Cared and uncared populations: understanding unmet care needs of older adults (65+) across different social care systems in Europe

Care is a basic need of human beings throughout their life. As anthropological and philosophical work has suggested, care constitutes individuals’ personhood (Buch 2015) and acts in the foundations of society itself (Fisher and Tronto 1990). The most paradoxical aspect of care, however, is that it is usually recognized because of the lack of it. People usually feel they are not receiving enough care when they stop being cared for or when new care needs emerge. Furthermore, demographic dynamics fundamentally impact social care demand and supply (Spijker et al. 2022). For instance, care needs are not the same between populations in the earlier stages of the demographic transition, characterized by high fertility rates where children take up most of the care and the social services, in comparison with those in the fourth stage of the transition that are facing ageing processes and challenges regarding caring for older people (Bom and Stöckel 2021; Rechel et al. 2013).

European countries are forerunners in this ageing process that will affect many countries worldwide (Vaupel and Kistowski 2008). Therefore, Europe is a critical scenario for understanding population ageing effects on care provision, policies, and welfare systems. Previous literature has highlighted that care is affected by its gendered provision, as is mainly given by women (Schmid et al. 2012; Uccheddu et al. 2019; Young and Grundy 2008); the central role played by the family and informal care provision (Pickard et al. 2007; Tennstedt et al. 1993); and new changes in the design and use of social services (Cantor 1991; Davey 2017; Spijker and Zueras 2020).

Some authors have suggested that we are facing a care crisis driven by demographic dynamics leading to population ageing and changes in family trajectories, household units, and social and economic transformations (Pérez Orozco 2021). Discussions about care provision have also underlined how it is affected by policy changes (Pfau-Effinger 2005) and social perceptions about ageing and support that usually shape specific care systems to help people with disabilities and facing limitations in daily life. However, in many societies, some individuals are not receiving the support they need and are facing unmet care needs that can negatively affect their health, well-being, and life expectancy.

In this article, we aim to analyse the unmet care needs experienced by people aged 65 and over within twelve European countries. We examined the socio-demographic characteristics of middle-age and older adults with care needs and estimated the prevalence of unmet care needs in the following social care systems: the Mediterranean, characterized by family-based care provision; the Nordic, where care provision is strongly linked to welfare-state services; the Western, where care provision is articulated between informal and formal care provision, also including the participation of private providers; and, the Eastern, which used to be based on ‘familialist’ care provision but has undergone various transformations since the fall of the Berlin Wall.

We present two types of results: First, the descriptive analysis of the analytical sample focusing on the prevalence of unmet care needs from an absolute approach and the demographic characteristics of those with any of these needs; second, binomial regression models, which illustrate how individuals’ demographic and economic characteristics and health status explain the experience of unmet care needs as well as its relationship with specific social care systems in Europe.

This study aimed to understand the unmet care needs of people aged 65+ from different social care systems in twelve European countries. Results showed that the most vulnerable individuals (with poor health, chronic disease, older age group, and women) are at lower risk of experiencing unmet care needs, rejecting Hypothesis A. This is consistent with previous evidence from England, which suggested that men were at a higher risk of experiencing these (Vlachantoni 2019) and that older people with poor health were more likely to report receiving care (Maplethorpe et al. 2015). These results are probably due to social awareness of the care and social support needed by older people with health problems, indicating the importance of social imaginaries.

In contrast, we observed that people living in countries with Mediterranean social care systems are at a higher risk of having unmet care needs than in other systems, in line with Hypothesis B. These results are indicative of the diverse approaches within social care systems, as well as of social awareness about the urgent care needs required by older adults. Additionally, results show that family-centred systems may face more challenges in meeting individuals’ needs due to its dependence on the availability of family members willing and able to provide care (Tennstedt et al. 1993), and these may be changing as women’s engagement in the labour market increases. For example, a study in Spain showed that the willingness to care for the older family members was lower among women with a high level of education and doing paid work (Zueras et al. 2018). Previous studies have also emphasized that ageing due to demographic changes poses challenges on the availability of informal because of low fertility rates and increases in the percentage of dependent elders who are childless (Spijker and Zueras 2020).

The main contribution of this study is its comparative approach to the analysis of this largely unexplored issue. Our findings show that unmet care needs change depending on the social care systems of the countries where older people live. Despite previous research has shown differences in social care systems between regions and countries (Ariaans et al. 2021; Dunatchik et al. 2019; Pfau-Effinger 2005), to our knowledge this is the first study comparing unmet care needs between different social care systems. Results spotlighted that the demographic characteristics like the age group and gender, were associated with unmet care needs, i.e., a higher risk was found for men than women and for younger than older age groups. In line with previous research, findings showed that the type of limitation explained the risk of facing unmet care needs, in our results individuals with only mobility limitations faced lower risk, meanwhile others have shown that the chance of suffer them is more strongly associated to ADL (Vlachantoni 2019). Living with other people in the household is associated with a lower risk, which may indicate that care is being provided by someone other than the couple, although previous research has shown that partners are still the main informal care providers (Kaschowitz and Brandt 2017; Uccheddu et al. 2019; Young and Grundy 2008).

In addition, people who live with someone other than a partner (compared with living alone or with a partner with or without another person) and who are neither owners nor tenants of the house in which they live are less likely to have unmet care needs. Previous evidence on the subject comes from England, where it was estimated that about 55% of older individuals with ADL, 24% of people with an IADL difficulty, and 80% of people with a mobility limitation have unmet care needs based on ELSA (Vlachantoni 2019). In contrast, this study found lower percentages of unmet care needs by each type of limitation, even for the population with only mobility difficulties, for whom the highest percentage was found in Greece. Nevertheless, these results are not fully comparable as the estimation comes from similar but not equivalent questions and filters in the analysed surveys (Ashokkumar et al. 2012).

However, further research about the relationship between these unmet needs and different social care systems is still needed; through the sensitivity check of the models, it was visible that there are differences within the groups of Nordic and Eastern countries. For instance, the results for Sweden and Poland may be explained by recent changes in care policies in these two countries. In the Swedish case, changes during the last three decades have been orientated towards enhancing voluntary choices and individuals’ involvement in their own care; however, these measures are taking place in a context where the second demographic transition may affect the availability of care provision by children and partners (Edlund and Lövgren 2022; Moberg 2021). Meanwhile, Poland’s history is characterized by an essential differentiation between hospice-palliative care, which emerged in the seventh decade of the last century, and home care (Krakowiak 2020), gaps between these two ways of care provision may reflect the lower quality of informal care provided in Poland when compared to the other countries (Dobrzyn-Matusiak et al. 2014).

In any case, this study has some limitations related to the sample and the measure that we used. The most relevant limitation is posed by the assumption behind measuring unmet care needs, which supposes that individuals facing any limitation, in fact, need help, even though some of them may be able to cope with these limitations without the support of a caregiver. Another limitation comes from the small sample size and lack of representativeness of the analysis by countries, which is why we used groups of countries based on theoretical typologies of social care systems, despite there are internal differences between the countries that are part of the Nordic and the Eastern social care systems. How to construct typologies of social care systems is still an ongoing debate. Previous evidence says that there may be more appropriate criteria than a regional approach (Ariaans et al. 2021; Damiani et al. 2011). Nevertheless, this study based its theoretical typology on previous work about welfare state configuration (Pfau-Effinger 2005).

Some relevant aspects come from using SHARE data to measure unmet care needs. While studies based on the ELSA usually ask if someone facing a limitation is receiving the help needed for performing a specific activity (e.g., bathing or eating), the SHARE asks this after all the questions about limitations for performing these activities are asked, which makes it impossible to know the specific activities for which individuals are facing these unmet needs. Likewise, we cannot truly know if the individual needs help to cope with the limitations that s/he is facing. This problem can only be solved by adding a new question in the survey that directly ask if the person needs care from other to perform these activities.³ Still, the main value of this study lies in its comparative nature, which makes it possible to provide an empirical estimate of unmet care needs in 12 countries and to gain insights into the differences between social care systems at the regional level, which may be useful for policy makers interested in care demand and provision in ageing societies.

Care provision within ageing scenarios make front of challenges in assuring people’s rights and well-being. This article suggests that individuals from older age groups and those in poorer health and worse functioning conditions face more negligible risks of experiencing unmet care needs. This scenario could indicate that social care systems meet the most pressuring needs: they are reactive but not preventive because they do not consider the future effects of unmet care needs on individuals’ morbidity, well-being, and physical and mental health. Also, living arrangements respond to higher needs of care and are effective in supplying at least some of it; in spite of that, whether this is sufficient, or the most appropriate care, should also be a matter of investigation. Care is a basic need that changes through life courses and poses challenges to ageing populations, particularly in those societies based on family-centred care provision. More information and research are needed to examine current and future responses to the actual care demands to leave no one behind.