Care inequality: care received according to gender, marital status, and socioeconomic status among Korean older adults with disability

Care is not simply about personal preferences, but rather is also about inequalities that penetrate deeply into society. Demographic and socioeconomic factors shape a person’s life experiences long before he or she requires long-term care. Group differences in care behaviors manifest in a variety of ways. Thus, it is necessary to discuss care not only in socioeconomic terms, but also in the context of national, ethnic, and cultural differences [1‐3]. Although many studies corroborate the caregiving profiles, inequalities in the care received by those who need it in specific social and cultural settings is a more complicated issue that requires further analysis empirically.

It is important to consider the impact of both personal and environmental characteristics on a variety of outcomes among persons receiving care [4]. A review of the literature suggests that personal characteristics (e.g., gender, race, marital status, functional status, dementia, and the availability of family members) and environmental characteristics (e.g., availability of formal caregivers, infrastructural investments in nursing homes, insurance systems for long-term care) are important predictors of the receipt of formal and informal care [4‐8]. For example, in the absence of available family members, people are more likely to receive formal assistance [8]. Focusing on psychosocial factors, such as satisfaction of care, is insufficient to understand the care choices of a given population [9].

In Korea, as in other East Asian countries, long-term care policy is still dominated by the Confucian model (i.e., reliance on family caregiving as the main bulwark of long-term care). This is reflected in the low level of investment in long-term care infrastructure (e.g., an informal family caregiver support system including carer allowance, policies governing compatibility of caregiving with work, and a care-giving workforce) the inadequate social security safety net (to enable seniors to live independently of their adult children) [10‐12], and the cultural stigma associated with having one’s parents or spouse cared for by strangers.

Group differences in care behaviors manifest in a variety of ways. Provision of care is typically considered to be a “feminine”’ domain, and much research has examined gender incongruence and role theory in this context [13‐15]. Gender differences in the provision of care, and segregated gender roles in caregiving, are common phenomena in both Western and Eastern countries. However, a more important and difficult problem—how to secure the best care and from whom—faces contemporary older Koreans who experienced gender segregation under the strong patriarchal culture since childhood [16, 17]. An international comparative study of informal caregivers suggested that the proportion of female caregivers was higher in Spain (66.7%) and Korea (64.8%) compared with Denmark (36.9%) and Sweden (35.0%) [18].

The impact of marital status, with respect to access to formal and informal care, has been indicated by community-based studies showing greater rates of family support among married persons [19], or a lower rate of formal care service use among the married [20], as well as gender differences in marital status effect on care use [14]. Previous research also suggests that those without available family members are more likely to receive assistance from formal sources [5].

Children providing care for their older family members have increasingly met with challenges, owing to the strain imposed by widespread job instability, multiple national economic crises, and an increase in women’s social participation. The dearth of available care, synergistically resulting from the dominant Confucian culture and the economic instability of the Korean family unit, may be responsible for the unequal distribution of care resources. The role of the caregiver is increasingly being fulfilled by family members, such as older women, who are already excluded from the labor market [21].

Until recently, most previous research on caregiving has been conducted from the perspective of the unpaid informal caregivers. If we only focus on analyzing unpaid family caregivers, that assumes that all caregivers are intimate care providers [9, 22]. This induces to concerns on methodological individualism [9]. Not all care should be analyzed as results of individual behaviors. To detect inequalities in care more precisely, it is necessary to include a wide range of variables relevant to care, including the gender, marital status, and socioeconomic status of the cared-for person. Any such investigation must go beyond existing research on the nature of care, which to date has focused only on the identity of the major informal caregivers [4‐8] or the prevalence and associated factors of unmet care needs [23]. Research that covers both the imbalance in care resources and inequalities in the care received is needed, including the variables of type of care (formal or informal), care received from a number of sources, the number of hours of care per day and number of days of care per month, and fees paid to caregivers.

This study was conducted to identify the care types and care resources available to older people with disabilities in daily activities, and to investigate whether they vary by gender, marital status, and socioeconomic status. We discuss the inequalities in care present in Korean society, in the context of both a rapidly aging population and a rapidly increasing number of people who need care but are still dependent on their families to provide it, even though family resources are increasingly scarce. This study will help stimulate research on imbalances in care resources, bring more focus to these issues and how they affect different populations.

According to this study of care in South Korea, one-third of disabled older adults do not receive formal or informal care from any source. Both men and women primarily received care from their spouse; in contrast, children more frequently provided assistance to their mothers than their fathers. When a husband was a caregiver, he was more likely to have paid formal services. Men received 4.3 days more care than women per month. Marital status had a great influence on care type and resources. Care deficit was more frequent in men than women, with the rate being highest among older men without a spouse. In terms of socioeconomic status, dependent older people with high household incomes were more likely to receive formal or informal help than those in other income brackets. A difference in the rate of use of paid formal caregivers according to household income was detected in women.

Although studies of older persons living in their own homes suggest that men use informal care services more so than do women (e.g., Wan and Arlingm, 1983) [24] and that women were more likely than men to report unmet need for assistance with household tasks [13], we observed a higher rate of use of both formal and informal services by the women in our cohort. In a Malaysian study, men were also more vulnerable to unmet need [25]. This suggests the importance of examining gender differences in a variety of social contexts to determine the impact of such differences on the receipt of formal and informal care.

According to traditional Korean mores, even health care professionals are restricted in the amount of physical contact they should have with patients of the opposite sex. Older Korean men may be not easy to find caregiver either inside or outside of their family, because of their high dependence on their spouses. Interestingly, primary caregivers for married men could be clearly divided into two types (Fig. 1): those without caregivers or spouses as caregivers. Other types of caregivers were relatively rare compared to women. Older men are reluctant to use care services because they are afraid to receive care from strangers [26]. Individual gender role identity continues to change throughout life. Especially for men, they emphasize only “healthy” characteristics, so if males show signs of passiveness, enervated, and lack of self-confidence, they may be more negative than females. Male sex role negatively affects an individual’s developmental process adaptation as much as female gender roles [27, 28]. In the aspect of care-giving and care-receiving for the elderly, such toxic effects of feminity and masculinity are evident in both men and women.

Average days of care received per month was higher in men than women even under the similar total hours of care received by both men and women (i.e., the intensity of care was the same for both genders). One of possible interpretations of this gender difference concerns task specificity, where, women may be the primary recipients of assistance for specific IADLs, such as using telephone and the public transportation, counting money, and other tasks that do not require close and continuous contact between the caregiver and receiver [4]. Even though we adjusted the ‘care received’ data by health status and functional limitations, we did not consider gender differences in the types of tasks for which help was needed. Self-rated health, number of chronic diseases, ADL and IADL scores, and cognitive functions (as rated by the MMSE) can be assumed to index the need for care to the same extent. The optimal source of assistance for various ADLs and IADLs depends both on the nature of the task and the characteristics of the group or individual providing the help. In the light of task specificity, we can also interpreted that men may have more difficulty in tasks that must be completed every day (for example, preparing meals, cooking, and doing laundry). This study further showed that a combination of care from the spouse and a paid formal source was more frequently seen among the women. This shows that elderly women prefer to use formal care services even if they have a spouse [26, 29]. Male caregivers have difficulty in providing physical care (e.g., for toilet use and bathing) and assistance with housework (e.g., cooking). Physical care might also be resisted by the care recipient. Male caregivers have fewer opportunities to talk to other family members or friends about care-related issues than women, and tend to be more reluctant to share their burden. This is supported that the number of caregivers was higher among women. Studies of older persons living at home suggest that men make greater use of assistance from informal sources, whereas women tend to make greater use of assistance from formal providers, such as paid homemakers and home health aides. But this reflects the longer life expectancy enjoyed by women, such that older men are more likely to have spouses who are still alive, while women are more likely to become widowed and thus be reliant on external help. One previous study showed however, this difference in caregivers according to gender was observed among married couples [29]. Male caregivers are reluctant to perform “feminine jobs” (e.g., cooking, household chores, laundry, etc.) and so are more likely to seek formal help.

A gender difference was also seen in terms of the likelihood of the primary caregivers of the respondents being their children. Children more frequently provided assistance with ADLs/IADLs to their mothers than their fathers. This can be interpreted as showing that women are more dependent on care from their children when they are widowed. Older women are more likely than men to maintain relationships outside of their spouse, such as with their children and close friends [30]. In Korean society, older women not only feel more of an obligation to take care of their children, but must also look after their grandchildren, according to requests from their employed sons and/or daughters [31]. When the mother becomes frail and dependent, support exchanges dependent on a past or anticipated future exchange become more apparent and important [32]. This contradicts the study results of Nishi (2010) claimed that survival “penalty” for older Japanese women are cared for by their daughters-in-law [33]. In this study, Japanese male elders receiving care from daughters-in-law tended to live longer than those receiving care from their spouses. However, paradox gains that women more likely to be widowed so they receive care from daughter-in-law more, while men are fundamentally rare such cases that they receive care from their daughter-in-law. Based on our KLoSA dataset, daughter-in-law as a primary caregiver were only 4 cases (1.1% of total) for older dependent men.

Household income influences patterns of caregiving in this population. The financial resources of a family are closely related to their access to care. There may be few resources available to pay a caregiver, other family members may have disabilities, and an adult family member may need to work and be unable to take on a caregiving role. Indeed, in the highest income level in this study, the likelihood of the major caregivers being other relatives and friends was high, suggesting that the rate of recruitment of informal caregivers might vary by income. A lack of Information on formal help (from long-term care insurance services) may also have affected this trend. No difference was detected in the cost of care, days of care per month, or hours of care per day according to household income. The total amount paid cost to caregivers was not different by household income. This is because care is mostly provided by an informal caregiver, regardless of the cared-for person’s economic situation.

Among the women in our study, the major caregiver was more likely to be a paid formal caregiver when the household income was high. This is an important result, because it suggests that women in the lowest household income level tend not to be cared for primarily by a paid caregiver, although the situation is not the same for men. Older Korean women are highly dependent on their children in economic terms, and tend to adhere to family decisions rather than their own preferences [34]. Sometimes, such women avoid using formal care services to avoid placing any economic burden on their children [18]. According to our analysis, this tendency was more pronounced in the women in low-income households. In addition, the burden imposed by an older family member requiring care is greater in the context of the Confucian culture that older generations were exposed to, which views the necessity of entering a long-term care facility to be the result of the immorality of the children [30, 32]. Older women in Korean culture, fearing that shameful accusations of disobedience might be labeled at their child, might conceal their care requirements or forgo care to ease the burden on their children [26]. For example, the well-known Japanese novel ‘The Ballad of Narayama’ (1956) by Shichirō Fukazawa, and one of the most renowned Noh plays “Ubasute-yama” (literally meaning “Dump the Grandmother Mountain”), were based on observations of this phenomenon throughout East Asian countries. In ancient Korea and Japan, old women in some villages were expected to go into the mountains and starve themselves to death voluntarily to relieve their families of the pressures of caring for them; usually, their husbands were already dead.

Other independent variables that showed significant associations were age, functional status, and self-rated health. As age increases, the number of caregivers increased, and the probability that children were primary caregivers has also increased. Unlike the previous studies which have found association between the educational level and the type and quantity of care received, we could not find association with any dependent variable. The current older generation had fewer opportunities to receive a normal education in their youth, because they were in school or were young adults during the period of Japanese colonialism (1939–1945) and the Korean war (1950–1953). Only about 7% of Korean older adults graduated college or university in 2016 [35]. This homogenous low educational level might induce low association between care receiving outcomes and educational level. Korea launched long-term care insurance for the elderly in 2008, and increased access to home care services and long-term care facilities may have influenced the caregiving and care-receiving rates. However, long-term care insurance is available only for those with a severe disability, such that many care needs of elderly persons must be met by family members. Only 6% of our study population with disabilities had enrolled to national long-term care insurance. It is also notable that more investment was made in the development of facility-based versus home care services: in 2013, 48.2% of long-term care expenses were attributable to home-based care, and 51.8% to institutional care. For the 5-year period from 2009 to 2013, institutional care expenses increased by 8.5%, while home-based care service expenses decreased [36]. In the Korean long-term care insurance program, care allowance is available for family caregivers as salaried type, but the proportion of such claims among all long-term care claims is small (14%), and only half level of payment of formal caregiver is provided to family caregivers [37]. Even with universal long-term care insurance, serious inadequacies and inequities in care remain.

Family resources that have been in charge of informal care are gradually disappearing. Koreans work the longest hours of any Organization for Economic Cooperation and Development (OECD) country: the average Korean worker works 2069 h per year, which is 305 h per year longer than the average—1746 h per year—among the 35 OECD member countries [38]. Those who were still working in the 1990s witnessed many senior employees being laid off during the national economic crisis that occurred under the International Monetary Fund (IMF)-supported economic program, and as a result are concerned about their own job security [39]. The minimum retirement age is gradually decreasing in Korea, and many middle-aged men are seeking to re-enter the workforce or transition to self-employment [40]. Women are also taking up work in middle age to meet the rising costs of private education for their children. In this social context, care for the older adults showed inequality and this care inequality is manifested by various factors. The support policy for informal caregivers is much more needed in the long-term care system. More precise monitoring and more accessible long-term care services is needed so that there are no elderly people who do not receive and neglected the care they need. In order to increase the accessibility of paid formal care to low-income older women, it is necessary to reduce the burden of copayment.

Korea has entered an aged society with 14% of the total population, and GDP is the 12th highest among OECD members of the world in 2018. However, the public social expenditure compared to GDP is 10.4%, which is the lowest among the OECD countries (average 21% of OECD countries). The welfare expenditure of the elderly is only 2.2% of the GDP, which is insufficient compared with the rapid population aging. Ten years have passed since the long-term care insurance system was settled, but still socially and culturally dependent on family-centered care. In the socioeconomic and cultural contexts like Korea, examining the elderly ‘s deficit of care and inequalities in care could give similar messages to countries facing to both aging populations and increasing health disparity during economic development. This study has a policy implication that the long-term care system should be improved to meet the diversity of the older adults and to tighten the care services with customized care plans. It is necessary to strengthen daily support including a meal delivery, laundry or other house chores for older men. Care service should have strategy considering gendered pattern of service acceptance. Although not existing in the Korean long-term care system now, a care coordinating service by case management should be developed urgently. The cost burden of the older Korean women with low economic independence inside their family can be supported through enough information and appropriate counselling by care coordinator or case manager.

The limitations of this study and alternative explanations of the results should be considered. First, this study sample was based on community-dwelling older adults, which limits the generalizability of findings. There are important differences between community and institutional care settings in terms of the care needs and characteristics of individuals, as well as their rate of use of formal and informal care services. Even though the amount of caregiving cost was higher in married people, the difference was not statistically significant in this data. Married elderly might have more information and higher social resource utilizations; however, it needs further study on this relationship with larger sample dataset. In addition, because our analyses were cross-sectional, we are unable to infer any causality regarding the caregiving-related variables. Another limitation of this study was the source of information regarding the personal characteristics of the respondents. Many of the instruments used in this study were self-report measures. Reliance on self-reports, particularly regarding information on functional status, may result in inaccuracies and inconsistencies that limit the reliability of the results. Clinical evaluations of the presence and severity of mental illnesses and disability can be considered in the future research. And data from both caregivers and care recipients are needed to obtain more detailed information about formal and informal care in the context of caregiver–receiver dyads. There is also a need for research encompassing certain facets of unmet care needs that were not covered in the present study. For example, the perception of care and/or other psychological responses such as loneliness might be different from individual characteristics. Research is needed on the extent to which the needs for autonomy and control are met in the elderly, as well as on the factors that predict the likelihood of experiencing an unmet care need. In addition, we did not expand our analysis to older adults’ health and survival outcomes according to care-receiving inequality. Further investigation concerning the unmet care needs of individuals and its long-term health outcome is needed in various long-term care settings. As discussed above, our study did not consider the specific ADLs and IADLs that formal and informal carers helped with. Men and women show differences in dependence for different ADLs and IADLs. It is assumed that members of an individual’s informal social network will be most likely to assist with tasks that do not require close and continual contact, such as shopping and management of finances. However, the consistency of the results was confirmed by the sensitivity analysis comparing results by degrees of ADL and IADL disability.

Unmet care needs were evident among the older men in this study, and this care deficit was greatest in those without a spouse; this may be interpreted as resulting from the gender segregation culture in Korea, which has a particularly large negative influence on elderly men. Household income also affects the likelihood of receiving care; especially, elderly women with a low household income are less likely to receive care primarily from a formal source. We identified inequalities in the care received among our cohort of older adults, and this will become an increasingly serious problem with the continued aging of Korean society. In societies where family care still accounts for a large proportion of all care, as in Korea, masculinity effect on care-receiving should be more considered in the further research as much as feminity of caregiving. Policies promoting a shared-care environment tailored to meet the needs, resources, and care preferences of individuals are needed.