The effects of marital and parental status on informal support and service utilization: A study of older Swedes living alone

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Abstract

Never-married individuals and childless persons living alone are at greater risk of having insufficient support in old age. This study investigated whether community-dwelling older people, living alone in an urban area of Sweden, benefit from having been previously married and having had children in terms of informal care received, and whether those without such filial support were compensated by formal services. The study sample consisted of 390 persons, 81 years and older, who were interviewed about family support and the use of public eldercare and market-based services. The study showed that parents had considerably higher odds of receiving informal support, whereas previously married individuals without children were no more likely to receive support than their never-married counterparts. Public home-help services did not fully buffer the lack of care among childless individuals. This indicates that even in an advanced welfare state like Sweden, children are assets for receipt of care in old age.

Introduction

A growing proportion of elderly people in Western countries live alone (OECD, 1996) and, consequently, have to rely on support from sources outside the household in times of need. Family and friends, along with formal services, form the support network for elderly and disabled persons living alone. The question of what informal and formal resources this group will likely draw upon for care is crucial for understanding the potential support deficits that older individuals with no residential partners are likely to face. In this analysis, we investigate whether community-dwelling older people, living alone in an urban area of Sweden, are more likely to receive informal support if they were previously married and had children, and whether those without such filial resources are more likely to receive formal support services. A previous study of this population showed that compared with older people who lived with others, those who lived alone were disadvantaged in their chances of receiving informal care, but were distinctly advantaged in their chances of receiving formal in-home care, suggesting a compensatory dynamic between the two sources of care (Larsson & Thorslund, 2002). We follow up on this research by examining, in more detail, this subsample of older people living alone to identify patterns of informal and formal care by contrasting those with filial resources of marriage and children, and those without such resources.

Informal support from relatives and friends, is the major source of assistance for the majority of disabled elderly living alone in the community, both in Sweden Johansson & Thorslund, 1992, Sundström, 1994a, Szebehely, 1999 and in other nations Andersson, 1993, Chappell & Blandford, 1991, Helset, 1993, Jorm et al., 1993, Kemper, 1992. The prime source of informal care for elderly people living alone is adult children, who, along with other relatives and friends, are often crucial for helping older adults avoid or postpone institutionalization. Following the onset of age-related impairments, unmarried elderly persons with children appear to have more supportive networks than those without children Barrett & Lynch, 1999, Bengtson et al., 1990, Connidis & McMullin, 1999. Several studies in the United States found that elders without children had less overall support from relatives Boaz & Hu, 1997, Choi, 1994, Gironda et al., 1999, Johnson & Troll, 1992, and the same pattern has been found in the Netherlands Broese van Groenou & Van Tilburg, 1996, Dykstra, 1993 and in Germany (Wagner, Schütze, & Lang, 1999). Research in Scandinavian countries has given mixed results. A nationwide survey of the Swedish 75+ population showed no difference in informal support between parents and childless individuals (Szebehely, 1998b). In Norway, a longitudinal population-based study of the oldest old revealed that although elders with no children received the same type of informal help as elders with children do, the childless received help over a shorter duration (Romøren, 2001).

When examining support patterns in the population of older people who live alone, we suggest that it is useful to isolate the unique effects of marriage and fertility, as the resources conferred by these statuses may uniquely contrast with those of the never married, most of whom are childless. (While the number of never-married individuals with children is expected to grow, this represents a small group among current elders and will not be a topic in this investigation.) Although the previously married without children may be disadvantaged in their support networks compared with those with children, it is unclear whether the former are advantaged in their support networks relative the never married due to the availability of in-law relatives who can provide support. A Canadian study found that marital history was insignificant in all aspects of support availability and exchange for unmarried, childless, elderly persons (Wu & Pollard, 1998).

Alternatively, the never-married may have developed an informal network of nonkin supports over their lifetimes and may also receive support from their family of origin, including their sibling's families. Several studies have shown that never-married and childless elderly persons, above all, women, have developed an independent and extra-familial lifestyle Connidis & McMullin, 1992, Rice, 1989, Wenger et al., 2000 and have shed light on strategies used by single women to remain independent in old age Morrissey, 1998, Rubinstein et al., 1991. Thus, it remains an open empirical question as to whether these three types of older individuals—the previously married without children, the previously married with children, and the never married—are equally served by their informal support networks.

Evidence is also equivocal regarding the question of whether those with smaller informal support networks are compensated by the formal care sector. On the one hand, research has shown that never-married and childless persons in the United States, Canada, and Sweden were more likely to receive support from formal sources than previously married persons and parents do Barrett & Lynch, 1999, Connidis & McMullin, 1994, Szebehely, 1998a. On the other hand, numerous studies from the United States have shown that having relatives, who may act as advocates in favor of their kin, enhances the use of formal services Choi, 1994, Jenkins, 2000, Langa et al., 2001, Logan & Spitze, 1994. A Norwegian study on filial care showed that elders who received practical help from their children had higher odds of receiving public home-help services than other elders do (Lingsom, 1997).

The division of responsibility between the family and the public sector represents a salient policy issue when studying the support network for the oldest old living alone. International debate has focused on whether formal care substitutes informal care, that is, whether families will reduce their care obligations when they have the opportunity to do so—the substitution model—or if formal care complements informal care (for an overview, see Penning, 2002). European studies showing that countries with the highest level of services, such as Denmark, Sweden, or the Netherlands, have the lowest level of in-home family care Andersson, 1993, Walker & Maltby, 1997 can be seen as support for the substitution model of care. However, most research concludes that formal and informal care are inversely related to each other Chappell & Blandford, 1991, Denton, 1997, Tennstedt et al., 1996. Reductions in the proportion of elderly people in Sweden receiving public home-help services over the last several decades appear to be accompanied by the substitution of informal family care (Szebehely, Fritzell, & Lundberg, 2001).

The present study examines the sources of care among older people living in a metropolitan area of Sweden. For several reasons, Sweden represents an ideal context within which to investigate the interrelationship between informal and formal care. With its open eligibility policy of delivering public eldercare, Sweden provides formal services to its older citizens as realistic alternatives to kin-care. Unlike many other nations, Sweden's public eldercare system has played an active role in promoting residential independence in its older population. A fairly extensive system for providing social services and medical care, in addition to relatively generous pension coverage, has made it possible, even for frail persons, to remain in their own homes until quite late in life (OECD, 1996). Public home-help services are provided by the municipality to community-dwelling persons who require assistance with domestic chores like shopping, cleaning, cooking, washing, and with physical care such as help to get up from bed, dressing, and going to the toilet. Users are charged a fee that varies according to both income and the scope of intervention. In 1994, when the data collection for this study began, 31% of solo living and 13% of coresiding, community-dwelling people (80+) in Sweden received public home-help services (Daatland, 1997).

Demographic patterns of fertility, living arrangements, and migration of the Swedish elderly are also salient factors in the use of formal and informal care. The level of conjoint living between parents and adult children or other relatives is very low in Sweden (about 3%), implying a preference for living independently of the offspring. This, combined with the fact that a considerable proportion, 1/5, of Swedish elderly people do not have any children (Sundström, 1994b), results in Sweden having a high proportion of its oldest old population living alone (82% of women and 44% of men; Statistics Sweden, 1999a). In urban areas, such as Stockholm, the proportion of elderly persons living alone is even higher, reflecting the relatively high proportion of women who moved there during the first decades of the 20th century in search of employment and who subsequently never married or had children (Statistics Sweden, 1999b).

In this investigation, we study elderly persons living alone and the significance of marital and parental status for receiving care when both formal and informal sources are taken into consideration. The previous discussion raises some concerns for care of older persons who live alone, particularly, because the availability of children is far from universal, and eligibility for community-based services has become increasingly restricted. Therefore, it is important to better understand whether having adult children and/or a previous marriage are social assets in terms of informal care to those in late life, and the degree to which public services buffer any deficits in care that might be experienced by the never married and the childless. Drawing on these ideas, we hypothesize that informal and formal services will target specialized groups such that (1) previously married individuals, and those with children, will be more likely to receive in-home support from informal sources than the never married and childless will and (2) never-married individuals will be more likely to receive in-home support from public services or from the private market than previously married persons will. We also anticipate that marriage and child availability will operate synergistically, such that married individuals with children will have the highest likelihood of receiving in-home support from informal sources and the lowest likelihood of receiving in-home support from formal services. Of particular interest is whether informal and formal supports target unique populations and, therefore, offset each other. This can be said to occur if any disadvantages experienced by the unmarried and childless elderly in terms of informal care are reduced or eliminated when examining care from any possible source (i.e., from either the informal or formal sectors).

Section snippets

Sample

The material in this study is based on a population-based longitudinal study in Stockholm, the Kungsholmen study. The sample consists of all individuals 75 years and older who were registered in the parish of Kungsholmen in 1987. Of the eligible participants, 1810 persons (76%) participated in the baseline data collection (8% dead/moved, 16% refused). In the first follow-up survey, 1105 participants participated (25% dead/moved, 14% refused). In the second follow-up survey, carried out between

Results

We first examined the univariate distributions of key analytic variables and their bivariate associations with marital and parental status (see Table 1). We note that 87% of the sample is female, with an average age of 87 years, and somewhat more than half of the sample (54%) had 2 to 7 years of education. Almost half of the sample (47%) were childless, 76% were previously married, and about three-quarters (73%) had weekly or more contact with friends. Turning to health variables, 22% of the

Discussion

In this investigation, we have examined the relationship between martial and parental status and the presence and source of care for older individuals living alone in a metropolitan area of Sweden. This analysis takes place in the context of a Scandinavian welfare states that, in principle, provides a safety net for disabled persons, regardless of family resources and socioeconomic status (Sipilä, 1997). Nevertheless, we found some evidence for the suppression of formal service use among older

Conclusion

Previous research has shown that never-married individuals and childless persons living alone are at greater risk of having insufficient support in old age. This study showed that parents had considerably higher odds of receiving informal support, thereby giving them better chances of remaining at home and avoiding institutionalization. Public in-home services did not fully buffer the lack of care among childless individuals, showing that even in an advanced welfare state like Sweden, children

Acknowledgements

This research was supported by a grant from the Swedish Association of Senior Citizens, SPF. We thank all the members of the Kungsholmen Project Study Group for the data collection and management and for giving us access to the database. We also thank Mats Thorslund and Marta Szebehely for valuable comments.

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