Balancing informal and formal care: Perspectives of older users and family caregivers (Based on the OASIS Study) Panel Discussion, the PROCARE Conference, Venice October 22-23, 2004 Prof. Ariela Lowenstein, Head Center for Research and Study of Aging Faculty of Welfare and Health Studies The University of Haifa, Haifa 31905 Israel ariela@research.haifa.ac.il
Old Age and Autonomy: The Role of Service Systems and Intergenerational Family Solidarity OASIS is an international research project, funded within the 5 th Framework Program of the European Community and is registered there as contract No. QLK-CT-1999-02182, acronym: OASIS".
What Should be the Appropriate Balance? Formal Service Care Informal Family Care
Conceptual Framework moving the boundaries between public and private. The distinction between state solidarity and family solidarity becomes uncertain Social care has come to mean both formal and informal caregiving networks existing side be side (Cantor 1989, 1991). Substitution vs. Complimentarity
The Partnership Norway Germany England Spain Israel ESHEL NOVA Norwegian Social Research, Oslo DZA The German Center of Gerontology, Berlin Keele University School of Social Relations University of the Basque Coun try, Bilbao Faculty of Sociology The Center for the Research and Study of Aging, University of Haifa Ariela Lowenstein, Coordinator The Association for the Planning and Development of for the Aged in Israel, Jerusalem
Rationale for Countries Selection The countries cover a diverse range of welfare regimes (institutional, conservative, residual) and familial cultures (family-oriented and individualistic). The four European countries represent various types of welfare states distinguished in the literature. Israel presents particular challenges as Israeli society has diverse family cultures and a wide range of social services for the elderly.
Objectives 1/2 To provide a knowledge base of how to support autonomy in old age to enhance quality of life of elders and their family caregivers. To analyze the interacting roles of family relations, service systems and individual coping on quality of life in old age. To learn how different family cultures and different welfare systems promote quality of life and delay dependency in old age.
Objectives 2/2 To compare patterns of norms, preferences and behaviors in different age cohorts and their contribution to quality of life. To identify family relations, coping strategies and background attributes as contributing to the promotion of autonomy and quality of life. To compare and analyze mixes of support by family carers and welfare services that are used and evaluated by elders and their family caregivers.
Heuristic Model Independent var i ables Intervening variables Dependent variables Individual Level (Resources and c a pabilities health, status, cohort, ed u cation, personality) Family Level ( marital status, li v ing arrangement, family resources) Family norms ( ideals regarding intergenerational support) (kind, access & satisfaction) Family transfers (intergenerational solidarity and intergenerational ambivalence) Coping Quality of life of elders and care-givers: Competence Autonomy Affect balance Life Satisfaction Societal Leve l (Family culture & welfare regime)
Innovative Aspects 1/2 The conceptual framework: Advancement of the theoretical knowledge bases through the empirical study of the two paradigms: Intergenerational Solidarity versus Intergenerational Ambivalence. Combined application of societal / macro level variables (social services) and individual / micro level variables (family intergenerational relations and strategies).
Innovative Aspects 2/2 OASIS is designed as a comparative study, combining cross-country comparison (welfare systems) with intergenerational comparison. OASIS makes use of combining both quantitative and qualitative data. OASIS is designed as a longitudinal study with data collection at two different points in time.
The Quantitative Sample Size: About 1200 persons in each country, n = 6106, with an oversampling of respondents older than 75 years of about 1/3, n = 2064. Research population: Inhabitants of urban areas in the five countries, aged 25 years and more. Sampling method: Random. Due to different legal restrictions in the countries, there were slight methodological differences between the sampling methods.
The Qualitative Sample Ten dyads in each country, consisting of one elder parent rated to be at risk of dependency and one adult child chosen by the parent as the one he most relies on. Both, parent and child, underwent in-depth semi-structured interviews by skilled interviewers.
Distribution of IGS Dimensions 75+ 100% 90% 80% 70% 70% 76% 75% 87% 76% 73% 71% 70% 72% 68% 75% 68% 75% 68% 90% 83% 68% Norway UK Germany Spain Israel 60% 57% 60% 56% 64% 53% 64% 63% 62% 59% 57% 50% 45% 46% 44% 45% 42% 40% 38% 34% 30% 29% 20% 10% 0% Emotional Relations Consensus Proximity Face to Face Contact Normative Instrumental Help Provided Instrumental Help Received
Percent in agreement (agree or strongly agree) with filial obligations by item and country (n). a Norway UK Germany Spain Israel should live close 29 31 40 57 55 should sacrifice 41 47 36 44 37 able to depend on 58 41 55 60 51 entitled to return 38 48 26 55 64 (n) (1179- (1153- (1193- (1152- (1183-1193) 1170) 1222) 1169) 1196) a Weighted samples, age 25+.
Normative Solidarity - Norms Family-welfare state balance index a by country. Mean scores by country b Norway England* Germany Spain Israel -3-2 -1 0 1 2 3 a Mean scores of an additive scale from 6 to 6, adding up responses («totally welfare state» (=2), «mainly welfare state» (=1), «both equally» (=0), «mainly family» (-1) and «totally family responsibility» (=-2)) in the three domains financial support, help with household chores and personal care. b Weighted samples *The data from England are biased (towards the family), because the response scale by mistake had only one option for the welfare state side (mainly), not two (mainly and totally). Source: OASIS 2000, N=5875
Normative Solidarity - Preferences Preference for services by age and country (%) a 100 90 80 70 60 50 40 Norw ay Israel Germany England Spain 30 20 10 0 25-49 50-74 75+ a Per cent with preference for «organised services» in response to the following question: «Turning now to your own personal preferences supposing you should come to need long-term help on a regular basis with household chores like cleaning, washing clothes etc? From whom would you prefer such help? From family, from organised services, or from others?» Source: OASIS 2000, N=5568
Percent in favor of total or mainly welfare state responsibility by age and country Financial support Household chores Personal care 100 90 80 70 60 50 40 30 20 10 0 25-49 50-74 75+ 100 90 80 70 60 50 40 30 20 10 0 25-49 50-74 75+ 100 90 80 70 60 50 40 30 20 10 0 25-49 50-74 75+ Norway UK Germany Spain Israel
Service Use - Comparative typology Norway England Germany Spain Israel Public Family Family Family Family Family Public Private Private Public Private Private Public Public Private Voluntary Voluntary Voluntary Voluntary Voluntary
The balance between services and family care The balance is different in the 5 countries. In Germany and Spain and less so in England, the 75+ receive more support, mostly from the family. In Norway and Israel, with a wider range of services, the family is providing less instrumental and personal care. Hence, family dominated service models like in Germany and Spain are vulnerable, in contrast to what both the older and younger generations prefer.
Complementarity versus substitution Welfare state services do not erode family solidarity. The younger and older generations in all the 5 countries emphasized the need for more services. Some substitution between families and services was observed, but mostly the emphasis was on complementarity between the two types of social care Alongside service provision, the family specializes in the forms of support that it is best able to give - emotional support.
Family norms and practices Filial norms are still quite strong and prevalent. However, support for filial responsibility is neither absolute nor unconditional. It was more strongly expressed in countries with a stronger family culture like Spain and Israel and lower in Norway, England and Germany. The older generations were those most eagerly pushing for governments to take more responsibility, except in Spain.
Family norms and practices Respondents in all countries prefer some form of partnership. The Norwegians and Israelis, and to a lesser extent the Spanish, put the welfare state in the dominant role, supported by the family. Respondents in England and Germany tend to favor an equal split. Older people in most countries were hesitant to push responsibility onto adult children for care. The majority prefer independence between generations and are reluctant to move to share households when needs arise. Adult children were not downplaying their responsibilities but shifting the focus from providing practical instrumental care to other forms of care, like emotional support or managed care.
Macro level Health and social care A wider use of more creative services in adapted and assisted housing, transportation and education is necessary. Access to services increased their use and was welcomed by all Proper status afforded to formal care in the workforce. More choice in care arrangements was preferred. The higher over-all coverage of help to elders in high service countries (mostly Norway and Israel) indicates that a family dominant care system is less able to cover needs. Countries that have legal obligations between generations, like Israel, need to reconsider it in light of demographic transition and the wish of the older generations for independence
Meso level the family Supportive and complimentary services in the workplace Health and social care for families to continue and support older members
Micro Level: Older people The opportunity to empower older people and allow service choice Social policy must move away from the notion of dependence. Positive images of ageing should be strengthened. The need to identify groups at risk of dependency in order to develop adequate services such groups.
The main conclusions First: personal resources had a greater weight on the well-being of elders. Thus, policy must concentrate on building, protecting and maintaining individual resources. Second, complementarity between families and services was more prevalent than substitution. Still both the old and the young preferred more welfare state services. Thus, policies should not build on families as primary carers