Global, regional, and national minimum estimates of children affected by COVID-19-associated orphanhood and caregiver death, by age and family circumstance up to Oct 31, 2021: an updated modelling study

BACKGROUND

In the 6 months following our estimates from March 1, 2020, to April 30, 2021, the proliferation of new coronavirus variants, updated mortality data, and disparities in vaccine access increased the amount of children experiencing COVID-19-associated orphanhood. To inform responses, we aimed to model the increases in numbers of children affected by COVID-19-associated orphanhood and caregiver death, as well as the cumulative orphanhood age-group distribution and circumstance (maternal or paternal orphanhood).

METHODS

We used updated excess mortality and fertility data to model increases in minimum estimates of COVID-19-associated orphanhood and caregiver deaths from our original study period of March 1, 2020-April 30, 2021, to include the new period of May 1-Oct 31, 2021, for 21 countries. Orphanhood was defined as the death of one or both parents; primary caregiver loss included parental death or the death of one or both custodial grandparents; and secondary caregiver loss included co-residing grandparents or kin. We used logistic regression and further incorporated a fixed effect for western European countries into our previous model to avoid over-predicting caregiver loss in that region. For the entire 20-month period, we grouped children by age (0-4 years, 5-9 years, and 10-17 years) and maternal or paternal orphanhood, using fertility contributions, and we modelled global and regional extrapolations of numbers of orphans. 95% credible intervals (CrIs) are given for all estimates.

FINDINGS

The number of children affected by COVID-19-associated orphanhood and caregiver death is estimated to have increased by 90·0% (95% CrI 89·7-90·4) from April 30 to Oct 31, 2021, from 2 737 300 (95% CrI 1 976 100-2 987 000) to 5 200 300 (3 619 400-5 731 400). Between March 1, 2020, and Oct 31, 2021, 491 300 (95% CrI 485 100-497 900) children aged 0-4 years, 736 800 (726 900-746 500) children aged 5-9 years, and 2 146 700 (2 120 900-2 174 200) children aged 10-17 years are estimated to have experienced COVID-19-associated orphanhood. Globally, 76·5% (95% CrI 76·3-76·7) of children were paternal orphans, whereas 23·5% (23·3-23·7) were maternal orphans. In each age group and region, the prevalence of paternal orphanhood exceeded that of maternal orphanhood.

INTERPRETATION

Our findings show that numbers of children affected by COVID-19-associated orphanhood and caregiver death almost doubled in 6 months compared with the amount after the first 14 months of the pandemic. Over the entire 20-month period, 5·0 million COVID-19 deaths meant that 5·2 million children lost a parent or caregiver. Our data on children's ages and circumstances should support pandemic response planning for children globally.

FUNDING

UK Research and Innovation (Global Challenges Research Fund, Engineering and Physical Sciences Research Council, and Medical Research Council), Oak Foundation, UK National Institute for Health Research, US National Institutes of Health, and Imperial College London.

Global minimum estimates of children affected by COVID-19-associated orphanhood and deaths of caregivers: a modelling study

BACKGROUND

The COVID-19 pandemic priorities have focused on prevention, detection, and response. Beyond morbidity and mortality, pandemics carry secondary impacts, such as children orphaned or bereft of their caregivers. Such children often face adverse consequences, including poverty, abuse, and institutionalisation. We provide estimates for the magnitude of this problem resulting from COVID-19 and describe the need for resource allocation.

METHODS

We used mortality and fertility data to model minimum estimates and rates of COVID-19-associated deaths of primary or secondary caregivers for children younger than 18 years in 21 countries. We considered parents and custodial grandparents as primary caregivers, and co-residing grandparents or older kin (aged 60-84 years) as secondary caregivers. To avoid overcounting, we adjusted for possible clustering of deaths using an estimated secondary attack rate and age-specific infection-fatality ratios for SARS-CoV-2. We used these estimates to model global extrapolations for the number of children who have experienced COVID-19-associated deaths of primary and secondary caregivers.

FINDINGS

Globally, from March 1, 2020, to April 30, 2021, we estimate 1 134 000 children (95% credible interval 884 000-1 185 000) experienced the death of primary caregivers, including at least one parent or custodial grandparent. 1 562 000 children (1 299 000-1 683 000) experienced the death of at least one primary or secondary caregiver. Countries in our study set with primary caregiver death rates of at least one per 1000 children included Peru (10·2 per 1000 children), South Africa (5·1), Mexico (3·5), Brazil (2·4), Colombia (2·3), Iran (1·7), the USA (1·5), Argentina (1·1), and Russia (1·0). Numbers of children orphaned exceeded numbers of deaths among those aged 15-50 years. Between two and five times more children had deceased fathers than deceased mothers.

INTERPRETATION

Orphanhood and caregiver deaths are a hidden pandemic resulting from COVID-19-associated deaths. Accelerating equitable vaccine delivery is key to prevention. Psychosocial and economic support can help families to nurture children bereft of caregivers and help to ensure that institutionalisation is avoided. These data show the need for an additional pillar of our response: prevent, detect, respond, and care for children.

FUNDING

UK Research and Innovation (Global Challenges Research Fund, Engineering and Physical Sciences Research Council, Medical Research Council), UK National Institute for Health Research, US National Institutes of Health, and Imperial College London.

Caring for Chronically Ill Older Adults: A View Over the Last 75 Years

We explore major trends over the last 75 years that affect care provision to chronically ill older adults. We examine shifting demographics that have altered the nature and dynamics of family and formal care systems. Next, we identify changes in clinical health care approaches, including the rising population of chronically ill older persons and concerns about continuity of care. We conclude with an assessment of the growing impact of the technological revolution on both family and professional care.

The effect of informal caregiver support on utilization of acute health services among home care clients: a prospective observational study

BACKGROUND

Emergency department visits and hospitalizations (EDVH) place a large burden on patients and the health care system. The presence of informal caregivers may be beneficial for reducing EDVH among patients with specific diagnoses. Our objective was to determine whether the presence of an informal caregiver was associated with the occurrence of an EDVH among clients 50 years of age or older.

METHODS

Using a database accessed through the Toronto Central Community Care Access Centre (CCAC), we identified 479 adults over 50 years of age who received home care in Toronto, Canada. Exposure variables were extracted from the interRAI health assessment form completed at the time of admission to the CCAC. EDVH data were linked to provincial records through the CCAC database. Data on emergency room visits were included for up to 6 months after time of admission to home care. Multiple logistic regression analysis was used to identify factors associated with the occurrence of an EDVH.

RESULTS

Approximately half of all clients had an EDVH within 180 days of admission to CCAC home care. No significant association was found between the presence of an informal caregiver and the occurrence of an EDVH. Significant factors associated with an EDVH included: Participants having a poor perception of their health (adjusted OR = 1.68, 95% CI: 1.11-2.56), severe cardiac disorders (adjusted OR = 1.54, 95% CI: 1.04-2.29), and pulmonary diseases (adjusted OR = 1.99, 95% CI: 1.16-3.47).

CONCLUSIONS

The presence of an informal caregiver was not significantly associated with the occurrence of an EDVH. Future research should examine the potential associations between length of hospital stay or quality of life and the presence of an informal caregiver. In general, our work contributes to a growing body of literature that is increasingly concerned with the health of our aging population, and more specifically, health service use by elderly patients, which may have implications for health care providers.

Caregiver Shortage Reaches Critical Stage

Stronger economy and shifting demographics put providers in bind in search for workers.

Gerontological Social Work Student-Delivered Respite: A Community-University Partnership Pilot Program

This study describes a community-university partnership to support a gerontological social work student-delivered respite program, the Houseguest Program (Houseguest). Houseguest was designed using a community-engaged scholarship model of integrating research, teaching, and service. Houseguest was piloted with a small group of community-dwelling, coresiding dementia caregivers and care recipients. We examined caregivers' experiences with student-delivered respite using qualitative data analysis. Thematic analysis produced 8 themes: (a) respite from full time caregiving role, (b) information on caregiving strategies, (c) no-cost supportive services, (d) opportunity for care recipients to socialize, (e) tailored activities for care recipients, (f) rapport-building between students and family dyad, (g) reciprocity between students and family dyad, and (h) program continuation. We conclude with a proposed community-engaged scholarship model for dementia caregiving. Through a community-university partnership, Houseguest reduced the impact of caregiver burden and created an opportunity for students to serve families affected by dementia through respite and tailored activities.

Long-term Care Insurance and Carers' Labor Supply - A Structural Model

In Germany, individuals in need of long-term care receive support through benefits of the long-term care insurance. A central goal of the insurance is to support informal care provided by family members. Care recipients can choose between benefits in kind (formal home care services) and benefits in cash. From a budgetary perspective, family care is often considered a cost-saving alternative to formal home care and to stationary nursing care. However, the opportunity costs resulting from reduced labor supply of the carer are often overlooked. We focus on the labor supply decision of family carers and the incentives set by the long-term care insurance. We estimate a structural model of labor supply and the choice of benefits of family carers. We find that benefits in kind have small positive effects on labor supply. Labor supply elasticities of cash benefits are larger and negative. If both types of benefits increase, negative labor supply effects are offset to a large extent. However, the average effect is significantly negative.

An estimation of the value of informal care provided to dependent people in Spain

BACKGROUND AND OBJECTIVE

The aim of this paper was to arrive at an approximation of the value of non-professional (informal) care provided to disabled people living within a household in Spain.

METHODS

We used the Survey on Disabilities, Autonomy and Dependency carried out in 2008 to obtain information about disabled individuals and their informal caregivers. We computed the total number of informal caregiving hours provided by main caregivers in Spain in 2008. The monetary value of informal care time was obtained using three different approaches: the proxy good method, the opportunity cost method and the contingent valuation method.

RESULTS

Total hours of informal care provided in 2008 were estimated at 4193 million and the monetary value ranged from EUR23,064 to EUR50,158 million depending on the method used. The value of informal care was estimated at figures equivalent to 1.73-4.90 % of the gross domestic product for that year.

CONCLUSION

Informal care represents a very high social cost regardless of the estimation method considered. A holistic approach to care of dependent people should take into account the role and needs of informal caregivers, promote their social recognition and lead to policies that enhance efficient use of formal and informal resources.

Time for living and caring: an intervention to make respite more effective for caregivers

This article presents the rationale for and description of a promising intervention, Time for Living and Caring (TLC), designed to enhance the effectiveness of respite services for family caregivers. It is guided by the theoretical principles of the Selective Optimization with Compensation (SOC) model, which individually coaches caregivers on how to assess their personal circumstances, identify their greatest needs and preferences, and engage in goal setting and attainment strategies to make better use of their respite time. Focusing on respite activities that match caregivers' unique needs is likely to result in improved well-being. We report on a pilot study examining TLC's feasibility and potential benefits and how caregivers viewed their participation. While additional research is needed to test and refine the intervention, we need to find more creative ways to enhance respite services.

Labour would recruit carers for nurse training

A new generation of nurses will be recruited from social care if Labour wins the general election.

Caring for Caregivers: Challenging the Assumptions

Informal and mostly unpaid caregivers - spouses, family, friends and neighbours - play a crucial role in supporting the health, well-being, functional independence and quality of life of growing numbers of persons of all ages who cannot manage on their own. Yet, informal caregiving is in decline; falling rates of engagement in caregiving are compounded by a shrinking caregiver pool. How should policymakers respond? In this paper, we draw on a growing international literature, along with findings from community-based studies conducted by our team across Ontario, to highlight six common assumptions about informal caregivers and what can be done to support them. These include the assumption that caregivers will be there to take on an increasing responsibility; that caregiving is only about an aging population; that money alone can do the job; that policymakers can simply wait and see; that front-line care professionals should be left to fill the policy void; and that caregivers should be addressed apart from cared-for persons and formal care systems. While each assumption has a different focus, all challenge policymakers to view caregivers as key players in massive social and political change, and to respond accordingly.

Disability and care needs among older Americans

CONTEXT

The cost of late-life dependency is projected to grow rapidly as the number of older adults in the United States increases in the coming decades. To provide a context for framing relevant policy discussions, we investigated activity limitations and assistance, care resources, and unmet need for a national sample of older adults.

METHODS

We analyzed the 2011 National Health and Aging Trends Study, a new national panel study of more than 8,000 Medicare enrollees.

FINDINGS

Nearly one-half of older adults, or 18 million people, had difficulty or received help in the last month with daily activities. Altogether, 1 in 4 older adults receiving help lived in either a supportive care (15%) or a nursing home (10%) setting. Nearly 3 million received assistance with 3 or more self-care or mobility activities in settings other than nursing homes, and a disproportionate share of persons at this level had low incomes. Nearly all older adults in settings other than nursing homes had at least 1 potential informal care network member (family or household member or close friend), and the average number of network members was 4. Levels of informal assistance, primarily from family caregivers, were substantial for older adults receiving help in the community (164 hours/month) and living in supportive care settings (50 hours/month). Nearly all of those getting help received informal care, and about 3 in 10 received paid care. Of those who had difficulty or received help in settings other than nursing homes, 32% had an adverse consequence in the last month related to an unmet need; for community residents with a paid caregiver, the figure was nearly 60%.

CONCLUSIONS

The older population-especially those with few economic resources-has substantial late-life care needs. Policies to improve long-term services and supports and reduce unmet need could benefit both older adults and those who care for them.

Stroke rehabilitation: availability of a family member as caregiver and discharge destination

BACKGROUND

In today's health care environment where resources are scarce discharge planning is an important component of resource allocation. Knowledge of the factors that influence discharge disposition is fundamental to such planning. Further, return to home is an important outcome metric related to the effectiveness of a stroke rehabilitation program.

AIM

To test the hypothesis that the patients who have a caregiver at home willing to participate in the care of the patient discharged from a stroke rehabilitation unit are more likely to be discharged home given other predictive factors being the same.

DESIGN

Retrospective cohort study using binary logistic regression analysis with outcome as discharge home vs. discharge not home after in-patient stroke rehabilitation.

SETTING

Hamilton Health Sciences multidisciplinary integrated stroke program unit.

POPULATION

During this period, 276 patients were admitted to the integrated stroke unit, of which 268 patients were living in the community prior to hospitalization. The remaining eight patients were admitted from a care facility, such as a nursing home or assisted living facility. Since a sample size of eight is too small, these patients were excluded from the analysis. As such, the analysis is based on the 268 patients who were living at home prior to the onset of stroke.

METHODS

The data points collected during the study period were age, gender, days from stroke onset to rehabilitation unit admission, pre-stroke living arrangement (lived alone vs. lived with spouse, partner, or another family member), FIMTM at admission, type of stroke, laterality of impairment, and discharge destination (i.e., private dwelling vs. nursing home, assisted living facility, or back to acute care).

RESULTS

As established by a number of previous studies, the most significant predictors of home as discharge destination was admission FIMTM. However, the second most important predictive factor for home discharge was prestroke living arrangement (lived alone vs lived with spouse/partner/other family member) as hypothesized by the authors.

CONCLUSION

Literature is rich with studies showing functional independence to be the most important predictor of home as discharge disposition but our analysis shows that pre-stroke living arrangement, i.e., lived alone vs lived not alone is also an important predictor for patients to be discharged home after stroke rehabilitation.

CLINICAL REHABILITATION IMPACT

If current discharge planning relies on the availability of a caregiver at home after discharge from in-patient stroke rehabilitation then it may be worthwhile to include these caregivers in the inpatient rehabilitation process, to prepare them for their loved one's return home. Additionally, once the patient is discharged home more resources should be made available to support caregivers in the community. This may include more home healthcare personnel training and availability along with respite care.

The medical, functional and social challenges faced by older adults with intellectual disability

INTRODUCTION

Little is known about the sociodemographic and clinical profile of older adults with intellectual disabilities (ID) in Singapore. We studied the sociodemographic and clinical profile of older adults with ID and investigated factors associated with caregiver availability and identity in this population.

MATERIALS AND METHODS

The study population involved all adults with ID aged ≥40 years receiving services from the Movement for the Intellectually Disabled of Singapore (MINDS), the largest such provider in Singapore. Information on sociodemographic and clinical profiles, functional status, and availability of caregivers were collected via interviewer-administered questionnaires from guardians of older adults with ID. Descriptive characteristics were computed and chi-square and logistic regression identifi ed predictors of caregiver availability and identity.

RESULTS

Participation was 95% (227/239). There were differences in client age, gender, and caregiver availability between recipients of residential and non-residential services (all P <0.05). Common comorbidities included hyperlipidaemia (17.6%), hypertension (15.9%), psychiatric diagnoses (16.3%) and epilepsy (10.6%). The majority were fully independent in basic activities of daily living, but only 21.1% were fully communicative. Only a small minority (9.4%) were exercising regularly. The majority (73.5%) of clients had a primary caregiver; almost equal proportions relied on either parents or siblings. Older client age was associated independently with the lack of a primary caregiver, independent of greater functional dependence and presence of medical comorbidities in the client.

CONCLUSION

Older adults with ID have multiple medical, functional, and social issues. More can be done to support the care of this unique group of adults with special needs.

[The social value of informal care provided to elderly dependent people in Spain]

OBJECTIVE

To analyze one part of the social benefit derived from non-professional (informal) caregivers by analyzing the hypothetical amount of resources that would need to be invested if informal care were substituted by formal care.

METHODS AND DATA

Using data from the Survey of Disabilities, Personal Autonomy and Situations of Dependency (EDAD-2008), we estimated the cost to society if informal care were substituted by formal care of the population aged 65 years and older. For this purpose, first we computed the total amount of informal caregiving hours provided in Spain in 2008, and then we obtained its monetary worth by using the proxy good method.

RESULTS

The monetary worth of informal care provided in 2008 ranged from 25,000 and 40,000 million euros, depending on the shadow price used to value one hour of care. These figures represented between 2.3% and 3.8% of the GDP for the same year. In regional terms, the valuation of informal care across Spain's autonomous regions showed a significant degree of dispersion, and in some regions, amounted to 6% of their GDP.

CONCLUSIONS

The comprehensive approach to the care of the elderly should take the role and needs of informal caregivers into consideration. Caregivers should be given greater social recognition.

Informal caregivers of cancer patients: perceptions about preparedness and support during hospice care

This study examined the perceptions of preparedness and support of informal caregivers of hospice oncology patients. Respondents included coresiding, proximate, and long-distance caregivers. Thematic analysis was used to analyze the qualitative data from 2 caregiver surveys, one administered prior to the care recipient's death and another completed 3 months postdeath. Respondents (N = 69) interpreted preparedness broadly and identified multiple sources of support including hospice personnel, family, friends, neighbors, and spiritual beliefs. Additionally, informational support, such as education, information, and enhanced communication were considered essential for preparing and supporting caregivers. Implications for social work research and practice are provided.

Talking 'bout my generation

Mrs Pinker* is ready for discharge, but her sons, George and Paul, think she should be admitted to a residential home rather than return home. Mrs Pinker lives alone and every 3 or 4 weeks she wakes up in the middle of the night, becomes anxious and calls 999. An ambulance is dispatched and Mrs Pinker is usually taken to accident and emergency

[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.

The battle for recruiting and retaining the best: are you up for the challenge?

In Dallas-Ft. Worth, TX, over 800 home care agencies compete for business--and employees - from seemingly every street corner. Among all those agencies, one of them, Haven Home Health, LLC, was named one of the area's small company "Best Places to Work" by the Dallas Business Journal. With the continuing shortages of home care professionals like nurses, aides, and therapists and struggles to recruit and retain talented, engaged employees in this industry, here's a look at what Haven's been doing, including some innovative employee programs, and why its team says it's one of the best places to work.

Medicaid nursing facility rates, capacity, and utilization: a structural analysis

This analysis extends earlier work using national data to examine Medicaid nursing facility (NF) utilization (participants per aged population) and its interrelationships with Medicaid per diem NF reimbursement rates and NF bed capacity, using state-level data over 19 years to estimate two-stage structural equations. Findings demonstrate complex relationships among these factors. Reimbursement rates showed no demonstrable impact on utilization but positive effects on beds. Beds, in turn, positively predict utilization and negatively predict rates. Findings suggest that policy makers might focus on constraining Medicaid NF costs through controlling bed stock rather than by keeping rates lower, which can have untoward effects on quality and equity.

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.

Caretaking as articulation work: the effects of taking up responsibility for a child with asthma on labor force participation

A well-established quantitative literature has documented the financial toll for women's caretaking. Still, we do not know much about the process by which women end up taking on an extensive caretaking role and what they do on a daily basis. Based on in-depth interviews with a convenience sample of fifty caretakers of school aged children with asthma and nine health professionals in the USA, this study examines how health professionals socialize mothers into an intensive caretaking role for their children with asthma, how mothers negotiated and perform that role, and the impact of care work on their labor force participation. Care providers assign broad caretaking tasks that require further articulation work to get the job done. Although mothers care for their children in varied ways, caring for a child with a chronic disease remains a time-consuming activity. Mothers pay a price for the indeterminate nature of articulation work by scaling back their involvement in the paid labor force.

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.

Nurses, nannies and caring work: importation, visibility and marketability

This paper examines nurses' international migration within the broader context of female migration, particularly against more studied groups of women who have migrated for employment in care-giving roles. We analyze the similarities and differences between skilled professional female migrants (nurses) and domestic workers (nannies and in-home caretakers) and how societal expectations, meanings, and values of care and 'women's work', together with myriad social, cultural, economic and political processes, construct the female migrant care-giver experience. We argue that, as the recruitment of foreign workers gains visibility, strategies are introduced to better prepare female migrant care-givers for the marketplace. Language, specifically command of English and accent modification, is highlighted as one means to assimilate migrant care-givers to host communities.

Caregiver time use in ALS

The authors evaluated the caregiver time for 70 patients with ALS. The mean number of caregivers per patient was 2.0 (SD 1.3). Caregiver time increased with worsening of disability (p = 0.0001). The most time-consuming duties were housekeeping, feeding, and toileting. With worsening of patients' disability, families relied increasingly on paid caregivers. Caregiver time is a hidden cost of ALS care and is a major burden for caregivers.

[The centrality of the family as a resource for homecare: gender and generational perspectives]

Given the critical situation of informal caregiving in Spain, we explore how in the current socio-economic and political context main caregivers value and understand their family members as a resource to support caregiving. This qualitative study had a postfeminist orientation and was developed in Mallorca (Spain) through individual interviews and focus groups with men and women home caregivers from three generations. The participants identified their families, understood as women, as their main source of help due to the emotional quality of care they provide. However, internal conflicts and gender inequities, among others, made us question the dominant discourse of family's privileged position to take care of dependent people. The implications of these results to public policy are discussed.

Recruitment and retention of ethnically diverse long-term family caregivers for research

The inclusion of ethnically diverse long-term care family caregivers is significant in research, particularly in social work research because of the importance placed on diverse populations. However, the inclusion of diverse populations poses a set of unique recruitment and retention challenges for researchers. This process can be particularly complicated when multiple long-term care recruitment partners are utilized and when the project involves a multi-phase data collection plan with different minority recruitment needs for each phase. In our work we learned that: (a) research teams should plan for gender and ethnic differences in the ways that family caregivers think about and approach research involvement, (b) socioeconomic disadvantages and ethnic differences have both independent and interactive effects on research participation, (c) physical and emotional "costs," as well as financial costs, of caregiver participation should be given more attention in informed consent procedures, and (d) agency collaboration for minority recruitment and retention requires continuous nurturing and sustained effort by all members of the research team.

Burden of support for partners of persons with spinal cord injuries

STUDY DESIGN

Cross-sectional survey.

OBJECTIVES

(1) To describe the support given to persons with spinal cord injuries (SCI) by their partners, (2) to describe the perceived burden of support by partners and (3) to examine predictors of perceived burden of support.

SETTING

The Netherlands.

METHODS

All members of the Dutch patients organisation DON (N = 1004) and their caregivers, if applicable, were invited. Physical disability of the person with SCI was measured using the Barthel Index (BI). A number of secondary conditions, other practical problems and psychosocial problems were recorded. Partner support was described using a list of ADL-support, other practical support and emotional support. Burden of support was measured by a six-item measure (Cronbach's alpha 0.92), Nonparametric descriptive statistics and correlations were used. Linear regression was used to identify predictors of caregiver burden.

RESULTS

Responses were obtained from 461 persons with SCI. Of 265 couples, patient as well as partner data were available. Mean age of the partners was 49.4 years (SD 12.2) and 69.8% were women. Mean BI of the persons with SCI was 12.3 (SD 4.7) on a 0-20 scale and 60.4% were seriously disabled (BI < 15). Most partners provided various kinds of support. ADL-support and other practical support were given much more often by partners of persons with serious disability, but less difference was seen regarding emotional support. Professional (paid) support was obtained by 45.3% of all couples. Perceived burden of support was high in 24.8% of partners of persons with serious disabilities against 3.9% of partners of persons with minor disabilities. Significant predictors of caregiver burden were (in order of importance) the amount of ADL support given, psychological problems of the patient, partner age, partner gender, BI score and time after injury (total explained variance 47%).

CONCLUSION

A substantial proportion of partners of persons with SCI suffer from serious burden of support. Prevention of caregiver burnout should be part of the lifelong care for persons with SCI.

Extent and cost of informal caregiving for older Americans with symptoms of depression

OBJECTIVE

The purpose of this study was to obtain nationally representative estimates of the additional time and cost associated with informal caregiving for older Americans with depressive symptoms.

METHOD

Data from the 1993 Asset and Health Dynamics Among the Oldest Old Study, a nationally representative survey of people age 70 years or older (N=6,649), were used to determine the weekly hours and imputed costs of informal caregiving for elderly people with no depressive symptoms in the last week, one to three depressive symptoms in the last week, and four to eight depressive symptoms in the last week.

RESULTS

Forty-four percent of survey respondents reported one to three depressive symptoms, and 18% reported four to eight depressive symptoms. In multivariate regression analyses that adjusted for sociodemographics, caregiver network, and coexisting chronic health conditions, respondents with no depressive symptoms received an average of 2.9 hours per week of informal care, compared with 4.3 hours per week for those with one to three symptoms and 6.0 hours per week for those with four to eight symptoms. Caregiving associated with depressive symptoms in elderly Americans represented a yearly cost of about $9 billion.

CONCLUSIONS

Depressive symptoms in elderly persons are independently associated with significantly higher levels of informal caregiving, even after the effects of major coexisting chronic conditions are adjusted. The additional hours of care attributable to depressive symptoms represent a significant time commitment for family members and, therefore, a significant societal economic cost. Further research should evaluate the causal pathways by which depressive symptoms lead to high levels of caregiving and should examine whether successful treatment of depression reduces the need for informal care.

[Home care practice in Ishigaki Island, Okinawa]

In Yaeyama district in Okinawa, despite the scarcity of health-care resources for home visit, most of the patients used to choose home care instead of in-hospital care because of their special beliefs and preference different from mainland. Since people resided in a large family and formed a tightly knit community, patients were able to receive care from their family and community members. However, together with increase in chronic care facilities and modernization of the island that have brought downsizing of the family unit and loose community, the elderly are facing difficulty in receiving home care due to lack of care-givers. In order to establish the system to support the patients who wish to receive domiciliary care and live at home in their own life style, Yaeyama Hospital is expected to provide community-based health-care services 24 hours a day. It is essential that medical and welfare professions who are in charge of home care maintain close relations in good communication and collaboration.

Caregiver and clinician shortages in an aging nation

Despite a burgeoning elderly population, the number of nurses and other providers of direct care has declined to critical levels at many health care facilities. There are also insufficient medical clinicians to meet the demand for health services. A shrinking workforce, an aging population, financial pressures, and increased consumer demand will translate into severe personnel deficits in the future. Similarly, family fragmentation and the trend toward bureaucratization of long-term care have reduced the availability of informal caregivers. Younger workers should be considered a scarce resource for health care organization and planning purposes. The ability of the United States to meet its entitlement promises is likely to be compromised by a reduced labor pool and simultaneous budgetary constraints. Because good geriatric care is often labor-intensive, meeting this goal poses an increasing challenge.

Lack of caregivers limits use of outpatient hematopoietic stem cell transplant program

Our goal was to compare direct and indirect medical costs and quality of life associated with inpatient vs outpatient autologous hematopoietic stem cell transplantation (AuHSCT). Twenty-one sequential outpatients and 26 inpatients were enrolled on this prospective trial. All candidates for AuHSCT were screened for eligibility for outpatient transplantation. Patients with either breast cancer or hematologic malignancy, insurance coverage for the outpatient procedure, one to three caregivers available to provide 24 h coverage, and no significant comorbidities were eligible to participate. Patients without caregivers or insurance coverage for outpatient transplant were accrued to the study in a consecutive manner as inpatient controls, based on willingness to participate in the quality of life portion of the study and to permit review of their hospital and billing records. Approximately half of all 139 prospective outpatient candidates were ineligible because they lacked a caregiver. Most commonly, the patient without a caregiver was single or widowed or their family and friends were needed to provide childcare. Most caregivers were college educated from families with incomes greater than US dollars 80000. Indirect costs to the caregivers totaled a median of US dollars 2520 (range US dollars 684-US dollars 4508), with the majority attributed to lost 'opportunity costs'. Overall, there were significant differences in the total costs of treatment for inpatient vs outpatient AuHSCT (US dollars 40985 vs US dollars 29210, P < 0.01)). In general, no significant differences were detected between inpatient and outpatient scores on quality of life measures. Although significant cost savings were associated with outpatient transplantation, this approach was applicable to only half of our otherwise eligible candidates because of a lack of caregivers. The financial burden associated with the caretaking role may underlie this finding.

Long-term care quality: facing the challenges of an aging population

As part of its continuing mission to serve trustees and staff of health foundations and corporate giving programs, Grantmakers In Health (GIH) convened a select group of grantmakers and national experts who have made a major commitment to improve the quality of long-term care, particularly the care provided in nursing homes. The roundtable explored various factors influencing both the quality of care provided to elderly patients, as well as the quality of their lives. The discussion ultimately centered upon the importance of grantmaker involvement to improve the quality of long-term care, including the services delivered, training for professional and paraprofessional staff, continued research and evaluation, and public policies regulating the long-term care industry. This report brings together key points from the day's discussion with factual information on demographic, financing, and public policy trends drawn from a background paper prepared for the meeting. When available, recent findings, facts, and figures have been incorporated.

Patient classification systems, Part 1: The third generation

In part 1 of this series, the authors review the evolution of patient classification system (PCS) utilization and describe a third-generation PCS model (3PCS) that focuses on optimizing the patient-caregiver process for the outcomes of cost, health, and caregiver satisfaction. Part 2 (September 1999) will review the implementation of 3 PCS in a large urban hospital. Project rationale, methods for developing and implementing the system, key system components, advantages of the new system, and obstacles to implementation will be presented.

The labour market costs of community care

This paper reports an empirical investigation into the influence of informal care responsibilities on the labour supply of women. The objective is to examine the argument that the UK policy of caring for the chronic sick 'in the community' involves a nontrivial opportunity cost in the form of the forgone labour supply of the informal carers upon which it relies. We find that informal carers who care for less than 20 h per week are, in fact, more likely to participate in the labour market, but tend to work for fewer hours per week than otherwise similar noncarers. Informal carers who care for 20 h or more a week are less likely to participate, but only slightly. However, when they do undertake formal employment, they tend to earn less per hour and work for fewer hours per week.