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Explaining the Process of Caregiving by Sandwich Generation
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22 July 2023
Posted:
24 July 2023
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Abstract
The sandwich generation caregivers provide simultaneous care for multiple generations. Caregiving is a dynamic process, and each generation has its unique set of needs. Moreover, studies have indicated a growing population within this group. However, despite extensive research efforts, the caregiving practices employed by the sandwich generation remain inadequately explained. Therefore, the objective of this study was to shed light on the caregiving practices offered by the sandwich generation. The grounded theory approach was selected as the conceptual framework for investigating the research objective. Purposive and snowball sampling methods were utilized to recruit 18 participants from the sandwich generation. The data collected through interviews and observations were analyzed using the 2015 version of Corbin and Strauss methodology. The findings revealed that sandwich generation caregivers are influenced by prominent personality traits, issues related to the elderly, and dependencies and interdependencies within the caregiving process. Sandwich caregivers employ a range of strategies influenced by intervening and background factors. Throughout this process, caregivers encounter both positive and negative consequences. Consequently, policymakers and planners should prioritize the establishment and expansion of support systems for caregiving.
Keywords:
Subject: Public Health and Healthcare - Health Policy and Services
1. Introduction
Midlife is an important developmental period between ages 40-60 in which multiple roles and responsibilities begin to compete with each other. In terms of caregiving, midlife is tied to parenting adolescent children and caring for older people parents. This combination of these two types of care has led to labeling these individuals as members of the sandwich generation [1].
They are sandwiched between the needs of their children, older people parents, and the demands of employment. The older people, as one of the vulnerable groups, face developmental challenges in physical, psychological, social, and economic fields as they age, which leads to their inability to take care of themselves. Therefore, they will need the support of family members to solve them [2,3]. Children, like the older people, need physical care, financial support, emotional support, independence, and education. The type and level of their needs will vary with age. In general, children need support and guidance from their parents for their comprehensive development [4,5].
Finding the time and energy to provide help for an aging parent while attending to their own needs and the needs of their dependent children can create conflicts, challenges, and stress leading to absenteeism, missed career opportunities, health-related stress, difficulty balancing work and family demands, guilt, depression, isolation, fatigue, physical capacity to provide needed help, amount and type of care needed, travel time [6,7].
Currently, 9-15% of the world's population belongs to the sandwich generation [8], but there is no statistical report of this generation group in Iran. It is obvious that due to recent demographic trends toward increased longevity, and longer working lives, the number of people in the sandwich position is expected to rise. The population of the sandwich generation is influenced by the population of the older people and children.
Due to demographic trends, especially decreasing mortality and increasing fertility, Iran’s population is rapidly aging. Iran’s 79 million people (9.3%) in 2016 made it the 17th most populous country in the globe [9]. According to the latest census, about 99.6% of the older people population lives in families. Also, referring to the latest census reports (2015), more than 25% of the population are people under the age of 18, and more than 95% of them live with their families. In general, more than 40% of households in Iran have four or more person households [10].
Also, playing a caring role is influenced by socio-cultural conditions, the amount and type of support provided by the sandwich generation to the older people and children also varies from one society to another. The specific and unique characteristics of the culture of Iran and the fact that the process of caring for the sandwich generation has not been studied, led the researchers of the present study to investigate this process in Iran, So the aim of the present study is to explain the care process provided by the sandwich generation.
2. Materials and Methods
The objective of this study was to examine the caregiving process employed by the sandwich generation. To achieve this, the research was guided by the grounded theory approach. Grounded theory method is the best option for exploring the processes in human interactions and increasing the understanding of social phenomena [11].
2.1. Participants and Recruitment
Due to the fact that in Tehran, there is no specific center, organization and institution to access the caregivers of the sandwich generation. For this reason, it was necessary to take sampling in active environments in the field of children, elderly and family. In this study, Rafidah Rehabilitation Hospital, Nikokaran Sharif Institute, Values Restoration Institute were the research environments. It was also announced in the virtual space (WhatsApp and Instagram). In this way, cases were identified that corresponded to the inclusion and exclusion criteria of the current study. In this study, using snowball sampling method, targeted and theoretical, 18 caregivers of sandwich generation were selected. The criteria for entering the study in the research included the person's consent to participate in the research, not having a psychiatric disorder, the ability to speak and living with two generations (children and elderly parents) under one roof.
2.2. Data Collection Procedures
Data were collected individually, face-to-face, telephone, in-depth, and semi-structured, depending on the participant's preference. The interviews were conducted from August 2019 to October 2019 by the first author (PhD student in the field of social work), who has received the necessary training in the field of qualitative research methods, and each interview lasts 30 to 60 minutes. All interviews were recorded with the consent of the participants using smart phones. Data were collected and analyzed simultaneously. This process continued until the saturation of the text was reached and no new data was obtained. The steps of data analysis included: open coding, determination of concepts, development of concepts and determination of their characteristics and dimensions, analysis of data for context, introduction of process into analysis and integration of categories. Immediately after the first interview, the process of data analysis began. Audio recordings of the transcribed interviews were coded in qualitative data analysis software (MAXQDA 2018). All authors participated in the data analysis process
2.3. Data analysis
Data analysis was done based on the 5 steps of Strauss and Corbin (2015). The first stage is open coding to identify concepts. Therefore, the interviews were typed in Word software immediately after being recorded. Then, in order to get a better understanding of the content, the researcher checked the texts several times. After review, initial coding was done. The titles chosen for the codes were either extracted from the words used by the participant or the researcher assigned a suitable title. After this step, the identified codes were connected to each other based on dimensions and common features. In the stage of data analysis for context, factors and conditions affecting the care process were identified. After that, the researchers sought to identify the strategies and solutions of the sandwich generation in response to the challenges and problems. During the analysis process, the obtained categories were continuously compared with each other. Therefore. The categories included in the process were abstract. The obtained categories were examined and based on them, the researchers wrote a story-line and explain the care process. Writing the story- line helped to arrange the categories and finally the core concept, casual condition, intervene condition, context condition, strategies, consequences were determined.
2.4. Ethical consideration
Ethical clearance was obtained from the ethics committee of University of Social Welfare and Rehabilitation Sciences, registered at IR.USWR.REC.1400.236. All the participants were provided with information related to the research objectives, confidentiality, anonymity, their right to withdraw, and the use of a voice recorder during the interviews.
2.5. Trustworthiness
The nine criteria of Corbin and Strauss were used to evaluate the strength of the data [12]. The present study shows the creativity of the research team, because it gives new insight into the field of care. In order to comply with the criterion of methodological consistency, sampling continued until theoretical saturation was reached and an attempt was made to use purposive and snowball sampling methods. It was also tried to collect and analyze the data alternately and to extract the desired concepts and classes for the care process from the data collection. The process of coding and identifying categories was described in detail in the data analysis section. Also, before starting to collect and analyze data, the researcher had received the necessary training in the field of qualitative research method. In addition to the researcher, other members of the research team, who are experts in conducting qualitative research, read the interview texts and checked the coding method. It should be noted that the members of the research team held weekly meetings from the beginning of the sampling and provided the necessary points to better advance this process. The researcher, relying on his research records in the field of geriatric social work and children, decided to conduct this research and was involved in collecting and coding the obtained data for 12 months.
3. Results
3.1. Participants’ Characterization
Eighteen people who take care of children and older parents simultaneously participated in this study. The characteristics of participants has been reported in the Table 1. All the research participants were women and were in the age group of 32 to 60 years. The duration of being a sandwich generation until the time of the interview varied from 6 months to 228 months.
3.2. Qualitative Analysis
The obtained concepts were placed in 6 categories of causal conditions, contextual factors, intervening factors, central concept, consequences, and strategies. The main concepts extracted from the research are stormy weather, care burden experience, grass growing from stone, supportive paradox, self-neglect, looking for beach, being sandwich, interdependence, cumulative burden over time, children neglect, embracing life, caregivers’ personality prominence, older people problems and dependencies, caring proficiency) Figure 1(. In Table 2, the method of concept extraction in the study has been reported.
3.2.1. Casual condition
3.2.1.1. Sense of obligation or inclination:
The sandwich generation may feel compelled or inclined to take on the role of being sandwiched between caring for their parents and their children. Their sense of compulsion can arise from the lack of cooperation from others in caregiving, physical challenges faced by the older people, or the financial dependency of the sandwich generation on the older people. On the other hand, some caregivers also embark on caregiving due to a sense of duty towards their parents and children or a spiritual aspect associated with providing care for them.
Participant No 9 (39- year- old, 24 months of caring period)
“She has a spinal cord injury and has undergone surgery due to her advanced age, and now she requires care due to her disability. According to your opinion, they have problems that require caregiving.”
Participant No 4 (48- year- old, 96 months of caring period)
“Well, she is not to blame. She is my mother, and she has worked hard. Regardless of the circumstances, this is the center of the family.”
3.2.1.2 The caregivers' personality prominence
Some Participants considered themselves prepared for caregiving due to possessing characteristics such as being idealistic, being organized, and having a supportive personality. On the other hand, these characteristics did not remain insignificant in enhancing the caregiving process and perceiving this experience positively.
Participant No 3 (58- year- old, 12 months of caring period)
“I, myself, tend to be somewhat idealistic. I believe that everything should be perfect. And since they can't manage everything, I took on the responsibility myself. “
Participant No 1 (47- year- old, 14 months of caring period)
“Personally, I have good management skills. I didn't let my daughter suffer, and I was able to take care of my mother without losing my job.”
3.2.2. Intervene condition
3.2.2.1 Caring proficiency:
Caregivers who had prior experience in caring for either an older people person or their own children before becoming sandwiched had a greater awareness of the caregiving process. Undoubtedly, their previous experiences had an influential impact on the competence of caregivers in this process.
Participant No 1 (47- year- old, 14 months of caring period)
“In the beginning, my sister took care of my mother, and after her, I had to deal with this situation. I did something in a way that my other sister couldn't compete with me. Now, I try to manage it myself. Whatever problem arises, I find it fun and interesting. I nurture that situation in a way that makes me feel better.”
3.2.2.2 Older people problems and dependencies:
Based on the type and level of older people individuals' difficulties, their caregiving needs also changed, and consequently, the caregiving services provided by the sandwich generation varied. The condition of the older people is not constant over time, so the entire caregiving process does not proceed under the same circumstances and situation.
Participant No 15 (32- year- old, 24 months of caring period)
“My father couldn't speak. They had severe Alzheimer's. They couldn't talk. They were somewhat depressed as well.”
3.2.2.3 Age and the number of family members:
In multi-generational families, where family members span across different age groups and generations, differences of opinion and conflicts arise among them. Over time, as the number of family members increases or as they age (including the older people, the sandwich generation, and children), the conflicts that arise tend to intensify. However, it should be noted that the needs of children at different ages are complex, and it cannot be claimed that increasing diversity and the level of problems necessarily result in more conflicts.
Participant No 13 (41- year- old, 228 months of caring period)
“My life problems weren't significant, and I didn't feel much pressure. My expenses weren't high, and my husband had a steady income. But since my youngest daughter was born, I realized that it's really challenging. Expenses increase when the second child is born, and life becomes even harder when the third child arrives. When the second child was born, I had to slowly return to work, and my problems started to pile up gradually.”
Participant No 11 (38- year- old, 120 months of caring period)
“At that time, they were young. They had the energy and patience to take care of the children, keep up with their activities. Now, as they are getting older, they can't tolerate the noise and commotion. That's why.”
3.2.3. Coping Strategies
Caregiving of people from two generations with different needs is a difficult and stressful job. Participants reported that they apply some strategies for self-care.
3.2.3.1 Distancing from the Situation
In some cases, family circumstances are such that the pressures and difficulties experienced by the sandwich generation are so overwhelming that they have a tendency to distance themselves from the home environment in order to find tranquility and regain composure. Furthermore, some caregivers of the sandwich generation prefer to temporarily extricate themselves from the home to prevent harm to their children.
Participant No 4 (48- year- old, 96 months of caring period)
“I said that I want to go somewhere for a while where I don't see anyone, where I don't see people.”
Participant No 11 (38- year- old, 120 months of caring period)
“Well, things are different. How it was in the beginning and how it is now are not the same. We also need to gather our thoughts. They are not always alive, but the circumstances are such that my husband is ill and unable to work. We are forced to be there for them.”
Due to various reasons, some members of the sandwich generation choose to relocate and live with their parents. However, there are those who prefer to maintain control over their circumstances and opt to live independently, moving out of their parents' home. In other words, they have no desire to become sandwiched.
3.2.3.2. Self-Soothing
The sandwich generation finds solace in spiritual practices such as prayer, sending blessings, and other activities of personal interest such as reading books, listening to music, and conversing with friends. They also find relief by expressing their emotions, often through tears, as a means of managing the prevailing conditions.
Participant No 15 (32- year- old, 24 months of caring period)
“I personally enjoy listening to music. Whenever I felt down, I would put on my headphones, sit on the balcony in the open air, and let my mind calm down. I would listen to music or read a book. It was through these things that I found solace.”
Engaging in calming activities such as listening to music or reading books helps the sandwich generation to take a short break from their sandwiched situation. Additionally, over time, paying attention to their own interests creates positive emotions within them.
Participant No 18 (42- year- old, 60 months of caring period)
“Or for example, I would stand up and pray, talk to God, asking why, why, and when I reach the end, I would say, "No, I seek forgiveness from Allah." Perhaps something worse could happen, but I convince myself again, even though a person may not be easily convinced.”
Some individuals in the sandwich generation find solace through engaging in spiritual activities. It serves as an opportunity for emotional release and psychological well-being.
3.2.3.3. Diversifying Responses to Needs
The sandwich generation is exposed to multiple demands from both the older people and their children, which may arise simultaneously. In such cases, the sandwich generation needs to respond to these demands concurrently. They may choose strategies such as mediation, delegating some responsibilities to the older people, or prioritizing responses in order to manage these conditions effectively.
Participant No 3 (58- year- old, 12 months of caring period)
“I was fortunate to become acquainted with the "Vaght-e Zendegi" Foundation. They have been a helpful resource for me.”
Participant No 14 (40- year- old, 9 months of caring period)
“Because my mother-in-law was ill at that time, I would first take care of my husband's tasks and then attend to the children. This was because my daughters are older.”
The sandwich generation may need to prioritize their needs in order to manage the circumstances and respond to the requests of both the older people and their own children. This prioritization will vary depending on the specific circumstances.
3.2.4. Outcomes of care
Positive outcomes:
3.2.4.1. Embracing Multigenerational Living
The start of caregiving responsibilities is often known, but the end time is uncertain. Some individuals begin caring for their parents during their single years, while others start after getting married. Over time, caregivers become more aware of how to provide care and manage the circumstances. This can lead to acceptance and adaptation to multigenerational living.
Participant No 11 (38- year- old, 120 months of caring period)
“It's unbearable. Due to her illness and everything, her tolerance has decreased. We don't expect anything from her, and we give her the right to that. By God, she has endured her own hardships and raised four children. She doesn't have the patience for our children anymore.”
Participant No 14 (40- year- old, 9 months of caring period)
"You know, this isn't my first time. When I got married, there was a son who was very dependent. He was dependent, not very responsible, but rather highly dependent. It means that when my husband was visiting his mother, we had to go to his mother's house for vacations. Or she would come to our house. There was nothing I could say, suddenly he would fall ill and suddenly come to our house. My mother-in-law is always with us, with everything. It's not that it's not difficult for me."
Over time, the experience of being a sandwich generation caregiver increases, and it also progresses with greater awareness in this process. However, this is not true for all caregivers. But generally, the passage of time is effective in accepting the conditions.
3.2.4.2 Grass growing from stone
Some older people individuals play a supportive role in the lives of the sandwich generation. This support can be financial, emotional, or through caring for their grandchildren. This contributes to strengthening the emotional bonds among family members and reduces tensions within the family. Additionally, witnessing their parents' old age serves as a wake-up call for the future sandwich generation. They become familiar with the challenges and health conditions associated with that stage of life and may make decisions and plans for healthy aging.
Participant No 11 (38- year- old, 120 months of caring period)
“In one aspect, it is very good that the older generation is there for us, they are a support system. My spouse's parents have filled the role of my own parents. When I am upset, facing financial difficulties, or any other problem arises, I talk to them.”
Participant No 9 (39- year- old, 24 months of caring period)
“Well, they get along very well together. They have become very supportive of each other. It has been a great experience for them, and they have become quite dependent on my mother as well. Sometimes when my sister suggests going to Isfahan, she says, "No, I'll stay with my grandmother.”
Living together can lead to reconciliation among family members and closer relationships between them.
Negative outcomes:
3.2.4.3 Neglect of Children
Some caregivers of the sandwich generation, despite employing various strategies, are unable to control certain circumstances. Some of them may inadvertently overlook their own children due to the heightened pressures from their offspring. As a result, children are exposed to dual parenting, experiencing academic disruptions, restricted autonomy, and the emergence of psychological issues.
Participant No 13 (41- year- old, 228 months of caring period)
“It seems that there may be some conflict in parenting styles between you and your mother-in-law, which is causing confusion for your children. As a mother, you have your own way of raising your children, while your mother-in-law has a different approach. This situation puts your children in a dilemma, as they question which parenting style to follow. It's important to have open and honest communication with your children, explaining your own values and principles in raising them. You can also try to find a middle ground and collaborate with your mother-in-law to create a consistent and supportive environment for your children.”
Participant No 14 (40- year- old, 9 months of caring period)
“When my mother-in-law had a stroke, it was during the children's exams. There was a lot of back and forth in the house. Either when she was in the hospital, I would go to the hospital, or my sister-in-law would bring her son to our house, and the children couldn't study.”
In these families, due to the presence of the older people, there is a lot of coming and going of relatives, and also, due to the older people's seniority and their presence in the sandwich generation's home, celebratory gatherings are held at their house. These gatherings have a negative impact on the academic performance of the sandwich generation's children.
3.2.4.4 Self- neglect
Sandwich generation caregivers are continuously engaged in meeting the needs of their family members from waking to sleeping. In other words, they divide their time among them. However, some caregivers lack the ability to manage their own needs, facing limitations in pursuing leisure activities, maintaining social relationships, ensuring adequate nutrition, attending to healthcare matters, obtaining sufficient sleep and rest. In some cases, they may even become unaware of their own well-being and consider leaving their occupation.
Participant No 3 (58- year- old, 12 months of caring period)
“Since the year 2021, I have taken my job seriously in order to be able to spend more time with my parents, but I have always been vigilant and taken care of them.”
Participant No 12 (40- year- old, 12 months of caring period)
“I have lumbar disc and now I am going to Milad hospital for endoscopy and colonoscopy. There is no one to take care of my mother-in-law and my son is also CF. I keep postponing my treatment.”
One of the neglects of the sandwich generation is not giving importance to their own healthcare. They prioritize the needs of other family members, and they also face time constraints.
3.2.4.5 Care burden:
Caregivers of the sandwich generation may experience physical, emotional, social, and financial burdens and pressures due to their multiple caregiving responsibilities.
Participant No 10 (45- year- old, 24 months of caring period)
"As far as I can endure. I don't know how far I can go. If I say I don't get tired, no, I do get tired. I feel exhausted. Sometimes I feel suffocated, and sometimes I just want to be alone, sit down, and distance myself from that environment for a while."
Participant No 18 (42- year- old, 60 months of caring period)
"My back hurts. My legs hurt, and sometimes I have headaches. Before Eid, I was sitting down to perform ablution when I suddenly felt a severe headache. I wondered why I was experiencing head pain; maybe my blood pressure was low. I went to the bathroom to perform ablution and as I reached for the sink, I fell. I couldn't understand anything. When I got up, I realized I was in the hospital. They had brought me there in an ambulance, and I had no idea what had happened. I underwent tests, echocardiography, and an electrocardiogram, and they said I had a minor stroke."
Considering that the sandwich generation engages in various daily activities, such as caregiving, bathing, transporting the older people or children, cooking, house cleaning, and shopping, they experience physical pressures and may encounter challenges.
3.2.5. Contextual Condition:
3.2.5.1 Stormy Weather:
With the entry of an older people individual into a nuclear family, the family dynamics undergo a transformation as they come from different generational and life stages. Multigenerational families face challenges such as limited physical space and interference from others, which reduce family members' adaptability and give rise to problems in their relationships.
Participant No 13 (41- year- old, 228 months of caring period)
“My mother-in-law expects my daughter to serve her, give her water, make tea for her, and serve her breakfast. My daughter is now a teenager, doesn't listen, and doesn't prioritize these tasks. My mother-in-law also insists on her demands.”
Older people individuals, due to their age and generational differences, are in a different life stage. This can lead to a lack of proper understanding of the circumstances of other family members and unrealistic expectations on their part.
Participant No 17 (60- year- old, 120 months of caring period)
“Due to the age difference between my children and their mother, their relationship with her is not the same as it used to be in the early years.”
In multi-generational families, it is expected that there would be a level of harmony and compatibility among family members, as their worlds are different from one another.
3.2.5.2 Supportive paradox:
The responsibilities of being a sandwich generation caregiver are demanding, requiring psychological, emotional, caregiving, social, and financial support from others. The term "others" refers to spouses, parents, children, friends, relatives, and so on. However, not all caregivers have access to such support, or some may receive limited support. Therefore, the caregiving context for sandwich generation individuals is not uniform.
Participant No 18 (42- year- old, 60 months of caring period)
“If I want to take a shower, I have to take my son with me. I place him on a chair to play. No one else watches over him. I also have to bathe him, dry him off, and dress him afterwards. It means I can't even shower alone. I don't have an hour for myself either.”
Participant No 4 (48- year- old, 96 months of caring period)
“When I wanted to bring my mother to live with me, everyone said they would support me. They said there would be blessings if I took care of her. But they didn't offer any support at all. During the first two years of caregiving, when they saw that my mother's condition was deteriorating, they withdrew and abandoned her.”
Caregiving is a long-term process with an uncertain duration. Therefore, it's possible for people around to withdraw over time.
Participant No 1 (47- year- old, 14 months of caring period)
"I have a particular obsession when it comes to caring for my mother. I don't trust anyone to take care of her. Now, if I want to go on a trip and send her to my older brother, I become worried. I think something might happen to her because I am an obsessive person and I don't trust anyone. This lack of trust takes a toll on me mentally and physically. "
Generally, sandwich generation caregivers do not trust other caregiving sources and prefer to handle the task themselves.
Participant No 15 (32- year- old, 24 months of caring period)
"Sometimes I see that some children send their parents to nursing homes, and I am amazed. They don't appreciate the value of these precious gems. Every parent has their good and bad sides, just like any other human being. "
Some sandwich generation individuals are opposed to entrusting their older people parents to external caregiving sources such as nursing homes. They consider sending them to nursing homes as an improper course of action and prefer to accept all the conditions and responsibilities themselves.
3.2.6. Core Concept:
3.2.6.1 Being Sandwiched:
Sandwich generation caregivers find themselves caught between the needs of their children and their older people parents. In addition to this, they are also involved in carrying out household chores and meeting the needs of their spouses. Some of them are also employed and have to address their own work-related demands. Consequently, the sandwich generation experiences pressure from multiple sides and feels sandwiched between these various demands.
Participant No 2 (42- year- old, 16 months of caring period)
“My mother can't walk much, can't stand in the bathroom. I take the mother to the bathroom, wash her body, take her out of the bathroom and put on her clothes. On average, a bath takes two hours.”
When the older people is not able to do their daily tasks independently, the sandwich generation accompanies them and the level of activities includes bathing, toileting, feeding, brushing, taking out, moving around, etc.
Participant No 13 (41- year- old, 228 months of caring period)
“The house is better when my wife's mother is not home, when she is home, when I come home from work, instead of telling me that work is good, this lady has been at work from morning to afternoon, she has worked outside the house, He is tired. Instead of reducing my fatigue, they make it more... It's inconsistent, it says the wrong thing, it destroys respect.”
One of the issues faced by the sandwich generation was the difficulty of living arrangement. Because there is incompatibility between family members.
Participant No 8 (31- year- old, 36 months of caring period)
“I cannot say that my child is right, even if my mother is guilty. I cannot say that my child is right, because I live in my mother's house. Sometimes, my child swears, or speaks unfairly, disrespects my mother, I can't fight my child because he is also very hurt.”
Both the older people and the children are important individuals in the sandwich generation, which respects them and strives to meet their needs. Therefore, when conflicts arise between them, calming and managing difficult situations becomes challenging. This is because it may be perceived as biased towards one side.
Participant No 7 (40- year- old, 6 months of caring period)
“If it's a school day and they have a class, I take them to school and then bring them back... I have to think about entertaining the children in the afternoon. I will take the children to a place in the afternoon where they will not be bored.”
The sandwich generation takes care of children's education, nutrition, clothing, hygiene and leisure.
4. Discussion
This study was conducted to explain the process of sandwich generation caregiving. According to the findings of the study, sandwich generation caregivers make the decision to simultaneously care for their elderly parents and their own children under the influence of factors such as mutual dependence and certain personality traits. Studies by Nichols and Junk (1997), Briggs et al. (2014), and Montgomery (1985) have also shown that caregivers, due to financial, emotional, geographical dependency, sense of duty, responsibility, problems of elderly individuals, returning home after divorce, compassion, inability to ignore a needy person, need for a sense of usefulness, need to help others, and feeling called to caregiving, put themselves in a caregiving situation [13,14,15].
According to the Five-Factor Model (FFM), personality traits of individuals are placed in five dimensions of neuroticism, extraversion, agreeableness, openness, and conscientiousness. These personality traits play a significant role in assuming various roles in life, and according to Snyder's (2015) study, these personality traits also influence the selected coping strategies of caregivers [16]. When entering the caregiving process, an individual may have experience and expertise in caregiving, which can have a significant impact on the caregiving process. Previous studies suggest that previous experiences affect the family's capacity for caregiving and success or failure in current caregiving and having experience can boost the self-esteem of caregivers and lead individuals to take on more supportive roles [17,18].
Caregivers face pressures and challenges from the beginning of caregiving, so the intensity and nature of these pressures may change over time. The experience of caregiving burden among caregivers is evident, and this study revealed that the age of the elderly, children, sandwich generation, and the number of family members play a determining role in the experienced caregiving burden. It is noteworthy that caregivers must take measures to prevent and reduce caregiving burden; otherwise, the caregiving burden can strain the relationship between the sandwich generation and their spouses [19].
Stormy weather and support paradox are the background factors of this study. Stormy weather means challenges that are experienced as a result of several generations living together. Based on the theory of family systems, it seeks to maintain stability and balance. But according to the different generations in the family, their attitudes and beliefs are different. These differences can lead to incompatibility between family members. In sandwich generation families, the middle-aged person is expected to understand and mediate between the other two generations. These expectations can also double the caregiver's responsibilities [20].
Caregivers need financial, psychological and social support from those around them during the care process. Access to this support varies from caregiver to caregiver. For example, it is possible that a caregiver receives psychological support but does not have social and financial support. Of course, it goes without saying that some caregivers do not have any support. The availability of support provides an opportunity for caregivers to take time for themselves and rejuvenate. Additionally, according to the results of Riley et al. (2007) study, having support can enhance resilience, self-esteem, and reduce psychological pressure [21].
Multigenerational care involves meeting the needs of different generations at the same time. Therefore, it can be said that the caregiver is placed between these needs. Caregivers play a role in doing daily household chores, meeting the daily needs of children, and providing practical assistance to the elderly. They experience the difficulty of balancing generations and the inability to plan at home. By using the existing definitions of sandwich production and the results of Hamilton and Tennakanen (2021) studies, this part of the research results can be explained. The sandwich generation is involved in several intergenerational transfers such as caregiving, financial assistance, practical assistance, and emotional closeness [22].
The results of the study showed that caregivers experience being sandwiched under the influence of causal, intervening and contextual factors. Being sandwiched as a central concept had the ability to partially integrate between the obtained concepts. When caregivers find themselves in this situation, they seek to find solutions, which in this study were called searching for the beach. Studies in this field have also pointed to the strategies used by the sandwich generation. Receiving social assistance, prioritizing oneself, allocating time for mental and physical strategies, and engaging in social relationships are among the solutions that were shared between the results of this study and other studies. But solutions such as the desire to be temporarily away from the family to reduce the pressure of care, the desire to live independently from the elderly, and mediation by previous studies, have not been confirmed or rejected [23,24].
This study revealed that the outcome of caregiving can be either positive or negative. In the present study, the concepts of green growth on stone and embracing life had positive consequences that the studied caregivers experienced. Green growth on stone includes harmonious family relationships, intergenerational transfer of experiences, stress reduction, strengthening emotional bonds, and being a source of support for the elderly.
The result of using these strategies can be positive or negative. In the present study, the concepts of green growth on stone and embracing life were the positive outcomes experienced by the caregivers studied. If the caregiver can choose a suitable solution according to their care and family conditions, then care will be a positive experience. Numerous studies have shown that caregivers experience positive outcomes such as receiving support, being understood by their spouse, strengthening life skills, bringing family members closer, feeling satisfied, transferring intergenerational experiences, and being a role model for children. In addition, it was found in this study that tensions between family members are reduced and also caring for the elderly can act as a boost for the sandwich generation's foresight. However, if a person does not have the ability or opportunity to use management strategies for these conditions, they may experience self-neglect, child neglect, and caregiving burden. Various studies also confirm that children are prone to depression, reduced performance, dual parenting and problem behavior [25,26].
The sandwich generation, due to being involved in caring for other family members and managing their relationships and needs, therefore does not have the opportunity to allocate time for themselves. Consequently, they tend to prioritize themselves over other family members [1,27]. On the other hand, meeting the multidimensional needs of family members also affects all dimensions of the sandwich generation and they experience the burden of caregiving [28,29].
5. Conclusions
The research findings provide insight into the sandwiching process, major strategies, and their consequences among caregivers of the sandwich generation. It should be noted that the reasons behind individuals' inclination to care for multiple generations, as well as the methods of providing care, the time invested, and other factors, vary across different countries. In Iran, caregivers of the sandwiched generation voluntarily or involuntarily find themselves in this position, leading to various impacts on different aspects of their lives. Sandwich generation families seek coping strategies and techniques to manage the situation, striving to establish and maintain balance. They may face the burden of caregiving, neglect of children and self-care, or caregiving may become a characteristic shared by two generations, evoking positive emotions within the sandwich generation. In other words, the experience of caregivers in the sandwich generation can be either positive or negative. To prevent or alleviate the consequences associated with caring for the sandwich generation, it is recommended to establish and implement dedicated services and support systems specifically tailored to the needs of sandwich generation caregivers. Therefore, it is crucial for planners and policymakers to prioritize this group and their circumstances, formulating appropriate support programs that consider the unique conditions of the sandwich generation, including childcare and elderly care services, as well as providing facilities to enhance caregivers' well-being. Professionals such as social workers and psychologists can utilize the generated knowledge to design interventions aimed at reducing the caregiving burden and providing self-care training. Some of the study's outcomes can be evaluated using existing validated tools, while others may require the development of new assessment instruments. Therefore, researchers are advised to employ available tools to investigate caregivers and, if necessary, design new instruments to capture relevant aspects of the caregiving experience.
6. Limitations
Due to the spread of the Covid-19 virus and its pandemic, it was not possible to conduct interviews at the participants' homes. Also, due to the non-satisfaction of the sandwich generation person or due to the young age of the child, it was not possible to conduct an interview with the sandwich generation children. Due to their physical and mental conditions and the spread of the Covid-19 virus, the older people could not leave their homes. Therefore, they were not interviewed either.
Author Contributions
Conceptualization, H.P, M.M, Y.A.M and K.A; Methodology, H.P, M.M, Y.A.M and K.A; Investigation and interviews, H.P.; Data curation and formal analysis, H.P, M.M, Y.A.M and K.A, Writing—original draft preparation, H.P.; Writing—review and editing, H.P, M.M, Y.A.M and K.A.; Supervision, M.M, Y.A.M. and W.M. All authors have read and agreed to the published version of the manuscript.
Funding
This research received no external funding.
Informed Consent Statement
Informed consent was obtained from all study participants.
Acknowledgments
We gratefully thank the Rofeideh Rehabilitation Hospital and Nikookaran Sharif Charity for their cooperation.
Conflicts of Interest
The authors declare no conflict of interest regarding this study.
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Figure 1.
Process of being sandwich.
Table 1.
Characteristics of research participants.
| Participants' Number | Age | Employment status of SG | Duration of care (Month) | |||||
|---|---|---|---|---|---|---|---|---|
| Sandwich Generation | Older Adult (Female) | Older Adult (Male) | First Child | Second Child | Third Child | |||
| 1 | 47 | 83 | 14 | Employed | 14 | |||
| 2 | 42 | 73 | 17 | Employed | 16 | |||
| 3 | 58 | 81 | 83 | 23 | Retired | 12 | ||
| 4 | 48 | 79 | 22 | 13 | Retired | 96 | ||
| 5 | 31 | 56 | 60 | 9 | 6 | Employed | 36 | |
| 6 | 41 | 63 | 63 | 12 | Employed | 24 | ||
| 7 | 40 | 62 | 17 | 6 | Housewife | 6 | ||
| 8 | 31 | 65 | 14 | 9 | 5 | Housewife | 36 | |
| 9 | 39 | 75 | 14 | Employed | 24 | |||
| 10 | 45 | 68 | 23 | 21 | 18 | Housewife | 24 | |
| 11 | 38 | 55 | 70 | 10 | 8 | Housewife | 120 | |
| 12 | 40 | 90 | 18 | 12 | 9 | Housewife | 12 | |
| 13 | 41 | 70 | 12 | 8 | 5 | Housewife | 228 | |
| 14 | 40 | 75 | 21 | 18 | 7 | Housewife | 9 | |
| 15 | 32 | 70 | 12 | 7 | Housewife | 24 | ||
| 16 | 38 | 65 | 8 | 3 (Month) | Housewife | 48 | ||
| 17 | 60 | 81 | 25 | 18 | Housewife | 120 | ||
| 18 | 42 | 70 | 16 | 10 | Housewife | 60 | ||
Table 2.
The process of concept extraction.
| Contextual Condition Contextual Condition Contextual Condition |
Stormy weather | Elderly's Lack of Adaptation to Sandwich Generation Children Elderly's Lack of Adaptation to Sandwich Generation Spouse Children's Lack of Adaptation to the Elderly Children's Lack of Adaptation to the Sandwich Generation Unrealistic Expectations of the Elderly Misunderstanding and Disruption of Peace by the Sandwich Generation from the Elderly Frequent Interference from Relatives Elderly's Uncooperativeness with the Sandwich Generation for Mobility Emergence of Marital Problems Physical Space Constraints Inappropriate Interference of the Elderly in Family Life Interference from Others |
| Supportive paradox | Lack of Support in Daily Tasks Insufficient Support from Relatives Decreased Access to Care Resources Lack of Trust in Other Care Resources Adequate Support from Relatives Lack of Organizational Support Resistance to Outsourcing Care Spousal Support Psychological Support for the SG from the Elderly Reduced Care Burden through Collaboration with Others |
|
| Negative outcomes Negative Outcomes |
Care burden | Feelings of Despair in the SG Workplace Challenges Lack of Recognition from Family Financial Burden Experience Psychological Burden Experience Physical Burden Experience |
| Self- neglect | Restricted Family Relationships in the SG Time Constraints in the SG Decreased Sleep and Insufficient Rest Job Abandonment Lack of Adequate Nutrition Limited Leisure Time Constraints in Monitoring Medical Affairs Restricted Social Relationships in the Sandwich Generation |
|
| Children- neglect | Emergence of Psychological Issues in Children Disruption in Children's Academic Matters Restriction of Children's Freedom of Action Dual Parenting of SG Children |
|
| Positive outcomes Positive outcomes |
Grass growing from stone | The Caregiving Wake-up Call for SG's Future Planning Children's Emulation of the Sandwich Generation Being a Support System for the Sandwich Generation's Elderly Reduction of Tensions Strengthening of Emotional Bonds Inter-generational Transfer of Experiences Adaptation of SG Spouse with the Elderly Adaptation of SG Children with the Elderly |
| Embracing life | Adaptation to the Passage of Time Normative Care Coping with Multi-Generational Living Acceptance of Aging Characteristics |
|
| Strategies for managing condition | Looking for beach | Tendency to Distance Oneself from Family to Reduce Care Pressure Desire for Independent Living Apart from the Elderly Prioritizing Needs for Responsiveness Utilizing Available Community Services Keeping Children Away from the Environment Mediating for the Sandwich Generation Remote Monitoring of the Elderly Finding Inner Peace through Spiritual Matters Finding Inner Peace through Establishing Relationships Finding Inner Peace through Emotional Outlet Finding Inner Peace through Engaging in Favorite Activities |
| Core Concept | Being sandwich | Managing Household Chores Performing Multiple Responsibilities Addressing Children's Everyday Needs Feeling Sandwiched Challenges in Creating Inter-Generational Balance Challenging Multi-Generational Living Arrangements Difficulty in Planning at Home Practical Assistance to the Elderly |
| Casual conditions Casual conditions |
Interdependence | Financial Dependence of the SG Sense of Duty Elderly Physical Challenges Lack of Cooperation from Relatives Spiritual Aspect of Caregiving |
| Caregivers' personality prominence | Idealistic Nature of the SG Being a Manager in the SG Having a Supportive Personality in the SG |
|
| Intervene condition | Cumulative burden over time | Alignment of Care Pressure with Dependency Level Alignment of Care Pressure with Family Size Increase in Care Pressure with Elderly Aging Variation in Care Pressure with Increasing Age in the SG Variation in Care Pressure with Children's Age Stages |
| Caring proficiency | Becoming Skilled in Caregiving Over Time Having Caregiving Experience |
|
| Older people problems and dependencies | Physical and Psychological Dependency of the Elderly on the SG Elderly Physical Challenges Elderly Mental Health Issues |
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