What is known about this topic. ⢠Population ageing brings health and socioeconomic challenges. ⢠As a consequence, more people will apply for social support.
Health and Social Care in the Community (2015)
doi: 10.1111/hsc.12259
Factors determining the use of social support services among elderly people living in a city environment in Poland Monika Burzynska
PhD
1
, Marek Bryla
PhD
2
, Pawel Bryla
PhD
3
and Irena Maniecka-Bryla
MD PhD (Assoc. Prof.)
1
dz, Poland, 2Department of Social Department of Epidemiology and Biostatistics, Medical University of Lodz, Ło 3 Medicine, Medical University of Lodz, Łodz, Poland and Department of International Marketing and Retailing, University of Lodz, Lodz, Poland
1
Accepted for publication 29 April 2015
Correspondence Prof. Irena Maniecka-Bryła Department of Epidemiology and Biostatistics Medical University of Lodz _ dz 90-752, ul. Zeligowskiego 7/9, Ło Poland E-mail: irena.maniecka-bryla@umed. lodz.pl
What is known about this topic
• • •
Population ageing brings health and socioeconomic challenges. As a consequence, more people will apply for social support services. A rise in the number of singleperson households among elderly people means that social support from the family must be compensated for by support from the state.
What this paper adds
•
•
•
This paper offers discussion around policies and social and health support services for older people in an ageing Polish population. This adds to the discussion regarding relevant changes to policy in an ageing population. This discussion serves as a useful comparison to other European countries. Analysis of factors contributing to receiving social assistance can help target those most in need.
© 2015 John Wiley & Sons Ltd
Abstract Ageing populations entail important social issues. The population of Lodz is characterised by the highest ageing ratio in Poland (17.2% people aged 65 or above). The aim of our study was to present factors determining the use of social support services in the subpopulation of elderly people in a city environment. The study, conducted between 2011 and 2012 with the use of a survey questionnaire, included 466 respondents aged 65 or older, who were looked after by the Municipal Social Welfare Centre, Lodz-Polesie. The response rate was 93.2%. Most beneficiaries were women (77.9%). The respondents were mostly widows (73.9% of women) or widowers (43.7% of men). Most respondents applied for nursing services (79.7%), while 28.3% asked for financial help. In Lodz as a whole, these percentages were 81.0% and 19.0%. A chronic disease was the most common cause of the application for help (73.4%). In 4.1% of applicants, the cause was a low income per capita. Multivariate logistic regression analysis indicated that the variables which contributed to receiving financial support included being a man, aged 65– 69 years, being single and receiving a monthly salary per capita below 500.0 PLN (Polish New Zlotys). The variables which contributed to receiving social care service in the form of nursing services included being a woman, aged 85 years or older, receiving a monthly salary per capita between 1001.0 and 1500.0 PLN, suffering from a chronic disease, which was a reason for applying for social support service, a result on the Activities of Daily Living scale confirming disability and a very negative self-evaluation of health. The results of the study have shown that the poor health condition of elderly people is the most frequent reason for applying for social services. Identifying reasons for applying for social care by elderly people might facilitate the introduction of workable solutions in the social and healthcare policy. Keywords: ageing, Poland, social and health services
Introduction The ageing of populations is a characteristic sign of the advancement of civilisation (Benyamini et al. 2003, Lyyra et al. 2006, Chipperfield 2008, McLaughlin et al. 2009). An increase in the number of elderly people living in the population will definitely affect health conditions and the health needs of the whole society (Antonovsky 1993, Jeste 2005, Murata et al. 2006, Kleinspehn-Ammerlahn et al. 2008, Baker et al. 2010, Annear et al. 2013). As the prospect of the ageing population of Poland is 1
M. Burzynska et al.
unavoidable, there is a need to modify health, social and economic policies, and the state should also focus on individual needs of elderly people (ManieckaBryła et al. 2011). Changes which are observed in this aspect of social life are associated with the percentage of elderly people in society and its rate of growth (Bullinger 2002, Asakawa et al. 2009, Kim et al. 2010). Such a situation results in many social and economic problems which the family cannot cope with. In the modern world, the family is often not able to fulfil its domestic responsibilities (Leinsalu 2002, Bjornskov 2008, Coudin & Alexopoulos 2010, Ordonez et al. 2011), which can be explained by societal pressure to achieve success, make a career and satisfy material needs. The traditional family model, which provided elderly generations with help, is disappearing (Attkosson et al. 1978). The number of households run by people aged 60 or older is going to rise rapidly in Poland. In 2030, an average household run by an elderly person (aged 60 or older) will comprise on average 1.46 people. By 2030, every third household will be constituted by a single person and the number of single households of elderly people will have doubled, which will contribute to changes in the consumption in households (GUS 2013). Ageing population is undoubtedly an issue to be addressed (Van Wijk et al. 1995, Carlson 1998, Włodarczyk 2001, Gilmore et al. 2002, Crimmins et al. 2009, Jung et al. 2010, Kyobutungi et al. 2010). The system of social support service in Poland, which used to be a part of the healthcare system, is responsible for combating poverty, and was restructured by the Social Welfare Act, 29 November 1990 (Journal of Laws 1990, No 87, Item 506). Due to the fact that the procedure of granting social benefits is fixed by legal provisions, there are differences between needs and offered help. Under the Social Welfare Act, 12 March 2004, people who come to social help centres are granted benefits (permanent, periodical or purpose) or provided with nursing services. Those whose monthly income is not higher than 542.0 PLN (Polish New Zlotys) for a single person or 456.0 PLN for a person living in a family are entitled to apply for the permanent benefit. In certain cases, even if the monthly income is higher, applicants are entitled to receive a special purpose benefit, a periodical benefit or any other help. The amount of the permanent benefit is equal to the difference between the income criteria per person and the real income of the person. It cannot be higher than 477.0 PLN or lower than 30.0 PLN per month. The amount of the periodical benefit cannot be lower than 50.0% of the difference between the income criteria per 2
person and the real income of the person. The monthly amount cannot be lower than 20.0 PLN (Social Welfare Act, 12 March 2004). The aim of the study was to present factors determining the use of social support services (financial and nursing help) offered by centres of social care to people aged 65 or older. The study was conducted in Lodz, which is the third largest city in Poland, whose population is characterised by negative epidemiological measures describing its health status as well as the highest ageing ratio in the country: 22.4% of the population are aged 60–65, and 17.2% are above 65 (GUS 2011). The average life expectancy of Lodz inhabitants in 2011 was 70.1 years for men and 78.4 for women and was shorter than the average life span in other Polish cities by 1.9 and 2.6 years, and the shortest life expectancy in the country. Such a situation results from the unfavourable mortality rate of Lodz inhabitants, which in 2011 was 14.3/1000 (Urzaz d Statystyczny w Łodzi 2011a).
Methods The Bioethics Committee gave approval for the study (Resolution no. RNN/109/11/KB of 15 February 2011). It was conducted between 2011 and 2012 among people aged 65 or over who were looked after by the Municipal Social Welfare Centre, Lodz-Polesie, which was randomly selected from five district centres of the Municipal Social Welfare Centre in Lodz. The population of Lodz-Polesie was 143,400 at the end of 2010. The percentage of aged 65 or more was 16.8% with a ratio of 121.7 women per 100 men. All persons aged 65 or older who were entitled to receive social support services and who had the mental ability to fill in a survey questionnaire were considered for the study. Data collection was carried out at the homes of the participants by trained social workers. The ability to complete the questionnaire was determined using the Hodgkinson Test (the Abbreviated Mental Test Score – AMTS). Those who were eligible were asked for informed consent before filling in the questionnaire. An authors’ survey questionnaire consisting of 77 questions on the socioeconomic situation of the respondents, as well as their self-rated health and self-evaluation of the quality of life was used as a study tool. A questionnaire was developed on the basis of literature and it was pilot tested. The Activities of Daily living (ADL) scale was used to test the ability to get dressed, maintain personal hygiene, walk, use a washroom, check for incontinence and self-feeding. Each function was evaluated in a threegrade scale. The respondent had a choice of three © 2015 John Wiley & Sons Ltd
Factors determining the use of social support services
variants of answers: completely independent (1 point), requiring assistance (0.5 point) and reliant on other people’s help (0 point). The respondent could get a maximum of 6 points. The score of 5–6 points meant complete independence, 3–4 points meant moderate disability (person needs partial assistance in performing ADL) and 2–3 points meant inability to live independently (full-time care required). The following hypotheses were tested in the study. First, poor health status significantly determines the application for social support services by elderly people. Most elderly people apply for nursing services: shopping, cleaning the apartment and other chores, grooming or feeding (in Poland, these services with elders are carried out by public health nurses). Second, low monthly income per capita in households of elderly people is a reason for frequent applications for social financial support. Third, as a result of their poor financial situation, elderly men do not cope with running their households, while elderly women need nursing services more often. Data were entered into Microsoft Excel and analysed using STATISTICA 9.0 (StatSoft Polska, Krakow, Poland). In addition to descriptive statistics, Pearson’s chi-square test and the Mann–Whitney U-test were used to compare the distributions of nominal and ordinal variables between two groups. Bivariate and multivariate logistic regression were applied to determine which factors were associated with the receipt of financial support or nursing support by respondents. Statistical significance was set at P < 0.05.
Results Background characteristics of respondents In 2010, 5336 people were granted social support in the studied centre, and those aged 65 or above made up 13.2% of people entitled to apply for social support (704 people – 574 females and 130 males). However, 54 people were excluded from the study due to a poor score on the Hodgkinson Test, 101 had died and 49 lost their right to apply for social support in the study period, and 34 refused to be included in the study. The remaining 466 were included in the study (a 93.2% response rate). This sample was compared against the set of all elderly people looked after by the Municipal Social Welfare Centre across the whole of Lodz. There were no significant differences in terms of gender, age and forms of support received. Over three-quarters (77.9%) of the respondents were women, a ratio of 352.0 women per 100 men. Respondents were aged 65–101 with a mean age of © 2015 John Wiley & Sons Ltd
79.0 years (SD: 7.8); 21.8% were aged 85 or over. Two-thirds (67.2%) were widowed (73.9% of women compared with 43.7% of men); only 4.1% were married while 12.4% were single and 16.3% divorced. Most (91.2%) lived alone, the percentage being higher among women (93.7%) than men (82.7%). Just over half (51.9%) had only elementary education, with only 7.3% having a university degree; 81.6% of men and 65.8% of women had blue-collar jobs in the past. No respondents worked when applying for social support services. Pension was the main source of income for 79.2% while only 12.0% had savings. Reasons for and receipt of social support services In many cases, respondents gave more than one reason for applying for social support services. The most common combination was having a chronic disease accompanied by disability. Having a chronic disease was the most common reason – 73.4% of all respondents, 65.0% of men compared to 75.8% of women – followed by disability – 42.9% of all respondents, 50.5% of men compared to 40.8% of women. Although 36 respondents had no regular income, only 19 reported poverty as the reason for applying for help. In total, 79.7% of applicants were granted nursing services (1.6% all elderly residents of Lodz-Polesie). Women were provided with that kind of help significantly more frequently: 91.2% of women (2.2% of women aged 65 and over in this district) compared with 48.5% of men (0.6% of men aged 65 and over in this district). Eighty-five respondents (18.2%) were given financial help (7 people – permanent benefit, 17 people – special purpose benefit, 1 person – periodical benefit). Men who were given financial help accounted for 1.1% of men aged 65 and over in LodzPolesie and women who were given this kind of help accounted for 0.3% of women aged 65 and over in this district. The applicants were entitled to more than one form of social care if they met required criteria. Thus, 43 people (9.2% of respondents), apart from being granted basic social support service, were also provided with basic help, and four respondents had their medical fees regularly paid by the Municipal Social Welfare Centre. There were no significant differences in terms of support received among the study sample and all elderly people looked after by the Municipal Social Welfare Centre across the whole of Lodz. In the population of Lodz, 19.0% of elderly beneficiaries were given financial help (compared to 28.3% in the study sample) and 81.0% were given nursing help (compared to 79.7% in the study sample). 3
M. Burzynska et al.
On self-rated health, the respondents were given five options: ‘very poor’, ‘poor’, ‘neither good nor poor’, ‘good’ and ‘very good’. The option ‘very good’ was excluded from the analysis as no respondent claimed his/her health as ‘very good’. It should be pointed out that the respondents gave mostly negative opinions: 42.7% of men and 38.1% of women called their health ‘poor’, every tenth man and every fifth woman claimed their health to be ‘very poor’. However, 7.8% of men and 5.3% of women claimed their health to be ‘good’. The remaining respondents said it was ‘neither good nor poor’. The data on the studied group and the analysed variables are presented in Table 1. Financial status of respondents Of 466 beneficiaries of the Municipal Social Welfare Centre, 36 people (25 men and 11 women) did not have any income. They were granted permanent benefits of 444.0 PLN. They were not entitled to any pensions, neither old age nor disability pensions. The livelihood of people without employment and who were not entitled to old-age pensions depended on financial benefits from social centres and help from friends, less from family members. Much more frequently, this problem affected men as almost one in four did not have any regular income (v2 = 50.78, df = 1, P = 0.032). This was due to the social and economic transformations which took place in Poland. After many manufacturing plants were closed down, a number of inhabitants of Lodz, who were mostly blue-collar workers, lost their job when they reached post-productive age (over 60 for women, over 65 for men). Due to their age, they had difficulty finding other employment and they were not entitled to apply for old-age pensions. At the moment of the study, in Poland, women were allowed to apply for old-age pension at age 60 and men at age 65. Sixty-seven applicants (14.4%) who met the required income criteria were provided with benefits whose amount was equal to the difference between their monthly income criteria and the real income. In 17 cases (3.6%), the income was higher than the required criteria. However, the centre granted the applicants special purpose benefits and the amount of money depended on their income and the necessities. The respondents, who had the highest income and who needed help due to their chronic and serious illness, were granted nursing services, and 48.5% of men and 91.2% of women used such services. Both men and women who received help from the Municipal Social Welfare Centre gained income per capita 1001.0–1500.0 PLN (50.0%). Eighty-five women 4
Table 1 Characteristics of the group under study (N = 466) Men Variable
n
%
Gender 103 100.0 Age 65–69 42 40.2 70–74 15 14.7 75–79 22 21.6 80–84 15 14.7 85 and older 9 8.8 Marital status Single 15 14.6 Married 10 9.7 Widowed 45 43.7 Divorced 33 32.0 Education Elementary 42 40.8 Vocational 18 17.5 Secondary 34 33.0 University 9 8.7 Number of people in household One 85 82.7 More than one 18 17.3 Income per capita (PLN) Up to 500 20 19.4 501–1000 21 20.4 1001–1500 50 48.5 Above 1500 12 11.7 Savings Yes 16 15.5 No 87 84.5 Reason for applying for help Chronic disease 67 65.0 Disability 52 50.5 Poverty 4 3.9 Life event 0 0.0 Form of received help Nursing services 50 48.5 Permanent benefit 45 43.7 Special purpose 8 7.8 benefit Periodical benefit 0 0.0 Elementary help 32 31.1 Medical fee 2 1.9 Self-rated health Good 8 7.8 Neither good 41 39.8 nor poor Poor 44 42.7 Very poor 10 9.7 ADL Fit 70 67.9 Moderately disabled 27 26.2 Disabled 6 5.9
Women
Total
n
%
N
%
363
100.0
466
100.00
51 46 75 98 93
14.0 12.9 20.7 26.9 25.5
93 61 98 113 101
19.8 13.3 20.9 24.2 21.8
43 9 268 43
11.8 2.5 73.9 11.8
58 19 313 76
12.4 4.1 67.2 16.3
200 19 119 25
55.1 5.2 32.8 6.9
242 37 153 34
51.9 7.9 32.9 7.3
340 23
93.7 6.3
425 41
91.2 8.8
31 64 183 85
8.5 17.6 50.4 23.4
51 85 233 97
11.0 18.2 50.0 20.8
40 323
11.1 88.9
56 410
12.0 88.0
275 148 15 4
75.8 40.8 4.1 1.0
342 200 19 4
73.4 42.9 4.1 0.8
331 22 9
91.2 6.1 2.5
381 67 17
79.7 14.4 3.6
1 11 2
0.2 3.0 0.4
1 43 4
0.2 9.2 0.9
19 135
5.3 37.3
27 176
5.8 37.8
138 71
38.1 19.3
182 81
39.2 17.2
229 98 36
63.2 26.9 9.9
291 125 42
64.7 18.6 16.7
PLN, Polish New Zlotys; ADL, activities of daily living.
(23.4%) and 12 men (11.6%) had incomes above 1500.0 PLN. The average monthly income earned by men was 1094.8 PLN and it was by 137.1 PLN lower © 2015 John Wiley & Sons Ltd
Factors determining the use of social support services
than the income earned by women. The difference between men and women was statistically significant (Mann–Whitney Z = 3.06, P = 0.018). A total of 66.3% of respondents claimed that financial problems made their life difficult. As many as 88.0% of households did not have any savings. Every fourth person was in debt. The respondents were asked a question: ‘Are you able to make ends meet?’ It should be stressed that 49.6% replied that they did so with extreme difficulty and another 42.9% said: ‘With difficulty’. Only one person in ten claimed that they were financially stable. More than half the respondents (61.2%) had such a low income that they could not satisfy basic needs. The analysis of sources of financial help confirmed that the people in need received it from institutions providing such help (56.1%); 32.2% of the respondents received help from friends and every tenth person (11.7%) from other family members. It should be pointed out that all applicants were granted nursing services from an institution responsible for providing such help, while 3.9% of the subjects received this form of help also from the spouse. Factors predicting receipt of financial support Table 2 presents the odds ratios for receiving financial help based on bivariate and multivariate logistic regression analysis. In the bivariate logistic regression analysis, five variables appeared to be statistically significant: being a man (P < 0.001), aged 65–74 years (P < 0.001), being a divorcee or single (P < 0.001), receiving a monthly salary per capita below 1000.0 PLN (P < 0.001) or not having savings (P = 0.021). In the multivariate logistic regression analysis, four variables appeared to be statistically significant: being a man (P = 0.015), aged 65–69 years (P = 0.011), being single (P < 0.001) and receiving a monthly salary per capita below 500.0 PLN (P < 0.001). The regression analysis confirmed that the odds of being provided with financial help were three times higher for men compared with women (OR = 2.96). The odds of receiving financial help for the youngest were higher too. In comparison with the oldest respondents (aged 85 years or older), beneficiaries aged 65–69 had odds of being provided with 15 times higher financial help (OR = 14.60). The reason for these statistics was the fact that older people were entitled to old-age pensions. In the group of people at the age of 75 or older, 95.4% were entitled to old-age pensions, whereas in the group of people at the age of 74 or younger, the number of people entitled to old-age pensions was 4.8% smaller. The marital status of the © 2015 John Wiley & Sons Ltd
respondents was significantly important and it decided whether the applicant was granted social support service to a great extent. In comparison with widowed people, the odds of receiving financial help for unmarried men and women were almost twice as high (OR = 1.93). The monthly income of the household earned per capita also had a significant influence on receiving financial help in the multivariate logistic regression model. The odds of receiving this kind of help were higher for respondents who earned up to 500.0 PLN per person per month compared with respondents with the highest income (OR = 637.40; Table 3). Factors predicting receipt of nursing services Logistic regression revealed the determinants of receiving nursing services by the respondents. In the bivariate logistic regression analysis, eight variables appeared to be statistically significant: being women (P < 0.001), aged 75 years or older (P < 0.001) and being a widower/widow or single (P < 0.001 and P = 0.018), receiving a monthly salary per capita between 1001.0 and 1500.0 PLN (P < 0.001), suffering a chronic disease, which was a reason for applying for social support service (P < 0.001), a result on the ADL scale confirming moderate disability (P < 0.001), a very negative self-evaluation of health (P = 0.022) and diabetes mellitus (P = 0.039). The multivariate regression model investigated the simultaneous impact of variables which, in the bivariate analysis significantly affected getting help. In the multivariate logistic regression analysis, six variables appeared to be statistically significant and they were decisive factors for receiving nursing services: being a woman (P < 0.001), aged 85 years or older (P = 0.019), receiving a monthly salary per capita between 1001.0 and 1500.0 PLN (P < 0.001), suffering from a chronic disease, which was a reason for applying for social support service (P = 0.029), a result on the ADL scale confirming disability (P = 0.030) and a very negative self-evaluation of health (P = 0.041). In comparison with men, the odds of receiving nursing services for women were more than five times higher (OR = 5.05). Age appeared to be a significant variable, as confirmed by the multivariate regression results. In comparison with the youngest respondents (65–69 years of age), the odds of being provided with nursing help for respondents aged 85 years or older were almost twice as high (OR = 1.83). The monthly income was another significant factor. The odds of receiving this kind of help for respondents with per capita income of 1001.0–1500.0 PLN were almost four times as high (OR = 3.58) than those whose per cap5
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Table 2 Odds ratios for receiving financial help in bivariate and multivariate logistic regressions (N = 466) Bivariate regression Variable
OR
Gender Women 1.00 Men 6.12 Age 65–69 43.1 70–74 22.5 75–79 3.50 80–84 1.47 85 and older 1.00 Marital status Single 3.81 Married 2.64 Divorced 9.58 Widowed 1.00 Education Elementary 0.98 Vocational 1.30 Secondary 1.01 University 1.00 Number of people in household One 0.49 More than one 1.00 Income per capita (PLN) Up to 500 720.0 501–1000 33.5 1001–1500 0.84 Above 1500 1.00 Savings No 3.47 Yes 1.00 Chronic disease Yes 0.33 No 1.00 Diabetes Yes 2.92 No 1.00 Self-rated health Very poor 0.46 Poor 1.14 Neither good nor poor 1.00 Good 1.67 ADL Fit 1.00 Moderately disabled 0.12 Disabled 0.22
Multivariate regression
95% CI
P
Reference group 3.56–10.50
