Socioeconomic inequality in long-term care

Abstract

In Western societies, the rapid population ageing has led to a drastically increasing demand for long-term care (LTC). In the Netherlands, LTC is not used equally by those with a lower socioeconomic status (SES) and certain socieconomic groups might be disadvantaged. Therefore, the first aim of the present dissertation was to investigate how SES-differences in LTC use have changed over the past decades in the Netherlands, and how these changes can be explained by both individual factors and characteristics of the LTC system. In addition, potential inequalities in LTC use raise the question to what extent they affect the wellbeing of older adults. LTC plays an important role in maintaining the wellbeing of individuals with health impairments, but also leads to an undesirable dependency on caregivers. Therefore, the second aim of this dissertation was to investigate the relationship between LTC use, the subjective evaluation of LTC and psychological wellbeing. The first study investigates how and why SES-inequalities in the use of LTC have changed over time. The findings indicate that they remained similar. However, the SES-gradient in informal care widened over time: Informal care use decreased steeply among higher, but not lower SES-groups. This exacerbation of SES-inequalities persisted even when we accounted for individual factors such as health and partner status. The second study investigates to what extent defamilization as a system-characteristic can explain SES-differences in LTC use in addition to individual factors. The findings indicate that de-familization had a limited direct impact on LTC use: It is associated with less use of privately-paid care, but does not impact informal care use beyond individual characteristics. Formal care, however, was used more by lower compared to higher SES-groups in a de-familized context, but was used less by them when de-familization is limited. Thus, lower levels of de-familization threaten the equitable access to formal care by lower SES-groups. The third study investigates how long-term care trajectories look like in a time of rapid retrenchment of the LTC system for different SES-groups in the Netherlands. Five distinct types of LTC trajectories are identified: No LTC use, privately paid care use, formal care use, informal care use and residential care use. Thus, individuals generally used one main source of LTC throughout their trajectory, yet sometimes mixed with other types of care. Higher SES-groups were more likely to be members of the “privately paid care” group, but otherwise, no SES-differences could be observed. The fourth study investigates how the relationship between LTC use, perceived care sufficiency and psychological wellbeing looks like in 1998, 2008 and 2018. The findings indicate that after taking health and partner status into account, no SES-differences in psychological wellbeing can be observed. There was no negative trend in the association between LTC and wellbeing over the three years of observation. However, perceiving LTC provision as insufficient was consistently associated with worse psychological wellbeing in all time periods. This effect was stronger than that of objective LTC use and highlights the importance of the subjective evaluation of care provision. Conclusion Given the drastic effects of population ageing and increasing LTC demands, the present dissertation highlights that lower SES-groups are less disadvantaged than expected as a high proportion still receives informal or formal care. Furthermore, no SES-group was substantially disadvantaged in their psychological wellbeing, which underlines that they are generally able to adjust to a more limited welfare state. To maintain the wellbeing of older adults from all SES-groups, practitioners and policymakers should take individuals’ subjective evaluation of LTC into account to realize LTC arrangements that are in line with their needs, so that no group of older adults becomes disadvantaged.