Gerdt Sundström

State provision down, offspring's up : the reverse substitution of old-age care in Sweden

Substitution among the providers of old-age care has usually meant a process whereby the state ‘takes over’ what families used to do, but during the 1980s and 1990s, both home help and institutional care were cut back substantially in Sweden as elsewhere. Comparable, nationally representative surveys in Sweden of the provision of care for older people living in the community enable analysis of the effects of these cutbacks on the sources and patterns of care. It emerges that increased inputs from families match the decline of public services, that is, a ‘reverse’ substitution has recently been taking place. Local studies, of older people who have been followed over time as the provision of home help has changed, support these conclusions. Of the increased informal care, most has been provided by daughters, but sons have also contributed. A problematic aspect of these shifting patterns of care is that an increasing number of family carers with increasingly heavy care commitments are now without formal or informal support, whereas in the recent past many could expect their responsibilities to be shared with the state. The evidence from this study also calls into question common metaphors and assumptions about the assumed interdependence between informal care and public services for older people, and challenges the so-called substitution thesis.

Balancing family and state care: neither, either or both? The case of Sweden

Old-age care has frequently been conceptualised as being either family-based or publicly-provided. This article analyses the overlap in provision from the two sources and their relationship in the Swedish welfare state. Many older people and their carers rely on both sources of help rather than on just one, and prefer to do so. The empirical evidence on patterns of care in Sweden supports a joint family-state conceptualisation of care. Its realisation may depend on general coverage rates of public services and the efficient targeting of frail elderly people who live alone. Most older people in need of care rely on help only from their family, but many are helped by both the family and the state, particularly those with the greatest needs. Dynamic concepts like ‘substitution’ and ‘complementarity’ are hard to apply in cross-sectional studies: there may be complementarity in individual cases but long-term substitution or its reversal in successive cohorts. Yet again, both sources of care may increase simultaneously in individual cases. The need for care varies considerably among Swedish municipalities, with implications for the levels of both public services and family support. High coverage rates of the public services may facilitate and support family care.

Needs and care of older people living at home in Iceland

Background: The Icelandic old-age care system is universal and the official goal is to support older people live independently for as long as possible. The aim of this study is to analyse living conditions and use of formal and informal care of older people in Iceland. Methods: The results are based on the new study ICEOLD, a telephone survey which included questions on social network, health, activities of daily living, and received support from the community and/or from relatives, neighbours, and friends. Results: Almost half of the sample (47%) receives some kind of care, with 27% of them receiving only informal care, which is understood to mean that informal care is of great importance and families are the main providers of help. For hypothetical future long-term care, older people wish to be cared for in their homes, but those already in need of assistance prefer to be cared for in institutions. Discussion: Caring relatives are the main providers of support to older people in their homes and it is important to provide them with suitable formal support when the care responsibility increases. Conclusions: As the care system in Iceland is now under reconstruction, the important contribution of informal carers must be recognised and taken into account when planning the care of older people.

Unequal but equitable: an analysis of variations in old-age care in Sweden

This study aimed to investigate whether contraction in services has led to inequitable service levels or simply large local variations. Previous attempts to explain service variations with aggregate, municipal level data have failed. We link representative Swedish data from 3,267 individuals aged 65 and older in 2002–2003 with coverage rates of public Home Help services in the 288 municipalities in which they reside. What past attempts have masked is that needs also vary substantially between municipalities; needs being defined as old people who live alone and need help with their activities of daily living (ADL). Once these local individual level variations are incorporated, municipal differences in public Home Help coverage largely vanish. Multivariate analyses confirm that advanced age, inability to perform ADL and solitary living are the major determinants of Home Help use. Variations in local supply have no association with individual use of public Home Help. These services are unequal but hence yet deemed to be reasonably equitable.

Incidence and risk factors for depression and anxiety disorders: results from a 34-year longitudinal Swedish cohort study.

This study is based on a total cohort (N = 192) of people born in 1902 and 1903 and living in southern Sweden. Subjects were assessed at baseline when 67 years of age and on eight further occasions over 34 years or until death. The participation rate in the nine examinations ranged from 78–100%. Interviews, psychological tests, and medical examinations were used as well as information on medical diagnoses from primary health care records and hospital records. The cumulative probability for the development of clinical depression during the follow-up was 8% and for anxiety 6%. The incidence rate for depression and for anxiety was highest during the period 67–81 years. Persons with poor financial status were more likely to be diagnosed with depression but no significant risk factor for anxiety was found. Only 14% developed depression and anxiety during the follow-up period, females more often than men. The strongest risk factors for the development of depression were perceived economic problems.

The effects of rationing home-help services in Spain and Sweden: a comparative analysis

In both Spain and Sweden the most important public support for older people that is provided in their own homes are home-help services. In Sweden, these programmes were expanded in years of economic growth but recently have radically declined. Spain still strives to expand them in spite of financial problems. Both countries ration these services but in different ways. Spain provides relatively few hours of help with household tasks, primarily to poor old people. At present, one to two per cent of the 65-plus population is covered. Local government is still trying to reach more people to relieve pressure on limited institutional care. Sweden continues to cut down the service from the present coverage of nine per cent of the 65-plus population. It is focusing on the oldest and frailest people of all social classes who live alone. It is gradually being transformed into home health care. Institutional care has not been cut back to the same degree. Spain uses strict needs assessments and eligibility criteria to target clients. Sweden has sharpened its needs assessments and raised fees to discourage users with lesser needs.

The changing balance of government and family in care for the elderly in Sweden and other European countries

Patterns of care for the elderly have changed dramatically in Sweden over the post‐war years, and new trends have emerged in the last decade. Relatively fewer elderly are institutionalised or use public Home Help and more are helped by family members. The family structure of the elderly in Sweden is more favourable today than before for providing help: more elders are married (or cohabit) and stay married longer and more of them have children and other kin than previously. Although old parents and their offspring very seldom live together, they often do not live far apart. Social services increasingly target elders who are short on kin, very frail and live alone, a pattern that is common in European countries. Both carers and cared‐for elderly persons want shared responsibility, that state and family together provide for frail elders. Paradoxically, more elders are cared for longer and more by their families, but eventually also a larger proportion of elders than before use public services; in particular, more elderly persons now use institutional care for some period before the end of their life than previously. This paper draws on evidence across 50 years of shifting patterns in Swedish old age care and makes comparisons with living arrangements and patterns of care in several western European countries.

Home help services in Sweden: responsiveness to changing demographics and needs

Decreases in Swedish home help services have not resulted in increased rates of unmet need. To understand these changes, we identified predictors of home help services and rates of institutional care and how these effects changed over time using longitudinal data (1994–2000) from 286 Swedish municipalities. Outcomes were home help coverage rates, intensity of home help per recipient, and rates of institutional living. Predictors reflected availability and need for services. Services decreased over time, but not uniformly. Coverage rates were higher in municipalities with a greater proportion of population 65 and older and greater proportion of unmarried elders. Decreases in coverage rates were greater in municipalities with a higher proportion of unmarried elders, greater ratio of older women to men, with more home help staff workers, and more expensive services. Home help was provided more intensively in municipalities with higher median incomes, higher unemployment rates and municipalities spending more per inhabitant on child care. Decreases in intensity were greater in municipalities with lower proportions of unmarried elders and fewer home help staff workers. Rates of institutional living were higher in municipalities that spent more on old age services and with a greater proportion of unmarried elders. Decreases in institutionalization were greater in municipalities with a greater proportion of unmarried elders and lower ratio of older women to men. Variability in how municipalities responded to these changes may explain continued low rates of unmet need. Results are consistent with both increased efficiency and more effective targeting, but cannot capture service quality.

Health and social networks as predictors of survival in old age

A random sample of non-institutionalised Swedish elderly (n = 1,062; aged 67+) were interviewed in 1954. All of them are now deceased; their interview data have been completed with dates of death and causes of death. A measure of survival capacity has been used, based on the endured total mortality risk from examination until death, according to life tables from Statistics Sweden. Survival analyses were performed by gender on the whole sample and on a number of sub-samples defined by age, health-status, social class, and marital status at examination. Physical health status and activity patterns had the overall most significant effects on subsequent longevity. Among the youngest elderly mental health was, however, even more important as a predictor of survival than was physical health. The impact of most other factors like social networks, mobility, and religiosity was of less magnitude, but their importance varied among sub-samples. Most of the variation in survival, however, remains unexplained.

A Haven in a Heartless World? : Living with Parents in Sweden and the United States, 1880-1982

A Haven in a Heartless World? : Living with Parents in Sweden and the United States, 1880-1982