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Do Spanish informal caregivers come to the rescue of dependent people with formal care unmet needs?p p p

Sergi Jiménez-Martín (UPF, BGSE, y FEDEA)Cristina Vilaplana (U. de Murcia)

Madrid, Mayo 2013

1

Preliminary concepts

Paid or free-of-charge attention providedby public or private institutions and nonFormal Care by public or private institutions and non-profit organizations (Keating, 1997)

Informal Care Attention provided by family, friends orneighbours (Keating, 1997)

Unmet needs Not covered demand of care

P t t t d i d f ill di bilit d li k d t

Dependency

Permanent state derived from age, illness or disability and linked tothe lack or loss of physical, mental, intellectual or sensorial autonomyRequire the care of another person/other people to perform basic

3activities of daily living.

Motivation: Decreasing sources of potential support

Factors affecting the supply of informal caregiversAverage household size:Average household size:

1998 3.23 people2007 2.74 people(Continuous Household Budget Survey, INE)( g y, )

Number of children per woman1975 2.803 children2008 1.458 children(Basic Demographic Indicators, INE)

Divorce rate (per 100 mariages)1980 4.7%2007 63.92%(Social Indicators, INE)

Female labor participation1987 31 83%1987 31.83%2008 60.13%(Active Population Survey, INE)

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Motivation: Increasing demands

Factors affecting the demand of careNumber of elder people living alone:

1998 784.283 (1.98% of population)2005 1 420 578 (3 18% population)2005 1.420.578 (3.18% population)(Continuous Household Budget Survey, INE)

Percentage of mentally ill people among those receiving informal care1994 19.2%2004 39.6%(Informal Support Survey, 1994 y 2004)

Population projections

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Motivation: Preferences

Preferences of elder people and informal caregiversOpinion about the participation of Public Sector in long-term care

Preference for the place for receiving care in case of need

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Literature

Previous research has concentrated on: causes and consequences of unmet needs (UNs) (Allen, 1994; Tennstedt et al.,consequences of unmet needs (UNs) (Allen, 1994; Tennstedt et al., 1994; Desai et al., 2001; Sands et al., 2006 ).

Consequences of UNs: Always negativeMorbility rate Degree of severity of disabilitiesDownfalls and accidents Health expenditureDownfalls and accidents Use of emergendy departments Physician visits Hospital stays

p(Allen and Moor, 1997)(Komisar et al., 2005; )(Long et al., 2005) Hospital stays

Institutionalization rate

Li it ti f i t diLimitations of previous studies:Did not take into accout the characteristics of informal caregivers network Omission of principal caregiver´s opinion

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Questions of interestQ

To what extent personal social services for dependent people (Home Care and Day Centres) are able to satisfy dependent’s needs

Which factors are associated to the emergence of personal unmet needs?

What is the effect of formal unmet needs over informal caregiving hours?

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DataData Informal Support Survey (IMSERSO, 1994 & 2004) Wh i f l i ( l i f i d Who answers: informal caregivers (relatives, friends,

neighbours) of older people (60 years and older), who maybe co-resident or not

Sample: N=1.665 in 1994, N=1.504 in 2004 Ceuta, Melilla and La Rioja excluded

Conclusions can not be applied to: Institutionalized dependent people Individuals who only receive formal care Individuals who only receive formal care

Innovative approach for determining the dependency degree Application of the Ranking Scale of Dependency (R. D. 504/2007, de 20 de abril)

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, )

Definition of Unmet Needs (UN)( )

Dependent( i f i )

Home Care(or informal caregiver)

applies for public formal careDay Centre

RejectedAccepted

Not satisfied (Q tit lit )

SatisfiedQuestion 1:

“In this card, there is a list of social i f d d t l lQuestion 2:

Question 3:“Tell me please, which is the (Quantity, quality) services for dependent people, please,

could you tell me which have you ever applied for?”

Question 2: Which of them are you receiving?

p ,valuation of the help received from

social services (excellent, good, regular, bad) with respect to the

Unmet needs Problem

g ) pfollowing aspects”: (i) provider’s

training, (ii) number of hours received, (iii) provider’s kindness ?”

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Unmet needs ProblemAnswer: Regular / Bad

Descriptive statisticsDecrease in 2004Higher for great dep.

Slight increase i 2004in 2004

Relation betwen FC and UN according to dependency degreeComparison 1994/2004

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Comparison 1994/2004

Descriptive statistics

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Descriptive statistics

For the case in which the dependent does not receive FC caregivers For the case in which the dependent does not receive FC, caregivers with UNs increase their caregiving hours by 33.38%.And when the dependent receives FC, caregivers with UNs devote 60 90% additional daily hours60.90% additional daily hours

Is this difference indicating an extra effort by caregivers tocompensate for formal care deficiencies?Self-selected group with regard to observable characteristics. estimating caregiving hours which control for the relevant observablevariables of each group.Self-selected with regard to unobservable characteristics (i.e.,inadequacy of formal care for the disabilities suffered by the dependent

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adequacy o o a ca e o e d sab es su e ed by e depe deindividual), OLS estimates will be inconsistent.

Double sample selection modelRelation between FC and UNs:

are unobsevable

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Double sample selection model

In the hours equation we must take into account

Define an equation for each subsample where we include theselectivity terms to correct the double selection problem(Tunali, 1986; Ham):(Tunali, 1986; Ham):

’ S l i i’s: Selectivity terms

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Empirical specification: The dependent variable•The variable “informal caregiving hours” (IC hours) records the number of daily caregiving hours devoted by the respondent caregivercaregiver.

•In the 1994 survey, the number of caregiving hours is recorded in 4 intervals: less than 1, 1-2, 2-5 and more than 5 hours/day. I h 2004 h b f i f l i i h•In the 2004 survey, the number of informal caregiving hours

was recorded in the following way: less than one hour, 1-3, 3-5, 5-8 hours/day and more than 8 hours/day.

•Thus, we estimate interval regressions with bivariate sample selection corrections.

•Two estimation methods:•Two stagesTwo stages•ML

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Empirical specification: explanatory variablesCarerecipient’s characteristicsGender, sex, marital status, level of education, dwelling arrangements, degree ofdependency, pathologies, type of benefit received, monthly household incomedependency, pathologies, type of benefit received, monthly household incomeCaregiver’s characteristicsGender, sex, level of education, marital status, number of caregiving years, permanentcaregiver, wilful caregiver, kinship dependent-caregiver, good relation with dependentbefore the onset of caregiving tasksInformal network:Secondary caregivers, kinship primary-secondary caregiver, children living ath h ldhouseholdFormal carePrivate formal careSocial services: Home Care (coverage index time devoted to personal care

Size of muncipality

Social services: Home Care (coverage index, time devoted to personal care,hours/week, cost/hour, copayment), Day Centre (coverage index, % psycogeriatricplaces, copayment)+ Regional policy variablesg p y+ Other Variables

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Empirical specification: Identification

•To ensure the identification of the model, not only by the non-linearity of the selection correction terms, standard selection models require the existence of at least one exclusion restrictionrestriction. •However, for the case of double sample selection models, Tunalli (1986) states that it is necessary to impose additional

i i id if h l irestrictions to identify the selection terms. 1. At least one variable of each selection equation must

not be related to the unexplained hours component. p p2. At least one variable included in the FC equation must

not appear in the UNs equation, and vice versa. 3 th i bl t t b i l d d i th h3. these variables must not be included in the hours

equations.

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Bivariate probit model: Results

Correlation coefficient NegativeDependent people who receive FC are less prone to suffer UNBigger effect in 2004

Marginal effects for binary variables using the sample mean andthe sample median

PathologiesPathologies

Almost constant for dementia osteoarticular problems

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p

Bivariate probit model: Dependency variables

Great dependent:FC=0&UN=1 by 47.01% in 1994 and 22.10% in 2004.

Moderate dependent:Moderate dependent:Lower decrease in the FC=0&UN=1 than GDDifferences between dependency degrees have shortened.

Severe or Great dependent:Severe or Great dependent: FC=1&UN=1 by 12.54% and 25.18% in 1994 and has

raised to 22.33% and 35.44, respectively, in 2004 higher probabilityof both receiving FC and considering it is unsatisfactoryof both receiving FC and considering it is unsatisfactory.Moderate dependency:

If they receive FC, lower prob. of not being satisfied

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Bivariate probit model: Regional Policy Variables

Higher coverage index of Home Care/Day Centre FC=0&UN=1 & FC=1&UN=1In 2004 the negative effect over:In 2004, the negative effect over:

FC=0&UN=1 is higher for Day Centre FC=1&UN=1 is higher for Home Care

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Bivariate probit model: Regional Policy variables

Home Care includes personal care and houseworkingp gMore time devoted to personal care: FC=1&UN=1

High variability across regions:Maximum: Navarra 80%Minimum: Extremadura 20%

More hours/month FC=0&UN=1 FC=1&UN=1 High variability across regions:

Maximum: Galicia 25.14 hours/monthMinimum: Andalucía 8 hours/month

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Bivariate probit model: Regional policy variables

C t/h & t FC 1&UN 1 d FC 0&UN 1 Cost/hour & copayment:FC=1&UN=1 and FC=0&UN=1 Cost/hour:

Maximum: Navarra 22.32 €/hourMi i E t d 6 18 €/hMinimum: Extremadura 6.18 €/hour

Copayment Home CareMaximum: 21% Galicia

Copayment Day Centre Copayment Day CentreMaximum: 40% Galicia

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Informal hours equations: Selectivity terms

1994:

FC=0UN 1

<FC=1UN=1

FC ICAgainst

Substitution

2004:

UN=1 UN=1SubstitutionModel

2004: 210: FC=1&UN=0 less IH than FC=1&UN=1

Informal Caregiving Hours: Dependency Results

Higher coefficients for FC=1&UN=1 as compared toFC=0&UN=1

.

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Informal Caregiving Hours: Results

F h d d d i f l i d For the same dependency degree, informal caregivers devotemore hours in 2004 than in 1994.For example, a level 2 great dependent with FC and UN implied an

i f 4 65 h / k i 1994 d 5 64 h / k i 2004increase of 4.65 hours/week in 1994 and 5.64 hours/week in 2004..

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Th di i i i h b d (l l 2) d The distance in caregiving hours between moderate (level 2) andgreat dependence (level 2) has increased between both waves:

2.76 hours/week in 1994 3 62 h / k i 2004 3.62 hours/week in 2004.

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Difference between with/without UN Difference between with/without UNFC=0&UN=0 vs. FC=0&UN=1

1994 1.09 more hour/week2004 1.68 more hour/week

FC=1&UN=1 vs. FC=1&UN=01994 1.70 more hour/week2004 2.01 more hour/week

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Informal Caregiving Hours: Kinship

Kinship of caregiver with respect to dependent:p g p pExistence of a gradient effect?1994:

Spouse always provide more CHp y p Son/daughter in law: only for FC=0&UN=1

2004: Spouse provides less CHp p Son/daughter in law: significant in three cases

More CH than spouse andson/daughter when FC=1&UN=0

FC ICComplementary

29Task-Specific


Living alone:Increase in the % of elder people living alone:

1994 24.95%2004 30.05%

Increase in the % of caregivers who invest more than20 min. in displacement timep

1994 29.26%2004 24.29%

The number of caregiving hours decreases if UN=1,with a greater effect if FC=1:

1994 -0.98 and -1.68 hours2004 -1.66 and -2.04 hours

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Number of caregiving years: Increase in caregiving hours (around 1.4) whenFC=0&UN=1 and the number of caregiving years isg g ygreater than 10 (or 12 for 2004).“Career in caregiving” (Aneshensel et al., 1995)Career sequence: 3 stagesq g

Acquisition role Enactment role Disengagement role

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P i l ti hi i d d t Previous relationship caregiver dependent: In 1994: increased the amount of caregiving hours in allsituations I 2004 In 2004:

We only observe a significant effect forFC=0&UN=1 and FC=1&UN=1Although the amount of care devoted hasAlthough the amount of care devoted hasincreased.

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Children under 18 living at household:g May represent an obstacle for caregiving tasks whenunmet needs are present. For the situation FC=1&IN=1, having young childreng y gdecreased the number of caregiving hours:

1994: -0.2 hours 2004: -1.42 hours

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Receiving help from other family members: The number of caregiving hours decreases for bothg g

waves by 3 hours when FC=0&UN=1 and nearly 4 hours whenFC=1&UN=1.

However, we found that one person tends to provide allp pinformal care. In 2004:

57.71% do not receive help from the family 20.15% receive help from 1 family member 14.63% receive help from 2 family members7.71% receive help from 3 family members

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Predicted number of IC hours

Wives provide more care than daughters for the national average Significant differences by Autonomous Communities related to the Significant differences by Autonomous Communities related to the

provision of social services

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The decomposition of the informal caregiving hours differentialp g g

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Conclusions

• The estimation results show a negative correlation between both the probability of receiving formal care and the probability of having unmet needs and a significantreceiving formal care and the probability of having unmet needs, and a significant selection bias of formal care and unmet needs on the number of caregiving hours.

• For both waves the number of caregiving hours increases with the presence of t d d i t h f l i i d f ti thunmet needs, and is even greater when some formal care is received, refuting the

substitution model, according to which the provision of formal care produces a decrease in the number of informal caregiving hours. F h S i h i h f l d i f l i i• For the Spanish case, it seems that formal and informal caregiving are not competing forces. Instead, informal care develops a compensatory and complementary role with respect to formal care.

d d h d ff b i d i• We need more data to asses the trade-off between caregiver and carereceiver’swelfare. Independent of what macroeconomic figures will show, we should question any reform that casts doubts on the future of many families.

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THANKS FOR YOUR ATTENTION

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Extra: Ranking Scale of Dependency

Case A: No cognitive impairment, intellectual disability or mental illness:10 activities and 51 tasks

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Ranking Scale of Dependency

Case B: There exists cognitive impairment, intellectual disability or mental illness:y11 activities and 59 tasks

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Additionally, for each task:

And finally:

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Classification in three dependency degrees:Moderate: needs help for DLA one a dayModerate: needs help for DLA one a daySevere: needs help two or three times per dayGreat: needs help for DLA several times per day

l l f i i i id h dTwo levels of supervision inside each degree:Level 1: can perform the activity by himselfLevel 2: requires some degree of supportLevel 2: requires some degree of support

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Ranking Scale of Dependencyg Sc e o epe de cy

Slight decrease in moderate dependency level 1 Increase in the percentage of individuals without any degree of dependency effect of the increase in the number of healthy lifedependency effect of the increase in the number of healthy life years at birth, from 67.7 in 1996 to 70.2 in 2003 (Eurostat. Health Indicators)

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Ranking Scale of Dependencyg Sc e o epe de cy

High degree of consistency between the classification obtained form Informal Support Survey (1994, 2004) and the Disabilities, Deficiencies and Health Status Survey (1999).The disparity for high dependency (15.39% vs. 9.45%) may beattributable to the fact that the forecasts for 2005 include thepercentage of elderly people who are institutionalized.

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pe ce age o e de y peop e w o a e s u o a ed.

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