if I need an errand they do it for me, if I need a little The disabilities that Andrea and others experience, combined soup, they bring it made for me.” The physical accessibility Guzzardo et al. 7 of neighbors makes them a reliable source of support. Within which keeps them bound inside their home. The isolation can these friendships, they help each other through illnesses, by lead to loneliness, sadness, and even fear. For example, providing instrumental support and companionship. Rafaela, a 52-year-old woman with some impairment, dis- Many participants discuss the importance of having cusses her sense of solitude that leads to boredom and friends who are Latina/os. In fact, some even point out that loneliness: they are only friends with other Latinas/os. The common interests and experiences as a minority group in the United I almost never go out, I am always here, since I do not have much of a place to go to . . . casually. I do not have much to do States, and as individuals with cultural identities and prefer- here, where to go or anything like that. I do not know much to ences that distinguish them from Americans, make other take a car or bus or go out, I don’t know how to walk much, and Latinas/os an important source of support in a place where well obviously well I do not go anywhere. one feels as a foreigner or stranger. They develop camarade- rie through their common experiences as a minority group in She explains that she spends her time cleaning the home the United States. For example, Hortensia, who is 57 years and that she has few friends. She further states, “I do not old and experiences considerable impairment, has limited have much support, since I feel lonely.” Experiences of lone- contact with family. She explains that she would like to par- liness and solitude as one ages contradicts strong beliefs sur- ticipate in more activities with a Latina/o group she belongs rounding caregiving for older family members. to, and would like other Latinas/os to participate as well: Some participants mention that “fear” hinders their ability and/or motivation to leave their home and explore their For people to participate in different kinds of activities, so that neighborhood and surrounding area, contributing to feelings they can feel more like they are part of a family. That way they get to know each other . . . and well the love that is missing, the of solitude or loneliness. For example, Dolores, who is 60 affection, well they can have that with one another, and they can and experiences some impairment, would like to “take have friendships and, they [end up] not feeling so alone. tours,” but she is too scared to go out on her own, to use public transportation, and she adds that this inability to be For Dolores, neighbors and friends are also important independent upsets her. Similarly, Blanca states, sources of support even though she has family members present in her life. One young neighbor in particular visits Sometimes you want to do something and you can’t. Sometimes every day, and Dolores explains that this woman is like a I want to go to the stores and it’s bad, it’s far away and I don’t daughter to her, and that they love each other. Family mem- know whether to go or not because I can’t find someone to go with. bers call frequently, but are not present on a daily basis, as in the case of this neighbor with whom she has a reciprocal relationship. “We (participant and husband) belong to her— For Blanca, as for many others, the lack of companion- She calls me, she says I am her adoptive mother.” However, ship deterrs her from leaving her home. Another example, when asked “if something were to happen to you, who would Eugenia, a 56-year-old woman with considerable impair- you trust?” she responds that she would rely on her children. ment, says that she does not like to leave her home alone This illustrates the limitations of friendships as not truly because she is afraid, to the point that she avoids going to the being able to take the place of family as sources of support. doctor, even when she is very sick, because she considers the Even though some friends can be framed as like family, there doctor’s office too far from her home. There are varied rea- are boundaries in those relationships that cannot be crossed. sons that people give for being “fearful.” For some, their The conflict between ideals and lived experiences within inability to speak English (and that one feels more confident this theme is in the very reliance on friends as important in Puerto Rico because one can speak in Spanish) impedes sources of support when family is not available or not pres- their motivation to leave their home, whereas one would feel ent. Friends combat the isolation that participants can experi- more confident in Puerto Rico because one can speak ence resulting from an absence of family or lack of support. Spanish. In addition, living in an impoverished neighbor- Beliefs that family should provide assistance in times of need hood where there can be drug use and crime can be a strong and illness combined with experiences of relying on friends deterrant to venturing outside and a reason to be fearful of are harmonized through the conceptualization of friends as leaving one’s apartment. family. However, there are limitations to what friends can do Another major reason that participants are isolated and for each other. fearful of leaving their homes is because of the risk involved due to their disability. Worries about a greater level of depen- dence, on others, with aging an increased disability can be a Finding Resolve and Meaning Despite Isolation source of fear or distress. For example, Hortensia, 57 years Some participants are embedded within networks that pro- old and experiencing considerable impairment, mentions a vide inadequate support, or are isolated with few sources of “fear” of aging related to not having a family support system support. Often, this isolation is related to their disability, in place: “My family has already forgotten me, imagine when 8 SAGE Open I am older, and family does not care [about] you.” Thus, the support is difficult. Many believe that asking for support cultural ideals that family is present as one ages and experi- from friends is generally not considered appropriate, espe- ences increased functional dependency directly conflict with cially for basic necessities like money, food, or housing, these participants’ lived experience of isolation. which illustrates the limits of “redefining friends as family.” However, participants in these situations also discuss mov- However, they do not consider that there is a problem with ing forward, or making do, given their situations, as a way of asking for help from family, if the need arises and familial maintaining their resolve to complete daily tasks, despite their support is available. They differentiate between friends and functional impairment. For example, Juan, 61 years old with family in their discourse on asking for help. The conclusion some impairment, states, “You can feel isolated (in the main- that they draw regarding this dichotomy is that it is more land). But, you have to make an effort, get along and compete suitable to request aid from family rather than friends, creat- (with others) . . . in whatever you can.” Similarly, 72-year-old ing a correspondence with cultural notions of familismo. Viviana, who experiences some impairment, explains: When it comes to asking for help from individuals in their informal network who are not family, several participants If I do anything strenuous, I get tired, sometimes I get dizzy mention that there is no problem when others who need help spells . . . I go out sometimes by myself . . . a little beat up ask for it, but it is not acceptable when thinking about sup- [disheveled] . . . and so I don’t like going out by myself anymore port for oneself. Carmen, 75 years old with considerable because I get dizzy . . . I’m afraid that something is going to impairment, says that when it comes to her neighbors, she happen to me . . . But I still go out alone . . . and I do the things helps them, but in her own case, she does not ask for help. In I have to do here by myself. discussing the receipt of free turkeys for Thanksgiving in the building where she lives, she states, “. . . God forbid, I ask for In addition, Rosario, a 60-year-old woman with consider- one for myself. Although asking for something is not a crime able impairment, says that she is temporarily not getting a but it would be the last thing I would do . . . the last.” She cleaning service that she usually receives. However, she mentions that it is all right to help others when they are in manages to fulfill tasks, even though they cause her great need, although people should not complain and feel sorry for difficulty and affect her health. themselves. Many participants’ problematic or negative feel- Some participants find that religion or a religious com- ings about asking for support for themselves are related to munity can help them manage or combat isolation and loneli- perception and how they would like to be seen by others. For ness, either by inspiring hope or meaning in life, or by example, 52-year-old César, who experiences some impair- directly providing an outlet for social interaction. For exam- ment, does not ask for help because it would be perceived as ple, Beatriz, 61 years old with considerable impairment, dis- complaining. It is important to accept one’s situation and cusses the positive influence of religion, given her depressive make the best of it. He feels that he could count on his sister, tendencies and suicidal thoughts: “When you think of the daughter, and girlfriend for anything he needs, but later states Scriptures you think that God does not want you to kill your- “if there’s no butter, we’ll eat bread without butter . . . I’ll self, that God wants you to live . . . and that keeps you strong dance to whatever rhythm.” César manages his situation by and sustains your mind.” minimizing the impact of poverty. According to Beatriz, her relationship with God is just as Aside from ingratitude, shame and embarrassment are important as family because it has helped her overcome her also linked to negative feelings about asking for help. For depressive symptoms. Hortensia, 57 years old and with con- example, Lourdes, 61 with considerable impairment, siderable impairment, refers to church and religion as oppor- explains, tunities to connect with others: If I need someone to help me I’m not going to ask for clothes or Inside the community, you learn a lot and grow, and in addition things like that . . . nor food . . . I’m not going to shame myself you visit a lot of people, you can do works of charity, and . . . Yes that would make me feel ashamed. I wouldn’t dare to. sometimes they will [visit you also] . . . yes, and it’s very Now with my sisters I would . . . they’re the only ones who offer important for me. . . . with my sisters . . . or with my brothers I might ask for something I need or ask to borrow [some money]. Isolation is managed through ideas of moving forward and performing daily tasks despite their disabilities (as dis- Hortensia, 57 years old and with considerable impair- cussed above) as well as through the meaning that religion ment, discusses asking for help, and explains that expressing provides. a need for help can lead to embarrassment and signal ungrate- fulness for what one has. She explains, (Not) Asking for Help Up till now, at this time I can’t say that I need help for other Despite cultural beliefs surrounding the importance given to things. It would be ungrateful on my part to say that. We all family support, individuals in the sample sometimes lack need support in one thing or another. Always humans need adequate support and describe situations in which asking for others . . . Guzzardo et al. 9 Thus, Hortensia paradoxically states that asking for help when providing support even when it entails personal sacri- may seem that she is ungrateful for what she has, but then fice or within problematic relationships. In addition, friends acknowledges that it is natural to need help from others. are redefined as family to emphasize their emotional close- Therefore, a way of managing feelings of discomfort with ness and to allow these interactions to fit within their frame- asking for help, is acknowledging that one does have some- work of familial relationships. Experiences of isolation are thing to be thankful for. Hortensia, similar to César (men- reconciled through finding ways to manage getting daily tioned earlier), utilizes positive attitudes to harmonize an tasks done, and finding a sense of meaning through religious incongruence between values or beliefs and experience. beliefs. Finally, when it comes to asking for help from others, some participants maintain a positive (“making the best” of a situation) and, therefore, grateful attitude as a way of harmo- Discussion nizing their beliefs and their contrasting experiences. The findings of this study contribute to our understanding of The findings also provide current evidence of familismo social support experiences among a specific group of older and marianismo (Applewhite et al., 2009; García-Preto, 2005; Puerto Ricans with disabilities living on the mainland. Ramos, 2004; Sanchez-Ayendez, 1988) among older Puerto Themes highlight the meaning of support within informal Ricans living in Boston, despite many years of residence in relationships for older Puerto Ricans with disabilities, such the mainland (averaging 37 years). Cultural notions of as the value placed on these relationships and the sense of familismo may add meaning to the exchange of support, unquestionable responsibility that goes along with exchanges thereby contributing to well-being despite negative interac- of support. This relates to our previous findings on aging as tion or conflict in relationships. Thus, cultural norms may a socially connected process for mainland Puerto Ricans help Puerto Ricans deal with and confront negative interac- (Todorova et al., 2015), underscoring the importance of tion in their relationships and at the same time make sense of social support and relationships for this population. Themes it. However, these cultural notions may also be facilitating also elucidate social support experiences that correspond abuse or situations that negatively affect their psychological with cultural ideals surrounding family support as well as well-being. For example, marianismo may lead to stress for experiences that are incongruent to those ideals. The incon- family caregivers, given that in their role as primary care- gruences in the first theme contrasts the value placed on sup- giver, women must place family needs above one’s own needs port from family with being unable to provide support (García-Preto, 2005; Ramos, 2004). Ramos (2004) also sug- because of a disability or when experiencing a fragmented gests that support exchanges within the family can be stress- network split between the United States and Puerto Rico. In ful for Puerto Ricans when the practice of traditional norms is the second theme, the reliance on friends contrasts with ide- hindered not only by socioeconomic difficulties but also by als on the availability and reliability of family. In the third social trends, such as higher rates of divorce, smaller families, theme, a dissonance exists between beliefs regarding family and geographic mobility. While the focus of our study is on responsibility and filial piety with experiences of isolation. individuals with disabilities who may need support, many of In the fourth theme, values of family support and collectivist these same individuals also act as caregivers for others, which cultural ideals are incongruent with situations that entail has clear relevance for their sense of self-worth. deciding whether or not to ask for help from others and worry Policy makers should not only recognize the importance about overburdening family members. Much of these incon- of family within Puerto Rican culture but also be aware that, gruences in social support can be made sense of within the with aging and as a by-product of migration, that they are general context of migration, and more specifically through also facing the reality of the absence of family. Many Puerto an understanding of the unique situation of Puerto Ricans in Ricans living on the mainland attempt to preserve relation- the U.S. mainland. While it is the same country, cultural ships on the island, particularly with family members (Duany, norms, and traditions are different. As a result of migration 2002b). Changing circumstances and social trends experi- and changes in physical place, these adults experience a dis- enced by Puerto Ricans on the mainland suggest that they are sonance between their cultural expectations and lived experi- not a group that is deeply embedded within a familial social ences of support and filial piety. Furthermore, there are network (e.g., adult children are busy with their own children intergenerational shifts in meanings of social support over and work obligations, and many family members live far time. These incongruences are more problematic for these away from each other). Given past research on the reliance individuals due to physical limitations, dependency on oth- on family among Latinas/os and Puerto Ricans (Almeida ers, and their corresponding decreased in the ability to pro- et al., 2011; Weiss et al., 2005), service professionals may vide certain types of support to others. assume that Puerto Ricans, much like other Latina/o groups, Our findings provide information that can contribute to can rely on family members for support as they age. This our understanding of social support among older Puerto study demonstrates that while some Puerto Ricans with dis- Ricans in the United States, by elucidating how the incon- abilities can rely on family and friends for support, others gruences between values and their lived realities are dealt may be living in isolation and lack adequate emotional and with in various ways. For example, participants find purpose instrumental support to address the challenges related to 10 SAGE Open functional impairment. Therefore, services and programs for authors are grateful to the National Institutes of Health, who have funded this project, under Grants P01AG023394 and P50HL105185. older Puerto Ricans should address this incongruence between values and actual experiences. Notes Issues of poverty are pervasive throughout the discus- sions of social support in our findings. Some individuals dis- 1. By “resilient national identity,” Duany discusses how Puerto cuss the difficulty of maintaining relationships with Ricans hold on to their national identity while living on the individuals in PR when one is unable to travel due to the cost mainland, defining themselves as boricuas or puertorrque- ños/as, refusing to “hyphenate” their name as Puerto Rican- of the airfare. Others discuss the quality of the community Americans, as other Latina/o subgroups do. neighborhood where they live, and the way it contributes to 2. Cultural beliefs and values refers to “a shared meaning” of their feelings of fear when there is a lack of companionship. ideas represented in the minds of a group of people that are Therefore, it is possible that the idea of asking others for help observed through practices or behaviors (adapted from Morris, with daily activities does not seem as concerning as having 2014). enough money to buy food. In their outreach strategies, ser- 3. According to the U.S. Census Bureau, both “Latino” and vices for older Puerto Ricans must take into consideration “Hispanic” refer “to a person of Cuban, Mexican, Puerto the problems with asking for support and the need for more Rican, South or Central American or other Spanish culture of urgent resources. origin, regardless of race” (U.S. Census Bureau, 2011 March). Even though Puerto Ricans in our study find ways of recon- There is disagreement among scholars regarding the use of ciling insufficient support with their beliefs and values, the these terms and differences between them. We use the term Latina/o because it is gender inclusive and primarily includes situations of isolated and fearful older Puerto Ricans with dis- those from Latin American countries, excluding people from abilities can be addressed through more formal types of sup- Spain. We want to acknowledge that the use of pan-ethnic port. Recent research suggests “convoys of care,” a labels obfuscates differences between subgroups and that combination of formal and informal support can improve the it is an imposed label often serving as a secondary identity. quality of life of older adults who experience increasing func- Individuals in the United States who self-identify as Puerto tional decline (Kemp, Ball, & Perkins, 2013). These formal Rican can include individuals who were born on the Island and interventions or services should engage in cultural humility later moved to the mainland, but can also include future gener- and seek to understand within-group variation, or differences ations of these migrants, who were born on the U.S. mainland. at the individual level (Duntley-Matos et al., 2017; Hook et al., Puerto Rico is a territory of the United States, and individuals 2016). For example, formal service professionals should not born on the Island are granted U.S citizenship. underestimate the social support needs of Puerto Ricans, given 4. The Boston Puerto Rican Health Study (BPRHS) data can be accessed by contacting Luis M. Falcón, PhD, Dean of Fine presumptions about the availability of family caregivers that Arts, Humanities & Social Sciences, luis_falcon@uml.edu. may characterize them as a group (Almeida et al., 2011; Weiss 5. The activities covered in the questionnaire include walking for et al., 2005). In addition, there may be an expectation that a quarter of a mile, walking 10 steps without resting, getting because of their citizenship Puerto Ricans are not as much in outside, walking from one room to another on the same level, need of outreach strategies to improve their knowledge and getting out of bed or chairs, eating (holding a fork, cutting access to the community-based formal service system that can food, drinking from a glass), dressing, bathing or showering, complement an existing informal network, or fill in the gap of using the toilet and getting to the toilet, using a manual can an unavailable or rapidly shifting informal network. opener, opening a frozen food package, and opening a milk or orange juice carton. Authors’ Note 6. Comadre sometimes means godmother or co-mother, but it can also be used to identify someone who is considered “like fam- The data can be accessed by contacting Luis M. Falcón, PhD, Dean ily” as in this case. of Fine Arts, Humanities & Social Sciences, University of Massachusetts, Lowell, luis_falcon@uml.edu. References Acknowledgments Acevedo, G. (2004). Neither here nor there: Puerto Rican circular The authors thank the participants who took part in the interviews migration. Journal of Immigrant & Refugee Services, 2, 69-85. for their generous time and insight. doi:10.1300/J191v02n01_05 Acosta-Belén, E., & Santiago, C. E. (2006). Puerto Ricans in the Declaration of Conflicting Interests United States: A contemporary portrait. Boulder, CO: Lynne Rienner. The author(s) declared no potential conflicts of interest with respect Alcantara, C., Chen, C.-N., & Alegria, M. (2014). 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Defining social (Eds.), The psychosocial development of Puerto Rican women support in context: A necessary step in improving research, (pp. 214-242). New York, NY: Praeger. intervention, and practice. Qualitative Health Research, 14, Morris, M. W. (2014). Values as the essence of culture: Foundation 942-960. doi:10.1177/1049732304266997 or fallacy. Journal of Cross-Cultural Psychology, 45, 14-24. Mulvaney-Day, N. E., Alegria, M., & Sribney, W. (2007). Social Author Biographies cohesion, social support, and health among Latinos in the United States. Social Science & Medicine, 64, 477-495. Mariana T. Guzzardo holds a PhD in Human Development and doi:10.1016/j.socscimed.2006.08.030 Family Studies with a specialization in Adult Development and Nguyen, A. W., Chatters, L. M., Taylor, R. J., & Mouzon, D. M. Aging, from the University of Connecticut, Storrs. She worked as a (2016). Social support from family and friends and subjective postdoctoral research associate at Northeastern University, focusing well-being of older African Americans. Journal of Happiness primarily on the analysis of qualitative data from the Boston Puerto Studies, 17, 959-979. Rican Health Study. In September 2017 she will begin her position O’Donovan, A., & Hughes, B. M. (2008). Access to social support in as an assistant professor in the Department of Human Development life and in the laboratory: Combined impact on cardiovascular and Women’s Studies at California State University, East Bay. Guzzardo et al. 13 Wallis E. Adams is a doctoral candidate in Sociology at Northeastern European Health Psychology Society and co-editor of the journal University. Her dissertation explores multiple stigmas and profes- Health Psychology and Behavioral Medicine. sionalization amongst Forensic Peer Specialists. Luis M. Falcón is dean of the College of Fine Arts, Humanities and Irina L. G. Todorova, PhD is a health psychologist with experi- Social Sciences at the University of Massachusetts, Lowell. He received ence in psycho-social, gender and cultural aspects of health and BA and MS degrees from the University of Puerto Rico and a PhD in health inequalities. She is on the faculty of Northeastern University, Sociology from Cornell University in 1987. A social demographer, his Department of Health Sciences, where she teaches qualitative research interests and publications are in the role of social and environ- research methods and health promotion. Todorova is a fellow of the mental factors in generating disparities – social, economic or of health.
Journal
SAGE Open – SAGE
Published: Jun 30, 2017
Keywords: Puerto Ricans; familismo; marianismo; social support; disability; qualitative methods