Mixed care for elderly people in spain and france: a comparative analysis

3 Revista de cercetare [i interven]ie social\ ISSN: 1583-3410 (print), ISSN: 1584-5397 (electronic) Selected by coverage in Social Sciences Citation Index, ISI databases MIXED CARE FOR ELDERLY PEOPLE IN SPAIN AND FRANCE: A COMPARATIVE ANALYSIS Jose A. CAMACHO BALLESTA, M. Angeles MINGUELA RECOVER Revista de cercetare [i interven]ie social\, 2017, vol. 57, pp. 89-103 The online version of this article can be found at: www.rcis.ro, www.doaj.org and www.scopus.com Published by: Expert Projects Publishing House On behalf of: „Alexandru Ioan Cuza” University, Department of Sociology and Social Work and Holt Romania Foundation REVISTA DE CERCETARE SI INTERVENTIE SOCIALA is indexed by ISI Thomson Reuters - Social Sciences Citation Index (Sociology and Social Work Domains) Working together www.rcis.ro expertprojects publishing 89 Mixed Care for Elderly People in Spain and France: A Comparative Analysis Jose A. CAMACHO BALLESTA1, M. Angeles MINGUELA RECOVER2 Abstract The aim of this paper is to make a comparative analysis of the factors influencing the receipt of mixed care in over 65’s in France and Spain who receive informal care. As a data source we used the SHARE w4 for 2011. We applied binary logistic regression models for the analysis of the factors predicting the use of mixed care. The main results are gender is a significant factor in Spain but not in France. The income and the receipt of additional regular state subsidies or benefits increase the use of mixed care in both countries. Our findings suggest that the dynamics of spatial proximity to their social network are different. In France the social network is more dispersed in the territory, while in Spain it tends to be concentrated within less than 1 km. It was confirmed that mixed care is an additional complement for those receiving informal care. Keywords: mixed care, informal care, social networks, proximity, gender, age. Introduction The EU member states are committed to providing long-term health care. This commitment has transformed the traditional notion in which the care of an individual was a family problem into a social problem requiring state support (Due, Holstein, Lund, Modvig, & Avlund, 1999; Pavolini & Ranci, 2008). Long-term care systems in Europe have a common structure in terms of services (old people’s care homes or care in the home and in terms of the financial benefits that can be used to pay for informal care or offset its costs (Rodrigues, Huber, & Lamura, 2012). Even though the structure is similar, the principle of universal health cover and the levels of protection regarding the treatment of 1 University of Granada, Regional Development Institute, Granada, SPAIN. E-mail: jcamacho@ ugr.es (corresponding author) 2 University of Granada, Regional Development Institute, Granada, SPAIN. E-mail: mminguela@ ugr.es Working together www.rcis.ro 90 REVISTA DE CERCETARE {I INTERVEN}IE SOCIAL| - VOLUMUL 57/2017 people in dependency situations varies a great deal from one country to the next (OECD, 2005). This scenario is producing changes in the implementation of social policies and an important process of budgetary reform in most countries (OECD, 2005; Pickard et al., 2007; Pavolini & Ranci, 2008; Huber, Rodrigues, Hoffmann, G¹sior, & Marin, 2009; Kraus et al., 2010; Colombo, Llena-Nozal, Mercier, & Tjadens, 2011). These changes are likely to have far-reaching effects on the social protection schemes for the elderly and for dependent people in Spain and France. In Spain, there are two key moments in the development of the social protection system for elderly and dependent people. The first was at the end of the 1980s in which there was an increase in institutionalization via the creation of psychiatric hospitals and high capacity care homes. In 1992 the State Gerontology Plan defined the impact of ageing, its economic, social and political implications and its role in the transformation of family customs and structures. This provoked a new debate about the care of elderly people with needs in their everyday lives (Sancho Castiello & Diaz Martin, 2006) and helped visualize the family care traditionally provided within the privacy of the home. The second key period began in the year 2002 with the renovation of the Pact of Toledo cross-party pensions agreement and the emergence of a new generation of social rights in the EU as a result of socio-demographic changes (Rodriguez Cabrero, 2011). This culminated with the publication and implementation of the Law of Dependence in December 2006. The basic pillars of this law were the principles of universality, accessibility and fairness which together produced a new subjective right, the right of people in a situation of dependence to receive care. This gave rise to the Sistema de Autonomia y Atención a la Dependencia (SAAD) (System for the Promotion of the Personal Autonomy and Care of People in a Situation of Dependence) which was established as a new form of social welfare protection, extending and complementing the protective work conducted until then by the health and social security system. The SAAD offers a series of economic benefits in terms of personal care, care within the family and support to nonprofessional carers, along with services such as telephone help lines, home help service, day and night centers, and residential care services. These mixed care services have grown in recent years but there are still big differences in provision around the country (Garcia, Prieto-Flores, & Rosenberg, 2008). The SAAD has two main sources of funding: public and private. Public funding comes from central government and local councils and is insufficient to cover all needs (Camacho, Rodriguez, & Hernández, 2008). Private funding involves either the beneficiaries paying the full cost of their treatment or a joint payment system in which the amount beneficiaries have to pay for the service varies according to their economic capacity to pay for it. 91 In France policies relating to the care of elderly and dependent people have appeared relatively recently. They did not enter the political agenda until the mid1980s due to the fact that care was traditionally provided within the family. Until 1994 there was no real social policy aimed at dependent people, just political debate and a few reports from experts. Social cover for elderly dependent people was associated with disabled status via a compensatory allowance for those requiring help from outside the family (Allocation compensatrice pour tierce personne) (Martin & Le Bihan, 2007). In 1997 the French Government set up the specific dependence provision or PSD (Prestation Specifique Dependance) created to provide cover for disabled elderly people and managed at a local level. This scheme received numerous criticisms because of its restrictive access criteria (Da Roit, Le Bihan, & Osterle, 2007). As a result in 2002 a system of universal cover (known as Allocation perssonalisèe á l’autonomie or APA) based on the provision of long-term care was established. This allowance was aimed at over-60s living at home or in an institution who needed help with everyday activities. An income threshold was established to calculate the contribution that each user had to make towards the cost of the service. Those people whose income was below the established threshold did not have to pay, while for those with higher incomes there was a joint payment system in which the richest participants paid up to 90% of the monthly cost of the service provided (Bihan & Martin, 2013). The system was implemented and managed at local level and the State guaranteed the same level of access to these services all over the country. With the basic premise of keeping the person at home for as long as possible, in the year 2003 numerous plans and a varied range of services (home care services, nursing care services, temporary accommodation, day care services) were established, leading to an increase in the presence of formal careers and services (Le Bihan, 2012). In France the care of dependent people has consolidated its position as the fifth risk (the others are health, pensions, family and accidents at work) in the statefamily-market triangle and the funding system is under debate. Spain and France both have welfare state models in which personal care has been and continues to be viewed within the context of the family and is considered a natural resource in which the State has tended to play a subsidiary role (Geerts & Van, 2012). Today the traditional system of care is undergoing a process of transition for the following reasons: the ageing of the population, the increase in dependency situations and the demand for care, the progressive reduction in the availability of informal carers with the increasing participation of women in the labour market, changes in family structures and dynamics and an increase in the mobility of the members of family units (European Commision, 2012; Rechel et REALITIES IN A KALEIDOSCOPE 92 REVISTA DE CERCETARE {I INTERVEN}IE SOCIAL| - VOLUMUL 57/2017 al., 2013). The object of our study is to make a comparative analysis of the factors that predict the use of mixed care amongst over 65s in France and Spain. Sample and Methods Our analysis uses data from the Survey of Health, Ageing and Retirement in Europe (SHARE) release 1.0.0 of wave 4 for the year 2011. SHARE is a multidisciplinary survey which analyses the state of health, the socioeconomic level and the social and family networks of over 50s in 16 European countries. We made a comparative analysis of the factors that influence the reception of mixed care in over 65s in Spain and France who receive informal care. Informal care is provided by members of the family or by friends and/or neighbours within the elderly person’s closest circle. Mixed care is a combination of informal care and professional care and services provided by public or private bodies. It is based on a complex system which combines family action with that of the market and the state (Le Bihan & Martin, 2010). The sample group was constructed on the basis of the following questions from the SHARE survey: Thinking about the last twelve months has any family member from outside the household, any friend or neighbor given you personal care or practical household help?, Which family member or other from outside the household, friend or neighbor has helped you in the last twelve months? and Is there someone living in this household who has helped you regularly during the last twelve months with personal care, such as washing, getting out of bed, or dressing? Who is that? Those who simultaneously answered that they receive help from professional care providers, who identified family members from older generations and replied “no” when asked if they received informal care were excluded from the analysis. The sample group is therefore made up of those who answered yes to the question about receiving informal care. These questions help establish the type of care received by over 65s in Spain (N329) and France (N401). Method The objective of our statistical analysis was to estimate the factors that predict receipt of mixed care in over 65s in Spain and France who receive informal care. The model used was a binary logistic regression. The dependent variable receives personal care has two categories: mixed care (value 1) as a reference and informal care (value 0). The exploratory variables are divided into four groups: personal factors, health factors, economic factors and socio-territorial factors. The IBM SPSS version 20.0 statistical software package was used. 93 Measures Personal factors: The personal characteristics of receivers of personal care include gender, age over 65 and the binary variable ‘living in a couple’. Health factors: The number and degree of the limitations that older people experience in their daily lives determines the need for personal care and the type received. SHARE classifies everyday activities into two large groups according to their difficulty and purpose (see, Table 1): Activities of Daily Living (ADL) essentially those activities involving care of oneself, and Instrumental Activities of Daily Living (IADL) more complex activities that generally involve a relation between a person and their environment. These activities help the person adapt to or deal with their surrounding environment. Table 1. Classification of Basic and Instrumental Activities of Daily Living. Adapted (Chan, Kasper, Brandt, & Pezzin, 2012) Economic factors. Annual household income (thinc variable) is classified bearing in mind the average income for EU 27, which in 2011 was 16,618 euros (Eurostat, 2015), producing a new binary variable: income lower than or equal to the average and above average. Spain and France have a system of periodic public economic benefits such as retirement pensions, early retirement, sickness benefit, disability pensions and social welfare benefits. SHARE allows us to group them together and create a binary variable ‘receives’ or ‘does not receive’ regular public economic benefits. Socio-territorial factors. In our research we consider the proximity of the elderly person’s social network to be a territorial factor. This network can be defined as the group of people and the family relations and/or affective bonds between them. This means that the social network is made up not only of family Dimensions Activities Activities of Daily Living (ADL). Number of limitations: 0 to 6. Dressing, including putting on shoes and socks. Walking across a room. Bathing or showering. Eating, such as cutting up your food. Getting in and out of bed . Using the toilet, including getting up or down. Instrumental Activities of Daily Living (IADL). Number of limitations: 0 to 7. Using a map to figure out how to get around in a strange place Preparing a hot meal Shopping for groceries Making telephone calls Taking medication Doing work around the house or garden Managing money, such as paying bills and keeping track of expenses REALITIES IN A KALEIDOSCOPE 94 REVISTA DE CERCETARE {I INTERVEN}IE SOCIAL| - VOLUMUL 57/2017 members but also of friends, neighbours, colleagues, ex-colleagues etc. (Due, Holstein, Lund, Modvig, & Avlund, 1999; Puga, Rosero-Bixby, Glaser, & Castro, 2007) Recent studies on the structure, type and implications of the social networks of elderly people include among others (Litwin, 1996; Mutchler & Burr, 2003; Garcia et al., 2005; Fiori, Antonucci & Cortina, 2006; Choi, Burr, Mutchler & Caro, 2007; Litwin, 2009; Fiori, Consedine & Merz, 2011). SHARE w4 includes a new module called social networks, which contains the main variables that describe and characterize the elderly person’s social network. As a result in our research we use the size of the social network made up of those people who are emotionally close or very close as identified by the person being interviewed (see more in McPherson, Smith-Lovin & Brashears, 2009; Litwin, Stoeckel, Roll & ShiovitzEzra, 2013). The territorial perspective is included in our study through the question, where does member X of the social network live? The geographical proximity between the person being interviewed and each member of their social network is classified into a maximum of seven categories. Each category was then awarded a score of between nine and one with the highest scores going to the members with maximum proximity (Table 2). As a result we obtained a variable called maximum geographical proximity, which identifies the member who is physically closest to the person being interviewed without going into more detail as regards the internal characteristics of the social network. Table 2. Scoring system used in the calculation of the maximum geographic proximity variable Categories Score Same home/ same building 9/8 Less than 1 km 7 Between 1 and 5 km 6 Between 5 and 25 km 5 Over 25km/ Between 25-100km/ 100-500km/ Over 500km/ Specify country. 4/3/2/1 Missing, Refusal and Don’t Know Not recorded 95 Results Table 3 shows the results for the variables used in the analysis. The first thing we observe is that the use of mixed care is much lower in Spain at around 15%, compared with France where 32.4% of the population of 65 or over receives it. Within the over 65s, the groups that receive most personal care in both countries are octogenarians and women (about 68%). In France 66.8% of the over 65s who receive personal care do not live in a couple. In Spain by contrast over half live with their spouses or partners. The economic asymmetries between Spain and France are also very significant. 69.3% of Spanish seniors have an income level which is lower than the average for EU 27. And only half of them receive regular public economic benefits compared to 90% in France. If we analyse social networks and their proximity to the elderly person (Figure 2), we find that the size of the social network is similar in France and Spain. However there are substantial differences in terms of proximity. In Spain two thirds of the care is provided inside the home while in France this figure is only one third. The numbers within 1 km are similar, while the social network between 1km and 25 km is significantly larger in France than in Spain. Table 3. Descriptive analysis of the variables involved in the study on the basis of the SHARE data Spain France Informal care (%) 85.1 67.6 Mixed care (%) 14.9 32.4 Age (average) (SD) 79.4 (7.6) 80 (7.7) Gender Men (%) 31.9 32.4 Women (%) 68.1 67.6 Live in a couple Yes (%) 55 33.2 No (%) 45 66.8 ADL (average)(SD) 1.7 (2.1) 0.9 (1.5) IADL (average)(SD) 2.4(2.5) 1.5 (1.9) Annual income Less than or equal to EU 27 (%) 69.3 45.6 Above average EU 27 (%) 30.7 54.4 Periodic public economic benefits Does not receive (%) 50.5 9.9 Does receive (%) 49.5 90 REALITIES IN A KALEIDOSCOPE 96 REVISTA DE CERCETARE {I INTERVEN}IE SOCIAL| - VOLUMUL 57/2017 Figure 1. Maximum proximity between the elderly person who receives personal care and the geographically closest member of their network Spain France Size of social network (average) (SD) 2.3 (1.5) 2.5(1.6) Member of the social network with greatest geographical proximity Same home (%) 60.2 35.4 Less than 1 km (%) 24 27.4 Between 1 and 5 km (%) 6.7 16.4 Between 5 and 25 km (%) 3.6 10.5 Over 25 km (%) 0 5.5 N/A (%) 5.5 4.7 103 Puga, D., Rosero-Bixby, L., Glaser, K., & Castro, T. (2007). Red social y salud del adulto mayor en perspectiva comparada: Costa Rica, España e Inglaterra. Población y Salud en Mesoamerica, 5(1), 1-21. Rechel, B., Grundy, E., Robine, J., Cylus, J., Mackenbach, J. P., Knai, C., & McKee, M. (2013). Ageing in the European Union. The Lancet, 381(9874), 1312-1322. Rodrigues, R., Huber, M., & Lamura, G. (2012). Facts and figures on healthy ageing and long-term care. European Centre for Social Welfare Policy and Research, Vienna. Rodriguez Cabrero, G. (2011). Politicas sociales de atención a la dependencia en los regimenes de bienestar de la unión europea. Cuadernos De Relaciones Laborales, 29(1), 13-42. Sancho Castiello, M., & Diaz Martin, R. (2006). La oferta de servicios sociales. el impacto de la futura ley de dependencia [ social services supply: The impact of the imminent Law of dependence]. In R. Puyol Antolin, & A. Abellán Garcia (Eds.), Envejecimiento y dependencia una mirada al panorama futuro de la población española. [ old age and dependency: A perspective view of the spanish population] (pp. 202-219). Madrid: Mondial Assistance. Suanet, B., Van Groenou, M. B., & Van Tilburg, T. (2012). Informal and formal homecare use among older adults in Europe: Can cross-national differences be explained by societal context and composition? Ageing & Society, 32(03), 491-515. REALITIES IN A KALEIDOSCOPE