Results
Descriptives
We observed around 215,000 transitions to LTC, corresponding to around 26.3% of individuals and 5.4% of the total person-years. In the subanalyses of institutionalized care, such transfers represented 3.8% of the total person-years (
N = 176,254). Table
2 provides detailed descriptive statistics on socio-demographic features of older adults, partners and children, as well as characteristics of LTC transitions. Percentage distributions are shown in total, and separately for men and women.
The number of women and men was similar in the full sample. The shares were similar also in terms of person-years of observations. The age structure was similar across gender, and two-thirds of the observations were younger than 75 years. Most were partnered, but women were less likely than men to have a partner, primarily as a result of widowhood. The majority relied on pensions for their livelihood, albeit some also contributed in the labor force. Fewer women than men held a higher education. The share with partners who received LTC was similar across gender. Fewer women than men were childless, and women were also more likely to have children living within 10 km (64 vs 60%). Furthermore, most older adults had a minimum of one child with either a partner or a high education. At the same time, quite a few had a child in poor health, whereas it was less common to have a child outside the labor force or on social assistance benefits. In total, almost 70% of older adults had at least one advantaged child.
In terms of LTC uptake, the use of home health care was most common. The patterns of use were a bit different across gender, and whereas the use of practical assistance, home health care and ‘other services’ was most common among women, men were more likely to use institutionalized care. Additional file
1 confirms the well-established associations between partnership, parenthood, higher education, higher income and immigrant status as deterrents for LTC transitions.
Modeled results
Table
3 portrays transitions into LTC, examining the relative importance of partners’ and adult children’s caregiving potential based on their presence, resources and geographical proximity (Model 1) and the more specific risk of transitions into institutionalized care (Model 2). In this latter sample, there is an overweight of women (54%), and a larger share of institutionalizations (3.8%) than what is portrayed in Table
2. Furthermore, the uptake is higher among women (4.2%) than among men (3.2%). Below, the findings for transitions to any uptake and to institutionalized care are discussed in terms of family composition and resources, respectively.
Transitions to LTC: family composition
With regards to the composition of the family network, the effects are broadly in line with our expectations (cf. Table
3). For older men, and in line with Hypothesis 1, the relative risk of transitioning into LTC is highest among those with no partner or adult children (i.e. the reference category). For women, the risk is highest for those who are not partnered but have a non-advantaged child living far away (OR = 1.05, CI = 1.01–1.08). The lower bound of the 95% CI for this group was, however, just 1.01, suggesting little substantive difference in risk to the reference category of older women with no partner or adult children. The risks of transitioning into institutionalized care follow a similar pattern to those observed for LTC transitions. Indeed, in line with Hypothesis 2, both unpartnered, childless older men and women had higher risks of transitioning into institutionalized care than partnered older persons and those with children. Interestingly, and somewhat counter to previous findings, we find unpartnered older men with children to have generally lower risks of transitioning into LTC than equivalent older women. For transitions to institutionalized care, the differences between unpartnered men and women with children are less pronounced.
Transitions to LTC: family resources
From the perspective of family resources, and in line with Hypothesis 3, older persons with both an advantaged partner (i.e., employed, degree-level education, above median income, not using LTC) and an advantaged child (i.e., degree-level education) living nearby are least likely to transition into LTC (male sample OR = 0.34, CI = 0.32–0.37; female sample OR = 0.31, CI = 0.28–0.33). It appears that the resourcefulness of partners matters more than the characteristics and proximity of adult children, although the latter still matters. As was suggested in Hypothesis 4, having an advantaged partner and no adult children is associated with considerably lower risks (male sample OR = 0.41, CI = 0.38–0.48; female sample OR = 0.38, CI = 0.31–0.46) of transitioning into LTC than having an advantaged child living nearby but no partner (male sample OR = 0.86, CI = 0.82–0.89; female sample OR = 0.90, CI = 0.87–0.93). In line with Hypothesis 5, in the absence of any partner, having an advantaged child living nearby is associated with lower risks (male sample OR = 0.86, CI = 0.82–0.89; female sample OR = 0.90, CI = 0.87–0.93) of transitioning into LTC than having a non-advantaged child living nearby (male sample OR = 0.92, CI = 0.89–0.95; female sample OR = 0.95, CI = 0.93–0.98).
Transitions to LTC: gender differences
Figure
1 presents the corresponding average marginal effects for the composite variables (c.f. top panel for transitions into LTC, bottom panel for transitions into institutionalizations only). Although older women are more likely to transition into LTC and institutionalized care than older men, variations in uptake based on differences in family composition and resources are broadly similar across older male and older female samples.
It is worth noting that relatively little variation in the risk of transitioning into LTC emerges from differences in the proximity of adult children. Indeed, comparing across equivalent partnership categories, older men and women with an advantaged child have similar risks of transitioning into LTC regardless of if the advantaged child lives nearby or far away (see Fig.
1). The same is broadly true for older men and women in equivalent partnership categories with non-advantaged children, with the possible exception being among older single women and older women with non-advantaged partners. For these two groups, the presence of an (advantaged or non-advantaged) adult child living nearby is associated with slightly lower risks of transitioning into LTC than is the case when the (advantaged or non-advantaged) adult child lives far away. The overall trends for institutionalizations are very similar to those observed for any LTC uptake (c.f. lower and upper panels in Fig.
1). Older men and women with partners and children who are advantaged have the lowest risk of transitioning into institutions, and most of the influence of adult children on these risks appears to emerge from their relative resources (i.e., educational attainment) rather than their relative proximity.
Discussion
Drawing on large scale and uniquely detailed population, socio-economic and municipal LTC register data, the current study examined the extent to which transitions into LTC among older men and women differed according to the presence and caregiving potential of partners and children.
Our results offer broad support to the expectations outlined in hypotheses 1–5. Few studies exist that account for the role played by family members in the uptake of LTC in general, but our findings corroborate those observed in Hayward et al. [
27] and Døhl et al. [
33], who report that older persons who live alone use more hours of formal home care than those who do not live alone. Indeed, the relative risk of transitioning into LTC was found to be highest among older persons with no partner or adult children (H1). Likewise, both unpartnered, childless older men and women had higher risks of transitioning into institutionalized care than partnered older persons and those with children (H2). The higher risk of transitioning into more extensive services, such as institutionalized care, among older persons with no partner or adult children is in line with the findings of others [
17,
18,
34].
Regarding the resources of family members, older persons with both an advantaged partner (i.e., employed, degree-level education, above median income, not using LTC) and an advantaged child (i.e., degree-level education) living nearby are least likely to transition into LTC (H3). Moreover, it appears that the resourcefulness of partners matters more than the characteristics and proximity of adult children. That is, having an advantaged partner and no adult children was associated with considerably lower risks of transitioning into LTC than having an advantaged child living nearby but no partner (H4). With that said, the characteristics of adult children still appear to matter. Indeed, in the absence of any partner, having an advantaged child living nearby is associated with lower risks of transitioning into LTC than having a non-advantaged child living nearby. Previous research suggests that partners are preferred caregivers and companions, but children tend to step up when partners are unavailable or unable to provide informal care [
46]. Our research adds to this by suggesting that it is not just the presence of partners and adult children that matters for transitions into formal LTC, but also their relative socio-economic resources.
Past research has emphasized the importance of geographical proximity in facilitating more frequent and better-quality contact, care and support exchange [
42,
43]. From this perspective, we might have expected to see lower risks of transitioning into LTC when older people have adult children living nearby. Our results are somewhat mixed from this perspective. Although we find slightly lower risks of transitioning into LTC when single older women or those with non-advantaged partners have an adult child living nearby, which corroborates previous research [
19], the broader picture suggests that the socio-economic resources of adult children matter more than their geographical proximity. Indeed, if we compare across equivalent partnership categories, the protective effect of having an advantaged child is the same regardless of if they live nearby or far away from the older person.
With regards to gender, previous research has offered rather mixed results and we refrained from forming any solid gender-related hypotheses. Previous research has shown husbands to receive more support from their spouses than wives [
29,
30]. In this regard, we could have expected older men to enjoy greater benefits from being partnered in terms of avoiding transitions into formal LTC, and perhaps especially when their partners are advantaged. Our results however do not support this, as we observed hardly any differences between men and women with advantaged partners. Nonetheless, men who had partners who were not advantaged were less likely to use LTC than equivalent women. Whether this is because female partners are more family-oriented and thus more likely to provide informal care or less able to assert their right to formal care, cannot be assessed with our data but should be explored in future studies. Among unpartnered older persons, women were more likely to transition into LTC than men.
Regarding gender and the role of adult children, research by Artamonova et al. [
19] observed that the presence of nearby children had a greater effect in reducing the risk of institutionalization among mothers than fathers, perhaps because fathers tend to receive less support from their adult children than mothers [
7,
14,
31]. In specific instances our research is in agreement. For instance, we observed larger reductions in risks associated with closer proximity of children for single older women and those with non-advantaged partners, as compared to older men in these partnership categories. In contrast, however, unpartnered older men with children appear to have generally lower risks of transitioning into LTC than equivalent older women.
Taken together, our findings suggest that available familial support, proxied by the presence and resources of family members, is considered in the allocation of LTC in Norway. Having resourceful partners and adult children is associated with fewer transitions into formal LTC than is the case when older persons have no partner or children or partners and children with non-advantaged characteristics. Had we found that older persons with resourceful family members had a higher uptake, it could have implied that resourceful family members are offered, or (successfully) push for, more intensive formal services. Our data do not, however, permit more detailed conclusions about the role of resourceful family members in modifying older persons’ care needs and their ability to navigate healthcare systems. Municipal out-patient settings are becoming increasingly complex and user-provider communication is key. In this context, we cannot rule out the potential for future inequalities in health provision to emerge based on familial resources, given that some older people can call upon a network of support from well-resourced family members, while others cannot.
A further limitation is that we are unable to account for predisposing factors such as health status and LTC needs. Further research is needed to assess in more detail how combinations of a wider range of individual predisposing and enabling factors, for example as indicated in the framework by Andersen and Newman [
47], affect associations between older persons’ health status, LTC needs and transitions to LTC. Although register data offer us the unique opportunity to study full populations and family networks with sufficient power to estimate effects accurately, rich survey data including subjective and preference-based measures that are likely to impact on transitions into LTC would complement our analysis in this regard.
A different limitation is the selection of variables used to define the advantaged and disadvantaged family networks, with implications for the interpretation and relevance of our findings for the practice spheres. Our definitions were largely informed by existing research, but adjustments were made based on empirical findings (cf. Additional file
1). The classification of advantaged children was, for instance, based solely on education, which was the only child characteristic associated with a reduced risk of transition to LTC for older men and women. This is perhaps not surprising, since education is associated with health literacy on one’s own behalf as well as that of others [
26]. Furthermore, employment was used as one element to classify an advantaged partner. This specific indicator could be somewhat problematic since employment might have effects which operate in opposite directions on transitions into LTC. For instance, while employment likely indicates a relative advantage in material resources, it also implies a constraint on the potential to provide informal care to a partner. Moreover, most of our sample (and their partners) are not employed due to retirement, and one could question the extent to which such non-employment is a sign of disadvantage.
Although our sample is restricted to older adults with three or fewer children, the results should be broadly generalizable to the full population of older adults in Norway, since large families have become rarer over time [
48]. However, linked to this, it is also possible that our sample is somewhat skewed towards younger ages, since individuals with four or more children are likely to be older than those with fewer children. Subsequently, as transitions to LTC are more frequent among those in the oldest ages, the real transition rates in the full older adult population may be slightly higher than what we have shown here. The extent to which this could influence the association (in terms of magnitude and direction) between LTC uptake and the advantaged family network composite variable is not clear.
Contrary to many other systems worldwide, the public healthcare system in Norway provides universal, highly subsidized diagnosis, treatment and long-term follow-up, including old-age care services, universally [
6]. The associations we find in terms of the presence and resources of family members and formal care uptake may nevertheless be found also in other countries. Should that be confirmed, an important next step is to learn more about the relative importance of the various mechanisms, and particularly the role of resourceful family members in informal care (cf. [
10,
49,
50]). Going forward, it will be important to monitor whether developing commercial (privately funded and provided) care markets will complement public care, or if public care will be disproportionally awarded to those most in need and unable to utilize commercial, privatized care options. Likewise, studies in countries where care policies are more familialised and cultural traditions place a greater emphasis on the family as care providers, might also reveal different patterns to those observed in Norway’s highly universalistic and defamilialised system. Indeed, alternative care systems may be even more conducive to increased inequalities in overall care provision between economically resourceful and less resourceful family networks.
Conclusions
Having resourceful partners and adult children is associated with fewer transitions into formal long-term care services than is the case when older persons have either no partner or children or have partners and children with non-advantaged characteristics. Although we are unable to distinguish between selection and social support mechanisms, our findings suggest that LTC provision in Norway appears to be awarded based on an overall assessment of need, in line with what is mandated by law, but accounting also for the availability of informal care as assessed here in terms of the composition and resources of older persons’ family networks.
Public health and care resources will become increasingly strained as populations continue to age. With upwards trends in the old-age dependency ratio, the female employment rate, the share of single-person households and childlessness, the ability of families to compensate for these increased care demands is extremely questionable [
2,
15]. These broad socio-demographic shifts might also be expected to translate into greater inequalities between older persons in terms of their ability to call upon networks of support from well-resourced family members, with possible implications for the uptake of LTC services in what will be an already strained system. Highly universalistic service provision and defamilialized policies, as seen in Norway, should allow individuals access to formal care relatively independently from their own resources [
51]. The fact that we observe important differences between older persons based on their family composition and relative resourcefulness in the Norwegian context, is thus worth noting. Whether this is the case also in familialized systems with weak state provision and/or high marketisation of care, warrants further research. The role of family networks in the future provision of formal old-age care is expected to become progressively important in the years to come. Inequalities in the health, care and welfare of older persons with and without resourceful family members are likely to increase.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.