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

Journal of Aging Studies 18 (2004) 231 – 244

The effects of marital and parental status on informal support and service utilization: A study of older Swedes living alone Kristina Larsson a,*, Merril Silverstein b a

Stockholm Gerontology Research Center, Box 6401, S-113 82 Stockholm, Sweden Ethel Percy Andrus Gerontology Center, University of Southern California, USA

b

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 nevermarried 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. D 2004 Elsevier Inc. All rights reserved. Keywords: Marital and parental status; Informal support; Service utilization

1. 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 * Corresponding author. Tel.: +46-8-690-58-11; fax: +46-8-335275. E-mail address: [email protected] (K. Larsson). 0890-4065/$ - see front matter D 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.jaging.2004.01.001

232

K. Larsson, M. Silverstein / Journal of Aging Studies 18 (2004) 231–244

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; Sundstro¨m, 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, Rosenthal, & Burton, 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, Lubben, & Atchison, 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, Schu¨tze, & 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, Scott, & Patterson, 2000) and have shed light on strategies used by single women to remain independent in old age (Morrissey, 1998; Rubinstein, Alexander, Goodman, & Luborsky, 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.

K. Larsson, M. Silverstein / Journal of Aging Studies 18 (2004) 231–244

233

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 nevermarried 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, Chernew, Kabeto, & Katz, 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, Harrow, & Crawford, 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 (Sundstro¨m, 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

234

K. Larsson, M. Silverstein / Journal of Aging Studies 18 (2004) 231–244

of the 20th century in search of employment and who subsequently never married or had children (Statistics Sweden, 1999b). 1.1. Research questions 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).

2. Data and methods 2.1. 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 1994 and 1996, 683 persons participated (34% dead/moved, 4% refused), 520 living in ordinary dwellings and 163 in institutions. This study uses cross-sectional data from the second follow-up survey, when the participants were 81 years or older, and is restricted to the 390 persons who lived alone in ordinary dwellings. The study design is reported in detail elsewhere (Fratiglioni, Viitanen, Ba¨ckman, Sandman, & Winblad, 1992; Fratiglioni et al., 1997). While the Kungsholmen area did not differ substantially from the whole inner-city area of Stockholm in terms of sex distribution and marital status of its elderly population, it did deviate from the rest of Sweden in its higher than average education and overrepresentation of women, particularly, never married women, in this particular age cohort (Statistics Sweden, 1989, 1993).

K. Larsson, M. Silverstein / Journal of Aging Studies 18 (2004) 231–244

235

Each participant in the study was interviewed by a nurse and was assessed with an extensive medical examination by a physician. A family interview was also performed with next of kin and, in some cases, a friend or neighbor. Eighty-one percent of the 390 participants in this study had an informant who was interviewed. Information from the informant was used to cross validate the responses concerning informal care patterns of the elderly participants. 2.2. Dependent variables We operationalized three general types of care that form the dependent variables in our multivariate equations. Formal services is defined as whether the participant was currently receiving public homehelp services. Both the participant and informant were asked whether the elderly person received public home-help services from the municipality. If the answers were unclear or contradictory, a search was made with the municipality of Stockholm’s home-help register to provide reliable information as to whether home-help services were used at the time the interview took place. Based on participant, informant, and register data, we constructed a dichotomous variable indicating whether home help was received (1) or not received (0). The receipt of informal care is based on questions asking both the participant and the informant if the elderly person received practical assistance at home from family members or friends. The participant and informant questionnaires contained several questions about informal support, a global question regarding receipt of informal support with practical chores at home and specific questions regarding several household tasks (cooking, shopping, laundry, and house cleaning), making the cross validation of the participant’s answers possible for those who had an informant. If the participant’s answers were incomplete, information from the informant was used to fill in the gap. If the answers from the participant and the informant were contradictory, and the participant had a dementia diagnosis, the participant’s answer was replaced by the informant’s answer (occurring in 1.8% of the sample). Three percent of the study group had a dementia diagnosis and lacked an informant. The answers from these participants were included in the analyses, without the possibility of a cross validation. Based on this information, a dichotomous variable was constructed indicating whether the participant received (1) or did not receive (0) informal support. Recognizing that older individuals and their families may pay out-of-pocket for in-home services, we included private domestic services as a third type of care. The participants and informants were asked whether the older individual received practical support at home from a paid private source. The same cross-validation procedure was used as with informal care. A dichotomous variable was constructed, indicating that participants used (1) or did not use (0) private domestic services. Finally, a global dichotomous item was constructed indicating whether the participant received care from any source (1)—informal, public-formal, or private-formal—or did not receive any care at all (0). 2.3. Independent variables 2.3.1. Marital and parental status Two dichotomous variables were constructed to indicate several combinations of marital and parental status. These variables signified: ‘‘the previously married with children’’ and ‘‘the never married without children’’ (two never-married persons with children were omitted from our analyses). The reference group was ‘‘previously married without children.’’ Among the previously married were those

236

K. Larsson, M. Silverstein / Journal of Aging Studies 18 (2004) 231–244

Table 1 Sample characteristics of community-dwelling persons living alone, by marital and parental status (N = 390; in percentages) Total

Background data Gender Female Male Age (in years) Mean Minimum to maximum Education 2 – 7 Years 8 Years or more Social networks characteristics Children Yes No Contacts with friends Often Seldom Functional and cognitive ability Functional limitations according to Katz ADL index Not dependent in any ADL Dependent in one or more ADLs Ability to move without aidsa No limitations Needs aids Ability to perform IADL-activitiesb No limitations Needs help with one IADL Needs help with two IADLs Needs help with three IADLs Needs help with four IADLs Cognitive limitations No dementia diagnosis Dementia diagnosis Formal and informal care Public home help services Yes No Informal care Yes No

Previously married Yes (n = 298)

No (n = 92)

87 13

86 14

90 10

87 81 – 100

87 81 – 100

54 46

Children P

Yes (n = 208)

No (n = 182)

.376

85 15

90 10

.176

87 82 – 98

.287

87 81 – 100

87 81 – 98

.975

55 45

49 51

.284

52 48

56 44

.611

53 47

69 31

2 98

< .001

73 27

76 24

64 36

.044

77 23

68 32

.031

78 22

78 22

82 18

.560

78 22

80 20

.711

52 48

51 49

54 46

.719

50 50

54 46

.542

42 20 13 13 12

41 21 12 14 12

45 18 12 10 15

.689

39 23 13 13 12

44 17 13 13 13

.709

84 16

85 15

84 16

.870

84 16

85 15

.896

27 73

27 73

29 71

.689

25 75

30 70

.258

49 51

53 47

37 63

.009

61 39

35 65

< .001

–

–

P

–

K. Larsson, M. Silverstein / Journal of Aging Studies 18 (2004) 231–244

237

Table 1 (continued) Total

Formal and informal care Private domestic services Yes No Formal and/or informal care Yes No a b

Previously married Yes (n = 298)

No (n = 92)

15 85

15 85

14 86

69 31

72 28

58 42

Children P

Yes (n = 208)

No (n = 182)

P

1.000

15 85

14 86

.777

.014

76 24

60 40

.001

Missing data for one person. Missing data for two persons.

participants who were widowed or divorced, as well as three currently married individuals whose spouses permanently resided in an institution. Variables were coded to strategically make contrasts of theoretical interest: the previously married with children group differs from the reference group in whether the children are present (both groups are married), and the never married without children group differs from the reference group in whether a previous marriage occurred (both groups are childless). Thus, each contrast varies one factor of interest, while holding the other one constant. 2.3.2. Contact with friends Amount of contact with friends was coded as a dichotomous variable, contrasting those having contact weekly or more often (1) with those having monthly contact or less or who report having no friends (0). 2.3.3. Activities of daily living (ADLs) The participants’ ability to perform basic tasks was assessed with the Katz index of independence in activities of daily living (Katz, Ford, Moskowitz, Jackson, & Jaffe, 1963). The following six tasks were assessed: bathing, dressing, going to the toilet, transferring, maintaining continence, and feeding. If assistance was required in the performance of any of the tasks, the participant was considered ADL impaired. A dichotomous item was constructed contrasting those who require assistance in one or more activity (1) with those who require no assistance in any activity (0). 2.3.4. Mobility The participants were asked if they could move independently, or needed to use an assistive device such as a stick, crutch, walking frame, or wheelchair. A dichotomous variable was constructed contrasting those needing to use aids (1) with those who were able to move independently without an aid (0). 2.3.5. Instrumental activities of daily living (IADLs) The participants were asked if they could manage practical household activities, such as cooking, shopping (groceries), laundry (washing clothes), and house cleaning on their own, or if they needed help. Affirmative responses to needing help were summed across the four areas to form an index score ranging

238

K. Larsson, M. Silverstein / Journal of Aging Studies 18 (2004) 231–244

from 0 (does not need help with any activity) to 4 (needs help with all four activities; Cronbach’s alpha = 0.79). 2.3.6. Cognitive ability The participants who were diagnosed as having a clinically definite dementia were included in the demented group, and the variable was dichotomized into have/have no dementia diagnosis. The procedure for diagnosing dementia is described in detail elsewhere (Forsell, Fratiglioni, Grut, Viitanen, & Winblad, 1992). 2.3.7. Demographic variables Gender was coded as a dichotomous variable contrasting men (1) with women (0). The level of education was grouped coded as a dichotomous variable contrasting those having 8 years of education or more (1) with those having 2 to 7 years of education (0). Age was considered as a continuous variable ranging from 81 to 100.

3. 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 sample had an ADL limitation, almost half (48%) needed a mobility aid, and 16% had a dementia diagnosis. Fifty-eight percent reported the need of help with at least one IADL (38% with two or more). Of all the independent variables, only contact with friends showed a significant relationship with marital and parental status, with participants who were previously married and who had children having greater contact than their counterparts. In terms of receiving care, slightly more than one-quarter of the sample (27%) received public homehelp services, half (49%) received care from an informal source, and 15% purchased private domestic help. In total, 69% received care from any of the three sources. Bivariate analysis showed that previously married participants and those with children were more likely to receive informal care than the never married and childless, but were no different in their use of public home-help or private domestic services (see Table 1). To study the net effects of marital and parental status on the four types of support, logistic regression equations were estimated, with the type of care received as the dependent variable. These corresponded to the following dichotomous outcomes: (1) public home-help services, (2) informal care, (3) privately paid domestic services, and (4) care from any source (see Table 2). In addition to health and demographic predictors, two dummy variables were included as independent variables in these equations, reflecting the cross-classification of marital and parental status: (1) previously married with children and (2) never married without children, with the reference group consisting of the previously married without children. Multicollinearity was examined by regressing each independent variable on all the others, and no serious problems in this area were detected (R2 between .03 and .49).

K. Larsson, M. Silverstein / Journal of Aging Studies 18 (2004) 231–244

239

Table 2 Logistic regression results for likelihood of receiving formal and/or informal care for community-dwelling persons living alone (n = 385) Public home help services Coefficient Background data Gender (women = 0, men = 1) Age Education (2 – 7 years = 0, 8+ years = 1) Functional and cognitive ability Katz ADL index (not dependent = 0, dependent = 1) Ability to move (needs no aids = 0, needs aids = 1) Dementia (no = 0, yes = 1) Need of help with IADLs (0 – 4) Social networks Contacts with friends (seldom = 0, often = 1) Never married without children (Ref = previously married without children) Previously married with children (Ref = previously married without children) 2LL

Informal care

Private domestic services

Formal and/or informal care

Odds Coefficient ratio

Odds Coefficient ratio

Odds Coefficient ratio

Odds ratio

0.085 0.038 0.782**

0.92 1.04 2.19

0.516 0.044 0.436*

0.60 0.96 0.65

0.427 0.65 0.001 1.00 0.778*** 2.18

0.181** 0.011 0.259

0.31 1.01 1.30

0.190

1.21

0.438

0.65

1.049**

0.35

0.146

0.86

1.017**

2.76

0.438

1.55

0.402

0.67

0.790*

2.20

1.581*** 4.86 1.214**** 3.37

0.154 0.86 0.625**** 1.87

0.345**

a 1.41

1.204* 3.33 2.878**** 17.78

0.748*

0.47

0.628**

1.88

0.488

1.63

0.715*

2.04

0.285

0.75

0.248

1.28

0.104

0.90

0.240

0.79

0.773*

0.46

1.355**** 3.88

0.017

1.02

1.238***

3.45

216.43

440.84

307.22

225.49

Two cases were excluded, as they were never married with children, and three cases had missing values in the covariates. a—No demented persons used private domestic services, and the variable was excluded from the analysis. * P < .10. ** P < .05. *** P V.01. **** P < .001.

Parameter estimates and their corresponding odds ratios for the logistic regression equations are found in Table 2. The first equation shows the predictions for use of public home-help services. The previously married with children were less than half as likely (0.46) as the previously married without children to use home-help services, whereas there were no differences between the unmarried childless and the previously married childless. This suggests a much more powerful effect of children over marriage in the use of public services. In addition, more frequent contact with friends decreased the odds of receiving public home-help services by more than half (odds ratio = 0.47), suggesting a compensatory influence of friendships. Greater frailty, requiring aids to move, dementia, and needing help with more IADLs, increased the odds substantially, with demented people receiving home care nearly five times the rate as

240

K. Larsson, M. Silverstein / Journal of Aging Studies 18 (2004) 231–244

the nondemented. Persons with higher educational levels had more than twice the odds of receiving public in-home support. In the second equation of Table 2, the logistic regression estimates predicting the receipt of informal care are shown. This analysis revealed that previously married persons with children were almost four times more likely to receive informal care (odds ratio = 3.88) compared with the previously married without children. There was no difference between childless persons who were previously married and not previously married. Thus, having had children seems to provide more of a benefit than having been previously married, in terms of elevating the chances of receiving informal care. The odds of receiving informal support increased as the number of IADLs with which the elderly person reported needing help increased. Those who had more frequent contact with friends had almost twice the odds of receiving informal support compared with those with less frequent contact (odds ratio = 1.88), whereas those with a greater education had lower odds than their less educated counterparts had (odds ratio = 0.65). The third equation in Table 2 shows the estimates predicting the receipt of private domestic services. No differences were found with regard to marital or parental status. The need for help with IADLs increased the likelihood of using private services, but, interestingly, dependence in ADLs decreased it. Inasmuch as no individuals with dementia bought market-based services, that variable is omitted from the equation. On balance, the need for instrumental care increases the use of private services, but the need for personal care under conditions of severe frailty seems to suppress their use. Higher educational level exhibited a positive association with use of private services. Finally, the fourth equation in Table 2 predicts the receipt of care from any of the three sources analyzed previously. This multivariate analysis revealed that previously married persons with children were 3.5 times more likely to receive care from any source, formal or informal, compared with previously married individuals without children. No difference was found between childless persons of each marital status. In addition, men had lower likelihood of receiving care than women did, and those using mobility aids, diagnosed with dementia, and, in particular, those needing help with more IADLs were more likely to receive care. Contact with friends also elevated the chance that care was received.

4. 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 (Sipila¨, 1997). Nevertheless, we found some evidence for the suppression of formal service use among older individuals with children and have clearly found advantages in the informal support achieved by this group, despite the fact that unlike many European countries, adult children in Scandinavia have no legal obligation to provide care for their parents or pay for it (Millar & Warman, 1996). Furthermore, there is little evidence that formal services fully compensate for the support deficits of the childless. While the use of public services is higher among the childless, they still appear to be relatively underserved when all sources of care are considered. In this analysis, public services do not erase the informal support disadvantage of the childless. Nevertheless, it is worth noting that children are not a guarantee of receiving adequate amounts of high quality support. The children of the oldest old are probably at retirement age themselves

K. Larsson, M. Silverstein / Journal of Aging Studies 18 (2004) 231–244

241

and may have difficulty providing assistance in the eighth and ninth decades of their parents’ lives (Burholt & Wenger, 1998). Previous marriage appeared not to enhance the chances of receiving either informal or formal types of support, discounting the possibility that in-law relatives may enlarge the support network and provide a compensatory benefit following the loss of a spouse. However, having more frequent contact with friends hints at the possibility that friends play a key role in reducing formal care and increasing informal care, perhaps, more so for the never married who have greater need to develop friendship support networks as alternatives to family. Alternatively, family members of siblings may be providing instrumental support in old age (see Connidis, 1994). In Sweden, conservative economic measures taken during the 1980s and 1990s resulted in priority for services being given to the oldest and frailest clients, implying that people with fewer needs have increasingly fallen outside the realms of public concern (Szebehely et al., 2001). This seems to be the case also in this urban sample, where the public home-help services target persons with greater functional and cognitive impairments. While targeting services at the most needy has some virtue in a period of fiscal cutbacks, this type of targeting of public resources may also increase care demands on the family of the more mildly, but still significantly, frail older individual. Furthermore, the fact that individuals with higher education were more likely to receive public home-help services might indicate that well-educated individuals were more successful at accessing and using public services, compared with those with lower levels of education. It might also indicate different preferences regarding formal versus informal care among the different social classes, as the more highly educated group was less likely to utilize informal care. Such evidence, however, might point to social class differentials in either the demand for, or the allocation of, public resources—a form of inequality that is in direct opposition to the stated public policy in Sweden. We also speculated that buying private domestic services on the market might compensate for reductions in public eldercare among people with only moderate impairments. We found some evidence for this, as the need for help with IADLs increased the odds of using services paid out of pocket. Persons with the most extensive functional needs, as indicated by the need for help with ADL, were less likely to directly purchase such services, and persons with dementia did not use private services at all. Although we treated each source of support as mutually exclusive in our first three models, there is, in fact, considerable overlap between formal and informal support: 57% of the home-help recipients also received in-home support from informal sources and 8% of them bought private domestic services (not shown). Although the relatively small sample did not provide sufficient power to examine informal and formal services simultaneously, this result, combined with our multivariate findings, indicates that public eldercare complements, rather than substitutes, informal care. The interrelationship between the formal and the informal care systems is complex, particularly in a welfare state with an ambition to provide universal and comprehensive eldercare. During the last decade, elderly Swedes have seen cutbacks in public home-help services among persons with moderate needs, and an increase in informal care. The effect of economic measures seems to be that informal care is substituting for public care. One limitation of this study is that the sample was not specifically representative of the nation of Sweden, as it was recruited from an urban area, and overrepresented never-married women. While this feature gave us opportunity to study the net effect of marital and parental status, it did not allow an analysis of gender interactions because there were very few never-married men among the oldest old. The study design afforded some unique advantages as well. Most important was the inclusion of relatives in the data collection: Four out of five participants had an informant who was interviewed. This

242

K. Larsson, M. Silverstein / Journal of Aging Studies 18 (2004) 231–244

made it possible both to get information about care given to cognitively impaired persons, who could not contribute with detailed information themselves, and to cross validate participants’ responses. It is unlikely that our results would have been substantially different if all interviews had been supplemented by information from relatives, since only a small proportion of responses from participants with informants were changed to achieve greater accuracy or consistency.

5. 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 are social assets in old age. We suggest that the Swedish experience regarding formal and informal care may be informative for many other nations facing similar increases in their elderly populations who live alone, but with fewer public resources to serve them in their homes.

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.

References ¨ ldre i Sverige och Europa [Elderly in Sweden and Europe]. A¨del-utva¨rderingen, vol. 93:4. Stockholm: Andersson, L. (1993). A National Board of Health and Welfare. Barrett, A. E., & Lynch, S. M. (1999). Caregiving networks of elderly persons: Variation by marital status. The Gerontologist, 39, 695 – 704. Bengtson, V., Rosenthal, C., & Burton, L. (1990). Families and aging: Diversity and heterogeneity. In R. H. Binstock, & L. K. George (Eds.), Handbook of aging and the social sciences (pp. 263 – 287). London: Academic Press. Boaz, R. F., & Hu, J. (1997). Determining the amount of help used by disabled elderly persons at home: The role of coping resources. Journal of Gerontology, 52, S317 – S324. Broese van Groenou, M., & Van Tilburg, T. (1996). The personal network of Dutch older adults: A source of social contact and instrumental support. In H. Litwin (Ed.), The social networks of older people. A cross-national analysis London: Praeger. Burholt, V., & Wenger, G. C. (1998). Differences over time in older people’s relationship with children and siblings. Ageing and Society, 18, 537 – 562. Chappell, N., & Blandford, A. (1991). Informal and formal care: Exploring the complementarity. Ageing and Society, 11, 299 – 317. Choi, N. G. (1994). Patterns and determinants of social service utilization: Comparison of the childless elderly and elderly parents living with or apart from their children. The Gerontologist, 34, 353 – 362.

K. Larsson, M. Silverstein / Journal of Aging Studies 18 (2004) 231–244

243

Connidis, I. A. (1994). Sibling support in older age. Journal of Gerontology, 49, S309 – S317. Connidis, I. A., & McMullin, J. A. (1992). Getting out of the house: The effect of childlessness on social participation and companionship in later life. Canadian Journal on Aging, 11, 370 – 386. Connidis, I. A., & McMullin, J. A. (1994). Social support in older age: Assessing the impact of marital and parent status. Canadian Journal on Aging, 13, 510 – 527. Connidis, I. A., & McMullin, J. A. (1999). Permanent childlessness: Perceived advantages and disadvantages among older persons. Canadian Journal on Aging, 18, 447 – 465. Daatland, S. O. (Ed.) (1997). De Siste A˚rene. Eldreomsorgen i Scandinavia 1960 – 95 [The last years. Public elder care in Scandinavia 1960 – 95]. vol. 22/97. Oslo: NOVA. Denton, M. (1997). The linkages between informal and formal care of the elderly. Canadian Journal on Aging, 16(1), 30 – 50. Dykstra, P. A. (1993). The differential availability of relationships and the provision and effectiveness of support to older adults. Journal of Social and Personal Relationships, 10, 355 – 370. Forsell, Y., Fratiglioni, L., Grut, M., Viitanen, M., & Winblad, B. (1992). Clinical staging of dementia in a population survey: Comparison of Dsm-Iii-R and the Washington University clinical dementia rating scale. Acta Psychiatrica Scandinavica, 86, 49 – 54. Fratiglioni, L., Viitanen, M., Ba¨ckman, L., Sandman, P. O., & Winblad, B. (1992). Occurrence of dementia in advanced age: The study design of the Kungsholmen project. Neuroepidemiology, 11, 29 – 36. Fratiglioni, L., Viitanen, M., von Strauss, E., Tontodonati, V., Herlitz, A., & Winblad, B. (1997). Very old women at highest risk of dementia and Alzheimer’s disease: Incidence data from the Kungsholmen project, Stockholm. Neurology, 48, 132 – 138. Gironda, M., Lubben, J. E., & Atchison, K. A. (1999). Social networks of elders without children. Journal of Gerontological Social Work, 31, 63 – 84. Helset, A. (1993). Elderly women in the Nordic countries: Level of living and situation in life. Scandinavian Journal of Social Medicine, 21, 223 – 226. Jenkins, C. L. (2000). Care arrangement decisions for frail older women: Quantitative and qualitative perspectives. Journal of Women and Aging, 12, 3 – 20. Johansson, L., & Thorslund, M. (1992). Care needs and sources of support in a nationwide sample of elderly in Sweden. Zeitschrift fu¨r Gerontologie, 25, 57 – 62. Johnson, C. L., & Troll, L. (1992). Family functioning in late late life. Journal of Gerontology, 47, S66 – S72. Jorm, A. F., Henderson, S., Scott, R., Mackinnon, A. J., Korten, A. E., & Christensen, H. (1993). The disabled elderly living in the community: Care received from family and formal services. Medical Journal of Australia 158, 383 – 385, 388. Katz, S., Ford, A. B., Moskowitz, R. W., Jackson, B. A., & Jaffe, M. W. (1963). Studies of illness in the aged. The index of Adl: A standardized measure of biological and psychosocial function. Journal of American Medical Association, 185, 914 – 919. Kemper, P. (1992). The use of formal and informal home care by the disabled elderly. Health Services Research, 27, 421 – 451. Langa, K. M., Chernew, M. E., Kabeto, M. U., & Katz, S. J. (2001). The explosion in paid home health care in the 1990s: Who received the additional services? Medical Care, 39, 147 – 157. Larsson, K., & Thorslund, M. (2002). Does gender matter? Differences in patterns of informal support and formal services in a Swedish urban elderly population. Research on Aging, 24(3), 308 – 337. Lingsom, S. (1997). The substitution issue. Care policies and their consequences for family care. Nova-Report, vol. 6. Oslo: Norwegian Social Research. Logan, J. R., & Spitze, G. (1994). Informal support and the use of formal services by older Americans. Journal of Gerontology, 49, S25 – S34. Millar, J., & Warman, A. (1996). Family obligations in Europe London: Family Policy Studies Centre. Morrissey, S. (1998). Resources and characteristics of elderly women who live alone. Health Care for Women International, 19, 411 – 421. OECD (1996). Caring for frail elderly people. Policies in evolution. Social Policy Studies, vol. 19. Paris: OECD. Penning, M. J. (2002). Hydra revisited: Substituting formal for self- and informal in-home care among older adults with disabilities. Gerontologist, 42(1), 4 – 16. Rice, S. (1989). Single, older childless women: Differences between never-married and widowed women in life satisfaction and social support. Journal of Gerontological Social Work, 13, 35 – 47.

244

K. Larsson, M. Silverstein / Journal of Aging Studies 18 (2004) 231–244

Romøren, T. I. (2001). Den fjerde alderen: Funktionstap, familieomsorg og tjenstebruk hos mennesker over 80 a˚r [The fourth age: Disability, family care, and use of services among people over 80 years] Oslo: Gyldendal. Rubinstein, R. L., Alexander, B. B., Goodman, M., & Luborsky, M. (1991). Key relationships of never married, childless older women: A cultural analysis. Journal of Gerontology, 46, S270 – S277. Sipila¨, J. (Ed.) (1997). Social care services: The key to the Scandinavian welfare model Avebury: Ashgate. Statistics Sweden (1989). Statistical yearbook of Sweden Stockholm: Statistics Sweden. Statistics Sweden (1993). Levnadsfo¨rha˚llanden. Pensiona¨rer 1980 – 1989 [Living conditions. Senior citizens] Stockholm: Statistics Sweden. Statistics Sweden (1999a). Unpublished data from a nationally representative survey, hek, about income distribution Stockholm: Statistics Sweden. Statistics Sweden (1999b). Befolkningsutvecklingen under 250 a˚r. Historisk statistik fo¨r Sverige [Population changes during 250 years. Historical statistics for Sweden]. vol. 1999:2. Stockholm: Statistics Sweden. Sundstro¨m, G. (1994a). Care by families: An overview of trends. In P. Hennessy (Ed.), Caring for frail elderly people. New directions in care (pp. 15 – 55). Paris: OECD. ¨ ldre Da’r [At home in old age]. A¨delutva¨rderingen, vol. 94:17. Stockholm: National Sundstro¨m, G. (1994b). Hemma Pa˚ A Board of Health and Welfare. Szebehely, M. (1998a). Changing divisions of carework: Caring for children and frail elderly people in Sweden. In J. Lewis (Ed.), Gender, social care and welfare state restructuring in Europe (pp. 257 – 283). Aldershot: Ashgate. Szebehely, M. (1998b). Hja¨lp i hemmet i nedska¨rningstid-hemtja¨nstens och anho¨rigas insatser fo¨r gamla kvinnor och ma¨n [Practical assistance at home in times of cut-backs: Home-help services and family contributions for older women and men]. In A. Sandquist (Ed.), A˚t var och en efter behov (pp. 93 – 179). Stockholm: Swedish National Association of Local Authorities. Szebehely, M. (1999). Omsorgsarbetets olika former-nya klasskillnader och gamla ko¨nsmo¨nster i a¨ldreomsorgen [Changing forms of care work: New class distinctions and old gender patterns in care for the elderly]. Sociologisk Forskning, 1, 7 – 31. Szebehely, M., Fritzell, J., & Lundberg, O. (2001). Funktionshinder och va¨lfa¨rd [Disability and welfare] Stockholm: Ministry of Health and Social Affairs. Tennstedt, S., Harrow, B., & Crawford, S. (1996). Informal care vs. formal services: Changes in patterns of care over time. Journal of Aging and Social Policy, 7(3 – 4), 71 – 91. Wagner, M., Schu¨tze, Y., & Lang, F. R. (1999). Social relationships in old age. In P. B. Baltes, & K. U. Mayer (Eds.), The Berlin aging study. Aging from 70 to 100 (pp. 282 – 301). New York: Cambridge University Press. Walker, A., & Maltby, T. (1997). Ageing Europe Buckingham: Open University Press. Wenger, C. G., Scott, A., & Patterson, N. (2000). How important is parenthood? Childlessness and support in old age in England. Ageing and Society, 20, 161 – 182. Wu, Z., & Pollard, M. S. (1998). Social support among unmarried childless elderly persons. Journal of Gerontology, 53B, S324 – S335.