The opportunity costs of informal care: does gender matter?

Gender identity in informal care: impact on health in Spanish caregivers

We examined the influence of gender identity on men's and women's perceptions of assuming the caregiver role to identify different coping strategies and the effects on caregiver health and quality of life. The study, performed in Andalusia, Spain, was based on a sociological analysis of the narratives produced during semistructured interviews with primary informal caregivers (16 men and 16 women) of different profiles. We observed a cultural assumption that women should assume the caregiver role and found that women shouldered the bulk of caregiving responsibilities and did not usually seek support. This might explain the high prevalence of chronic health disorders, stress, anxiety, depression, neglect of health, and social isolation we observed among women caregivers. Because the caregiver role was not socially imposed on men in our setting, men caregivers adopted a flexible attitude and tended to seek external support before their health and quality of life were seriously affected.

"Do I stay or do I go?"--job change and labor market exit intentions of employees providing informal care to older adults

This article examines whether providing informal eldercare to an older dependent person predicts employees' intentions to change jobs or exit the labor market and, if so, which particular aspects of both caregiving (e.g. time demands, physical/cognitive care burden) and their current work environment shape these intentions. We used data from a sample of 471 caring and 431 noncaring employees in Austria and split the analyses by gender. We found different aspects of informal caregiving to be associated with the intention to change jobs and with the anticipated labor market withdrawal of male and female workers. A time-based conflict between informal eldercare and paid work was significantly and positively related to the intended job change of female workers but not of their male counterparts. Flexible work arrangements were found to facilitate the attachment of female workers to their jobs and the labor market. Intentions to exit the labor market of male workers appeared to be triggered by a physical care burden rather than time demands.

HIGHLIGHTS

We studied the effects of providing informal eldercare on the turnover intention of men and women in a group of workers who were also the main carers providing support to a dependent older person with substantial care needs. The intention of male and female workers to change jobs and exit the labor market is shaped by the different characteristics of informal caregiving. Time-based conflicts between informal care and paid work are associated with a higher relative risk of anticipating job changes for female workers. Flextime facilitates the job and labor market attachment of female workers with eldercare responsibilities. The intensity of personal care provided to an older relative is significantly positively related to male workers' relative risk of anticipated labor market exit. Care to an older person in need of supervision makes the labor market exit of female workers less likely, lending thus support to the idea of the respite effect of work.

The Psychological Effects of Providing Personal Care to a Partner: A Multidimensional Perspective

The expected increasing demand for informal care in aging societies underscores the importance of understanding the psychological implications of caregiving. This study explores the effect of providing regular help with personal care to a partner on different aspects of psychological well-being. We use cross-sectional data from the Norwegian Life Course, Ageing and Generation study (n. ~15,000; age 40-84) and two-wave panel data from the Norwegian study on Life Course, Ageing and Generation (n. ~3000; age 40-84). To separate the effects of providing care from those of the partner's disability, caregivers are contrasted with non-caregivers with both disabled and nondisabled partners. We separate outcomes into cognitive well-being (life satisfaction), psychological functioning (self-esteem, mastery), and affective well-being (happiness, depression, loneliness). Findings show that caregiving has important cross-sectional and longitudinal detrimental psychological effects. These effects are fairly consistent across all aspects of well-being, demonstrating that caregiving has a broad-based negative impact. Among women, however, these effects are similar to if not weaker than the effects of a partner's disability. Caregiving effects are constant by age, education, and employment status, but stronger among caregivers with health problems. Providing personal care to a partner is associated with marked adverse psychological effects for men and women irrespective of age and socio-economic status. Hence, no sociodemographic group is immune from caregiving stress, so programs should be targeted generally. The results also suggest that the health needs of caregivers demand more attention.

Economic analysis of the intangible impacts of informal care for people with Alzheimer's disease and other mental disorders

OBJECTIVES

Valuation of the intangible impacts of informal care remains a great challenge for economic evaluation, especially in the framework of care recipients with cognitive impairment. Our main objective was to explore the influence of intangible impacts of caring on both informal caregivers' ability to estimate their willingness to pay (WTP) to be replaced and their WTP value.

METHODS

We mapped characteristics that influence ability or inability to estimate WTP by using a multiple correspondence analysis. We ran a bivariate probit model with sample selection to further analyze the caregivers' WTP value conditional on their ability to estimate their WTP.

RESULTS

A distinction exists between the opportunity costs of the caring dimension and those of the intangible costs and benefits of caring. Informal caregivers' ability to estimate WTP is negatively influenced by both intangible benefits from caring (P < 0.001) and negative intangible impacts of caring (P < 0.05). Caregivers' WTP value is negatively associated with positive intangible impacts of informal care (P < 0.01).

CONCLUSIONS

Informal caregivers' WTP and their ability to estimate WTP are both influenced by intangible burden and benefit of caring. These results call into question the relevance of a hypothetical generalized financial compensation system as the optimal way to motivate caregivers to continue providing care.

When is a carer's employment at risk? Longitudinal analysis of unpaid care and employment in midlife in England

This article examines the thresholds at which provision of unpaid care affects employment in England. Previous research has shown that providing care for 20 or more hours a week has a negative effect on employment. The present article explores the impact of a lower threshold and asks whether provision of care for 10 or more hours a week has a negative effect on employment. The article focuses on women and men aged between 50 and State Pension Age (60 for women, 65 for men). The study uses data from the first four waves of the English Longitudinal Study of Ageing (ELSA), collected in 2002/2003, 2004/2005, 2006/2007 and 2008/2009. Across these waves, there are 17,123 people aged 50-59/64 years, of whom 9% provide unpaid care to an adult. Using logistic regression analysis of the longitudinal data, the study finds that employed women in their fifties who start providing care for <10 hours a week are significantly more likely to remain in employment one wave later than similar women who have not started to provide care. In contrast, employed women in their fifties who start providing care for 10 or more hours a week are significantly less likely to remain in employment one wave later than similar women who have not started to provide care. Employed men aged between 50 and State Pension Age, who provide care for 10 or more hours a week at the beginning of the period have a significantly reduced employment rate one wave later than those who do not provide care. The study therefore suggests that carers' employment may be negatively affected when care is provided at a lower intensity than is generally estimated in England. This has important implications for local authorities, who have a duty to provide services to carers whose employment is at risk.

Cross-national differences in the prevalence and correlates of burden among older family caregivers in the World Health Organization World Mental Health (WMH) Surveys

BACKGROUND

Current trends in population aging affect both recipients and providers of informal family caregiving, as the pool of family caregivers is shrinking while demand is increasing. Epidemiological research has not yet examined the implications of these trends for burdens experienced by aging family caregivers. Method Cross-sectional community surveys in 20 countries asked 13 892 respondents aged 50+ years about the objective (time, financial) and subjective (distress, embarrassment) burdens they experience in providing care to first-degree relatives with 12 broadly defined serious physical and mental conditions. Differential burden was examined by country income category, kinship status and type of condition.

RESULTS

Among the 26.9-42.5% respondents in high-, upper-middle-, and low-/lower-middle-income countries reporting serious relative health conditions, 35.7-42.5% reported burden. Of those, 25.2-29.0% spent time and 13.5-19.4% money, while 24.4-30.6% felt distress and 6.4-21.7% embarrassment. Mean caregiving hours per week in those giving any time were 16.6-23.6 (169.9-205.8 h/week per 100 people aged 50+ years). Burden in low-/lower-middle-income countries was 2- to 3-fold higher than in higher-income countries, with any financial burden averaging 14.3% of median family income in high-, 17.7% in upper-middle-, and 39.8% in low-/lower-middle-income countries. Higher burden was reported by women than men and for conditions of spouses and children than parents or siblings.

CONCLUSIONS

Uncompensated family caregiving is an important societal asset that offsets rising formal healthcare costs. However, the substantial burdens experienced by aging caregivers across multiple family health conditions and geographic regions threaten the continued integrity of their caregiving capacity. Initiatives supporting older family caregivers are consequently needed, especially in low-/lower-middle-income countries.

The effect of informal care on work and wages

Cross-sectional evidence in the United States finds that informal caregivers have less attachment to the labor force. The causal mechanism is unclear: do children who work less become informal caregivers, or are children who become caregivers working less? Using longitudinal data from the Health and Retirement Study, we identify the relationship between informal care and work in the United States, both on the intensive and extensive margins, and examine wage effects. We control for time-invariant individual heterogeneity; rule out or control for endogeneity; examine effects for men and women separately; and analyze heterogeneous effects by task and intensity. We find modest decreases-2.4 percentage points-in the likelihood of working for male caregivers providing personal care. Female chore caregivers, meanwhile, are more likely to be retired. For female care providers who remain working, we find evidence that they decrease work by 3-10hours per week and face a 3 percent lower wage than non-caregivers. We find little effect of caregiving on working men's hours or wages. These estimates suggest that the opportunity costs to informal care providers are important to consider when making policy recommendations about the design and funding of public long-term care programs.

Informal eldercare and work-related strain

OBJECTIVES

In light of an aging workforce, reconciling informal eldercare and paid work becomes increasingly pertinent. This article investigates the association between informal eldercare and work-related strain and tests for both the "competing demands" and "expansion" hypotheses.

METHOD

The sample of 938 Austrian employees consisted of employees caring for older relatives and a control group of employees without eldercare obligations. We ran a Tobit regression model on work-related strain with different measures of informal eldercare as explanatory variables and controls for both personal and workplace characteristics.

RESULTS

Accounting for different characteristics of eldercare within one estimation model revealed that informal eldercare was associated with work-related strain in 2 ways, that is, it increased with both care hours and subjective care burden. However, after controlling for these burdensome attributes of eldercare, the carer status as such was found to be negatively associated with work-related strain. In addition and independently of care commitments, work-related factors, such as advanced skills and job motivation, reduced work-related strain.

DISCUSSION

This article lends support to both the "competing demands" and the "expansion" hypotheses. Commitment to eldercare can enhance work-related outcomes but entails work-related problems if care burden and time demands of eldercare are substantial. Thus, workers with eldercare responsibilities cannot be considered less productive from the outset. An individual assessment of their situation, considering the care and work setting, is required. Findings from this study support the design of workplace initiatives to uphold workers' productivity in general and bring specific attention to policies alleviating workers' eldercare burden.

Informal caring-time and caregiver satisfaction

This paper examines the role of care decision processes on informal caring-time choices. We focus on three care decisions: the caregiver's own decision, a family decision and a recipient request. Results show that informal caregivers, engaged in care activities as a result of a family decision, are more likely to devote more than 5 h to care activities, even after allowing for endogeneity. Our findings are robust to controlling for a large number of socio-demographic characteristics, including care recipient and caregiver characteristics. Supplemental analysis, developed to explore whether care arrangements are related to informal caregiver's satisfaction, indicates that the family decision heavily penalizes informal caregivers. Given the importance of informal care activities in reducing health care costs, our findings imply that care decision processes should be taken into consideration when formulating health care policies.

Is Policy Well-Targeted to Remedy Financial Strain among Caregivers of Severely Injured U.S. Service Members?

U.S. military service members have sustained severe injuries since the start of the wars in Iraq and Afghanistan. This paper aims to determine the factors associated with financial strain of their caregivers and establish whether recent federal legislation targets caregivers experiencing financial strain. In our national survey, 62.3% of caregivers depleted assets and/or accumulated debt, and 41% of working caregivers left the labor force. If a severely injured veteran needed intensive help, the primary caregiver faced odds 4.63 times higher of leaving the labor force, and used $27,576 more in assets and/or accumulated debt compared to caregivers of veterans needing little or no assistance.

Work restrictions experienced by midlife family care-givers of older people: evidence from six European countries

This paper examines differences in work restrictions of midlife family carers of older people in terms of prevalence, gender and explanatory variables, in six European countries: Germany, Greece, Italy, Poland, Sweden and the United Kingdom. A sample of 2,897 carers aged 45–64 was extracted from the EUROFAMCARE (Services for Supporting Family Carers of Older People in Europe: Characteristics, Coverage and Usage) European project database, in order to analyse four possible work restrictions experienced in connection with the activity of care-giving: the reduction of working hours; giving up working; difficulties in career developments and forced occasional work. The results show that work restrictions are experienced differently between countries especially by women: they are reported to a higher degree in the United Kingdom, Germany and Greece, less so in Italy, and seldom in Poland and Sweden. Gender differences within countries are not so marked. Country differences are explained in the light of the different welfare regimes characterising the countries under investigation, in order to elucidate how policy makers may act to improve working carers' conditions through appropriate policies.

The employment costs of caregiving in Norway

Informal eldercare is an important pillar of modern welfare states and the ongoing demographic transition increases the demand for it while social trends reduce the supply. Substantial opportunity costs of informal eldercare in terms of forgone labor opportunities have been identified, yet the effects seem to differ substantially across states and there is a controversy on the effects in the Nordic welfare states. In this study, the effects of informal care on the probability of being employed, the number of hours worked, and wages in Norway are analyzed using data from the Life cOurse, Generation, and Gender survey. New and previously suggested instrumental variables are used to control for the potential endogeneity existing between informal care and employment-related outcomes. In total, being an informal caregiver in Norway is found to entail substantially less costs in terms of forgone formal employment opportunities than in non-Nordic welfare states.

The trade-off between formal and informal care in Spain

Understanding the factors that determine the type and amount of formal care is important for predicting use in the future and developing long-term policy. In this context, we jointly analyze the provision of care at both the extensive (choice of care) and the intensive margin (number of hours of care received). In particular, we estimate and test, for the first time in this area of research, a sample selection model with the particularities that the first step is a multinomial logit model and the hours of care is an interval variable. Our results support the complementary and task-specific models which evidence has been found in other countries. Furthermore, we obtain evidence of substitution between formal and informal care for the male, young, married and unmarried subsamples. Regarding the hours of care, we find significant biases in predicted hours of care when sample selection is not taken into account. For the whole sample, the average bias is 2.77% for total hours and 3.23% for formal care hours. However, biases can be much larger (up to 10-15%), depending on the subsample and the type of care considered.

Informal caregiving patterns in Korea and European countries: a cross-national comparison

PURPOSE

This ecological study examined demographic and institutional differences in informal caregiving. We conducted a cross-national study about the characteristics of informal caregivers in 12 European countries and Korea.

METHODS

Data were collected from individuals aged 50 years and older participating in the 2004/2005 Survey of Health, Ageing and Retirement in Europe and the 2006 Korean Longitudinal Study of Ageing. We examined the associations between informal caregiving and macrolevel characteristics (gross domestic product, total fertility rates, labor force participation rates, level of women's empowerment, long-term care resources).

RESULTS

Korea and some southern European countries, notably Spain and Italy, had high percentages of women, homemakers, coresidents, and spouses in informal caregiving roles. In contrast, Northern European countries such as Denmark and Sweden had high proportions of employed informal caregivers. Lower female labor force participation was associated with higher proportions of women caregivers. A higher proportion of women caregivers in the population were also associated with a lower national gross domestic product per capita.

CONCLUSION

Our findings suggest that several contextual and institutional variables are associated with the proportion of women participating in caregiving.

Time-bound opportunity costs of informal care: consequences for access to professional care, caregiver support, and labour supply estimates

The opportunity costs associated with the provision of informal care are usually estimated based on the reduced potential of the caregiver to partake in paid work (both in terms of whether they are able to undertake paid work, and if so the hours of work undertaken). In addition to the hours of informal care provided, these opportunity costs are also likely determined by the necessity to perform particular informal care tasks at specific moments of the day. The literature, to date, has largely overlooked this dimension of informal care. We used Dutch data from time use diaries which report patterns of informal care throughout the day which enables investigation of when particular activities are undertaken. We found that whereas some tasks must be performed at a relatively fixed time of day, others are shiftable and can be performed at other times or even on different days. Household and organisation activities are more likely to be undertaken by employed caregivers, and seem largely to be shiftable; whereas personal care contains unshiftable activities. This implies additional opportunity costs of providing personal care tasks - we term these "time-bound" opportunity costs. Since the care recipient's need for care may in part relate to unshiftable tasks, we conclude that one should be careful with using care need as an instrument of informal care in labour supply equations.

Cost of informal care for diabetic patients in Thailand

AIMS

The study estimated the cost of informal care for 475 randomly selected diabetic patients as identified by International Classification of Diseases, tenth revision (ICD-10 codes=E10-E14) and who received treatment at Waritchaphum hospital in Sakhon Nakhon province of Thailand during the financial year 2008.

METHODS

Informal care was valued by using revealed preference method. Information of informal caregiving was collected through direct personal interview method either from the patients or from the caregivers. The data on time spent for informal care were collected by using recall method.

RESULTS

The study covered a total of 190 informal caregivers. Average time spent on informal care was 112.38h per month. The estimated cost of informal care was USD 110,713.08 using opportunity cost approach and USD 93,896.52 using proxy good method in 2008 (1 USD=32 Thai Baht).

CONCLUSIONS

The study concluded that the hidden cost associated with informal caregiving is a burden for the Thai society. Hence, the economic cost associated with informal caregiving should be considered for future analyses of both the public health consequences of diabetes and interventions aimed at decreasing diabetic complications.

Do they care too much to work? The influence of caregiving intensity on the labour force participation of unpaid caregivers in Canada

The recent growth of the home care sector combined with societal and demographic changes have given rise to concerns about the adequacy of the supply of family and friend caregivers. Potential caregivers face competing time pressures that pull them in the direction of the labour market on one hand, and towards unpaid caregiving duties on the other. This paper examines the influence of unpaid caregiving on the labour supply of a cohort of working-aged caregivers in Canada, with particular emphasis on caregiving intensity. Results suggest that caregivers are heterogeneous in both their caregiving inputs and associated labour market responses, thereby underscoring the importance of controlling for caregiving intensity when measuring labour supply. The negative influence of primary caregiving on labour supply appears to be at the level of labour force participation, rather than on hours of work or wages.

Seeking a balance between employment and the care of an ageing parent

RATIONALE

A growing number of middle-aged people are engaged in informal care of their parents while employed. To provide support as employers, co-workers or staff, health care professionals need insight into the experiences of people managing these responsibilities.

AIM

To elucidate the experience of providing informal care to an ageing parent while managing the responsibilities of a working life.

METHODS

Narrative interviews were performed with 11 persons with experience of the phenomenon. Transcribed interviews were analysed with phenomenological hermeneutics.

ETHICS

Informed consent was given prior to the interviews. The study was approved by a research ethics committee.

FINDINGS

Providing informal care to an ageing parent while also pursuing a working life implies seeking balance: a balance between providing support to the parent's needs and one's responsibilities at work. Being employed supports this balance as it provides both fulfilment and refuge. Being capable of managing both roles grants a sense of satisfaction, supporting one's sense of balance in life. The balance can be supported by sharing the responsibility of caring for the ageing parent with others.

STUDY LIMITATIONS

Despite perceived saturation and an effort to provide for the possibility to consider internal consistency, the findings should be considered as a contribution to the understanding of the phenomenon, as experienced by individuals in their life world.

CONCLUSIONS

It is essential to recognise the impact that providing care for an ageing parent may have on the lives of a growing number of people, particularly if they have employment responsibilities. Acknowledgement by others supports one's ability to attain balance; as co-workers and managers, we can acknowledge the efforts of an informal caregiver and as health care staff recognise the valuable contribution made by people in mid-life who provide informal care for their ageing parents.

Economic burden for informal caregivers of lung and colorectal cancer patients

BACKGROUND

Informal care provides many benefits to cancer patients, but can be costly to caregivers. This study quantified the economic burden for informal caregivers of lung cancer (LC) and colorectal cancer (CRC) patients, examining differences by cancer type, phase of disease, stage at diagnosis, patient age, and relationship.

METHODS

A cross-sectional survey of caregivers of LC and CRC patients participating in the Share Thoughts on Care survey was conducted. Economic burden was calculated using the opportunity cost of caregiver time, the value of work hours lost, and out-of-pocket expenditures. Factors associated with economic burden to caregivers were modeled using fixed-effects generalized least squares estimation.

RESULTS

Informal caregivers (1,629) completed mailed surveys. Of these, 663, 822, and 144 were surveyed during the patient's initial phase (first year after diagnosis, not within 6 months of death), continuing phase (after 1 year, not within 6 months of death), and terminal phase (within 6 months of death) of disease, respectively. The accumulated economic burdens for caregivers were $7,028, $19,701, and $14,234 for those evaluated during the patient's initial phase, continuing phase, and terminal phase of disease, respectively. Economic burden was higher for caregivers of LC patients than CRC patients (p = .044) and for caregivers of patients diagnosed at stage 4 versus stage 1 (p = .001). Spouses faced higher economic burden than other relatives (p = .000) or friends (p = .000).

CONCLUSIONS

Economic burden for informal caregivers of LC and CRC patients is substantial and should be included in estimates of the societal cost of cancer care.

[Long-term care services in Spain: an overview]

To date, both in Spain and virtually all the other European Union (EU) countries, dependency has been seen to be a fundamentally private problem to be dealt with by the family concerned. In this way, whether through informal carers or contracted professionals, in the domestic environment or in care homes, it is the dependent person themselves and their families who currently bear the majority of the costs. In light of this, current concern lies in the social change that is coming on, mainly the accelerated aging process and the increased participation of middle-aged women in the labour market, which heighten the need for collective organisation of that which until now has been resolved within family circles. In this context, at the same time that the Government announces to issue a <<Long Term Care Law>> by the end of 2005, our paper briefly analyzes what we consider the four crucial issues in this area: the current scope of dependency problems and its possible future evolution, the characteristics of the current spanish long-term care system and its main problems; the role that health services should have in the dependency issue; and finally, the benefits and drawbacks of the main alternatives that the Administration could manage in case it intends to increase its involvement in this field.

Economic consequences for other family members of mental health problems in older people

OBJECTIVES

We estimated the effects of poor mental health among older family members on the labour supply and incomes of younger family members living in the same household. Due to policy differences, effects for Scotland were compared with other parts of the UK.

METHODS

Effects were estimated using the British Household Panel Survey (waves 1999-2006), with data from 621 older respondents and 800 younger family members. Mental health was assessed using the General Health Questionnaire (GHQ), together with self-reported presence of depression, anxiety, or other mental health problems.

RESULTS

The associations between labour supply and mental ill-health were found to vary by gender and region of the UK. For men, there were larger negative effects in Scotland relative to the rest of the UK. For women, mental ill-health was associated with increased labour supply in Scotland, while in the remainder of the UK, a negative association was observed. Income losses accrued across all groups except among Scottish females, with the largest significant negative effects observed among men living in the remainder of the UK.

CONCLUSIONS

Mental health problems among older family members are associated with significant labour market effects for younger family members. To reduce the economic consequences, better assessment of mental health among older people may be warranted. Further employment support for younger family members, in the form of more flexible work policies, might also serve to ameliorate economic losses.

Who will care? Employment participation and willingness to supply informal care

The impact of informal care responsibilities on the willingness and ability of caregivers to undertake paid employment has been the subject of a number of studies. In contrast, the effect of employment status on willingness to undertake informal care has been less well explored. This paper concentrates on this less-studied direction of causality using the data provided by 15 waves of the British Household Panel Survey. We find that employment participation and earnings both impact negatively on willingness to supply informal care. This evidence has implications for health and social care policy since informal care has been shown to be a significant substitute for formal long-term care.

Construct validity of the Work Productivity and Activity Impairment questionnaire across informal caregivers of chronically ill older patients

OBJECTIVES

To assess the validity of the Work Productivity and Activity Impairment questionnaire as adapted for caregiving (WPAI:CG) to measure productivity loss (hours missed from work, impairment while at work, and impairment in regular activities) due to unpaid caregiving for medically complex older adults.

METHODS

The WPAI:CG was administered along with the Caregiver Strain Index (CSI) and Center for Epidemiologic Studies Depression Scale (CESD) to a caregiving population (N = 308) enrolled with their older, medically complex care-recipient in a cluster-randomized controlled study. Correlation coefficients were calculated between each productivity variable derived from the WPAI:CG and CSI/CESD scores. Nonparametric tests for trend across ordered groups were carried out to examine the relationship between each productivity variable and the intensity of the caregiving.

RESULTS

Significant positive correlations were found between work productivity loss and caregiving-related strain (r = 0.45) and depression (r = 0.30). Measures of productivity loss were also highly associated with caregiving intensity (P < 0.05) and care-recipient medical care use (P < 0.05). The average employed caregiver reported 1.5 hours absence from work in the previous week and 18.5% reduced productivity while at work due to caregiving. Employed and nonemployed caregivers reported 27.2% reduced productivity in regular activities in the previous week.

CONCLUSION

The results indicate high convergent validity of the WPAI:CG questionnaire. This measure could facilitate research on the cost-effectiveness of caregiver-workplace interventions and provide employers and policy experts with a more accurate and comprehensive estimate of caregiving-related costs incurred by employers and society.

Proximity to death and participation in the long-term care market

The extent to which increasing longevity increases per capita demand for long-term care depends on the degree to which utilization is concentrated at the end of life. We estimate the marginal effect of proximity to death, measured by being within 2 years of death, on the probabilities of nursing home and formal home care use, and we determine whether this effect differs by availability of informal care--i.e. marital status and co-residence with an adult child. The analysis uses a sample of elderly aged 70+ from the 1993-2002 Health and Retirement Study. Simultaneous probit models address the joint decisions to use long-term care and co-reside with an adult child. Overall, proximity to death significantly increases the probability of nursing home use by 50.0% and of formal home care use by 12.4%. Availability of informal support significantly reduces the effect of proximity to death. Among married elderly, proximity to death has no effect on institutionalization. In conclusion, proximity to death is one of the main drivers of long-term care use, but changes in sources of informal support, such as an increase in the proportion of married elderly, may lessen its importance in shaping the demand for long-term care.

Does informal care from children to their elderly parents substitute for formal care in Europe?

This paper analyzes the impact of informal care by adult children on the use of long-term care among the elderly in Europe and the effect of the level of the parent's disability on this relationship. We focus on two types of formal home care that are the most likely to interact with informal care: paid domestic help and nursing care. Using recent European data emerging from the Survey on Health, Ageing and Retirement in Europe (SHARE), we build a two-part utilization model analyzing both the decision to use each type of formal care or not and the amount of formal care received by the elderly. Instrumental variables estimations are used to control for the potential endogeneity existing between formal and informal care. We find endogeneity of informal care in the decision to receive paid domestic help. Estimation results indicate that informal care substitutes for this type of formal home care. However, we find that this substitution effect tends to disappear as the level of disability of the elderly person increases. Finally, informal care is a weak complement to nursing care, independently of the level of disability. These results highlight the heterogeneous effects of informal care on formal care use and suggest that informal care is an effective substitute for long-term care as long as the needs of the elderly are low and require unskilled type of care. Any policy encouraging informal care to decrease long-term care expenditures should take it into account to assess its effectiveness.

Older people--recipients but also providers of informal care: an analysis among community samples in the Republic of Ireland and Northern Ireland

Data on both the provision and receipt of informal care among populations of older adults are limited. Patterns of both informal care provided and received by older adults in the Republic of Ireland (RoI) and Northern Ireland (NI) were evaluated. A cross-sectional community-based population survey was conducted. Randomly selected older people (aged 65+, n = 2033, mean age (standard deviation): 74.1 years (6.8), 43% men, 68% response rate) provided information on the provision and receipt of care, its location, and the person(s) who provided the care. Twelve per cent of the sample (251/2033) identified themselves as informal caregivers (8% RoI and 17% NI). Caregivers were more likely to be women, married, have less education and have less functional impairment. Forty-nine per cent (1033/2033, 49% RoI and 48% NI) reported receiving some form of care in the past year. Care recipients were more likely to be older, married, have more functional impairment, and poorer self-rated health. Receiving regular informal care (help at least once a week) from a non-resident relative was the most common form of help received [28% overall (578/2033); 27% RoI and 30% NI]. Five per cent (n = 102/2033) of the sample reported both providing and receiving informal care. Levels of informal care provided by community-dwelling older adults were notably higher than reported in single-item national census questions. The balance of formal and informal health and social care will become increasingly important as populations age. It is essential, therefore, to evaluate factors facilitating or impeding informal care delivery.

Informal and formal care for elderly persons: how adult children's characteristics affect the use of formal care in Japan

Informal care by adult children remains the most common source of caregiving for elderly parents in Japan, even after the introduction of long-term care insurance in 2000. We estimate how the potential supply of child caregivers affects the use of formal care of elderly parents, focusing on the differences across children. We find that the effects of children's presence vary substantially with gender, marital status, and opportunity costs of children. The potential supply of daughters-in-law, as the traditional source of informal care, is less important in providing care than that of unmarried children. The opportunity costs of children make a difference in the use of formal long-term care.

Your next of kin or your own career? Caring and working among the 50+ of Europe

An increasing demand for both formal and informal care is likely to result from the ongoing demographic transition at the same time as there is a further move away from the traditional domestic division of labour. Public policy-making that aims at increasing the supply of informal care necessitates knowledge about the relative importance of various incentives for individual care providers. This paper takes as a point of departure that the willingness to supply informal care is partly explained by the extent to which it adversely affects labour-market outcomes and analyses the effect on labour-market outcomes of providing informal care to one's elderly parent(s) among the 50+ of Europe. Data from SHARE (Survey of Health, Ageing, and Retirement in Europe) was used to examine the association between, on the one hand, hours of informal care provided and, on the other, (1) the probability of employment, (2) hours worked, and (3) wages, respectively. The results suggest that giving informal care to one's elderly parents is associated with significant costs in terms of foregone labour-market opportunities and that these adverse effects vary between countries.

Informal care and Medicare expenditures: testing for heterogeneous treatment effects

We estimate the effect of informal care on Medicare expenditures not only for care provided by children but also by the source of informal care (sons versus daughters, children versus others) and recipient characteristics (marital status). Our conceptual framework predicts heterogeneous effectiveness by source and recipient of informal care. We estimate two-part expenditure models as a function of informal care, controlling for endogeneity. We find that informal care by children reduces Medicare long-term care and inpatient expenditures of single elderly. We find that children are less effective caregivers among recipients who are married. For single elderly, child caregivers are more effective than other types. Gender of a child caregiver does not matter.

A tool to analyse gender mainstreaming and care-giving models in support plans for informal care: case studies in Andalusia and the United Kingdom

OBJECTIVE

To present a tool to analyse the design of support plans for informal care from a gender perspective, using the plans in Andalusia and the United Kingdom as case studies.

METHODOLOGY

A tool was drawn up to analyse gender mainstreaming and care-giving models involved in the documents. In the gender mainstreaming aspect, a symbolic dimension (gender mainstreaming in the plan's theoretical framework and analysis of situation) and an operational dimension (gender mainstreaming in the plan's proposals and actions) were defined. Four care-giving models were analysed using the following categories: the plan's definition of carer, focal point of interest, objectives and acknowledgement or otherwise of conflict of interests. A qualitative discourse analysis methodology was used.

RESULTS

The analysis tool used shows that the plans do not incorporate gender mainstreaming systematically, but there are interesting aspects from a gender perspective that are present at both a symbolic and an operational level. Both plans use a combination of care-giving models, but the model for superseding informal care is not included in either plan.

CONCLUSIONS

The proposed tool proved useful for the examination of the gender perspective in the formulation of the plans selected for analysis. Both plans introduce measures to improve the quality of life of informal carers. However, gender mainstreaming also implies interventions that will change situations of sexual inequality and injustice that occur in informal care in the long term. Likewise, aspects of feminist theory must be considered in order to draw up plans and policies that are sensitive to informal care and the emancipation of women carers.

Labor market work and home care's unpaid caregivers: a systematic review of labor force participation rates, predictors of labor market withdrawal, and hours of work

As people continue to age and receive complex health care services at home, concern has arisen about the availability of family caregivers and their ability to combine employment with caregiving. This article evaluates the international research on unpaid caregivers and their labor market choices, highlighting three conclusions: first, caregivers in general are equally as likely to be in the labor force as noncaregivers; second, caregivers are more likely to work fewer hours in the labor market than noncaregivers, particularly if their caring commitments are heavy; and finally, only those heavily involved in caregiving are significantly more likely to withdraw from the labor market than noncaregivers. Policy recommendations are targeting greater access to formal care for "intensive" caregivers and developing workplace policies for employed caregivers.

The earnings of informal carers: wage differentials and opportunity costs

A substantial proportion of working age individuals in Britain are looking after sick, disabled or elderly people, often combining their work and caring responsibilities. Previous research has shown that informal care is linked with substantial opportunity costs for the individual due to forgone wages as a result of non-labour market participation. In this paper we show that informal carers exhibit further disadvantages even when participating. Using the British Household Panel Study (BHPS) we decompose wage differentials and show that carers can expect lower returns for a given set of characteristics, with this wage penalty varying along the pay distribution and by gender. Furthermore, opportunity costs from forgone wages and wage penalties are estimated and found to be substantial.

The chicken or the egg? Endogeneity in labour market participation of informal carers in England

Around 14% of the UK labour force has informal care responsibilities and almost everyone in society will be an informal carer in their lifetime. A well-known fact in the small economic literature on informal care is the apparent negative relation between care responsibilities and labour market participation. Yet, caring and labour market participation may be endogenous. Using an instrumental variable approach and panel data techniques and employing data from the British Household Panel Study from 1991 to 2002, this paper shows that not accommodating for endogeneity in the labour market participation equation may significantly overestimate the impact care exhibits on the employment decision of informal carers. Moreover, it is shown that a negative impact on employment only applies to some care-types. Policy implications are derived.

Caregiver psychoeducation for schizophrenia: is gender important?

INTRODUCTION

Females care for individuals with chronic illness more commonly than males and have different attitudes to illness. Additionally, they experience greater burden and reduced quality of life, when compared to their male counterparts. Since knowledge has been shown to be related to burden, we sought to determine whether there were gender differences in knowledge acquisition during a six-week caregiver psychoeducation programme (CPP).

METHODS

Caregivers of people with schizophrenia completed a 23-item adapted version of the self-report Family Questionnaire (FQ) before and after the six-week CPP. Using a Generalized Linear Mixed Model, we studied the differences in proportions of correct answers before and after the programme by gender.

RESULTS

Over a 46-month study period, 115 caregivers (58% female) participated in the programme. There was an overall improvement in knowledge with an effect size of 1.12. The improvement was statistically significant (P<0.001) within each of six specific areas of knowledge. However, female caregivers gained more knowledge overall and specifically regarding signs and symptoms, recovery and especially caregiver support. Knowledge gains regarding medication were roughly equal, while male caregivers gained more knowledge about risk factors.

DISCUSSION

Our findings indicate that there are gender differences in the amount and type of knowledge gained during a CPP, with female caregivers showing greater knowledge acquisition than their male counterparts in most areas. Interventions designed to assist caregivers may be improved by targeting areas of knowledge specific to each gender. Such an approach might further reduce burden and improve the outcome for their relatives affected by schizophrenia.

Coping by stroke caregivers: sex similarities and differences

Informal care provision presents many challenges. As the population ages, more people are forced to enter the role of informal caretaker. Despite the increase in the need for caregivers and the importance of providing care, there is little empirical research examining how men and women approach and cope with providing care. The current study examined stroke patients and their care providers to assess possible gender differences in the impact of caretaking on caretakers and care recipients. Results indicate no significant difference in patient well-being based on the gender of the caregiver. Some measures indicated that men have advantages as caregivers. Results are discussed with regard to the accuracy and utility of sex-role stereotypes about caregivers. In addition, these data provide potential insight about how to decrease caregiver burden, delay long-term hospitalization of the patient, and increase the quality of life for caretakers and patients.

Informal care and health care use of older adults

Informal care by adult children is a common form of long-term care for older adults and can reduce medical expenditures if it substitutes for formal care. We address how informal care by all children affects formal care, which is critically important given demographic trends and the many policies proposed to promote informal care. We examine the 1998 Health and Retirement Survey (HRS) and 1995 Asset and Health Dynamics Among the Oldest-Old Panel Survey (AHEAD) using two-part utilization models. Instrumental variables (IV) estimation controls for the simultaneity of informal and formal care. Informal care reduces home health care use and delays nursing home entry.