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SOCIAL POLICY & ADMINISTRATION ISSN 0144-5596 DOI: 10.1111/spol.12295 VOL. 52, NO. 1, January 2018, PP. 91–110

Receipt of Formal and Informal Help with Specific Care Tasks among Older People Living in their Own Home. National Trends over Two Decades Lena Dahlberga,b, Hanna Berndta, Carin Lennartssona and Pär Schöna a

Aging Research Center, Karolinska Institutet and Stockholm University, Stockholm, Sweden b School of Education, Health and Social Studies, Dalarna University, Falun, Sweden

Abstract Sweden is seen as a typical example of a social democratic welfare regime, with universal and generous welfare policies. However, in the last decades, there have been substantial reductions in the Swedish provision of care for older people. This study aimed to examine trends in sources of care-receipt in older people (77 +) living in their own home and with a perceived need for help with two specific tasks: house cleaning and/or food shopping. Trends in care-receipt were examined in relation to gender, living alone, having children and socio-economic position. Data from the 1992 , 2002 and 2011 data collection waves of the national study, Swedish Panel Study of Living Conditions of the Oldest Old (SWEOLD), were used. Response rates varied between 86 and 95 per cent, and the sample represents the population well. Trends and differences between groups were explored in bivariate and logistic regression analyses. There was a reduction in formal care-receipt regarding house cleaning and food shopping over the study period. It was more common for women than men to receive formal care, and more common for men than women to receive informal care. Reductions in formal care have affected older women more than older men. Still, living alone was the most influential factor in care-receipt, associated with a greater likelihood of formal care-receipt and a lower likelihood of informal care-receipt. It can be concluded that public responsibility for care is becoming more narrowly defined in Sweden, and that more responsibility for care is placed on persons in need of care and their families.

Keywords Home help; Informal care; Family care; Welfare state; Re-familialization; Sweden

Author Emails: [email protected]; [email protected]; [email protected]; [email protected] © 2017 John Wiley & Sons Ltd

SOCIAL POLICY & ADMINISTRATION, VOL. 52, NO. 1, JANUARY 2018

Introduction Sweden is seen as a typical example of a social-democratic, or Nordic, welfare regime, with universal and generous welfare policies, and welfare provision based on principles of equality and solidarity (Esping-Andersen 1990; Greve 2007; Ferragina and Seeleib-Kaiser 2011). The welfare mix is central in the discussion on welfare regimes (Esping-Andersen 1990, 2002; Powell and Barrientos 2004). In Sweden, the public sector has the formal responsibility for funding and providing care for older people, and a guiding principle of the policy on care for older people is to provide publicly subsidized, widely available services that can be used by everyone in need, regardless of economic means and family resources (Sipilä 1997). However, in the last decades, the Swedish provision of care for older people has changed dramatically, with substantial reductions in formal care and trends of re-familialization, deinstitutionalization and marketization of personal care and practical support (Szebehely and Trydegård 2012). Based on nationally representative data, this article examines groups of older people (77+) living in their own home and in need of care that have been affected by reductions in formal care, with the focus on two common tasks: house cleaning and food shopping. The Swedish welfare model in transition In Sweden, there are two main forms of social care for older people: home help and institutional care. Home help covers both personal care and practical support. The aim of home help is to support older people in their daily life and enable them to stay in their own home as long as possible, which is in line with a general ambition of supporting people to ‘age in place’ (Prop. 1996/97:124 1997; cf. Genet et al. 2011). Home help can be complemented by healthcare services provided by a district nurse team, and together these services can be offered around the clock. Formal care for older people is needs assessed and available to all citizens aged 65 years or older. Compared to most other countries, Sweden has a comprehensive system of care for older people (e.g. Szebehely and Trydegård 2012). However, the provision of formal care has not kept pace with the growth of the number of oldest old in the population. Since the 1980s, there has been a decline in formal care for older people in Sweden (Thorslund 2010), which by international standards has been considerable (Carrera et al. 2013). Initially, the reduction in care for older people concerned home help, while institutional care continued to increase. Since early 1990s, the reduction in formal care has been particularly pronounced regarding institutional care, while the decrease in coverage rates of home help has been more limited and with a slight increase in recent years. In 2012, approximately 22 per cent of all Swedes aged 80 years or older received home help and another 16 per cent received institutional care, that is, a total of 38 per cent receiving either home help or institutional care (National Board of Health and Welfare 2014). This can be compared to the situation in 1980, when more than 60 per cent of 92

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this age group received home help or institutional care (Thorslund 2010). The decline in formal care for older people has not been a result of legislative changes, but should be understood in the light of the economic recession in the 1990s and the raised threshold for eligibility for home help and institutional care in many local authorities (Johansson et al. 2011). Due to the Swedish system of extensive local autonomy, there are considerable variations in the coverage of care for older people across different local authorities (Trydegård and Thorslund 2010). Reductions in formal care provision could be justified if there have been parallel functional improvements among older people. Results from different health trends studies are diverse, though, in part due to focusing on different time periods and including different health indicators (e.g. Parker and Thorslund 2007; Christensen et al. 2009). Recently, a Swedish study showed no health improvements among the oldest old during the period 1992–2011. Instead, there were increased prevalence rates of several health problems. Still, the proportion of the population managing activities of daily living without help increased during the latter part of this period (Fors et al. 2014). This has been confirmed in other research showing that recent cohorts of older people may be managing daily life better despite disease (Jagger et al. 2007; Schön et al. 2011). However, several studies have shown that there has been a decrease in Swedish formal care provision for older people even accounting for reduced levels of need (Larsson 2006a; Thorslund 2010; Szebehely and Trydegård 2012), and that care has become more targeted towards people in greatest need of care (Larsson 2006a; Savla et al. 2008). The decline in formal care for older people has been accompanied by refamilialization of care. Although formal care for older people is extensive in Sweden, the contribution of informal carers, such as family and friends, is significant and increasing. It has been estimated that informal carers provide approximately two-thirds of all care for older people living in their own home (e.g. Sundström et al. 2002), and the proportion of older people relying on their family for care has increased over the years (Johansson et al. 2003; Larsson 2006b; Szebehely and Trydegård 2012). There has also been a marketization of care, with an increase in publicly funded care provided by private organizations. Such trends have taken place in many Western countries as part of an enthusiasm for neo-liberal ideas of competition and consumer choice (Rodrigues and Glendinning 2015). In Swedish care for older people, New Public Management inspired reforms have been implemented from the early 1990s onwards (Blomqvist 2004). One important reform led to the introduction of competition with public service providers, i.e. an opportunity for the establishment of private companies providing tax-funded care for older people. In addition, legislation regarding tax deduction for privately paid household services was introduced in 2007. It has been reported that such privately paid services are increasing, but still play a marginal role in the Swedish system of care for older people (Ulmanen and Szebehely 2015). It should also be noted that not all privately paid services are replacing home help services as they may be bought by people without care needs. © 2017 John Wiley & Sons Ltd

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Group specific patterns of a care model in transition Ageing affects sub-groups of the population in different ways. Importantly, older women have poorer health than men but live longer. Although the degree of gender inequalities varies across studies and dimensions of health (Gorman and Read 2006), research suggests that such inequalities are significant among the oldest old (Schön and Parker 2009). In addition, socioeconomic position functions as a strong discriminator of health status and risk of premature mortality (Mackenbach 2012). Research in Sweden (Fors et al. 2008) and elsewhere (e.g. Huisman et al. 2013) reveals the persistence of socio-economic inequalities amongst the oldest old, with poorer health and function and higher mortality rates in individuals with lower socio-economic position. There are also social differences across sub-groups of the population. As women tend to live longer than men and marry men who are older than themselves, women are more likely to enter widowhood than men and at a younger age than men (e.g. Gruneir et al. 2013). Another gender difference is that women tend to have higher levels of social contacts than men (e.g. Victor et al. 2006). Naturally, health and social differences across sub-groups of the population have implications for their need for social care and access to care. The receipt of formal, needs-assessed care and informal care from family and friends vary across different groups of older people. Gender differences have been established regarding care-receipt, with more informal care-receipt amongst men, often provided by their younger wives (e.g. Noel-Miller 2010; Gruneir et al. 2013). While some research has found no difference between men and women in the amount of formal home help received (Meinow et al. 2005), other research has found that it is more common for men to receive informal care from the person they live with and for women to rely on formal care (e.g. Geerlings et al. 2005; Gruneir et al. 2013). Research has established that receipt of formal care is more common amongst older people living alone than amongst older people living with somebody (Meinow et al. 2005; Sigurdardottir and Kåreholt 2014; cf. Geerlings et al. 2005), and a recent study has shown that the determining factor for home help utilization is access to informal care, i.e. living with a spouse and having children, rather than gender per se (Larsson et al. 2014; cf. Davey et al. 2006). Regarding socio-economic position, the patterns of receipt of formal care are less clear. Some research has shown that people with lower socioeconomic position are more likely to use formal care (Larsson 2006a), while other research has not found any socio-economic difference (Rostgaard and Szebehely 2012). Previous research has described the development as a dualization of care: there has been an increase in privately paid care among people with higher education levels, while informal care is more common and increasing among people with lower education or income levels (van Groenou et al. 2006; Rostgaard and Szebehely 2012; Szebehely and Trydegård 2012). However, a recent study has found an increase in family care also among people with higher education (Ulmanen and Szebehely 2015). 94



Aims of the study This study aims to identify which groups of older people have been affected by reductions in formal care, with the focus on two common tasks: house cleaning and food shopping. Trends in sources of care-receipt in older people (77+) living in their own home and with a perceived need for help with these tasks are examined in relation to gender, living alone, having children and socio-economic position. With this focus, our study adds to previous research by, first, examining receipt of care in relation to the perceived need for help with specific tasks. The implication of this is that changes in coverage and sources of care over time and differences across sub-groups of older people may be less sensitive to variations in need, for example, due to health improvements or improved functioning in the population over time, improved housing standards or health inequalities. Second, although there is research on the development of care in Sweden, this has to a large extent been based on the same dataset, that is, the Swedish Living Conditions Surveys (ULF/SILC) from Statistics Sweden. Our study is based on a different national dataset, with high response rates also amongst the oldest old, i.e. the key target group of care for older people, and offers an opportunity to validate findings from previous research. Methods Design and participants This article is based on data from the Swedish Panel Study of Living Conditions of the Oldest Old (SWEOLD), a national longitudinal study. Samples analyzed in this article were assembled from three data collection waves, undertaken in 1992, 2002 and 2011. SWEOLD draws participants from the Swedish Level of Living Survey (LNU), a study of approximately 0.1 per cent of the Swedish population aged 18–75, which began in 1968. SWEOLD recruits all people aged 77 or older who have previously been part of the LNU sample, and is a nationally representative sample of survivors from the birth cohorts 1892–1934. Due to this sample design, the sample is relatively small. Therefore, the 2011 wave of SWEOLD was complemented with an additional representative sample of women and men born between 1911 and 1925, and living in Sweden at the time of interview, stratified by gender and five-year age groups. The additional sample was obtained using personal identification numbers issued to all Swedish residents by the state, and included 302 people. The analyses presented in this article included only older people living in their own home, i.e. not living in institutions, comprising 468 individuals in 1992, 529 in 2002 and 737 in 2011. Procedure Different interview methods were used to avoid high non-response because of poor health or impaired cognition and to keep the sample representative of the Swedish population. Data collection was primarily done face to face, © 2017 John Wiley & Sons Ltd

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although when preferred interviews were carried out via telephone. If the participant was unable to answer the questions, for example, due to cognitive impairment or physical frailty, indirect (or mixed) interviews were carried out with the older person’s spouse/partner or another close person. Response rates were 95.4 per cent in 1992, 87.3 per cent in 2002, and 86.2 per cent in 2011, and the sample represents the population well (Lennartsson et al. 2014). Informed verbal consent was obtained prior to each interview. Ethical approval for the SWEOLD study was provided by the Regional Ethical Review Board in Stockholm (reg. no. 2010/403-31/4). For more detailed information about the study, see Lennartsson et al. (2014).

Materials This study focuses on two aspects of practical support: help with house cleaning and food shopping. Both house cleaning and food shopping are tasks that require relative good physical functioning. Thereby, these are some of the first tasks that older people need help with and tasks that older people will need help with at both low and high levels of functional limitations. At the same time, these tasks are different in the time and effort required to undertake them. As food shopping is usually less time demanding for informal carers than house cleaning, it can be expected that informal carers help more with food shopping than house cleaning. Help with house cleaning and food shopping was measured in relation to perceived care needs, i.e. the respondent’s own perception of needs. This was done as part of a scale addressing instrumental activities of daily living. First, respondents were asked two questions on whether they usually clean the house or shop for food by themselves, respectively. The response alternatives were, ‘Yes, completely by myself’, ‘Yes, with help’, and ‘No, not at all’. Individuals responding ‘Yes, with help’ or ‘No, not at all’ received the subsequent question, ‘Would you be able to do the house cleaning yourself if you had to?’ and an equivalent question for food shopping. The analyses in this article are based on those who responded ‘No’ or ‘Do not know’ to this item, i.e. on respondents with a perceived need for help. The following item was included to determine from whom they received help, ‘Who usually helps you with house cleaning?’, with an equivalent item for food shopping. The response alternatives were, ‘Spouse/partner’, ‘Daughter’, ‘Son’, ‘Other female relative’, ‘Other male relative’, ‘Other person’, ‘Home-care services’, ‘Privately paid help’ and ‘Voluntary organization’. It was possible to mention more than one source of help. The first six response categories concern informal carers and were merged for analysis. The last response category was excluded from the analysis, since it was not included in 1992 and extremely rare in 2002 and 2011 (highest frequency: n = 6). Similarly, privately paid help was not included in 1992 and was relatively rare in 2002 and 2011, and therefore only included in descriptive analyses of the whole sample. Information on age and gender was obtained from a national register as part of the sampling process. Living alone was measured via the item ‘Do 96



you live alone’ (‘Yes’; ‘No’), while having children was measure via the item ‘How many children now living do you have?’ (zero was coded as ‘No children’; one or more as ‘Having children’). Socio-economic position was measured by the respondent’s and his/her partner’s occupation, and was classified according to the Swedish Socioeconomic Classification system. The dominant household occupation was then used for the household as a whole. The dominant household occupation assumes that some socio-economic positions have greater influence than others on attitudes and behaviour patterns of the household in general. Criteria for determining the dominant household occupation include, for example, level of qualification required, being self-employed, and manual characteristic of the occupation (Erikson 1984). For the purpose of this article, socio-economic position was treated as a dichotomous variable (lower socio-economic position; higher socio-economic position), where ‘manual workers’, ‘routine lower non-manuals’, ‘small farmers’ and ‘entrepreneurs without employees’ were classified as ‘lower socio-economic position’, and ‘skilled lower non-manuals’, ‘intermediate and upper non-manuals’, ‘academic professionals’, ‘large farmers’ and ‘entrepreneurs with employees’ were classified as ‘higher socio-economic position’.

Data analysis Analyses were directed towards examining trends in sources of help with house cleaning and food shopping. Descriptive analyses were performed for the total sample as well as for the following sub-samples: women and men; individuals living alone or living with somebody; individuals with or without children; and individuals with lower and higher socio-economic position. In addition, gender stratified analyses on who provided the informal help with house cleaning and food shopping were performed to study separate trends for women and men over time. Likelihood-ratio chi-square tests were performed to test the statistical significance between sub-groups and between years. Lastly, logistic regression analyses were performed to study how gender, living alone, having children and socio-economic position influenced the receipt of help with house cleaning and food shopping. In all analyses, the 1992 and 2011 samples were weighted because of an under-representation of individuals aged 77 in 1992, and an over-sampling of men and women of the oldest age groups in 2011. Data was analyzed using Stata 13.0 (64-bit) for Windows. Results Table 1 shows the characteristics of the sample in 1992, 2002 and 2011. At all three time-points, approximately 60 per cent of the respondents were women, and over half of the sample was living alone. In 1992, a slight majority was classified as having lower socio-economic position (53.5 per cent), whereas in 2011 a majority was classified as higher socio-economic position (62.7 per cent). © 2017 John Wiley & Sons Ltd

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SOCIAL POLICY & ADMINISTRATION, VOL. 52, NO. 1, JANUARY 2018 Table 1 Characteristics of sample in 1992, 2002 and 2011 Characteristic Women (%) Age M (SD) range Living alone (%) Children (%) Lower socio-economic position (%) Received help with house cleaning (%) Perceived need for help with house cleaning (%) Received help with food shopping (%) Perceived need for help with food shopping (%)

1992 (n = 468)

2002 (n = 529)

2011 (n = 737)

60.6 81.9 (4.0) 77–95 56.8 81.5

58.0 82.7 (4.5) 77–99 56.3 84.5

60.9 82.8 (4.6) 77–101 53.1 87.4

53.5

49.2

37.3

55.2

58.4

52.0

30.6

32.8

31.7

44.8

47.7

38.6

25.2

22.5

22.6

Note: Due to internal non-response, n varies across items. Non-response was never greater than 13.

Over half of the sample at all three time-points received help with house cleaning, and less than half of the sample received help with food shopping. However, receiving help with a task does not necessarily mean that a person does not have the ability to perform that task. Instead, it may be a result of, for example, gender roles, household composition or competence. Throughout the study period, just over 30 per cent of the sample reported that they had a perceived need for help with house cleaning, and 22–25 per cent reported that they had a perceived need for help with food shopping. There was no significant variation in prevalence over time regarding the need for help with any of these tasks. Across all years of data collection, more men than women reported the need for help with house cleaning and food shopping (for both tasks, p < 0.01), and more individuals living with somebody than individuals living alone reported that they had the need for help with house cleaning or food shopping (for both tasks, p < 0.01). In 2002, people with children were more likely to report the need for help with house cleaning compared to people without children (p = 0.053). In 2011, more people with a higher compared to a lower socio-economic position reported the need for help with food shopping (p = 0.008) (results not shown). In 2011, 11.8 per cent of the sample reported using privately paid help with house cleaning, which can be compared to 7.5 per cent in 2002. Privately paid help with food shopping was rare (in 2002: 2 per cent; in 2011: 2 per cent; the item on privately paid help with house cleaning and food shopping was not included in 1992). 98



Help with house cleaning Table 2 reports the source of help with house cleaning among those who had a perceived need for help. For the sample as a whole, formal care providers were the main source of help with house cleaning in 1992, but during the study period there was a shift and in 2011 the main source of help was informal. During the period, the proportion of older people receiving formal help with house cleaning decreased significantly (from 63.9 per cent in 1992 to 42.9 per cent in 2011), whereas informal help was relatively stable over the same time (45.6 per cent in 1992 compared to 50.5 per cent in 2011). Some respondents received help with house cleaning from more than one form of care-provider. In 1992, 9.5 per cent received such help from formal as well as informal care providers. In 2002 and 2011, the corresponding proportions were 4 and 2.5 per cent, respectively (not tabulated). There had, thus, been a decrease in receiving care from a combination of formal and informal care providers (p = 0.004). When looking at women and men separately, the decrease in formal help was only significant for women. For women, there was an increase in informal care. Gender stratified analyses showed that women received significantly more formal and less informal help with house cleaning than men. There was also a significant difference in the receipt of formal and informal help with house cleaning between individuals living alone and individuals living with somebody. In 2011, 62.6 per cent of individuals living alone received help with house cleaning from formal care providers compared to 16 per cent among individuals living with somebody. There was a significant decrease in the receipt of formal help from 1992 to 2011 in both groups (e.g. among individuals living alone from 85 per cent to 62.6 per cent). A higher proportion of individuals living with somebody reported receipt of informal help than people living alone (in 2011: 77.9 per cent compared 30.4 per cent). In 1992, individuals with children used significantly less formal help with house cleaning than individuals without children (58.3 per cent compared to 92.3 per cent). By 2011, the proportion using formal help had significantly decreased in both groups and there was no longer a significant difference in the use of formal help with house cleaning. There were no significant differences between individuals of higher and lower socio-economic positions regarding formal and informal help with house cleaning. Help with food shopping Table 3 reports sources of help with food shopping. Looking at the whole sample, there was a decrease in formal help with food shopping (from 43.4 per cent in 1992 to 25.1 per cent in 2011). Informal carers were the main source of help with food shopping throughout the study period, and receipt of informal help increased over this period. As with house cleaning, some respondents received help with food shopping from more than one form of care-provider. The proportion receiving such help from formal as well as informal care providers was 7.94 per cent in 1992, compared to 4.24 per cent in 2002 and 5.49 per cent in 2011 (not tabulated). © 2017 John Wiley & Sons Ltd

99

100

63.9 79.0*** 37.9 32.3*** 85.0 58.3** 92.3 60.2 69.5

50.0 56.6* 37.3 24.2*** 66.0 50.7 46.7 48.1 51.6

42.9 49.0* 30.4 16.0*** 62.6 42.2 47.2 46.4 41.3

< 0.001 < 0.001 0.374 0.028 0.001 0.012 0.002 0.085 0.002

pa 45.6 31.0*** 70.7 79.0*** 23.7 52.7*** 11.1 46.9 44.1

43.6 36.3** 57.6 71.2*** 26.4 42.3 50.0 44.2 43.2

50.5 44.4* 63.2 77.9*** 30.4 50.5 50.1 52.3 48.3

1992 (n = 148) 2002 (n = 172) 2011 (n = 247)

Informal care

0.407 0.063 0.373 0.868 0.316 0.710 0.003 0.512 0.646

pa

Notes: a = p-value for time trend 1992–2011. Statistical significance between groups: †p < 0.1 (not cited in the table), *p < 0.05, **p < 0.01, ***p < 0.001. Likelihood-ratio chi-square tests performed to test the statistical significance between groups and years. Row percentages for each year do not add up to 100 per cent, as it was possible to mention more than one source of help and as privately paid care is not included in the table.

Total Women Men Living with somebody Living alone Children No children Lower socio-economic position Higher socio-economic position

1992 (n = 148) 2002 (n = 172) 2011 (n = 247)

Formal care

Source of help with house cleaning in 1992, 2002 and 2011 among respondents with a perceived need for help (%)

Table 2




43.4 53.5** 23.3 14.3*** 62.3 40.4 56.0 44.4 40.4

29.7 30.9 27.0 8.2*** 44.9 27.1 40.9 23.0 † 37.5

25.1 31.0** 11.1 3.9*** 42.1 22.8 39.2 32.8 † 19.6

0.004 0.005 0.114 0.063 0.020 0.001 0.293 0.210 0.013

pa 64.3 58.1 † 76.7 87.8*** 49.4 67.3 52.0 61.7 68.1

67.0 64.2 73.0 93.9*** 47.8 71.9* 45.5 72.1 62.5

75.7 72.3 83.9 93.5*** 61.4 79.8* 50.4 69.9 79.9

1992 (n = 126) 2002 (n = 118) 2011 (n = 182)

Informal care

0.066 0.079 0.385 0.305 0.175 0.063 0.917 0.376 0.145

pa

Notes: a = p-value for time trend 1992–2011. Statistical significance between groups: †p < 0.1, *p < 0.05, **p < 0.01, ***p < 0.001. Likelihood-ratio chi-square tests performed to test the statistical significance between groups and years. Row percentages for each year do not add up to 100 per cent, as it was possible to mention more than one source of help and as privately paid care is not included in the table.

Total Women Men Living with somebody Living alone Children No children Lower socio-economic position Higher socio-economic position

1992 (n = 126) 2002 (n = 118) 2011 (n = 182)

Formal care

Source of help with food shopping in 1992, 2002 and 2011 among respondents with a perceived need for help (%)

Table 3


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Although the use of informal carers was the most common source of help with food shopping among both women and men, a significantly higher proportion of women than men received support from formal carers (significant for 1992 and 2011), and there was a tendency for men more than women to be supported by informal carers (significant for 1992). In 2011, 31 per cent of women and 11.1 per cent of men received help with food shopping from formal care providers, whereas the proportion receiving informal help with this task was 72.3 per cent for women and 83.9 per cent for men. The decrease in formal help and increase in informal help with food shopping was significant for women, but not for men. Compared to individuals living with somebody, a significantly larger proportion of individuals living alone received formal help (in 2011: 42.1 per cent compared to 3.9 per cent), and a significantly smaller proportion of them received informal help with food shopping (in 2011: 61.4 per cent compared to 93.5 per cent). For both groups, there was a significant decrease in the receipt of formal care during the study period. Throughout the study period, there was a tendency for it to be more common with formal help and less common with informal help among individuals with children compared to individuals without children, although this difference was only significant for informal help in 2002 and 2011. For individuals with children, formal help with food shopping became less common and informal care became more common over the study period. There were no socio-economic differences with regard to receipt of formal help with food shopping at the beginning of the study period. In 2002, a smaller proportion of respondents with a lower socio-economic position received formal care than respondents with a higher socio-economic position. This pattern had reversed by 2011. Then, formal care was more common amongst those with a lower rather than a higher socio-economic position. To sum up, the bivariate analysis showed that receipt of formal help with house cleaning and food shopping was more common among women than men and among individuals living alone than individuals living with somebody. Informal help was more common among men (significant for house cleaning only) and those living with somebody (both tasks).

Logistic regression analysis Results of logistic regression analyses are presented in table 4. Regression analyses confirm that living alone is a strong predictor for receipt of formal help and non-receipt of informal help with both house cleaning and food shopping among respondents with a perceived need for help. In 1992, women had higher odds of receiving formal care and smaller odds of receiving informal help with house cleaning. In 1992, not having children increased the chance of receiving formal help with house cleaning and decreased the chance of receiving informal help. Respondents without children also had an increased chance of receiving formal help with food shopping in 2011 and a decreased chance of receiving informal help 2002 and 2011. 102



(n = 172) 1.41 5.52*** 0.93 0.83 (n = 117) 0.67 10.86*** 1.77 0.49

(n = 144) 3.58** 5.40*** 3.79 † 0.53 (n = 120) 1.87 7.22*** 1.43 1.05

House cleaning Women Living alone No children Lower socio-economic position

Food shopping Women Living alone No children Lower socio-economic position

(n = 179) 2.13 16.39*** 3.93 † 1.84

(n = 243) 1.50 8.32*** 1.50 1.03

2011 OR

(n = 120) 0.88 0.15*** 0.71 0.80

(n = 144) 0.31** 0.17*** 0.15** 1.32

1992 OR

(n = 117) 1.37 0.05*** 0.35* 1.51

(n = 172) 0.68 0.16*** 1.29 1.08

2002 OR

Informal care

Notes: The table reports odds ratios (OR). All variables were entered into the analyses simultaneously. p-values: †p < 0.1, *p < 0.05, **p < 0.01, ***p < 0.001.

2002 OR

1992 OR

Formal care

(n = 179) 0.78 0.88*** 0.14** 0.69

(n = 243) 0.69 0.12*** 0.81 1.56

2011 OR

Logistic regression analyses with gender, living situation, children and socio-economic position as predictors of formal and informal help with house cleaning and food shopping among respondents with a perceived need for help

Table 4


103


Source of informal help So, who provided informal help with house cleaning and food shopping and did the pattern of informal caregiving change over time? Spouses/partners and children were the two most common sources of informal help with house cleaning and food shopping, with only around 8 per cent of older people receiving informal help with these tasks from other relatives or friends. Informal help with house cleaning and food shopping from spouses/partners and children is reported in table 5. The analyses included only those participants who reported having a partner or a child, respectively. The results show that among both women and men the most common source of informal help with both house cleaning and food shopping was that of a spouse/partner. However, it tended to be more common among men than women to receive help with such tasks from a spouse/partner (significant in 1992 only), although the receipt of informal help with food shopping from spouses/partners increased among women over the study period. A larger proportion of women than men received help with food shopping from children (significant in 1992 and 2011), while there were no significant differences regarding house cleaning. Help from children with house cleaning and food shopping was stable over time. It was more common for children to help with food shopping than with house cleaning. Discussion Sweden has been identified as the most purely social democratic welfare regime (Ferragina and Seeleib-Kaiser 2011), with a key role for the state in welfare provision. It is evident that there has been a considerable shift in the Swedish welfare mix in the last couple of decades (cf. Rostgaard and Szebehely 2012; Carrera et al. 2013). Our study shows that there has been a reduction in formal care both regarding house cleaning and food shopping. Parallel to this, there has been a trend of re-familialization of care. These changes have especially affected women. Our study is limited to two specific care tasks, but general developments of reduced formal care and increased informal care have been observed in a number of Swedish studies ( Johansson et al. 2003; Larsson 2006b; Szebehely and Trydegård 2012). Over the study period, just over 30 per cent of the respondents had a perceived need for help with house cleaning and 22–25 per cent had a perceived need for help with food shopping. These figures could be considered in relation to the fact that 22 per cent of people aged 80 or over in Sweden received home help (National Board of Health and Welfare 2014). These figures are not fully comparable, though, since the perceived needs reported in our study were met not only by formal care providers and since home help is given for tasks other than those covered in our study. Previous research has also shown that there may be an overlap in care receipt from different sources of care (e.g. Szebehely and Trydegård 2012; Ulmanen and Szebehely 2015). Directing the focus towards specific care tasks, as is done in our study, means that the overlap between sources of care was smaller than in research that considers 104



(n = 55) 56.4 52.4 58.8 (n = 40) 80.0 76.5 82.6

(n = 55) 76.4 50.0** 85.4

(n = 46) 71.7 53.3 † 80.7

House cleaning Total Women Men

Food shopping Total Women Men

(n = 70) 78.9 80.8 77.2

(n = 92) 69.7 62.4 76.6

2011

0.417 0.077 0.751

0.414 0.433 0.333

pa

(n = 99) 38.5 44.1 † 27.8

(n = 122) 21.2 25.6 14.0

1992

(n = 96) 41.7 47.0 30.0

(n = 142) 23.9 26.6 18.8

2002

Child(ren)

0.921 0.991 0.848 0.725 0.674 0.585

(n = 157) 40.9 47.7* 21.6

pa (n = 209) 21.7 25.5 12.6

2011

Notes: a = p-value for time trend 1992–2011. Statistical significance between groups: †p < 0.1, *p < 0.05, **p < 0.01, ***p < 0.001 (not cited in the table). Likelihood-ratio chi-square tests performed to test the statistical significance between groups and years.

2002

1992

Spouse/partner

Informal help from spouse/partner or child with house cleaning and food shopping in 1992, 2002 and 2011 among respondents with a spouse/partner or child and with a perceived need for help (%)

Table 5


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the whole care situation; if a person in need of help with a specific task receives such help from one caregiver, there is no or very little need for further help with the same task from another caregiver. Changes in the provision of care observed in the present study have predominantly affected women and older people living alone, among which there has been a considerable reduction in formal help with both house cleaning and food shopping. People living alone lack access to the most important source of informal care, that is, spouses/partners. Access to informal care may reduce the need for formal care, but access to informal care is also increasingly taken into consideration when the need for formal care is assessed (National Board of Health and Welfare 2003), and such considerations are contributing to the development of raised thresholds for eligibility for home help in many local authorities (Johansson et al. 2011). On the other hand, informal carers and relatives can also help the older person to apply for care and act as ‘advocates’ in favour of their older relative in the assessment process (Lingsom 1997). As women live longer than men and tend to marry older men, they are less likely to be supported by a spouse/partner. The present study shows, though, that even among partnered women and men, informal care from a spouse/partner tended to be more common among men, although due to small numbers in this analysis this pattern was only significant in 1992. Still, there was an increase in women receiving help with food shopping from their spouse/partner. This may be a reaction to reduced formal care as well as a reflection of changing gender role attitudes regarding domestic work. Our results show that women relied more on formal care with house cleaning and food shopping than men did and were also less likely to have available informal care to fill the gap by diminishing formal care. This suggests that women are particularly vulnerable to welfare state reductions (cf. Savla et al. 2008). As men relied more on informal than formal care, they were less affected by reductions in formal care. Here, it is important to note, though, that when taking factors other than gender into account, living alone was the most influential on receipt of formal and informal care. Older people who live alone have less access to informal care and are most dependent on formal care. A shift from formal to informal care affects women especially strongly also as caregivers. As shown in previous research and confirmed in this study, women – as wives and daughters – stand for a large share of informal care (e.g. Dahlberg et al. 2007; Principi et al. 2014; Ulmanen and Szebehely 2015). With declining formal care, there can be raised expectations on relatives of older people to take on caring responsibilities. While informal caregiving can be a positive experience, it has well-documented negative consequences including strain, ill-health and work restrictions (e.g. Herlitz and Dahlberg 1999; Principi et al. 2014). Re-familialization of care is a shift from universalism – a central characteristic of the social-democratic welfare regime – towards individualism. With re-familiarization of care, older people become more dependent on their families and other relatives, which threatens their autonomy. 106



Independency is highly valued in Swedish society and emphasized in governmental documents on dignity in care (e.g. Social Ministry 2008), and there is a corresponding consistent and strong support for formal care amongst Swedes (Svallfors 2011; Carrera et al. 2013; Edlund and Johansson Sevä 2013). Universalism in care for older people also means that services should be ‘generously offered according to need and not purchasing power, and that the same services are affordable for the poor as well as attractive for the better off’ (Rostgaard and Szebehely 2012; cf. Sipilä 1997). There are divergent findings regarding socio-economic patterns of formal care-receipt in previous Swedish research: while some suggest that people with a lower socio-economic position are more likely to use formal care (Larsson 2006a), others have found no socio-economic difference (Rostgaard and Szebehely 2012) or even an increase in formal care among older people with higher education, suggesting that this group has a better capacity to negotiate access to scarce resources (Ulmanen and Szebehely 2015). The present study did not identify socioeconomic position as an important discriminator for receipt of informal care or for formal help with house cleaning. However, in 2002 formal help with food shopping was more common amongst respondents with a higher rather than a lower socio-economic position, and in 2011 formal care was more common amongst those with a lower rather than a higher socio-economic position. This may be an indication of changes in the receipt of privately paid care, that is, that older people with a higher socio-economic position have started to purchase services privately. Increases in privately paid help have been identified in previous research, although it has been concluded that this is still rare in the Swedish system of care for older people (Ulmanen and Szebehely 2015).

Strengths and weaknesses This study adds to existing knowledge by examining receipt of care in relation to the perceived need for help with specific tasks. Strengths of this study include that it was based on a nationally representative sample of the oldest old, with high response rates achieved. Thus, our study provides representative data of the key target group of care for older people. In addition, there has been a consistency in the inclusion of items in different waves of data collection, which enables comparison across time points. In this study, focus was placed on two specific care tasks. This is a strength, as the same tasks are measured at each time point, whereas studies of the general development of home help may be affected by changing scopes of such help. This may, however, also be a weakness, as it limits the potential to draw conclusions regarding the care system as a whole. In this study, low numbers of people using privately paid care prevented any sub-group analysis on receipt of privately paid care. A recent study has shown, though, that privately paid care for older people in Sweden is marginal, albeit increasing (Ulmanen and Szebehely 2015). Lastly, it should be noted that the present study did not consider the intensity, frequency or quality of care. © 2017 John Wiley & Sons Ltd

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Conclusions Knowledge on which groups receive formal and informal care is crucial in policy and planning of care for older people. By studying two specific care tasks, this study indicates that public responsibility for care is becoming more narrowly defined, and that more responsibility is placed on persons in need of care and their families, and in the longer run perhaps also on the private market. This would mean that Sweden is heading towards a more mixed system of care for older people, and this study suggests that women are particularly affected by such a development.

Acknowledgements This work was supported by the Swedish Council for Health, Working Life and Social Research (grant number 2012-1704).

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