Introduction

Profound demographic changes, including rapid population aging, have greatly increased the demand for long-term care for older adults throughout the world, with a large share of this care being informally provided at home by family members (Agree and Glaser, 2009). Within families, the most prevalent source of caregiving in later life is a spouse, and women, more than men, often shoulder this responsibility alone (Bertogg and Strauss, 2018).

Providing care to family members generates a strain on the caregiver’s health, but potential gender differences in the impact of providing care have not been investigated extensively by previous studies. To fill this gap, we used longitudinal data from five waves of the Survey of Health, Ageing and Retirement in Europe (SHARE) between 2004 and 2017, to examine how the impact of spousal caregiving on health varies between women and men, and across different European contexts (Uccheddu et al., 2019):

• Eastern Europe: Czech Republic, Estonia, Poland, and Slovenia
• Southern Europe: Greece, Italy, Portugal, and Spain
• Western Europe: Austria, Belgium, France, Germany, Luxembourg, and Switzerland
• Northern Europe: Denmark, Netherlands, and Sweden

The 2017 wave was the first to include new countries (from Eastern Europe) with a second wave of longitudinal data. We define caregiving as intensive help with personal care provided to spouses,¹ and we are particularly interested in how the transitions into and out of caregiving affect the health status of caregivers.² In our study we focused on heterosexual couples who were living together throughout the period of observation. Therefore, whereas other studies have especially focused on the consequences of bereavement on the health of the spousal caregiver, we are interested in investigating the health consequences of caregiving for a spouse who might have a non-critical illness. We use the Frailty Index (FI) as a health outcome, which is a measure of general health status and is an important factor that can be used to predict morbidity and mortality (Romero-Ortuno and Kenny, 2012).

Spousal caregiving and health by country and gender

Frailty scores range in theory between 0 (no health deficits present) and 100 (all deficits present). However, the maximum values observed were 82.5 for men and 83.8 for women. The mean value of the variable ranges from 10.8 for men to 12.0 for women, with standard deviations of 9.2 and 9.9 respectively.

To provide a first overview of the gendered pattern of both caregiving responsibility and health, in Figure 1 we report the average percentage of men and women aged 50 years and over who, between 2004 and 2017, provided care for their spouse across different types of welfare state (left panel) and the average value of the FI for men and women age 50+. Among the 17 European countries under analysis, women more often provide care to their spouses than men (Figure 1, left panel). The gender difference is minimal and statistically insignificant in Northern Europe, but this descriptive does not control for other possible causes, such as country-specific gender differences in the levels of care needs.

The frailty score of women living in Eastern, Southern, and Western Europe is  two to three times higher than that of women living in Northern Europe (Figure 1, right panel), and consistently higher than that of men, especially in Southern Europe. However, there is considerable international variation, with Denmark, Greece, the Netherlands and Switzerland having a relatively low average FI compared to other countries³ (Figure 2).

The health costs of starting (and the health benefits of stopping) spousal caregiving

To move beyond the research traditionally conducted within this field, we investigated how the caregiver’s health status changed in response to starting and stopping spousal caregiving. While the current literature assumes that the health effects of each are the same (with an opposite sign) we used an innovative statistical approach that allowed us to measure the two effects independently (Allison, 2019).

While, not surprisingly, the detrimental health effects of starting caregiving are clear, the beneficial effects of transitioning out of caregiving are not; only in Southern and Eastern Europe are benefits observed, and for women only (Figure 3). Men and women in these contexts also experienced a stronger worsening of health effects from caregiving than in Western and Northern Europe.

Implications

Our results suggest that the negative consequences of the transition into spousal caregiving outweigh the positive effects of a transition out of caregiving. However, the detrimental effects of spousal caregiving on health appear to be reversible, especially for women in Southern and Eastern European countries. This might be a consequence of the fact that in less generous welfare states, where care responsibilities are strongly endogenized within the family, women are constrained to provide more intensive forms of informal family caregiving (Bertogg and Strauss, 2018; Brandt, 2013). When women are burdened by their caregiver role, in a context where outside formal support is scarce, health problems may ensue, due to higher levels of stress and fewer available coping resources. Being freed from such an intensive caregiving task might thus provide a sense of relief.

Our study underlines the asymmetric and gendered nature of care transitions and the need to account for care trajectories when assessing the impact and consequences of caregiving. A better understanding of the spousal caregiver career over the life course is important for all those who plan and provide care for both caregivers and, potentially, for their impaired spouse.

References

Agree, E.M., Glaser, K., 2009. Demography of informal caregiving, in: International Handbook of Population Aging. Springer, pp. 647–668.

Allison, P.D., 2019. Asymmetric Fixed-effects Models for Panel Data. Socius 5, 2378023119826441. https://doi.org/10.1177/2378023119826441

Bertogg, A., Strauss, S., 2018. Spousal care-giving arrangements in Europe. The role of gender, socio-economic status and the welfare state. Ageing and Society 1–24. https://doi.org/10.1017/S0144686X18001320

Brandt, M., 2013. Intergenerational Help and Public Assistance in Europe: A Case Of Specialization? European Societies 15, 26–56. https://doi.org/10.1080/14616696.2012.726733

Romero-Ortuno, R., Kenny, R.A., 2012. The frailty index in Europeans: association with age and mortality. Age and Ageing 41, 684–689. https://doi.org/10.1093/ageing/afs051

Uccheddu, D., Gauthier, A.H., Steverink, N., Emery, T., 2019. The pains and reliefs of the transitions into and out of spousal caregiving. A cross-national comparison of the health consequences of caregiving by gender. Social Science & Medicine 240, 112517. https://doi.org/10.1016/j.socscimed.2019.112517

Footnotes

¹ Informal care within the household was assessed with the following question: “Is there someone living in this household whom you have helped regularly during the last twelve months with personal care, such as washing, getting out of bed, or dressing?”, with answer categories “Yes” and “No”. To avoid problems of misclassification, individuals who provided care to persons other than a “Spouse/Partner” (such as parents, siblings, friends, etc.) were set to missing.

² We observed the following number of transitions into caregiving: Northern Europe, men 380 (3.13% of total sample), women 358 (3.11%); Western Europe, men 883 (3.66%), women 999 (4.55%); Southern Europe, men 471 (3.61%), women 485 (4.18%); Eastern Europe, men 444 (3.80%), women 572 (4.86%).

Besides, we observed the following number of transitions out of caregiving: Northern Europe, men 224 (1.84% of total sample), women 196 (1.70%); Western Europe, men 592 (2.45%), women 535 (2.44%); Southern Europe, men 307 (2.35%), women 278 (2.39%); Eastern Europe, men 290 (2.48%), women 312 (2.65%)

³ Denmark (men = 8.69; women = 9.22), Greece (men = 8.78; women = 9.86), Netherlands (men = 8.53; women = 9.60), and Switzerland (men = 8.01; women = 8.36).

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Gender disparities in health are influenced by a wide set of biological, socioeconomic, and institutional factors (Read and Gorman, 2010). Men usually have better education, better jobs, higher incomes, and higher social status than women, which should give them an advantage in access to health care. Conversely, a well-developed welfare state might help women obtain more autonomy and economic independence (Bambra, 2007).

The key challenge that remains is to understand the intersections between SES, gender, and health in different welfare state typologies. To what extent does the impact of socioeconomic factors on the health of women and men vary across different welfare states? The knowledge gap around this question is even greater at older ages, when health and healthcare services become more important.

Our study

In our research (Uccheddu et al., 2019), we focused on how the association between three different measures of SES (i.e., education, income, and wealth) and a Frailty Index (a multi-dimensional health indicator) (Romero-Ortuno and Kenny, 2012) varies according to gender and across different European contexts. We tested these associations using cross-national data from five waves of the Survey of Health, Ageing and Retirement in Europe (SHARE, 2004-2015). We did so for three European welfare clusters:

1. Northern Europe (Social Democratic), which includes Denmark and Sweden;
2. Western Europe (Bismarckian/Conservative), composed of Austria, Belgium, France, Germany, and Switzerland;
3. Southern Europe (Latin/Mediterranean), represented by Italy and Spain.

The three clusters represent different welfare state regimes and geographical regions:

1. Northern European countries are characterized by a universalistic approach to social rights and high levels of defamilization (i.e., the extent to which the welfare state permits individual entitlements to a socially acceptable standard of living independent of family relationships) and decommodification (i.e., the degree to which the welfare state frees individuals from market dependence for a socially acceptable standard of living) (Bambra, 2007, 2004);
2. Western European countries typically have earnings-related access to social support, welfare programs that tend to maintain existing social patterns, a marginal role of the market, and an emphasis on the role of the family;
3. in Southern European countries state support to families is extremely limited and women are encouraged to take up family and care responsibilities.

Our measure of education was based on the international classification ISCED-97 and refers to the respondent’s highest level of education. We classified education as low (ISCED 0, 1 and 2), medium (ISCED 3 and 4) or high (ISCED 5 and 6). This variable was collected only in the baseline interview. Country and wave-specific quartiles of income and wealth were estimated at the household level and adjusted for family size. These two measures were assessed in each wave of the survey and refer, by survey design, to the year preceding the measurement of the dependent variable. The Frailty Index (FI), our dependent variable, is a composite measure of various deficits, measured at each wave of SHARE, on respondents aged between 50 and 104 years. FI scores were expressed in the range 0-100. High values indicate higher frailty and therefore a poor health status. While the observed minimum of the FI was 0 in the whole sample, its maximum was 83.75, and its average was lower for men (11.05) than for women (13.60).

To assess the influence of SES on health, we estimated a series of “hybrid” (i.e., between-within) regression models and controlled for a series of confounding factors. This method allowed us to account for two types of variation: between-individual and within-individual variation over time.

Results

Table 1 reports the mean values and standard deviations of the FI. Two interesting results emerge. First, the observed mean of the FI was higher for women than for men in all the welfare clusters under analysis. Second, for both men and women, the average FI levels were higher in Southern and lower in Northern Europe, suggesting a north-south gradient in health conditions.

To investigate the intersections between SES, gender, and health, we included gender and SES interaction terms in separate regression models for all older adults combined (Table 2). Note that since the analysis was carried out separately for each welfare cluster, adjusting for country fixed effects, the parameters implicitly refer to a different standard and for this reason they are comparable only in relative terms.

We found that the association between SES and frailty is stronger for women than for men in Southern (education and wealth) and Western European countries (education), as indicated by the statistically significant interaction effect of gender in those contexts (between-individual estimates). For example, we found that the association between education and health was strongest for women living in Southern Europe (b_medium = –2.15; b_high = –2.13), less strong in Western Europe (b_medium = –1.07; b_high = –0.75), and smallest in Northern Europe (b_medium = –0.21; b_high = –0.29).

Southern European women were also more vulnerable than men to the influence of wealth in terms of frailty: the FI of women in the 4^th quartile of wealth is 3.7 points lower that of women in the 1^st quartile. 

However, in an analysis of within-individual variation over time, the association between SES and FI was not statistically significant (results not shown). This means that the differences in health between high- and low-income or wealth groups were more due to differences between individuals than to individual changes in income or wealth.

Concluding remarks

In summary, our findings suggest that SES, as a predictor of health in later life, does not have the same impact across gender within different socioeconomic contexts. In Southern (Italy and Spain) and Western European countries (Austria, Belgium, France, Germany, and Switzerland) especially, the impact of education and wealth on health is stronger for women. Conversely, in Northern Europe (Denmark and Sweden) we did not observe any gender difference in health status according to SES.

Our results are in line with the idea that women’s SES is related to the extent to which the welfare state facilitates women’s autonomy and economic independence from the family (Bambra, 2007). The international variations observed between individuals might be due to the more generous, decommodifying, and defamilializing welfare state policies of the Scandinavian countries that better protect against the health effects of low SES. The more equal distribution of socioeconomic resources in the Northern European countries, combined with high levels of defamilization, may have contributed to smaller gender inequalities in health than in the less redistributive and less protective Southern and Western European countries.

An implication of our findings is that policy and practice aiming to reduce later-life gender and socioeconomic inequalities in health should focus on reducing the objective and systematic inequalities – such as the educational ones – that we examined in our study and which originate in the early stages of life.

References

Bambra, C., 2007. Defamilisation and welfare state regimes: A cluster analysis. International Journal of Social Welfare 16, 326–338.

Bambra, C., 2004. The worlds of welfare: illusory and gender blind? Social Policy & Society 3, 201–211.

Read, J.G., Gorman, B.K., 2010. Gender and Health Inequality. Annual Review of Sociology 36, 371–386.

Romero-Ortuno, R., Kenny, R.A., 2012. The frailty index in Europeans: association with age and mortality. Age and Ageing 41, 684–689.

Uccheddu, D., Gauthier, A.H., Steverink, N., Emery, T., 2019. Gender and Socioeconomic Inequalities in Health at Older Ages Across Different European Welfare Clusters: Evidence from SHARE Data, 2004–2015. Eur Sociol Rev 35, 346–362.

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