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

The impact of unpaid caring on cognitive function: a rapid review

OBJECTIVES

Our review aimed to examine the role of unpaid care in influencing cognitive function independently or via risk factors for dementia.

METHOD

This rapid review, registered in PROSPERO and following PRISMA guidelines, searched EMBASE, MEDLINE, and APA PsycINFO databases for longitudinal studies comparing dementia, cognitive function and associated risk factors for dementia between carers and non-carers. Studies were assessed for quality. Data were synthesised narratively.

RESULTS

Five studies looked at cognitive function directly; others examined risk factors: depression, social isolation, physical activity, body-mass index, type 2 diabetes, high blood pressure, educational attainment, and alcohol consumption. Unpaid carers have increased risk of depression and social isolation, and younger carers have lower educational attainment. Studies evaluating the link between unpaid caring and cognitive decline suggest that caring at low and moderate intensities may act as a protective factor against cognitive decline, but not at higher intensities. Female gender and high-intensity caring significantly influence the strength of association between unpaid care and dementia risk factors.

CONCLUSION

The impact of unpaid caring on cognitive health is complex, influenced by factors like intensity of care and social and cultural context. Across all studies, high-intensity caring negatively impacts carers physical and mental health, which in turn affect their cognitive health.

The Effects of Spousal Caregiving on Middle-Age and Older Caregivers' Health and Well-Being: Evidence From Vietnam

Background: Population aging is escalating globally, intensifying the demand for long-term care (LTC), primarily met by informal caregivers, notably spouses. Evidence from developed countries suggests potential adverse effects on caregivers' well-being. Yet, research on this topic is scarce in developing nations. We investigate the effect of informal caregiving on older spousal caregivers' health and well-being in Vietnam, a rapidly aging country with an early stage of LTC system development. Methods: Utilizing the national survey on aging in Vietnam with propensity score matching estimations to mitigate potential endogenous problems of the decision to provide care between caregivers and non-caregivers. Results: Findings showed caregiving increased poor psychological well-being, life dissatisfaction, and functional limitations by 7.3%, 9.7%, and 8.6%, respectively. The caregiving effects are heterogenous by demographic characteristics. Conclusions: We are the first to examine spousal caregiving in Vietnam, highlighting the urgency of addressing its negative impacts and suggesting several potential policy interventions.

Projected costs of informal care for older people in England

BACKGROUND

Health economics research and economic evaluation have increasingly taken a societal perspective, accounting for the economic impacts of informal care. Projected economic costs of informal care help researchers and policymakers understand better the long-term consequences of policy reforms and health interventions. This study makes projections of the economic costs of informal care for older people in England.

METHODS

Data come from two national surveys: the English Longitudinal Study of Ageing (ELSA, N = 35,425) and the Health Survey for England (N = 17,292). We combine a Markov model with a macrosimulation model to make the projections. We explore a range of assumptions about future demographic and epidemiological trends to capture model uncertainty and take a Bayesian approach to capture parameter uncertainty.

RESULTS

We estimate that the economic costs of informal care were £54.2 billion in 2019, three times larger than the expenditure on formal long-term care. Those costs are projected to rise by 87% by 2039, faster than public expenditure but slower than private expenditure on formal long-term care. These results are sensitive to assumptions about future life expectancy, fertility rates, and progression of disabilities in the population.

CONCLUSIONS

Prevention schemes aiming to promote healthy aging and independence will be important to alleviate the costs of informal care. The government should strengthen support for informal caregivers and care recipients to ensure the adequacy of care, protect the well-being of caregivers, and prevent the costs of informal care from spilling over to other sectors of the economy.

Childhood Adversities and Caregiving for Older Parents: Building Capacity for a Caring Society

OBJECTIVES

This study investigates the relationships between childhood adversities and the provision of informal care for older parents in later life in China.

METHODS

The data came from 4 waves of the China Health and Retirement Longitudinal Study (N = 20,047). Using multilevel logistic regression models, we examined the relationships between adverse experiences in childhood and both the propensity and intensity of caregiving for older parents. Drawing on the regression results, we then estimated the total number of caregivers for older parents in China.

RESULTS

Experiencing 1 additional childhood adversity was associated with a decrease of 8% in the odds of providing informal care (p < .001). The association between childhood adversity and caregiving remained significant after sociodemographic factors and later-life outcomes were controlled for. We estimated that 58.3 million middle-aged adults in China were providing care for parents in 2020. Had people experienced 1 fewer adversity in their childhood, there would have been 2.2 million more caregivers in 2020. Had they experienced 2 fewer adversities, there would have been 3.4 million more caregivers.

DISCUSSION

The factors associated with informal caregiving can be traced back to early-life experiences. To address the shortage of informal care supply, it is crucial to foster a caring culture from the very beginning of human development.

Work and Retirement Among Women: The Health and Employment After Fifty Study

BACKGROUND

Women increasingly work beyond age 50+ but their occupational health is under-researched.

AIMS

To investigate what jobs older contemporary women do, when they exit their jobs and what factors predict job exit.

METHODS

Data came from the Health and Employment After Fifty cohort, which recruited women aged 50-64 at baseline in 2013-14 and has followed them up annually collecting: demographic, lifestyle and work information. Exits from employment were mapped longitudinally over five follow-ups. Time-to-first event Cox regression analyses were used to identify risk factors for job exit.

RESULTS

At baseline, 4436 women participated, 64% of whom were working. The proportions of women working at 50-54, 55-60 and over 60 years were 86%, 79% and 38%, respectively. Amongst all women, after adjustment for age, managing comfortably financially and not coping with the mental demands of the job were associated with exit. Risk factors for job exit differed in the age bands: 50-54; 55-59 and >60 years, reflecting socio-economic status, markers of health (musculoskeletal pain and poor self-rated health) and work factors (under-appreciation, job dissatisfaction, temporary/permanent contracts, coping with work's physical demands).

CONCLUSIONS

Factors contributing to exit from work among older women differ by age group, after controlling for perceived financial position, age and mental demands of the job. A number of work characteristics predict job exit and suggest that employers can play an important role in supporting women to continue working until older ages. Identification and treatment of musculoskeletal pain could also enable work amongst older women.

What works to support carers of older people and older carers? an international evidence map of interventions and outcomes

BACKGROUND

Unpaid carers of older people, and older unpaid carers, experience a range of adverse outcomes. Supporting carers should therefore be a public health priority. Our understanding of what works to support carers could be enhanced if future evaluations prioritise under-researched interventions and outcomes. To support this, we aimed to: map evidence about interventions to support carers, and the outcomes evaluated; and identify key gaps in current evidence.

METHODS

Evidence gap map review methods were used. Searches were carried out in three bibliographic databases for quantitative evaluations of carer interventions published in OECD high-income countries between 2013 and 2023. Interventions were eligible if they supported older carers (50 + years) of any aged recipient, or any aged carers of older people (50 + years).

FINDINGS

205 studies reported across 208 publications were included in the evidence map. The majority evaluated the impact of therapeutic and educational interventions on carer burden and carers' mental health. Some studies reported evidence about physical exercise interventions and befriending and peer support for carers, but these considered a limited range of outcomes. Few studies evaluated interventions that focused on delivering financial information and advice, pain management, and physical skills training for carers. Evaluations rarely considered the impact of interventions on carers' physical health, quality of life, and social and financial wellbeing. Very few studies considered whether interventions delivered equitable outcomes.

CONCLUSION

Evidence on what works best to support carers is extensive but limited in scope. A disproportionate focus on mental health and burden outcomes neglects other important areas where carers may need support. Given the impact of caring on carers' physical health, financial and social wellbeing, future research could evaluate interventions that aim to support these outcomes. Appraisal of whether interventions deliver equitable outcomes across diverse carer populations is critical.

[Reconciling Employment and Informal Caregiving for an Elderly Person at Home: Factors Influencing a Reduction in Employment due to Caregiving and Work-Related Wishes of Informal Caregivers]

OBJECTIVE

Reconciling informal caregiving and gainful employment is a challenge for many informal caregivers. The goals of this paper are to identify factors influencing care-related employment reduction, and to record work-related wishes for improving the compatibility of informal caregiving and being employed.

METHODS

Analyses were based on the cross-sectional Benefits of Being a Caregiver Study of 426 employed caregivers of an older person in need of care. Data were collected on characteristics of the care receivers and caregivers, and aspects of the caregiving and employment situation. Potential influencing factors of care-related employment reduction (n=426) were analyzed using binary logistic regression. The wishes regarding the compatibility of informal care at home and employment were examined descriptively using structured content analysis according to Mayring.

RESULTS

One quarter of the employed informal caregivers (n=108) reduced their hours of employment due to the demands of caregiving. The profile of influencing factors of a care-related employment reduction was composed of a higher number of working hours, higher effort for activities of daily living, and co-residence with the care receiver. Employed caregivers primarily expressed a desire for flexibility in working hours, a reduction in working hours, and some concessions with regard to absenteeism.

CONCLUSIONS

Relieving the burden on caregivers in the activities of daily living in form of formal and informal support services can probably reduce the likelihood of a care-related reduction in gainful employment.

Impacts of family care for children and the elderly on women's employment: evidence from rural China

Introduction

China's traditional culture makes rural women and men take on different family responsibilities.

Methods

Use "China Family Panel Studies" (CFPS) data and build Logit and propensity score matching models to empirically study the impact of children care and elderly care on rural married women going out to work. And explore the welfare effects of basic education public services in helping rural women take care of their families.

Results

The results show that caring for children has a significant hindering effect on rural married women's job hunting. Especially for those in low-income families, the employment inhibition is most significant among women aged 20-30 with multiple children. Contrary to previous cognition, supporting the elderly has a certain weak stimulating effect. The kindergarten public services in rural areas can help women take care of their children and relieve their work pressure. The primary school public services have not played a role in alleviating them.

Discussion

This shows that there are still a large number of female laborers in rural China who are unable to go out to work due to family care. The improvement of rural basic education public services can promote more rural women going out to work. This finding will provide a policy reference for the introduction of a formal care system and the establishment of basic education public services in China.

Inequalities in unpaid carer's health, employment status and social isolation

Providing higher-intensity unpaid care (higher care hours or care within the household) is associated with negative impacts on people's paid employment, mental health and well-being. The evidence of effects on physical health is mixed and carer's social and financial outcomes have been under-researched. The biggest evidence gap, however, is on how outcomes vary by factors other than type or level of care provision, in particular socio-demographic factors. Our study used two waves of data (2017/19 and 2018/2020) from the United Kingdom Household Longitudinal Study for people aged 16 and older. We investigated the effects of providing care for 10 or more hours a week or within the household in interaction with people's socio-demographic characteristics. Outcomes included mental and physical health, social isolation, employment status and earnings. We found that caring responsibilities interacted with gender, ethnicity, socio-economic status (as measured by highest educational qualification), or age to affect carers differentially in a number of areas of their lives leading to, and exacerbating, key disadvantages and inequalities.

Life Course Pathways Into Intergenerational Caregiving

OBJECTIVES

We develop a framework for the analysis of pathways into intergenerational caregiving to older people provided by family members using life course concepts of key turning events in life, cumulative processes, and linked lives within the family realm.

METHODS

Using framework analysis, we analyze semistructured qualitative interviews from a sample of dyads (older cared-for adults and their main family carers comprised of children, children-in-law, and grandchildren) in Austria (N = 24) and Slovenia (N = 52). Data were collected in 2019 through purposive sampling, including dyads from a differentiated socioeconomic background and gender.

RESULTS

The analysis reveals 4 nonexclusive pathways into caregiving. One pathway is associated with single turning events occurring in family or work trajectories of carers that expanded the possibilities for caregiving later in life. A second pathway referred to cumulative processes that later influenced transitions into caregiving, such as personal biographies marked by weak labor market attachment. Another cumulative pathway, exclusive to caregiving, is characterized by continued and sustained exchanges of support within families that cement reciprocal ties that underpin caregiving at later stages. In the fourth pathway, life trajectories of siblings, but also family relationships and conflicts, constrained carers into their role.

DISCUSSION

Decisions regarding caregiving within families can be best understood as processes, linked to developments in other trajectories in carers' lives, as much as to internal family dynamics and relationships. Becoming a carer may be itself the result of intertwined accumulated vulnerabilities, as well as cumulative exchanges within families.

Patterns of help and care by adult only children and children with siblings

Adult children with siblings can share caring for older parents but adult only children face this responsibility alone. Given increased longevity and reliance on informal care-giving, as well as an increase in one-child families, there is a need to investigate only children's care-giving further. Using data from three large-scale British birth cohorts, this paper investigates patterns of parent-care, care intensity and wellbeing at ages 38 and 42 (N = 17,255, N = 16,703; born 1970), 50 and 55 (N = 12,775, N = 11,339; born 1958) and 63 (N = 2,364; born 1946), how sibling composition intersects with gender in relation to care-giving and whether different care-giving patterns are associated with wellbeing. Only children are more likely to provide parent-care and the pattern is consistent with an interpretation that differences by sibling status might increase with age. Provision is gendered, and the sibling group composition matters for involvement. Although care-giving is related to wellbeing, we found no evidence that this differs between only children and those with siblings. The literature on only children has hitherto focused largely on childhood, suggesting that on some outcomes they benefit from a concentration of parental resources. Our results suggest that in middle adulthood parental care needs may instead be concentrated for the only child without the ‘resource’ of siblings. This indicates a need to develop further our understanding of this growing demographic subgroup.

Associations of discontinuation of care: A longitudinal analysis of the English Longitudinal Study of Ageing?

Informal carers play a vital part to ensuring that individuals in need of care, due to illness or disability, continue to experience a good quality of life. Care provision has been studied extensively, however, little is known about the associations of discontinuing care. This knowledge is important not only to ensure that informal carers are supported, even after caring episode, but also to ensure the care-recipients are not left without support. By conducting longitudinal analysis of the English Longitudinal Study of Ageing (ELSA), this paper uniquely starts to unveil the associations of discontinuing the caring role and the patterns of care provision prior to discontinuing. A multivariable binary regression analysis was conducted of the ELSA waves 7 (2015) to 8 (2017), total sample size of N = 6,687. 10.5% (n = 701) respondents were identified as discontinued carers. The dependent variable was care provided in wave 7 but not in wave 8 (a discontinued carer), compared to providing care in both waves (a continuing carer). Socio-demographic, such as age, gender, marital status, economic activity and health acted and caring patterns, such as intensity and relationship with care-recipient, acted as independent variables. Results showed nearly 30% of discontinued carers had provided care to a spouse. Nearly a quarter of continuing carers had transitioned between care-recipients, which raises the question of a potential 'Serial Carer Trajectory'. The regression analysis noted that being divorced or widowed increased the odds of discontinuing care. Providing 20-49 hr of care per week was associated with lower odds of discontinuing the role. This paper suggests that policymakers should take a holistic approach to policies to support carers through all stages of their caring journey, including after discontinuing the caring role. This could ensure carers settle into life post-caring and continue to feel valued and recognised.

Benefits and barriers of technologies supporting working carers-A scoping review

Combining work and care can be very challenging. If not adequately supported, carers' employment, well-being and relationships may be at risk. Technologies can be potential solutions. We carried out a scoping review to find out what is already known about technologies used by working carers. The search included academic and grey literature published between January 2000 and June 2020. Sixteen relevant publications were analysed and discussed in the context of the broader discourse on work-care reconciliation. Technologies discussed can be classified as: (a) web-based technologies; (b) technologies for direct communication; (c) monitoring technologies; and (d) task-sharing tools. Technologies can help to make work-care reconciliation more manageable and alleviate psychosocial and emotional stress. General barriers to using technology include limited digital skills, depending on others to use technologies, privacy and data protection, cost, limited technological capabilities, and limited awareness regarding available technologies. Barriers specific to some technologies include work disruptions, limited perceived usefulness, and lacking time and energy to use technologies. More research into technologies that can address the needs of working carers and how they are able to use them at work is needed.

Are informal family caregivers stigmatized differently based on their gender or employment status?: a German study on public stigma towards informal long-term caregivers of older individuals

Background

Stigma and informal caregiving are determinants for health and wellbeing, but few studies have examined stigma towards informal caregiving. Public stigma may be expressed differently towards caregivers depending on their gender and employment status due to societal norms. Therefore, this study analyzes if there is a difference in public stigma shown by the general population toward informal caregivers of care recipients aged 65 years or older based on the observed caregiver’s gender or working status.

Methods

A cross-sectional study was conducted in Germany. Data from 1038 adult participants from the general population in Germany were assessed with an Online-Survey. They were recruited with a quota-system based on the German micro census. Participants were randomly assigned to one of 16 vignettes describing a caregiving situation, which varied in the caregiver’s gender and working status, and care recipient’s gender and type of impairment. After reading the vignette, they were asked to provide sociodemographic information and complete three questionnaires on public stigma assessing their emotional (Emotional Reactions), behavioral (Social Distance) and cognitive reaction (Statements on informal caregivers) to the caregiver described in the vignette. Regression analyses, adjusted for sociodemographic data of the participants, were conducted.

Results

Findings indicated an association between reading about male caregivers and increased social distance, compared with reading about female caregivers. Reading about working caregivers was associated with decreased social distance and increased appreciative statements, compared to reading about non-working caregivers. Analyses after stratifying by gender of the caregiver in the vignette indicated an association between reading about female working caregivers and increased appreciative statements, compared to reading about female non-working caregivers. When stratifying by working status, an association was found between reading about male working caregivers and increased social distance, when compared to reading about female working caregivers.

Conclusions

This study’s findings indicate that gender and working status of the perceived informal caregivers are of relevance to the public stigma directed towards these caregivers. Male and non-working informal caregivers were shown more public stigma than female and working informal caregivers. Thus, interventions to reduce public stigma, in particular towards male and non-working caregivers, are recommended.

Shifting from Fragmentation to Integration: A Systematic Analysis of Long-Term Care Insurance Policies in China

Introduction

Long-term care is an effective intervention that help older people cope with significant declines in capacity. The growing demand for long-term care signals a new social risk and has been given a higher political priority in China. In 2016, 15 local authorities have been selected to pilot the long-term care insurance programme. However, the current implementation of these programmes is fragmented, with a measure of uncertainty. This study aims to investigate the principles and characteristics of long-term care insurance policies across all pilot authorities. It seeks to examine the design of local long-term care insurance systems and their current status.

Methodology

Based on the 2016 guidance, a systematic search for local policy documents on long-term care insurance across the 15 authorities was undertaken, followed by critical analysis to extract policy value and distinctive features in the delivery of long-term care.

Results

The results found that there were many inconsistencies in long-term care policies across local areas, leading to substantial variations in services to the beneficiaries, funding sources, benefit package, supply options and partnership working. Policy fragmentation has brought the postcode lottery and continued inequity for long-term care.

Discussion

Moving forward, local authorities need to have a clear vision of inter-organisational collaboration from the macro to the micro levels in directional and functional dimensions. At the national level, vertical governance should be interacted to outline good practice guidelines and build right service infrastructure. At the local level, horizontal organizations can collaborate to achieve an effective and efficient delivery of long-term care.

What are the consequences of caring for older people and what interventions are effective for supporting unpaid carers? A rapid review of systematic reviews

OBJECTIVES

To identify and map evidence about the consequences of unpaid caring for all carers of older people, and effective interventions to support this carer population.

DESIGN

A rapid review of systematic reviews, focused on the consequences for carers of unpaid caring for older people, and interventions to support this heterogeneous group of carers. Reviews of carers of all ages were eligible, with any outcome measures relating to carers' health, and social and financial well-being. Searches were conducted in MEDLINE, PsycInfo and Epistemonikos (January 2000 to January 2020). Records were screened, and included systematic reviews were quality appraised. Summary data were extracted and a narrative synthesis produced.

RESULTS

Twelve systematic reviews reporting evidence about the consequences of caring for carers (n=6) and assessing the effectiveness of carer interventions (n=6) were included. The review evidence typically focused on mental health outcomes, with little information identified about carers' physical, social and financial well-being. Clear estimates of the prevalence and severity of carer outcomes, and how these differ between carers and non-carers, were absent. A range of interventions were identified, but there was no strong evidence of effectiveness. In some studies, the choice of outcome measure may underestimate the full impact of an intervention.

CONCLUSIONS

Current evidence fails to fully quantify the impacts that caring for older people has on carers' health and well-being. Information on social patterning of the consequences of caring is absent. Systematic measurement of a broad range of outcomes, with comparison to the general population, is needed to better understand the true consequences of caring. Classification of unpaid caring as a social determinant of health could be an effective lever to bring greater focus and support to this population. Further work is needed to develop and identify suitable interventions in order to support evidence-based policymaking and practice.

Constraints that discourage participation in the labour market by female carers of older relatives in Santiago, Chile

Providing care for older people who have support needs is mainly a familial and female responsibility in Chile. Despite Chile's development level, the participation of females in the workforce lags behind (at around 50%), and 72% of female carers of an older relative are not in the labour force. This paper explores the reasons why in Latin America adult children remain out of the labour force while caring for an older parent or parent-in-law who has support needs. It draws on 30 in-depth interviews of family carers from low- to high-income households. The interviews were carried out in Chile in 2017, and were analysed using an inductive thematic analysis to identify core themes related to the subjects' reasons for remaining out of the labour force. Four factors hinder the combination of paid work and caring for a parent or parent-in-law with support needs: (a) externalised care was too expensive; (b) finding non-precarious, flexible work was difficult; (c) their perception of femininity or womanhood conflicted with the idea of combining care and paid work; and (d) they experienced a lack of public and/or social support.

What factors enable mid-life carers to re-enter the labour market in New Zealand?

OBJECTIVE

To assess the characteristics of carers and the caregiving situation associated with return to paid employment among older unemployed carers in New Zealand.

METHODS

A baseline sample of 280 unemployed carers was identified from responses by people aged 55-70 to the 2012-2016 biennial waves of the New Zealand Health, Work and Retirement longitudinal survey. Multiple logistic regression analysis was used to assess characteristics uniquely predicting employment status at two-year follow-up.

RESULTS

Sixteen percent were employed at follow-up. Economic living standards, physical health and preference to be in paid employment were positively associated with being employed at follow-up. There were no statistical differences according to age, gender, ethnicity, marital status, education and care characteristics.

CONCLUSION

Individual preferences were the strongest predictor of return to paid employment. Despite New Zealand employment legislation allowing all employees to request flexible working arrangements, economic and health differences in workforce retention among carers persist.

'A fifty mile round trip to change a lightbulb': An exploratory study of carers' experiences of providing help, care and support to families and friends from a distance

While the role of carers has been widely investigated, the experiences of those who care from a distance have been little explored, especially in the United Kingdom. However, contemporary patterns of family life suggest that this may be a significant experience for many. This exploratory study employed an anonymous online survey, conducted April-November 2017, to collect data about specific issues (experiences, challenges and satisfactions) faced by carers living at a distance requiring at least 1 hr travel time (each way) from the person they support. One hundred and twenty-eight participant responses were analysed. Qualitative (thematic) analysis identified that 'distance carers' carry out multiple care tasks, both when with, and apart from, the person they care for. Distance creates specific challenges for carers who have to work to 'bridge the distance gap' and who cannot 'just drop in' and see the person they support. Distance further exposes carers to emotional, financial and temporal demands. The use of technologies or the availability of a wider support network may support distance carers, and some explore the viability of relocation. However, these potential support strategies were identified as 'fragile' and at risk of breaking down. Despite the challenges identified, distance carers also reported satisfactions derived from supporting their relative/friend. While the numbers of those providing distance care are unknown, this research suggests that this is a significant carer group, whose needs should be recognised in health and social care policy, practice and research.

Parental Caregiving and Employment among Midlife Women in Japan

In this paper, we examine how parental caregiving affects women’s employment in Japan. Drawing on the 2005–2014 Longitudinal Survey of Middle-Aged and Elderly Persons, we estimate logistic regression models for the employment status of middle-aged women in various types of employment as a function of caregiving intensity to examine when and in what context caregivers’ employment may be at risk for Japanese women. The results showed that working women who began providing 5 or more hours of care per week were significantly more likely to leave their jobs than non-caregiving women; those who began providing fewer than 5 hours of care per week did not show this likelihood. Among women in regular employment, those who began to provide 5 or more hours of care per week and those who provided care in the previous year were more likely to stop working or change jobs than their non-caregiving counterparts.

The high cost of unpaid care by young people:health and economic impacts of providing unpaid care

Background

Many countries worldwide have experienced reductions in provision of formal long-term care services amidst rising need for care. Provision of unpaid care, meanwhile, has grown. This includes care provided by young people. Care responsibilities can affect a young people’s health, education and employment. We aimed to investigate the impacts on the employment and health of young people aged 16 to 25 of providing care, and the associated individual and public expenditure costs.

Methods

We examined employment, earnings and health impacts for individuals, and a range of economic impacts for society, focusing on young people aged 16 to 25 providing unpaid care in England. We applied regression analysis to data from three waves of the UK Household Longitudinal Study (2013/2015, 2014/2016, and 2015/2017) to compare employment and health outcomes among carers and non-carers, and two-part Generalised Linear Models to estimate costs. To address potential selection bias, we then used propensity score matching methods to explore outcomes for a matched sub-sample of young adult carers who started providing care at baseline (2014/16).

Results

Young people aged 16 to 25 who provided care at baseline (2014/16) were less likely to be in employment, had lower earnings from paid employment, and had poorer mental and physical health at follow-up (2015/17) compared to young people of the same age who were not providing care at baseline.. There were substantial costs to the state of young adults providing care from lower tax revenue, welfare benefit payments, and health service use. In aggregate, these costs amounted to £1048 million annually in 2017.

Conclusions

High individual impacts and costs to the state of providing unpaid care, and the potential of such impacts to compound existing inequalities, have many implications for policy and practice in the health, social care, employment and welfare benefits sectors. In particular, the findings reinforce the case for reducing the need for young people to provide unpaid care, for example through better provision of formal care services, and to provide ongoing support for those young people who do provide care. As impacts are seen in a number of domains, support needs to be multidimensional.

Relationships between informal caregiving, health and work in the Health and Employment After Fifty study, England

BACKGROUND

To investigate the prevalence of caregiving and its relationship with work, health and socio-economic circumstances in the Health and Employment After Fifty (HEAF) study.

METHODS

The HEAF study comprises 8134 men and women aged 50-64 years recruited from 24 general practices. Socio-demographic, lifestyle and health characteristics and hours per week giving personal care were elicited by postal questionnaire. Objective clinical information about diagnoses/medications was retrieved from health records. Work-related and health risk factors for intense caring responsibilities (≥20 h/week vs. no hours) were explored using logistic regression with adjustment for age and social class.

RESULTS

In all, 644 (17%) men and 1153 (26%) women reported caring responsibilities, of whom 93 and 199 were intense caregivers, who were more likely to be socio-economically disadvantaged; less likely to be working and, if combining caring with working (41 men and 90 women), more likely to be part-time/working shifts, than non-carers. Men caring ≥20 h/week were more likely to have COPD and to report musculoskeletal pain, poor/fair self-rated health, depression and sleep problems. Among working women, caring ≥20 h/week was associated with these same health outcomes and also with a doctor-diagnosed mental health problem or musculoskeletal pain in the previous year.

CONCLUSIONS

Caregiving is common and unequal in the HEAF cohort, with more high-intensity informal care provided by those with greater levels of socio-economic deprivation, which could affect their employment and health. Caregivers need support to lead long, healthy lives, rather than becoming care needers themselves. Employers and governments need to take caregiving into account and support it actively.

Challenges of combining work and unpaid care, and solutions: A scoping review

The number of people who combine work and unpaid care is increasing rapidly as more people need care, public and private care systems are progressively under pressure and more people are required to work for longer. Without adequate support, these working carers may experience detrimental effects on their well-being. To adequately support working carers, it is important to first understand the challenges they face. A scoping review was carried out, using Arksey and O'Malley's framework, to map the challenges of combining work and care and solutions described in the literature to address these challenges. The search included academic and grey literature between 2008 and 2018 and was conducted in April 2018, using electronic academic databases and reference list checks. Ninety-two publications were mapped, and the content analysed thematically. A conceptual framework was derived from the analysis which identified primary challenges (C1), directly resulting from combining work and care, primary solutions (S1) aiming to address these, secondary challenges (C2) resulting from solutions and secondary solutions (S2) aiming to address secondary challenges. Primary challenges were: (a) high and/or competing demands; (b) psychosocial/-emotional stressors; (c) distance; (d) carer's health; (e) returning to work; and (f) financial pressure. This framework serves to help those aiming to support working carers to better understand the challenges they face and those developing solutions for the challenges of combining work and care to consider potential consequences or barriers. Gaps in the literature have been identified and discussed.

Supporting carers of stroke survivors to reduce carer burden: development of the Preparing is Caring intervention using Intervention Mapping

Background

Burden is well documented among carers of stroke survivors, yet current evidence is insufficient to determine if any strategies reduce this negative outcome. Existing interventions for carers of stroke survivors typically involve supporting carers according to their individual needs through face-to-face interactions and provision of information including workbooks or educational guides. To date, no interventions have been developed using a method which systematically incorporates evidence, behaviour change theories, and stakeholder involvement to change the behaviours of carers and relevant individuals who support carers. This study aimed to develop a programme plan for a theory and evidence-based intervention to reduce burden in carers of stroke survivors.

Methods

Informed by evidence from two systematic reviews and 33 qualitative interviews, the first four stages of Intervention Mapping were used to guide the intervention development process: 1) needs assessment; 2) identifying outcomes and objectives; 3) selecting theoretical methods and practical applications; and 4) creating a programme plan. Structured and facilitated involvement from stakeholders, including carers, researchers, and professionals from health and community services was integral to the intervention development process. Stakeholders helped to prioritise the focus of the intervention, develop the goals, outcomes and objectives for the programme, and generate and refine intervention ideas.

Results

Stakeholders prioritised the need for carers to feel prepared before and during the transition from hospital to home as key to reducing burden. The proposed intervention ‘Preparing is Caring’ targets this need and involves providing and signposting carers to relevant information and support for practical and emotional needs. This is to be delivered before, during, and immediately after the stroke survivor’s transition from hospital to home by a person taking on a single point of contact role. It is comprised of multiple theory-based components including: training packages for information and support providers working with carers and wider staff teams, plus elements to support carers to feel prepared.

Conclusions

We have developed a comprehensive programme plan for a multiple-component, theory and evidence informed behaviour change intervention aimed at preparing carers before and during the transition from hospital to home. Future work is required to refine, implement and evaluate the Preparing is Caring intervention.

Carers’ involvement in telecare provision by local councils for older people in England: perspectives of council telecare managers and stakeholders

This paper explores telecare manager and other ‘stakeholder’ perspectives on the nature, extent and impact of family and other unpaid/informal carers’ involvement in the provision of telecare equipment and services for older people. Data used in the paper are derived from a larger study on telecare provision by local councils in England. The paper aims to add to the growing evidence about carers’ engagement with electronic assistive technology and telecare, and considers this in the context of typologies of professionals’ engagement with carers. How carers are involved in telecare provision is examined primarily from the perspectives of senior managers responsible for telecare services who responded to an online survey and/or were interviewed in 2016 as part of a wider study. The perspectives of three unpaid carers were captured in a separate strand of the main study, which comprised more detailed case study interviews within four selected councils. Thematic and comparative analysis of both qualitative and quantitative survey data revealed the varied involvements and responsibilities that carers assumed during the telecare provision process, the barriers that they needed to overcome and their integration in local council strategies. Findings are discussed in the context of Twigg and Atkin's typology of carer support. They suggest that carers are mainly perceived as ‘resources’ and involvement is largely taken for granted. There are instances in which carers can be seen as ‘co-workers’: this is mainly around responding to alerts generated by the telecare user or by monitored devices, but only in those councils that fund response services. Though some participants felt that telecare devices could replace or ‘supersede’ hands-on care that involved routine monitoring of health and wellbeing, it was also acknowledged that its use might also place new responsibilities on carers. Furthermore, the study found that meeting carers’ own rights as ‘co-clients’ was little acknowledged.

Caring hours and possible need for employment support among primary carers for adults with mental illness: Results from an Australian household survey

Intensive unpaid caring is associated with greater likelihood of not being employed, but impacts for mental health carers specifically remain unknown. This study aimed to: (a) examine the association between caring intensity and not being employed for primary mental health carers, (b) ascertain whether this relationship differs from that for other disability carers, (c) enumerate Australian primary mental health carers with a possible need for employment support and (d) describe these carers' unmet support needs and barriers to employment. Co-resident, working age primary mental health (n = 137) and other disability carers (n = 821) were identified in the Survey of Disability, Ageing and Carers (collected July-December 2015). Multiple logistic regression analyses examined associations between levels of caring intensity (1-9, 10-19, 20-39, 40+ hr/week) and not being employed. A 'possible need for employment support' indicator was derived from information about current employment status, caring hours, past impact of caring on employment and desire for more work or workplace accommodations. After controlling for demographic and caring role factors, mental health carers providing 40+ hr of care weekly had greater odds of not being employed compared to carers providing <10 hr (AOR 13.38, 95% CI: 2.17-82.39). For other disability carers, the odds of not being employed were also higher among those providing 20-39 hr of care (AOR 3.21, 95% CI: 2.18-4.73). An estimated 54.1% (95% CI: 43.1-64.8) of carers had a possible need for employment support, with the proportion increasing as level of caring intensity increased. Of carers who were not employed, 42.2% (95% CI: 30.3-55.0) reported a desire to work, and the main reported barrier was no alternative care arrangements or disruption to the person supported. Findings suggest that improving employment participation for mental health carers requires a greater balance between unpaid care and access to formal services for people with mental illness.

Employment disadvantage and associated factors for informal carers of adults with mental illness: are they like other disability carers?

BACKGROUND

Providing unpaid support to family and friends with disabling health conditions can limit a carer's capacity to participate in employment. The emotional support needs and unpredictability of caring for people with mental illness may be particularly demanding. While previous research suggests variable employment rates across carers for different conditions, there are limited data on mental health carers specifically.

METHODS

This study analysed employment patterns for working-age, co-resident carers of adults with mental illness in an Australian cross-sectional household survey, the 2015 Survey of Disability, Ageing and Carers.

RESULTS

Significantly more mental health carers were not employed (42.3%, 95% CI: 36.6-48.1) compared to non-carers (24.0%, 95% CI: 23.5-24.6). Employed mental health carers were more likely to work fewer than 16 h per week (carers: 17.2%, 95% CI: 12.8-22.8, vs. non-carers: 11.7%, 95% CI: 11.3-12.1) and in lower skilled occupations (carers: 22.6, 95% CI: 17.5-28.7, vs. non-carers: 15.7, 95% CI: 15.1-16.2). Among the sub-group of primary mental health carers, 25.8% (95% CI: 15.6-39.5) had reduced their working hours to care and a further 26.4% (95% CI: 17.2-38.2) stopped working altogether. In corresponding comparisons between mental health carers and carers for people with other cognitive/behavioural conditions, and physical conditions with or without secondary mental illness, there were no differences except that mental health carers were more likely to be working in a lower skilled occupation than other cognitive/behavioural condition carers (14.8% of the latter, 95% CI 10.1-21.2). Multivariate logistic regression analyses revealed that female mental health carers were less likely to be employed if they were aged 35-54, had no post-secondary education, had a disability, or cared for someone with severe activity limitations. For male mental health carers, having a disability or caring for someone with severe limitations or who did not receive paid assistance were significantly associated with not being employed.

CONCLUSIONS

These results highlight the employment disadvantage experienced by mental health carers compared to non-carers, and similarities in employment patterns across carers for different conditions. Improving the availability of paid support services for people with mental illness may be an important target to assist carers to maintain their own employment.

Stage 1 Registered Report: A scoping review protocol to map the evidence on family carers who combine work with care

Background: Family carers are considered the backbone of care provision in the community for those who are dependent due to frailty, disability or chronic illness. As the proportion of older people increases worldwide, it is anticipated that there will be a corresponding increase in reliance on family carers. Furthermore, due to the increasing participation of women in the workforce and delayed retirement, the proportion of carers who combine paid employment with caregiving responsibilities is likely to increase. Consequently, support for family carers who balance work with care is becoming a growing health, business, economic and social issue. However, research in this field is somewhat fragmented. Aim: This paper presents a protocol for a scoping review which aims to systematically and comprehensively map out the available published and unpublished literature on family carers who combine work with caring responsibilities. Methods: The scoping review will be undertaken in six steps: (1) identify the research question; (2) identify relevant studies; (3) select studies; (4) chart the data; (5) collate, summarise and report the results and (6) consult with relevant stakeholders. The review will be guided by the PRISMA-ScR framework guidelines to ensure methodological and reporting quality. A minimum of two reviewers will independently review articles for inclusion within the review. The review process will be iterative and the research question(s) and search strategy will be refined as the review progresses. Conclusion: This review will provide a mapped synthesis of the extent and nature of the available published and unpublished literature on family carers who juggle the competing demands of caregiving and paid work. Findings will be used to determine whether there is merit in carrying out a full systematic literature review and will provide direction for the next steps of a larger research project, which aims to support family carers in the workplace.

Carer-related research and knowledge: Findings from a scoping review

The review discussed in this paper provides a unique synthesis of evidence and knowledge about carers. The authors adopted a scoping review methodology drawing on a wide range of material from many different sources published between 2000 and 2016. It offers key insights into what we know and how we know it; reinforces and expands evidence about carers' profile; shows knowledge is uneven, e.g. much is known about working carers, young carers and carers of people with dementia but far less is about older carers or caring for someone with multiple needs. A striking feature of much research is a focus on caring as a set of tasks, rather than a dimension of an, often dyadic, relationship. While there is substantive evidence about the negative impact of caring, the review suggests that links between caring and carer outcomes are neither linear nor inevitable and vary in depth and nature. A reliance on cross-sectional studies using standardised measures is a major weakness of existing research: this approach fails to capture the multidimensionality of the caring role, and the lived experience of the carer. Although research relating to formal support suggests that specific interventions for particular groups of carers may be effective, overall the evidence base is weak. There is a tension between cost-effectiveness and what is valued by carers. Developing robust evaluative models that accommodate this tension, and take account of the dyadic context of caring is a critical challenge. A fundamental deficit of carer-related research is its location in one of two, largely separate, paradigmatic frameworks: the "Gatherers and Evaluators" and the "Conceptualisers and Theorisers." The authors suggest that developing an integrated paradigm that draws on the strengths and methods of existing paradigms, has considerable potential to generate new knowledge and new evidence and extend understanding of care and caring.

Combining employment and care-giving: how differing care intensities influence employment patterns among middle-aged women in Germany

Given an ageing population and increased participation by women in the labour force, the relationship between unpaid care and the availability of women to the labour force is gaining in importance as an issue. This article assesses the impact of unpaid care on transitions into employment by women aged between 45 and 59 years. It uses the German Socio-Economic Panel (SOEP) from the years 2001–2014 to estimate Cox regression models for 6,201 employed women. The results indicate that women with higher caring responsibilities and women with lower caring responsibilities are heterogeneous in terms of the socio-economic characteristics that they exhibit: higher-intensity care providers tend to have a lower level of educational attainment and a weaker attachment to the labour force than women with less-intensive caring responsibilities. Furthermore, while women with more-intensive caring roles are highly likely to exit the labour market altogether, female carers with less-intensive roles seem to be able to combine work and care better. These results highlight the importance of providing more affordable institutional and professional care services, especially for low- and medium-income families.

The Association Between Informal Caregiving and Exit From Employment Among Older Workers: Prospective Findings From the UK Household Longitudinal Study

Objective

This study investigated associations between informal caregiving and exit from paid employment among older workers in the United Kingdom.

Method

Information on caregiving and work status for 8,473 older workers (aged 50-75 years) was drawn from five waves of Understanding Society (2009-2014). We used discrete-time survival models to estimate the associations of caring intensity and type on the probability of exiting paid work (from >0 to 0 hours/week) in the following year. Models were stratified by sex and working hours, and adjusted for age, self-rated health, long-standing illness, occupation, and partner's employment status.

Results

No association was found between caregiving intensity and exit from paid work. Full-time employees who provided care within the household (women and men) or cared for a partner/spouse (women only) more likely to stop working, compared to those not providing care. Women who entered a caregiving role (more than 10 hours/week) were between 2.64 (95% confidence interval [CI]: 1.46, 4.79) and 4.46 (95% CI: 2.53, 7.88) times more likely to exit work (for part-time and full-time workers, respectively), compared to women providing no care.

Discussion

This study highlights the onset of caregiving as a key period for older workers. Ensuring that caregiving responsibilities are adequately recognized and supported may help extend working life.

Caught between two stools? Informal care provision and employment among welfare recipients in Germany

In many countries, population ageing is challenging the viability of the welfare state and generating higher demands for long-term care. At the same time, increasing participation in the labour force is essential to ensuring the sustainability of the welfare state. To address the latter issue, affected countries have adopted measures to increase employment; e.g. welfare recipients in Germany are required to be available for any type of legal work. However, 7 per cent of welfare benefit recipients in Germany provide long-term care for relatives or friends, and this care-giving may interfere with their job search efforts and decrease their employment opportunities. Our paper provides evidence of the relationship between the care responsibilities and employment chances of welfare recipients in Germany. Our analyses are based on survey data obtained from the panel study ‘Labour Market and Social Security’ and on panel regression methods. The results reveal a negative relationship between intensive care-giving (ten or more hours per week) and employment for male and female welfare recipients. However, employment prospects recover when care duties end and are subsequently no longer lower for carers than for non-carers.

Carer Characteristics and Health, Wellbeing and Employment Outcomes of Older Australian Baby Boomers

Supporting caregivers and enabling continued workforce participation are central strategies in Australia's response to an ageing population, however these strategies have potential disadvantages for carers, particularly women, including reduced workforce participation and retirement income, and poorer health status. This paper explores the nexus between paid work and caregiving for Australia's baby boomer cohort as this group faces unprecedented pressures to manage paid work alongside caring longer and more intensively for family members, including grandchildren. A sample of 1261 men and women aged 60 to 64 completed the 2011-12 Life Histories and Health survey, a sub-study of the New South Wales 45 and Up Study. The survey collected data on sociodemographic, psychosocial, life history and health-related variables including caregiving and employment status. Around a third (32.5%) of the sample (52.2% female) were involved in some type of caregiving at the time. Compared to non-carers, carers reported lower workforce participation (45.8% versus 54.7% for non-carers) as well as poorer health, more mobility difficulties, lower quality of life and lower self-rated SES. Carers who also cared for grandchildren were more likely to be in part-time or no paid work compared to other carers. Working carers tended to be more highly educated, have fewer mobility difficulties, better self-rated health and higher SES than non-working carers. Male carers were more likely than female carers to be in full-time or no paid work. Results indicate that reduced workforce participation and health status of caregivers varies by gender and type of caregiving. Policy reforms are recommended to mitigate these adverse consequences on those providing care, their families, employers and the community.

Examining life course trajectories of lesbian, gay and bisexual people in England - exploring convergence and divergence among a heterogeneous population of older people

Because of limitations in collecting sexuality data, there are very few studies that quantitatively explore the life courses of lesbian, gay, bisexual (LGB) individuals. Likewise it is rare that normative patterns of life course trajectories are assessed in terms of their applicability to LGB individuals. We review the current literature on LGB life course trajectories and discuss potential reasons for gaps in the literature. We explore approaches for defining LGB status. We use data from a cohort of people aged 50 and over (English Longitudinal Study of Ageing) to explore the tempo and occurrences of transitions to adulthood and to older age, and establish some of the differences based on sexual orientation. We examine the connecting health behaviours and life course turning points that may explain some of the differences described above. We show that while the first quartile of transitions to adulthood are experienced fairly uniformly by sexual orientation, differences open up thereafter. LGB people's life course trajectories are marked by different patterns of care, with LGB people less likely to provide care in the form of parenthood, but potentially more likely to provide care earlier to close friends or relatives. Analyses of connecting events suggest that LGB life course trajectories may be marred by higher levels of volatility, including higher risk financial hardship. Caveats to these results are outlined in full in the paper.

The relationship between elder care-giving and labour force participation in the context of policies addressing population ageing: a review of empirical studies published between 2006 and 2016

This paper systematically reviews empirical research published between 2006 and 2016 on the relationship between informal care-giving to elders and labour force participation (LFP). It does so in the context of Organisation for Economic Co-operation and Development policy responses to population ageing. In this context, conclusions regarding the LFP and care-giving relationship should at least be applicable to the sub-population of working-aged individuals who are most likely to provide informal elder care. Currently, these are women in mid-life and the recipients of their care are mostly extra-residential parents. The review's key conclusion is that mid-life women care-givers of elderly parents are significantly likely to reduce their working hours and also to work fewer hours relative to their non-care-giving counterparts. In drawing this conclusion, the review shows that studies finding only modest care-giving effects on LFP either do not adequately control for care-giving intensity or their conclusions apply to sub-populations less likely to be affected by policies addressing population ageing.

Public expenditure costs of carers leaving employment in England, 2015/2016

In the context of global population ageing, the reconciliation of employment and unpaid caring is becoming an important social issue. The estimation of the public expenditure costs of carers leaving employment is a valuable measure that is of considerable interest to policy makers. In 2012, the Personal Social Services Research Unit estimated that the public expenditure costs of unpaid carers leaving employment in England were approximately £1.3 billion a year, based on the costs of Carer's Allowance and lost tax revenues on forgone incomes. However, this figure was known to be an underestimate partly because it did not include other key benefits that carers who have given up work to care may receive. This paper presents a new estimate of the public expenditure costs of carers leaving employment. Key sources of information are the 2009/2010 Survey of Carers in Households, 2011 Census and 2015/2016 costs data. As well as Carer's Allowance, the estimate also now includes the costs of other benefits that carers leaving work may receive, namely, Income Support and Housing Benefit. The results show that the estimated numbers of carers who have left employment because of caring have increased from approximately 315,000 to 345,000. Due mainly to the inclusion of a wider range of benefits, the public expenditure costs of carers leaving employment in England are now estimated at £2.9 billion a year. The new estimate comprises £1.7 billion in social security benefits paid to people who have left their jobs because of unpaid caring, plus another £1.2 billion in taxes forgone on this group's lost earnings. The paper concludes that, if there was greater public investment in social care, such as "replacement care" to support carers in employment, and fewer carers then left employment, public spending on benefits would be lower and revenues from taxation would be higher.

‘I just felt as though I had to drop something’: the implications of care for female working elder carers’ working lives

This paper explores the challenges that female elder carers in the United Kingdom face in combining paid work with elder care, and the implications of this care for their current and future working lives. In-depth interviews with 11 working women from a large organisation were conducted, and five of the women were re-interviewed after a period of one year to examine any changes in their situation. The interviews revealed the precarious nature of their daily schedules, which required constant effort to maintain, the intrusion of elder care into their working lives, and the impact it had upon their career development and future aspirations. The findings provide insight into the reasons why carers, especially women, are more likely to reduce their working hours, do not take advantage of training opportunities and retire early. The findings are discussed in relation to the expectation of an extended working age and gender equality.

The dynamics of social care and employment in mid-life

This study investigates the relationship between the provision of informal care to older parents/parents-in-law and the employment status of adult children in mid-life. The study analyses unique panel data for a cohort of individuals born in 1958 in Britain, focusing on respondents at risk of providing care (i.e. with at least one surviving parent/parent-in-law) and in employment at 50. Logistic regression is used to investigate the impact of caring at 50 and 55 on employment status at 55, controlling for socio-demographic characteristics, the respondent's health status and their partner's employment status. Separate models examine (a) the likelihood of exiting the labour force versus continuing work, and (b) amongst those continuing in work, the likelihood of reducing hours of employment. Different types of care (personal, basic and instrumental support) are distinguished, along with hours of caring. The results highlight that providing care for more personal tasks, and for a higher number of hours, are associated with exiting employment for both men and women carers. In contrast, the negative impact of more intense care-giving on reducing working hours was significant only for men – suggesting that women may juggle intensive care commitments alongside work or leave work altogether. Facilitating women and men to combine paid work and parental care in mid-life will be increasingly important in the context of rising longevity.

A study of dyadic interdependence of control, social participation and occupation of adults who use long-term care services and their carers

PURPOSE

Unpaid care is an important source of support of people with long-term conditions. Interdependence of carers' and care recipients' quality of life would be expected due to the relational nature of caregiving. This study aims to explore interdependence of quality of life in carer/care-recipient dyads, especially in relation to mutual interdependence due to social feedback in the caregiving relationship and also the partner effects of one partner's experience of long-term care support on the other's outcomes.

METHODS

Using data collected in an interview survey of 264 adults with care support needs and their unpaid carers in England, we employed regression analysis to explore whether there is mutual interdependence of care-related quality of life within carer/care-recipient dyads for three quality of life attributes: Control over daily life, Social participation and Occupation. The influence of factors, including satisfaction with long-term care, were also considered on individuals' and dyad partners' care-related quality of life.

RESULTS

We found mutual interdependence of quality of life at the dyad-level for Control over daily life, but not Occupation or Social participation. A partner effect of care recipients' satisfaction with long-term care on carers' Control over daily life was also observed. Higher care recipient satisfaction with care services was associated with higher Control over daily life. By contrast, for Social participation and Occupation, there were only significant effects of care recipients' satisfaction with long-term care and their own quality of life.

CONCLUSIONS

These findings highlight the importance of considering the wider impact beyond the individual of long-term care on quality of life in the evaluation of long-term care policy and practice.

What do we know about older former carers? Key issues and themes

Despite a significant growth in the number older former family carers, they remain largely invisible in carer-related research and literature. To begin to address this deficit, a four-stage literature review was conducted to identify existing knowledge about older former carers. Narrative synthesis of the findings yielded five themes - the concept of 'older former carer', the legacies of caring, influences on the legacies of caring, conceptualising post-caring and support services for older former carers. Critical analysis of these findings suggests that existing evidence has a number of strengths. It highlights the terminological and conceptual confusion in the field, identifies the profound financial and health-related legacies older former carers' experience, the factors which shape these legacies and some of the complexities of bereavement older former carers face. The support needs of older former carers are also illuminated. However, the field is characterised by key weaknesses. The evidence base is fragmented and uneven. In part this reflects lack of definitional consensus and in part the fact that there is much more evidence about some sub-groups, such as carers of relatives admitted to a care home, than others. Methodology-related weaknesses include small sample sizes and a focus on a single, often condition-specific, group of older former carers. An overarching criticism relates to the narrow conceptual/theoretical purview. As post-caring tends to be viewed as one of the final temporal 'stages' of the carer's 'care-giving career', a bifurcatory model of carer/former carer is created, i.e. that a carer actively provides care and a former carer is no longer caring. This constructs being a former carer - namely formerality - as a single fixed state failing to capture its dynamic and shifting nature and constrains the potential of research to generate new knowledge and extend understanding.

Perceptions of unmet needs for community social care services in England. A comparison of working carers and the people they care for

Previous UK research has found expressed unmet need for services by unpaid working carers and among disabled and older people. There are, however, suggestions from research that views on unmet needs for services differ between carers and care-recipients. Working carers in the UK say that the care-recipient is sometimes reluctant to accept services and the few international comparative dyad studies that have been carried out find that carers perceive higher unmet need than care-recipients. Recent policy discussions in England have also recognised that there may be differences of opinion. We collected data in 2013 from working carer/care-recipient dyads in England about perceived need for services for the care-recipient, disability, unpaid care hour provision and individual and socio-demographic characteristics. We find that care-recipients as well as their carers perceive high unmet need for services, although carers perceive higher unmet need. For carers, unmet need is associated with the disability of the carer-recipient and being the daughter or son of the care-recipient; for care-recipients it is associated with unpaid care hours, carers' employment status and carers' health. The majority of dyads agree on need for services, and agreement is higher when the working carer provides care for 10 hours or more hours a week. Services for care-recipients may enable working carers to remain in employment so agreement on needs for services supports the implementation of legislation, policy and practice that has a duty to, or aims to, support carer's employment.

Fit for caring: factors associated with informal care provision by older caregivers with and without multimorbidity

Due to an increased prevalence of chronic diseases, older individuals may experience a deterioration of their health condition in older ages, limiting their capacity for social engagement and in turn their well-being in later life. Focusing on care provision to grandchildren and (older) relatives ('informal care') as forms of engagement, this paper aims to identify which individual characteristics may compensate for health deficits and enable individuals with multimorbidity to provide informal care. We use data from the SHARE survey (2004-2012) for individuals aged 60 years and above in 10 European countries. Logistic regression estimates for the impact of different sets of characteristics on the decision to provide care are presented separately for people with and without multimorbidity. Adapting Arber and Ginn's resource theory, we expected that older caregivers' resources (e.g., income or having a spouse) would facilitate informal care provision to a greater extent for people with multimorbidity compared to those without multimorbidity, but this result was not confirmed. While care provision rates are lower among individuals suffering from chronic conditions, the factors associated with caregiving for the most part do not differ significantly between the two groups. Results, however, hint at reciprocal intergenerational support patterns within families, as the very old with multimorbidity are more likely to provide care than those without multimorbidity. Also, traditional gender roles for women are likely to be weakened in the presence of health problems, as highlighted by a lack of gender differences in care provision among people with multimorbidity.

The Effectiveness of Paid Services in Supporting Unpaid Carers' Employment in England

This paper explores the effectiveness of paid services in supporting unpaid carers' employment in England. There is currently a new emphasis in England on 'replacement care', or paid services for the cared-for person, as a means of supporting working carers. The international evidence on the effectiveness of paid services as a means of supporting carers' employment is inconclusive and does not relate specifically to England. The study reported here explores this issue using the 2009/10 Personal Social Services Survey of Adult Carers in England. The study finds a positive association between carers' employment and receipt of paid services by the cared-for person, controlling for covariates. It therefore gives support to the hypothesis that services for the cared-for person are effective in supporting carers' employment. Use of home care and a personal assistant are associated on their own with the employment of both men and women carers, while use of day care and meals-on-wheels are associated specifically with women's employment. Use of short-term breaks are associated with carers' employment when combined with other services. The paper supports the emphasis in English social policy on paid services as a means of supporting working carers, but questions the use of the term 'replacement care' and the emphasis on 'the market'.

Reaching out or missing out: approaches to outreach with family carers in social care organisations

Outreach is advocated as a way of improving the uptake of services among underserved populations and of filling the gaps between mainstream services and the populations they are intended to support. Despite the policy emphasis on providing better help for family carers, research consistently shows that many of those providing unpaid care to a family member or friend report difficulties in finding out about the assistance to which they are entitled. This article presents results from a concurrent mixed-methods study, which aimed to describe different ways of working with family carers in adult social care departments and to collect the views of a range of stakeholders about the advantages and disadvantages of the approaches that were identified. A total of 86 semi-structured face-to-face interviews were undertaken with a purposive sample of funders, carers' workers, representatives of voluntary organisations and family carers based in four contrasting localities. An email survey was sent to all local councils in England with social care responsibilities and resulted in a 53% response rate. Data collection took place in 2012, with a small number of interviews being completed in 2011. Our approach to data analysis combined methodological, data and theoretical triangulation. The findings presented here mainly draw on the interview data to highlight the different models of outreach that we identified. The article highlights important differences between outreach and the provision of information. It concludes that organisations providing support for carers need to consider the advantages and disadvantages of different models of outreach as they develop carers' support and the extent to which different models might be more effective than others in reaching particular types of carer.

Knowledge generation about care-giving in the UK: a critical review of research paradigms

While discourse about care and caring is well developed in the UK, the nature of knowledge generation about care and the research paradigms that underpin it have been subjected to limited critical reflection and analysis. An overarching synthesis of evidence - intended to promote debate and facilitate new understandings - identifies two largely separate bodies of carer-related research. The first body of work - referred to as Gathering and Evaluating - provides evidence of the extent of care-giving, who provides care to whom and with what impact; it also focuses on evaluating policy and service efficacy. This type of research tends to dominate public perception about caring, influences the type and extent of policy and support for carers and attracts funding from policy and health-related sources. However, it also tends to be conceptually and theoretically narrow, has limited engagement with carers' perspectives and adopts an atomistic purview on the care-giving landscape. The second body of work - Conceptualising and Theorising - explores the conceptual and experiential nature of care and aims to extend thinking and theory about caring. It is concerned with promoting understanding of care as an integral part of human relationships, embedded in the life course, and a product of interdependence and reciprocity. This work conceptualises care as both an activity and a disposition and foregrounds the development of an 'ethic of care', thereby providing a perspective within which to recognise both the challenges care-giving may present and the significance of care as a normative activity. It tends to be funded from social science sources and, while strong in capturing carers' experiences, has limited policy and service-related purchase. Much could be gained for citizens, carers and families, and the generation of knowledge advanced, if the two bodies of research were integrated to a greater degree.