Geographies of Care and Caregiving

The importance of care and caregiving as a field of study can be understood as part of the general shift toward greater emphasis on the social aspects of healthcare, and as part of the response within the social sciences to broader changes in contemporary health policy and practice in Western developed countries such as Canada, New Zealand, and the United Kingdom. Specific concern for the geographical dimensions of care and caregiving has its beginnings in research on the spaces and places of mental healthcare. Key studies in the late 1970s and 1980s critiqued the de institutionalization of mental health services from asylums to community-based care and the implications for individuals coping with mental illness. This body of work focused on the gaps between often nonexistent spaces of care in the community and the needs of people with mental illness. Concerns were raised about how de institutionalization, in combination with the lack of service quality and quantity in the community, left many ex patients poorer, homeless, drug addicted, and even prisoners in the criminal system.

Following this early work in the mental health sector were four changes within the subdiscipline of medical/health geography that have led to the growing engagement with research questions and issues concerning care and caregiving. First, there has been a broadening of scope from focusing solely on the biomedical to considering issues of health, healing, and well being. Second, theories and concepts originating in social, cultural, and feminist geography that examined the body, inclusion and exclusion, and the links between people and their economic, social, and political contexts informed and shaped the way that health and healthcare were studied. Third, the interest in developing a situated understanding of the complex relations surrounding healthcare provided an impetus for studying the intersection between health, place, and the activities, routines, and relationships involved in care and caregiving. Finally, the use of techniques such as interviews to research the experiences and meanings of care and caregiving paralleled the increased interest, use, and validation of qualitative methods in human geography. Key studies in the geography of care and caregiving illustrate the strengths of qualitative methods for capturing the rich experiences and in depth meanings of health and healthcare in everyday contexts. The contributions of other social and health science disciplines such as nursing, health policy, gerontology, and sociology have also helped shape and direct this area of inquiry.

Underlying the growing work on the geographies of care and caregiving are broader concerns about changes in health policy and practice. Since the 1980s, concerns in Western developed countries about rising fiscal deficits, an aging population, and growing healthcare costs led to a period of massive healthcare restructuring and policy change. Strategies to deal with these issues coupled with advances in medical technology, and increasing life ex ectancies for individuals with disabilities and chronic illnesses, have affected where care is provided, how care is delivered, and who performs caregiving. Research on de institutionalization has been broadened to include acute and long term care. For example, the lengths of hospital stays for acute care have decreased, and therefore patients are released from hospital sicker, often requiring ongoing treatment at home. Advances in healthcare technology have made it possible for many treatments and interventions that were previously administered in hospital settings by healthcare professionals to be managed in homes and communities by individuals and their families. For some people, the home has become a place where complex, sophisticated, long term care is provided. Another cost containment strategy is the restructuring of healthcare work. This involves the transferring of responsibilities and activities to workers who are not as highly skilled or paid, and in the case of informal caregivers are not paid at all. For example, bathing was once the domain of nurses but now responsibility for this activity has been transferred to nursing assistants and home care workers. In addition, restructuring of state provided, publicly funded, home care services is also underway, resulting in stricter eligibility criteria to receive services, cut backs in the amount of hours of care, and greater restriction in the type of caregiving that workers can perform. Ultimately, these strategies have combined to change the places where care occurs, which shifts from healthcare institutions such as hospitals to homes, and the people who are responsible for caregiving as services are downloaded from trained healthcare professionals onto community volunteers, families, and individuals.