Culture matters: Employment, informal eldercare and caregiver

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Culture matters:
Employment, informal eldercare and caregiver burden in Europe
Wouter De Tavernier
Centre for Comparative Welfare Studies, Aalborg University
Fibigerstræde 1.90b
9220 Aalborg Ø
Denmark
[email protected]
+45 40 83 57 69
Ethical approval is not required for this study
Culture matters:
Employment, informal eldercare and caregiver burden in Europe
Abstract
As populations age, a double demand is placed on women in their 50s and 60s. Policy-makers hope to
cope with rising costs of pensions and health care by increasing their labour market participation; yet
the same women are expected to give informal care to their care-dependent parents. In this study, we
go into this seeming contradiction, investigating what determines caregiving decisions and caregiver
well-being, specifically focusing on the role of employment and culture. Using 2012 SHARE data on
some 5300 women aged 50-65 from 16 European countries, we find no effect of employment on
informal caregiving. Norms do affect caregiving: while more women give some form of informal
eldercare in countries where eldercare is not seen as a family responsibility, the intensity of caregiving
is much higher in countries with familialist norms. Regarding well-being, the relation between culture,
employment and informal care is a more complex one. In countries where eldercare is not considered
a family responsibility, giving informal eldercare negatively affects well-being, especially among nonemployed women. In countries with familialist norms, on the contrary, well-being is higher among
individuals caring intensively for a dependent elder. In all countries, employment coincides with
higher well-being, whether or not care is given. These results have two important implications. First,
the general agreement on the existence of the informal caregiver burden may well be the consequence
of this research mainly being done in a Western context: in countries where family care is the norm,
giving informal eldercare actually increases rather than decreases well-being. And second, policymakers should focus primarily on keeping women in this age group in employment, as this is good for
their well-being yet would not affect their involvement in informal care. As such, this study strongly
advocates policies aiming at allowing individuals to combine work and eldercare.
Keywords
Female labour market participation; informal eldercare; informal caregiver burden; culture; Europe
Introduction
As populations age, researchers, politicians and the general public worry more and more about the
challenges this process poses to welfare systems across the developed world. This concern generally
focuses on two elements: increasing costs of retirement pensions and health care threaten the
financial sustainability of the welfare state; and the possibility that society will not be able to offer
sufficient care to cover the needs of the elder population. While states generally aim to tackle the
former issue by attempting to raise the labour market participation rate in society, many believe we
will need to rely more on the family to cope with the latter. As, culturally, societies still rely mainly on
women for the supply of informal care, these strategies generate conflicting demands for the women in
their 50s and 60s. On the one hand, they are expected to be on the labour market, while on the other,
they are relied on for supplying informal care for their parents and parents-in-law (‘filial care’). In the
light of this dilemma, it is crucial to also take into account the possibly very negative consequences of
giving informal care for the informal caregivers themselves. There is a vast body of literature on
‘informal caregiver burden’ that lists a series of consequences caregivers can suffer from, including
stress, depression and low well-being.
Cultural factors are largely overlooked in eldercare research, especially in relation to the caregiver
burden. That is not surprising as many of these studies are limited to one country or even a specific
region, city or care institution, leaving little variation in culture. As norms, values and roles are aspects
of culture, it would seem probable that culture indeed affects not only caregiving itself, but also
caregiver burden. Hence, in this study we want to investigate why women care for their parents or
parents-in-law and under which circumstances this leads to lower well-being. In doing so, we want to
focus specifically on the importance of culture for both caregiving decisions and informal caregiver
burden.
We take two general approaches to the prevalence of informal eldercare as the starting point for our
study. On the one hand, rational choice theories (labour supply theory and rational choice
institutionalism) think of the decision to give care as a rational consideration where utility-maximising
individuals way off (possible loss of) income, cost of professional care and time available for caring. On
the other, from a sociological institutionalist perspective, caregiving is related to roles and norms that
either limit the available options to choose from or make certain options more salient or appealing
than others. Both theories can easily be connected to the caregiver burden. Among other reasons,
burden develops when giving care poses serious time constraints on the individual. If one works fulltime, it could be very hard to also fulfil ones care responsibilities. As such, caregiver burden goes hand
in hand with the scarcity of time that is at the core of labour supply theory. Moreover, roles are core to
informal caregiver burden, as role overload and role conflict can cause serious strain on caregivers.
Individuals are in distress when they cannot act in accordance with the norms and expectations they
themselves or others have about them. As these roles are essentially cultural phenomena, culture may
well play an important role in the development of informal caregiver burden.
For this study, we make use of data on 16 countries from the 2012 wave of the Survey on Health,
Ageing and Retirement in Europe (SHARE). From this dataset, we select women aged 50 to 65 with at
least one parent or parent-in-law who is still alive. For this sample, we indeed show that societal
norms regarding eldercare affect not only the choice to give care to a parent(-in-law), but also
caregivers’ well-being. Our analyses show that the caregiver burden indeed exists, but mainly in
Western European countries where eldercare is not seen as a family responsibility. In countries where
it is considered a family responsibility, mainly in Southern and Eastern Europe, giving eldercare on the
contrary improves well-being. Hence, the general agreement on the existence of the informal caregiver
burden may well be the consequence of the fact that most studies on the topic come from Western
Europe and North America.
Theoretical framework
There are three dominant theories explaining why individuals supply informal care: labour supply
theory offers a rational choice approach at the individual level and usually coincides with rational
choice institutionalist explanation at the aggregate level; sociological institutionalism offers an
alternative at the aggregate level, bringing in cultural aspects, such as norms. Labour supply theory
follows a classical economic approach, where the decision to give care depends on considerations of
time and income, especially in relation to employment (income) and the cost of professional care.
Following the logic of this theory, informal care is provided when professional care is too expensive
compared to (possible) labour income. According to rational choice institutionalism, individuals will
consider policies in their utility-maximising decisions regarding time and income, and hence informal
care. As such, policies can affect decisions for instance by lowering the price of professional care or by
subsidizing informal care. Finally, sociological institutionalism posits that individuals have – and
share – norms and expectations about how society’s elders should be taken care of, such as whether or
not care should be supplied by the family. These norms do not necessarily determine care choices, but
do limit the options available or make certain options more probable than others. These theories are
not mutually exclusive and hence several attempts have been made to make an overarching
framework within which all these approaches are combined, e.g. bounded rationality (Kato 2007) or
Searing’s (2007) construction of roles, rules and rationality.
In this article, however, we want to go beyond the question why individuals get involved in supplying
informal care, and also assess how caregiving affects well-being within these broader normative
contexts. Much has been written about the informal caregiver burden, many studies clearly showing
strong negative effects of caregiving on caregivers’ well-being – at least when care is given intensively
(van Campen, de Boer and Iedema 2013). The fact that many studies measure this burden in terms of
depression illustrates just how detrimental informal caregiving can be for the caregiver. Nonetheless,
most studies are limited to one specific country (e.g. Brouwer et al. 2005) or even one specific setting
such as a city or a hospital (e.g. Carretero, Garcés and Ródenas 2007; van Exel et al. 2004; Van Pelt et
al. 2010), and thus little is known about the role of cultural factors such as norms in the development
of this informal caregiver burden. Hence, after going into the three theories on why individuals give
informal eldercare, we will discuss the caregiver burden and the possible role of culture therein.
Theories on employment and informal care supply
Rational choice: Labour supply theory and rational choice institutionalism
The classical economic approach to female labour market participation is oriented towards the supply
side of the labour market, and thus concerns the availability of informal care. According to this theory,
women will decide to enter into paid employment on the condition that it maximises their utility. This
decision is a fully rational one, based on full information about the job and its characteristics. The
concept of utility is central to labour supply theory: it contains the individual’s preferences concerning
the characteristics of a specific job, usually operationalized as wage income and the amount of time left
outside working hours. The general assumption is that individuals want to find a balance between
labour income and leisure time they consider optimal, and that they will maximise either one as long
as this does not affect the other.
In many situations, however, it is not possible to increase for example the wage without giving in on
leisure time, in which case one has to find a balance between both competing interests. This balance
can diverge depending on the individual as not everyone values the same amount of income or leisure
time equally. Many factors play a role in how people consider a certain balance between wage and
working hours as optimal – and hence utility-maximising –, though here we will only list the two that
are at the core of labour supply theory.i On the one hand, individuals – and especially women – with a
higher earnings potential are more likely to choose to be in paid employment (Attanasio, Low and
Sánchez-Marcos 2008; Blau and Kahn 2007; Cloïn, Keuzenkamp and Plantenga 2011; James 1992). On
the other, and seemingly contradictory, if one’s wage and/or accumulated assets are substantial
already, the individual is more inclined to opt for a reduction of working hours than for an increase in
wage, as the latter is unlikely to coincide with higher consumption levels.
Rational choice institutionalism is built on the same rational choice principles that are at the core of
labour supply theory (Bevir 2010; Hall and Taylor 2007), though adds state policies and institutions to
the equation. The basic idea is that the individual adapts its behaviour according to existing (state)
policies and institutions in a predictable way (Pfau-Effinger 2005). This process is assumed to proceed
somehow automatically as individuals’ inherent strive for utility maximisation is being held back by
practical issues such as dependent children or elder family members. By addressing these issues with
certain policies, individuals will change their behaviour. Policies improving (access to) professional
care services diminish the need for informal care. As such, they are at the core of women’s
emancipation in the institutionalist framework, by taking care responsibilities away from the family.
At the other side of the familialism spectrum, we find policies giving financial rewards to those
supplying informal care. These policies target the availability of informal care by lowering the
opportunity cost of (temporarily) quitting paid employment. Parental leave or cash-for-care schemes
to take care for elder relatives are typical examples. Work-family policies may even influence the
likelihood of women staying in the labour market when they do not make use of them (Butts, Casper
and Yang 2013). As such, social policies can support women’s emancipation by including them in paid
labour, pushing them towards a dual earner family model with reduced economic dependency and a
stronger bargaining position within the household (Borchorst and Siim 2002; Orloff 1993).
Rational choice institutionalism is never far away in studies taking a labour supply approach to female
labour market participation: typically, policies are taken into consideration in the analysis or policy
proposals are made in the conclusions. Gornick, Meyers and Ross (1997) for example frame
employment decisions of women within labour supply theory, assuming that women value time
outside employment more when they have dependent family members. In that instance, labour supply
theory predicts women will reduce their working hours or even quit the labour market in case
professional care is unavailable or too costly relative to the (potential) wage earned. Institutionalist
theory, then, expects the individual to (re-)enter paid employment if policies are introduced focusing
on reducing the costs of professional care (Han and Waldfogel 2001) or extending its coverage
(Andreβ et al. 2006; Kreyenfeld and Hank 2000). Paying benefits to informal care suppliers, on the
other hand, results in less involvement in paid labour (Keefe and Rajnovich, 2007; van Damme,
Kalmijn and Uunk 2009).
Not all studies on informal care in the classical economic tradition follow this logic of time and income.
A notable exception is the study of Brouwer et al. (2005), arguing that informal care delivers ‘process
utility’ where the process of giving care itself brings joy to the caregiver. Indeed, enjoyment or
happiness could be a form of utility, just like time or income. The authors link process utility to
preferences of caregiver and –receiver and whether alternatives to informal care are available.
Remains the question: what shapes these preferences and the alternative options available?
Culture: Sociological institutionalism
The study of Brouwer et al. (2005) reveals a major shortcoming of both rational choice theories: their
fundamental assumption about individuals’ goals and preferences. This is illustrated by the article of
Gornick, Meyers and Ross (1997): Why would individuals – and especially women – be eager to reduce
paid employment once they have a dependent family member, or quit their jobs altogether? This is
fundamentally a cultural question, one about the individual’s norms and values, and about the
individual’s expectations of the norms and values of others (James 1992; Jensen 1996). Labour supply
theory expects all individuals to make a rational choice about labour market involvement based on
wage and working hours, but fails to include the context that determines the value of income or nonworking time for the individual. Whether it is being in paid employment or taking care of a family
member that gives the highest feeling of self-fulfilment to an individual is dependent on these norms.
Moreover, both theories fail to take the broader societal context into account. Even if a woman is
oriented towards the labour market, her dependent parent may well expect to be taken care of by his
or her daughter; and also other individuals in the local community or the social environment might
have such expectations.
Sociological institutionalism fills this gap by explicitly linking individual behaviour to culture (Bevir
2010; Hall and Taylor 2007). Jensen (1996), for instance, shows that culture determines whether and
how individuals will make use of the institutions that are there. Culture encompasses a system of
meanings, norms and values (Pfau-Effinger 2005), common among the members of a (sub-)society,
that is passed on via processes of socialisation in interaction with others. As an internalised set of
meanings, norms and values, it shapes individual action via habits, ideas of what is good and bad, and
perceptions on how one is supposed to behave, such as social roles. In conclusion, institutions in the
sociological sense “provide the ‘frames of meaning’ guiding human action” (Hall and Taylor 2007:
178). The argument of sociological institutionalism is not deterministic in nature, but is rather about
limiting the options individuals can choose from: “Institutions influence behaviour not simply by
specifying what one should do but also by specifying what one can imagine oneself doing in a given
context” (Hall and Taylor 2007: 178-179). Hence, it is complementary rather than contradictory to the
rational choice approach of labour supply theory and rational choice institutionalism (Searing 2007):
in the terms of the latter, culture shapes the utility of paid employment and informal care – either by
limiting the options that are available to the individual, or by giving more leverage to specific
preferences. Subsequently, individuals make a well-considered decision based on the options they see
or consider feasible. As Kato (2007: 228) describes it in the context of bounded rationality: “an
individual only ‘intends’ to be rational.” Within a certain society, it may well be impossible – or
unthinkable – for a married woman with small children to enter (a specific kind of) paid employment
outside the home, while in another, the presence of small children in the family may merely make
women value time outside paid employment more.
Well-being
Informal caregiving is known to be a cause of stress, especially when combined with paid employment
(Gordon et al. 2012). This phenomenon, known as informal caregiver burden (e.g. Carretero, Garcés
and Ródenas 2007; van Exel et al. 2004; Van Pelt et al. 2010), is framed within the transactional stress
theory by Pearlin et al. (1990), and is presented as a two-stage process. In the first stage, stress
emerges from the kind and intensity of the care demanded (‘role overload’, see Pearlin 1989), and
from the negative emotions that can come with care (e.g. Lee and Singh 2010). In the second stage,
however, there is a ‘spillover’ of care to other parts of caregivers’ lives, as it reduces their leisure time,
diminishes social relations and conflicts with the demands of paid employment. A strategy to escape
from this situation of role overload is to reduce involvement either in caregiving or in the labour
market. Stone and Short (1990), for instance, indeed find that informal caregiving can cause a
reduction of one’s participation in the labour market. However, making this trade-off between the role
of the worker and that of the carer can cause role conflict, as both roles coincide with cultural norms
and thus expectations of the individual and its environment. Hence, both role overload and role
conflict can put strain on the caregiver and reduce their well-being.
Caregiving decisions and informal caregiver burden are entangled, not only because informal carers
with substantial burden wish to retreat from caregiving (Brouwer et al. 2005). Many of the processes
leading to informal caregiver burden are determinants of giving care as well. Role overload is
essentially about scarcity of time, and hence feeds into the rational choice theories on informal care
supply. As well-being is seriously affected by combining care and employment, it offers an explanation
for why exactly individuals have to choose between income and time outside work. Moreover, also
culture plays an important role in the development of caregiver burden. Role conflict is related to
norms assigning certain tasks to certain groups of individuals, thereby pushing them into a specific
role. It emerges when one is not able to fulfil the tasks connected to one or more of these roles. Hence,
in a familialist culture, role conflict emerges when a woman is not able to give the care needed by her
parents(-in-law).
Conceptual framework
Figure 1 presents our conceptual framework based on the above literature.ii Lines and concepts
indicated with dotted lines will not be subject to our statistical analysis – either because it is not
possible to measure them or because they are not core to this study – though they are included here as
it is important to keep these relations in mind when discussing the results. Hence, the figure sums up
the expectations and hypotheses for this study.
< Insert Figure 1 about here >
On the left side of the scheme we find two variables at the aggregate level that are negatively
correlated: in countries with a more familialist culture, female labour market participation in the age
group from 50 to 64 will be lower. These variables influence individuals’ decisions. In countries with
strongly familialist norms, women will be more likely to care for a dependent elder. In countries with
high female labour market participation, more women will be in paid employment and thus will be
less involved in filial care due to the scarcity of time that is core to labour supply thinking. If filial care
and employment are combined, however, role overload will be high and well-being will decrease. On
the other hand, if a woman decides not to care for her dependent parents or parents-in-law in a
country with highly familialist norms, she will experience role conflict which will lower her wellbeing.iii Finally, there is a ‘feedback loop’ from well-being to employment and filial care: individuals
who experience lower well-being as a consequence of their involvement in paid employment and/or
informal care may well revise that involvement.
Data, operationalisation and methods
For our research, we use 2012 data of the Survey of Health, Ageing and Retirement in Europe (SHARE,
wave 4). SHARE is a large longitudinal survey aimed at investigating a variety of issues connected to
old age, and includes information on individuals aged 50 or more and their household members. It is
one of the only international datasets including information on informal eldercare, and the only one
we know of that would allow for the testing of our conceptual framework. Four countries, mainly postcommunist republics, entered the SHARE survey in the fourth wave, bringing the amount of countries
included in the survey to 16: Austria (AT), Belgium (BE), Czech Republic (CZ), Denmark (DK), Estonia
(EE), Germany (DE), France (FR), Hungary (HU), Italy (IT), the Netherlands (NL), Poland (PL), Portugal
(PT), Slovenia (SI), Spain (ES), Sweden (SE) and Switzerland (CH). From these data we select all
women aged 50 to 65 who have at least one living parent or parent-in-law, resulting in a sample of
5304 individuals.
Filial care refers to whether the respondent says to have given personal care or practical household
help to a parent(-in-law), and is operationalised as an ordinal variable with three values: does not give
care; gives care up to twice a week (low care intensity); and gives care more than twice a week (high
care intensity). We choose this distribution as the study of van Campen, de Boer and Iedema (2013)
indicates happiness levels are higher among informal carers giving less than six hours of care per week
compared to individuals not giving care, and lower among individuals giving more than 11 hours of
informal care per week. It is, however, important to note that information about informal caregiving is
only available when the dependent person is living in another household. Therefore, we may
underestimate the occurrence of informal caregiving to a certain degree in countries where
respondents are more likely to live together with their parents or parents-in-law. This is the case in
many Southern and Eastern European countries, with up to ten per cent of the Spanish, Polish and
Portuguese sample units having an elder living in the household.
The items available in the SHARE dataset do not allow for a reliable measurement of role overload and
role conflict, hence it is not possible to account for this intermediary step in the model. Our measure
for well-being, scaled from zero to ten, is established using factor analysis and subsequent reliability
analysis (Cronbach’s Alpha = 0,80). It is constructed using the following items: satisfaction with life;
looking forward to each day, thinking one’s life is meaningful, looking back at one’s life with happiness,
feeling full of energy, thinking life is full of opportunities, and thinking the future looks good.
We also include a series of control variables at the individual level. For the age variable, we subtract 50
from the age so the intercept refers to women aged 50, the youngest women in our sample. The
variable ‘married’ indicates whether the individual is married or in a registered partnership. ‘Bad
health’ contains the subjective health indicator, rated from excellent (0) to poor (4). Being in paid
employment is included as a variable with three categories: not employed (0), employed part-time (1)
and employed full-time (2), with full-time being defined as having at least 32 contracted hours of paid
employment per week. We did the analyses as well with employment represented by two dummies
(part-time and full-time employment), leading to very similar results. We choose to represent
employment here as one variable as it makes sense from a labour supply perspective (with part-time
employment meaning one has less time available for caring as someone not in employment, but more
than someone in full-time employment) and is more intuitive to interpret in interactions. Further, two
more control variables are included at the individual level: the health condition of the parent(-in-law)
as rated by his or her child (similar to the individual’s self-rated health) and a dummy indicating
whether the distance between the individual and his parent or parent-in-law is less than 25
kilometres. In case the individual has more than one parent or parent-in-law who is still alive, these
two variables refer to the health status of the one with the worst health and the one living closest by,
respectively.
Regarding the country level, the 2007 special Eurobarometer ‘Health and Long-Term Care’ (European
Commission 2007: 67) is used to measure familialist norms. It contains the proportion of individuals
in a country who are of the opinion that elders living alone needing regular help should either be
helped in their own homes by one of their children, or should move in with one of their children. As no
data are available for Switzerland in this dataset, its familialism score is taken from the 2012
International Social Survey Programme (ISSP) dataset ‘Family and Changing Gender Roles IV’. It is the
proportion of individuals that is of the opinion that the family should be the primary caregiver. For the
nine countries from SHARE that are available in both datasets, they result in very similar proportions,
with a difference in proportions larger than 0,1 only occurring in Denmark. The female labour market
participation rate between age 50 and 64 for the year 2010 is taken from the Eurostat Statistics
Database (Eurostat 2014) and is included as a proportion as well.
As we have two types of dependent variables, we apply two different kinds of regression techniques.
First, we test the importance of familialism and female labour market participation for giving filial care
using random intercept logistic regression (proc glimmix in SAS). And subsequently we assess whether
these variables interact with filial care in their effects on well-being. Therefore, we employ random
intercept linear regressions using the proc mixed command in SAS).
Descriptive statistics
The descriptive statistics are presented in Table 1. First, we see that the sample size differs from
country to country, with most sample units coming from France (n = 846), while Slovenia is least
represented (n = 106). For most countries, the women in the sample are on average around 56 years
of age, with Estonia having the youngest sample (54,8) and Sweden the oldest (57,7). The vast
majority of women in our sample are married, though with some substantial between-country
differences: two out of three Austrian respondents are married, compared to virtually all Slovenian
ones. Also regarding self-rated health of the respondents, there are some differences between the
countries. With an average score of 1,3 (one equals ‘very good’ and two means ‘good’), the Danish
sample units consider themselves markedly more healthy than the Estonian and Hungarian ones with
an average score right in the middle between ‘good’ and ‘fair’.
With a third of the women in the sample in part-time employment and another 22 per cent in full-time
employment (meaning that they have at least 32 contractual working hours per week), more than half
of the respondents are in paid employment. With four out of five women in paid employment, the
samples from social-democratic welfare states include most working women. At the other end of the
spectrum, we find around three to four women out of ten in paid employment in the familialist welfare
states. The corporatist and post-communist welfare states are found all over the spectrum, with
Switzerland and Estonia approaching the Scandinavian female employment rate, while those in
Poland, Slovenia and Austria are comparable to the rates found in familialist countries. However, there
are some striking differences in terms of part-time and full-time employment, too. While female
employment is predominantly part-time in the samples from Scandinavia and the corporatist
countries, the large majority of employed respondents in the post-communist countries work full-time
– Poland being a notable exception. For all countries, the average health status of the parent or parentin-law fluctuates around three, meaning ‘fair’. Belgian elders on average have the best subjective
health score (2,6), Estonian elders the worst (3,2). Finally, two thirds of the sample lives within a 25
kilometre distance of his or her closest-by parent or parent-in-law. While only one in two Danish
sample units live within this radius, this is 86 per cent among Italians.
In general, the level of well-being in our sample is highest in the social-democratic and corporatist
welfare states, Denmark and Switzerland having the best scores, while Belgium lags somewhat behind
on its regional counterparts. In the familialist and post-communist welfare states, results are less
uniform: overall, well-being is lower, though Spain and Poland reach the same level as Belgium and
Slovenia even comes close to Swiss levels. At the other side of the spectrum, Portugal and, to a lesser
extent, Hungary score dramatically lower than all other countries in terms of well-being.
The information on giving filial care, intensity of this care, female labour market participation and
familialist norms presented in Table 1 is visually represented in Figures 2 and 3. First, in both figures
we can see that the relation between familialist norms regarding eldercare and female labour market
participation in the age group studied is not a straightforward one. Overall, there seems to be a
negative relation between both concepts. However, Switzerland, Estonia and Germany clearly break
with this pattern, combining higher levels of female employment with above-average agreement with
the statement that eldercare is a family responsibility. Moreover, the size of the circles in Figure 2
illustrates that between-country differences in terms of giving care are rather small, and that there
does not seem to be a clear pattern in terms of in which countries women tend to be more involved in
caregiving than in others. About 18 per cent of the sample gives informal care. In Figure 3, however, a
very different picture emerges. There, we look at how many days per year caregivers actually give
care. In the Scandinavian countries, little care is given, with on average one day of care per week in
Sweden and even almost half as much in Denmark. At the other side of the spectrum, we find the
familialist countries, from 250 days of help per year in Italy to 315 days per year in Portugal – this is
the equivalent of about respectively five and six days per week. The corporatist countries can be found
in the middle with in between about 100 (Switzerland) and 200 days of care per year (Austria). The
post-communist countries, finally, seem to be split in two groups. While informal carers in Estonia,
Poland and Czech Republic on average are situated in between Austria and Italy in this regard,
Hungary and Slovenia approach Portuguese levels, with around 300 days of help per year. Figure 3
indeed seems to indicate that the amount of care given by caregivers is lower in countries with less
familialist norms regarding eldercare and in countries with higher female labour market participation
rates.
< Insert Table 1 about here >
< Insert Figure 2 about here >
< Insert Figure 3 about here >
Analyses
In Table 2 we find the results of the multilevel logistic regressions in which giving filial care is
modelled. As filial care has three categories depending on care intensity, in every model a different
pair of outcomes is compared. In Model 1, the odds of giving care to a parent or parent-in-law up to
twice a week (low care intensity) are compared to not giving care, and in Model 2 women giving care
more than twice a week (high care intensity) are put alongside the same group. Model 3, then,
compares the carers with high care intensity to those with low care intensity.
We find that older women give more care: they are more likely to give care, and tend to give more
intensive care. Note that this is not the consequence of differences in employment status (transitions
into part-time employment or exit from the labour market), as this is controlled for in the model.
Married women are less likely to give filial care. In contradiction to the expectations of labour supply
theory, employment does not affect caregiving at all. Unsurprisingly, women with bad health are less
inclined to give care to an elder, while both the likelihood of giving care and care intensity increase as
the health situation of the elder deteriorates. Women living closer to their parents(-in-law) are also
more likely to give care, and to do so more than twice per week. The country-level variables show
some interesting differences depending on care intensity: in countries with high female labour market
participation in the age group from 50 to 64, women are more likely to give care at a lower intensity,
though much less likely to be involved in intensive caregiving. This effect, when controlled for
employment at the individual level, probably indicates that the female labour market participation
rate also acts as a cultural norm: a high rate is likely to indicate that women are expected to be in paid
labour. Finally, regarding the extent to which the idea that eldercare is a family responsibility is
supported in a country, we find the exact opposite pattern: women are less likely to give low intensity
care in a setting with more familialist norms, though are much more likely to give high intensity care.
< Insert Table 2 about here >
< Insert Table 3 about here >
In Table 3 we find the outcomes for well-being. In none of the models does age affect well-being, while
being married positively influences the dependent variable and being in bad health has a negative
effect. Also having a parent or parent-in-law in poor physical condition lowers one’s well-being.
Distance between the respondent and the elder has no effect, and employment is positively related to
well-being. The results regarding caregiving are less straightforward to interpret. Depending on the
model, women giving care maximum two times per week either do not differ from those not giving
care at all in terms of well-being, or have slightly higher well-being scores. However, the effect of high
care intensity depends on the interactions included. In Model 1, we find that high care intensity has a
positive effect on well-being, and in Model 2 we see that this effect can completely be attributed to the
high well-being of informal carers in paid employment. These findings go against much of the
literature regarding caregiver burden, and are hence explored further in relation to the cultural
setting. In Models 3 and 4 we also include the female labour market participation rate in the studied
age group and the extent to which people in the country are of the opinion that eldercare is a family
responsibility, and their respective interactions with giving high intensity care to a parent or parentin-law. The effects of these interactions can be found in Tables 4 and 5.
< Insert Table 4 about here >
< Insert Table 5 about here >
In Table 4, we calculate the effects of the interactions between employment, filial care and female
labour market participation from Model 3 in Table 3, and hence show the total effects for two
situations: countries with a low female labour market participation rate between age 50 and 64 (25
per cent) and countries with a high rate (75 per cent). When looking at countries with a low female
labour market participation rate, we find the lowest levels of well-being among women who are
neither employed, nor give care. The highest levels of well-being in these countries are found, on the
contrary, among women giving intensive care to a parent or parent-in-law, while at the same time
being employed full-time. Women not giving care and in full-time employment, and those giving
intensive care while not employed have intermediate levels of well-being, the latter scoring higher. In
countries with a high female labour market participation rate, we find the exact opposite pattern: here,
well-being is lowest among women giving intensive eldercare and not being in employment, and it is
highest among full-time employed women not caring – though the difference between the latter and
full-time employed women giving intensive care is very small and, to a certain extent, the same is also
true for non-employed women not giving care. In sum, no matter the setting, women in full-time
employment have higher well-being, though not caring in a country with low participation of women
in the labour market is detrimental for well-being, while giving care more than two days per week
reduced well-being in countries with high female labour market participation. Finally, in the former
countries, differences in well-being between these four groups of women are bigger than in the latter.
Table 5 presents the same information, but split up by whether on average, people consider eldercare
a family responsibility in the country. In strongly familialist countries, a similar picture emerges as
before: the highest levels of well-being are found among full-time employed women giving intensive
care, while the lowest are found among those not employed and not giving care. The picture in
countries where eldercare is not considered a family responsibility by many is slightly deviant. Nonemployed women giving intensive care are feel worst – as was the case for countries with a high
female labour market participation rate in Table 4 –, while those in full-time employment giving
intensive care have highest well-being. Though, again, the difference with those employed but not
caring is small. These results stress once again the importance of employment for well-being among
women in this age group, as well as acting according to the general expectation in society. Also here,
the range in well-being is higher in familialist countries.
We can draw a few conclusions from Tables 4 and 5. First, the female labour market participation rate
does indeed seem to act as a norm, the expectation that women above age 50 are expected to be in
paid labour. Second, no matter the situation in terms of norms or caregiving responsibilities,
employment always coincides with higher well-being. And third, giving high intensity informal care
raises well-being in settings where family care for elders is the norm, while it is detrimental for wellbeing in settings where norms are more concerned with female labour market participation and less
with familial care, at least among those women not in employment. Hence, the cultural setting
determines whether informal caregiving leads to a burden.
Conclusion
Ageing societies generate seemingly conflicting demands regarding women in their 50s and 60s. On
the one hand are they needed in the labour market so that they can contribute to society financially,
which is necessary to cope with ageing-related costs such as rising pension and health care expenses.
On the other hand, it will be difficult for the professional care sector to meet the increasing care
demands in many European countries and hence policy-makers look at those same women for the
supply of informal care to dependent elders. Many studies, however, show that informal care can have
severe negative consequences for the well-being of informal carers. This study aims at investigating
whether combining employment and care is possible and sustainable (in terms of caregiver burden),
and specifically focuses on the role of culture herein.
There are two general approaches to answering the question why individuals give informal care:
rational choice and culture. Labour supply theory states that individuals make a rational choice
regarding working and caring, in which they consider the benefits of working in terms of income –
relative to the cost of having to buy in care – and the time left outside work that can be used for caring.
It is assumed that women will value non-working time more in case they have dependent family
members. Building on this approach, rational choice institutionalism says individuals’ behaviour can
be changed by influencing the parameters based on which individuals make this rational decision:
income, price of care and time available. Sociological institutionalism takes a different point of
departure and assumes care decisions are influenced by cultural aspects such as norms and values.
Individuals then give care because they themselves or society considers it their role to do so. We argue
that both approaches are strongly related to the informal caregiver burden. Caregiver burden is
inherently related to the rational choice perspective, as time constraints generate role overload and
thus lower well-being among those individuals combining work and care, forcing them to make a
decision. Culture, on the other hand, is about roles, and individuals not behaving in accordance with
their own or society’s conceptions of roles can experience role conflict, and thus reduced well-being.
Using data on some 5300 women aged 50 to 65 from 16 European countries from the 2012 wave of
the Survey on Health, Ageing and Retirement in Europe (SHARE wave 4), we find little support for
labour supply theory: employment and caregiving appear not to be related to one another – neither in
terms of giving care, nor in terms of care intensity. However, this does not mean caregiving is not a
rational choice. Women living further from their parents are less likely to give care, which indicates a
rational choice based on time constraints. It does mean, however, that time and income are not
sufficient to explain caregiving. Norms do have a strong effect on caregiving: in countries where most
people consider eldercare a family responsibility or with a low female labour market participation rate
in the age group 50-64, individuals were less likely to give low intensity care though more likely to
give high intensity care than in countries with non-familialist norms or high female employment.
Regarding well-being of the informal caregiver, the relationship between caregiving, employment and
familialist norms is a complex one. After disentangling the interaction terms (see Tables 4 and 5), it
becomes clear that caregiver burden indeed exists, but only in countries where eldercare is not seen as
a family responsibility and where female labour market participation is high. Moreover, the reduction
in well-being due to high intensity caregiving in those countries mainly occurs among non-employed
women; the effects of giving such care is more ambiguous among working women. In countries with
familialist norms regarding eldercare, on the contrary, giving high intensity care to a parent or parentin-law actually increases well-being considerably. Hence, the broad agreement on the existence of the
informal caregiver burden might well be the consequence of those studies mainly being executed in
Western European countries and North America.
In conclusion, the dilemma between informal care and female employment appears not to exist in
reality. Given our findings that employment always coincides with higher well-being, no matter the
setting or caregiving responsibilities, and that there is no trade-off between employment and
caregiving, the main policy focus of all countries should be to keep women in employment and to
facilitate work-care combinations. Especially in countries where norms are not familial but instead
oriented towards female labour market participation, policies aiming at pushing women into full-time
informal eldercare would have detrimental consequences for those women’s well-being.
The main weakness of this study lies in its cross-sectional design that does not allow us to analyse
possible effects of caregiver burden on selection into employment or care. As described in the theory
and the conceptual framework, caregiver burden is likely to affect people’s choices regarding
employment and care. Individuals experiencing high burden may decide to quit employment or stop
giving care. That would offer an alternative explanation to why well-being is so high among women
combining employment and informal care: those who did suffer from the combination may have
reduced their involvement in either activity. The two-year time span in between SHARE waves – and
the fact that the previous wave did not include much of the information we use here – does not offer a
good opportunity to control for this effect. Hence it will be up to future research, using survey data
with smaller intervals between waves, to check whether employment and care combinations indeed
increase well-being in countries with familialist norms, or whether it is rather the case that individuals
with low well-being select themselves out of care and/or employment.
Disclaimer
This paper uses data from SHARE wave 4 release 1.1.1, as of March 28th 2013 or SHARE wave 1 and 2
release 2.6.0, as of November 29th 2013 or SHARELIFE release 1, as of November 24th 2010. The
SHARE data collection has been primarily funded by the European Commission through the 5 th
Framework Programme (project QLK6-CT-2001-00360 in the thematic programme Quality of Life),
through the 6th Framework Programme (projects SHARE-I3, RII-CT-2006-062193, COMPARE, CIT5-
CT-2005-028857, and SHARELIFE, CIT4-CT-2006-028812) and through the 7th Framework
Programme (SHARE-PREP, N° 211909, SHARE-LEAP, N° 227822 and SHARE M4, N° 261982).
Additional funding from the U.S. National Institute on Aging (U01 AG09740-13S2, P01 AG005842, P01
AG08291, P30 AG12815, R21 AG025169, Y1-AG-4553-01, IAG BSR06-11 and OGHA 04-064) and the
German Ministry of Education and Research as well as from various national sources is gratefully
acknowledged (see www.share-project.org for a full list of funding institutions).
Notes
i
Note that cultural elements can also influence utility, see section on cultural effects.
ii
Note that we limit ourselves to the relations that are most important for this study. One could think of reasons
to link any concept in this framework to practically any other, though that would not be helpful for our
understanding of the role culture plays in informal caregiving decisions and in the development of caregiver
burden.
iii
As the available data do not allow us to test the intermediate steps of ‘role conflict’ and ‘role overload’, we will
only test the relation between familialism, employment and filial care on the one hand, and well-being on the
other. However, we include these mechanisms in our conceptual framework to explain the mechanisms we
believe are behind the relations tested.
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+
+
Familial
norms
-
+
-
FLMP*
+
Employment
* Female labour market participation
Figure 1. Conceptual framework.
Role
conflict
Filial
care
+
+
Wellbeing
+
-
+
+
-
+
Role
overload
Table 1. Descriptive statistics
Social-democratic
Corporatist
All
DK
SE
AT
BE
CH
DE
FR
NL
5304
280
190
621
447
321
149
846
246
Individual level
n
Age
56,07
56,50
57,68
55,92
56,34
56,30
56,87
56,46
56,80
(4,05)
(3,92)
(3,6)
(4,24)
(3,9)
(4,04)
(3,57)
(4,31)
(3,42)
Married
82%
78%
77%
68%
89%
76%
81%
76%
87%
Bad health (0-4)
1,88
1,30
1,61
1,59
1,82
1,51
2,06
1,90
1,80
(1,04)
(1,10)
(1,12)
(1,08)
(1,00)
(0,92)
(0,88)
(0,97)
(0,97)
Employed part-time
32%
57%
52%
26%
35%
60%
59%
34%
54%
Employed full-time
22%
18%
28%
17%
13%
11%
4%
19%
6%
Bad health elder (0-4)
2,85
2,62
2,83
2,64
2,58
2,67
3,16
2,91
2,94
(1,00)
(1,19)
(1,10)
(1,06)
(1,03)
(0,97)
(0,82)
(1,01)
(0,89)
Lives <25km from elder
66%
51%
53%
66%
74%
55%
74%
55%
62%
Gives care up to twice a week
9%
17%
22%
7%
12%
12%
9%
10%
12%
Gives care more than twice a week
9%
0%
2%
8%
5%
4%
10%
11%
7%
189,49
35,41
54,63
194,44
123,58
106,60
188,31
191,86
128,78
(162,60)
(22,12)
(82,65)
(164,37)
(135,05)
(130,40)
(149,64)
(179,74)
(134,51)
Days per year giving
carea
Well-being (0-10)
7,84
8,88
8,28
8,44
7,76
8,66
8,00
7,96
8,56
(1,66)
(1,17)
(1,49)
(1,53)
(1,54)
(1,20)
(1,48)
(1,47)
(1,18)
Female labour market part. 50-64
52%
63%
72%
49%
43%
67%
60%
51%
54%
Eldercare is family responsibility
50%
22%
17%
47%
39%
63%
55%
36%
24%
Country-level
a
Only includes women giving care
Table 1. (Cont.)
Familialist
Post-communist
ES
IT
PT
CZ
EE
HU
PL
SI
259
296
225
676
302
167
173
106
Individual level
n
Age
54,99
55,70
56,75
55,49
54,82
55,50
56,28
55,40
(3,89)
(4,53)
(4,12)
(3,99)
(3,96)
(3,24)
(3,4)
(3,98)
Married
97%
96%
89%
76%
86%
98%
81%
99%
Bad health (0-4)
2,00
1,69
2,24
1,99
2,48
2,52
2,33
1,95
(1,01)
(1,04)
(1,12)
(0,94)
(0,93)
(0,88)
(0,92)
(0,93)
Employed part-time
26%
29%
14%
18%
13%
4%
22%
9%
Employed full-time
16%
11%
17%
41%
55%
49%
6%
31%
Bad health elder (0-4)
2,82
2,82
2,66
2,96
3,19
3,14
3,16
3,08
(0,92)
(0,95)
(1,20)
(0,89)
(0,69)
(1,01)
(0,82)
(0,82)
Lives <25km from elder
71%
86%
82%
73%
53%
69%
76%
65%
Gives care up to twice a week
5%
6%
3%
8%
7%
2%
8%
2%
Gives care more than twice a week
12%
12%
15%
14%
8%
11%
12%
8%
270,57
251,19
315,73
237,86
205,66
297,81
227,62
308,62
(134,27)
(137,32)
(109,62)
(172,24)
(165,40)
(115,45)
(152,04)
(129,81)
Days per year giving
carea
Well-being (0-10)
7,70
7,25
6,22
7,24
7,28
6,76
7,76
8,51
(1,71)
(1,51)
(1,56)
(1,67)
(1,67)
(2,03)
(1,94)
(1,08)
Female labour market part. 50-64
42%
36%
53%
50%
63%
44%
39%
43%
Eldercare is family responsibility
58%
50%
59%
66%
61%
71%
86%
46%
Country-level
a
Only includes women giving care
Eldercare is family responsibility
100%
PL
80%
HU
60%
ES
IT
40%
CZ
PT
SI AT
BE
FR
NL
20%
CH
EE
DE
DK
SE
0%
0%
20%
40%
60%
80%
Female labour market participation rate (50-64)
100%
Figure 2. Circle size indicates the share of the sample giving help to a parent(-in-law), by female labour
market participation rate and attitude on familial eldercare.
Eldercare is family responsibility
100%
PL
80%
HU
60%
ES
IT
40%
CZ
PT
EECH
DE
SI AT
BE
FR
NL
20%
DK
SE
0%
0%
20%
40%
60%
80%
Female labour market participation rate (50-64)
100%
Figure 3. Circle size indicates the amount of help given by those respondents giving help to a parent(in-law), by female labour market participation rate and attitude on familial eldercare.
Table 2. Random intercept logistic regressions of filial care
FILIAL CARE
(Constant)
Age (50 = 0)
Married (0-1)
Employed (0-2)
Bad health (0-4)
Model 1
Model 2
Model 3
0-1
0-2
1-2
-3,12 ***
-3,00 **
0,11
0,04 **
0,06 ***
0,03 †
-0,79 ***
-0,62 ***
0,30 †
0,06
-0,19 ***
-0,03
-0,07
-0,17 **
-0,03
Bad health elder (0-4)
0,19 ***
0,32 ***
0,14 †
Lives < 25km from elder (0-1)
0,72 ***
1,55 ***
0,89 ***
Female labour market part. 50-64
2,07 *
-3,44 *
-5,94 **
Eldercare is family responsibility
-1,16 *
1,59 *
2,75 *
† p < 0,1; * p < 0,05; ** p < 0,01; *** p < 0,001
Note: The dependent variable ‘filial care’ has three categories: does not give care to a parent or
parent-in-law (0), gives care up to twice a week (1), and gives care more than twice a week (2). In
each model two groups are compared; the odds are calculated for belonging to the more careintensive group.
Table 3. Random intercept linear regressions of well-being (scale: 0-10)
WELL-BEING
Model 1
Model 2
Model 3
Model 4
(Constant)
8,61 *
8,61 ***
7,49 ***
9,35 ***
Age (50 = 0)
0,01
0,01
0,01
0,01
Married (0-1)
0,53 ***
0,54 ***
0,54 ***
0,54 ***
Bad health (0-4)
-0,58 ***
-0,58 ***
-0,58 ***
-0,58 ***
Bad health elder (0-4)
-0,09 ***
-0,09 ***
-0,09 ***
-0,09 ***
Lives < 25km from elder (0-1)
-0,06
-0,05
-0,05
-0,05
Filial care
Does not give care (R.C.)
Low intensity
0,08
0,19 †
0,18 †
0,18 †
High intensity
0,21 **
0,03
1,29 **
-0,91 ***
0,13 ***
0,12 ***
0,11 ***
0,12 ***
Employed (0-2)
Interact. with low care intensity
Interact. with high care intensity
Female labour market part. 50-64
Interact. with high care intensity
Eldercare is family responsibility
Interact. with high care intensity
† p < 0,1; * p < 0,05; ** p < 0,01; *** p < 0,001
-0,13
0,27 **
-0,13
0,30 ***
-0,13
0,26 **
2,17
-2,61 **
-1,54 †
1,81 ***
Table 4. Effects of the interactions between employment, care and female labour market participation
rate on well-being (from Table 3, Model 3)
WELL-BEING
Female labour market participation rate
25%
75%
‘intensive’
‘intensive’
no care
care
no care
care
Not employed
0,54
1,18
1,63
0,96
Employed full-time
0,76
2,00
1,85
1,78
Table 5. Effects of the interactions between employment, care and degree of familisation in a country on
well-being (from Table 3, Model 4)
WELL-BEING
Eldercare is a family responsibility
25%
75%
‘intensive’
‘intensive’
no care
care
no care
care
Not employed
-0,39
-0,84
-1,16
-0,71
Employed full-time
-0,15
-0,08
-0,92
0,05
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