Measuring the overall strain of caregiving: a multidimensional approach

1. Measuring the overall strain of caregiving: a multidimensional approach Jiweon Jun, University of Toronto ItoPeng, University of Toronto Ki-Soo Eun, Seoul National University Photo by rawpixel.com

2. The Hardest, yet the Most Rewarding Job in the world… Jobdescription • Lift up to 75 pounds • Standing up almost all the time • Working from 135 to unlimited hours per week • To be on call at all times • Knowledge in medicine, finance and culinary arts necessary • No vacations • Can eat, only after the associate have eaten • The work load goes up on Thanksgiving, Christmas, New Year’s and other holidays • Operate on little to no sleep. • Salary = $0, no medical, dental benefit (source: youtube ad. American greetings) Caregiving • One of the most important forms of human work that sustains our existence. • Often challenging and strenuous

3. “The Hidden Patient”(Fengler and Goodrich, 1979) • Many informal caregivers suffer negative physical, emotional, social outcomes • …at risk of losing their own health and well-being • Empirical measurements of care burden (consequences) are important • To find ways to reduce negative consequences of caregiving, we need to identify: • in which areas caregivers experience strain • who are more likely to be at risk • what may be potential buffers for caregiving strain We do this by building the measurement for the Multidimensional Care Strain

4. Multidimensionality of the Caregiver Strain • The consequences/burden of caregiving are multidimensional. • If a caregiver experiences burden from multiple dimensions at the same time, he/she may find it more challenging. • We aim to build a multidimensional measure that assesses the overall strain of caregiving

5. Purpose of the Research • Explorethe strain of caregivers from a multidimensional perspective • In doing so: • Develop a multidimensional summary measure that can measure the level of overall burden for individual caregivers • Conduct Exploratory Analyses • Identify caregivers who are “Multidimensionally strained” (i.e. heavily burdened), and see how the distribution differs across various characteristics • Identify dimensions that most caregivers experience strain – to see “how” caregivers are strained • Explore which variables (conditions) are associated with being multidimensionally strained • Examine what may be potential buffers for caregiving strain (Formal, informal support, and Appreciation) • Open up a discussion about dimensions that are important for understanding caregiving strain, how multidimensional care strain can be measured

6. Construction ofthe Multidimensional Care Strain Measurements Previous Studies, Methodology, and Dimensions & indicators

7. Measuring Caregiver Strains

8. Example of traditional measurement: Expanded Caregiver Strain Index (it just sums up the total score)

9. A Brief Introduction of the Methodology • The Alkire-Foster Method (AF Method) in multidimensional poverty research • A threshold based, counting approach, measuring overall deprivations • Example of AFMethod • A person is classified to be “multidimensionally poor” when she/heexperience deprivation (not meeting the cut-offs) in more than 4 indicators at the same time (this is just a simplified example) • In this example, Tom and Emily are identified as multidimensionally poor.

10. Identifying the Multidimensionally Strained • Identify the relevant care strain dimensions to consider • Select indicators that measure each dimension and provide weight • in this case, we applied equal weight for each dimension, and indicators within a dimension are also given equal weight (nested weight). • The total sum of weight is 1. • Examine whether caregivers meet the cut-off points in each indicators • Set the overall cut-off point for the multidimensionally strained (k=x) • Identify caregivers who fail to meet the cut-off points in x% of the weighted indicators as the multidimensionally strained

11. Dimensions and Indicators for the Multidimensional Care Strain Index Psychological

13. Empirical Application Data and Sample, Unidimensional Analysis, Multidimensional Analysis

14. Empirical Application - Data and Sample • Survey of Eldercare and Childcare in Korea, 2018 • Collected as a part of Care Work and the Economy Project • 501 family caregivers who take care of an elderly person aged 65+ • Only the caregivers who consider themselves as the main caregiver were included • Who either live with the elderly or who visits their elderly care recipients at least three time a week providing a minimum 2 hours of care per visit • Includes 77 male caregivers • 500 mothers who are taking care of children below the age of 10 as the main caregivers

16. % of caregivers classified as multidimensionally strained according to different overall cut off points The overall threshold for the multidimensionally strained as k=40, a caregiver is strained if she/he suffers strain in at least 40% of the weighted indicators 44% are considered as Multidimensionally Strained

17. What can they Reveal? :Multidimensional Care Strain Measurements • The Multidimensionally Strained, H: the percentage of caregivers who are multidimensionally strained • The Average Strain Score, A: the intensity of strain that multidimensionally strained caregivers suffer. • The MSCI (Multidimensional Care Strain Index): the level of the overall strain for the group (MSCI=H X A)

18. MCS measures, Caregivers Engaged in Eldercare

19. MCS measures, Caregivers Engaged in Childcare

20. The Incidence of the multidimensionally strained by sub groups, some examples

21. Example: The percentage contribution of each indicator to the overall level of the multidimensional care strain, by age of the child • 0-2 years: physical dimension is the most problematic • As the age increases, the contributions from… • physical & daily life constraints(-) • the relational and financial strain (+) • stress indicator relatively stable across the agegroup

22. Determinants of Being Multidimensionally Strained : Results from Multivariate Analysis • Controlling for other factors, the likelihood of being multidimensionally strained….. • was associated with total hours spent on care: the longer the hours spent, the more likely to be multidimensionally strained • more dependent on the characteristic of care recipients (e.g., dementia, age of the child), rather than the individual characteristics of the caregiver such as age and gender (not statistically significant). In particular, for the childcare, the age of the child was the most influential variable (the odds were 5 times greater for the youngest child group)

23. Determinants of Being Multidimensionally Strained : Results from Multivariate Analysis • Controlling for other factors, the likelihood of being multidimensionally strained….. • was inversely associated with the level of household income, implying that not having financial resources mattered for the added strain (but only significant for eldercare) • living arrangement (elderly) and the presence of other child below 10 was not significant after controlling for other factors

24. The Effect of Challenging/Unfavorable Care Situation on the Likelihood of Being Multidimensionally Strained • The likelihood of experiencing multidimensional strain was increased when • Having meals with an interruption during care • Caregiving requires multitasking • Required constant monitoring of the care recipient (only significant for childcare)

25. The Effect of Formal Support • Tested whether formal, informal support and being genuinely appreciated by other family members can be buffers for caregiving strain • Contrary to our expectation, having formal supports (measured by the use of external care service) increased the odds of multidimensional care strain, in case of the eldercare • The effect disappeared when controlled for whether the care recipient has dementia

26. The Effect of Formal Support • Use of external care service – maybe a proxy for the severity of the condition, rather than identified as buffer • The use of care service is limited in Korea, and allowed only to the elderly who meets the qualifications. So caregivers with greater strain are more likely to use the service • For childcare, having formal support indeed decreased the odds, but again, the effect disappeared once the age of the child was controlled (the use of service is also structured by age)

27. The Effect of Informal Support • Having financial support from other family members for caregiving were also associated with the increased likelihood of being multidimensionally strained • Again, it may suggest that caregivers who receive financial support from family members are under greater strain, therefore family members are more likely to offer financial support when the main caregiver is in greater need • However, Being satisfied with the share of care work with other family members actually reduced the likelihood of being multidimensionally strained, as expected

28. The effect of feeling genuinely appreciated (Eldercare) • Feeing genuinely appreciated by family members about care work significantly reduced the odds of being multidimensionally strained by 47% compared to feeling not at all or superficially appreciated, controlling for all other factors including the care situation and support related variables • It is interesting that people actually distinguish genuine and superficial appreciation • 70% of caregivers answered they felt genuinely appreciated • 28% answered other family members were just pretending to or being superficially appreciative of their work • Only 2% of the respondents answered that feeling not being appreciated at all (so in the analysis we combined this with the superficially appreciate category) • Despite all the hardship, a genuine appreciation can actually help relieve some of the strains

29. Summary and Conclusion • Developed a multidimensional measure of care strain that can be applied to both childcare and eldercare • Demonstrated that the multidimensional care strain is associated with care recipient’s condition & the situation under which the care is being provided, rather than caregiver’s individual characteristics • Found out that the use of external care service and financial help from the family were associated with the increased likelihood of multidimensional strain • these can be a proxy for the severity, implying that the formal support in Korea is insufficient • Being genuinely appreciated matters!

30. Summary and Conclusion • Policy Implication • identify target group (caregivers with multidimensional strains) • Identify target area – development of practical support programs for caregiver, considering the importance of appreciation and care condition • As an exploratory work, we hope to open up the discussion • e.g., Which dimensions are important, how much weight should be given, • e.g., What about the overall threshold of 40% - is it reasonable? • Next step • Also look at “Heavily Strained” “Strained” “Lightly Strained” • The relationship between the well-being and the multidimensional care strain – whether being multidimensionally strained are actually negative for well-being (test of the measurement)

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