The organisation of care for elderly people or individuals with functional diversity is one of the main challenges faced by western societies at the beginning of the 21st century. The “crisis of care” has intensified as women have progressively moved into the paid labour force and as fertility rates decrease and life expectancy increases in many countries. These ageing societies have resulted in heavy pressures on families and also on welfare state regimes.1

The provision of care varies across Europe according to labour markets and welfare state regimes. Mediterranean countries form a distinctive cluster where the management of care is delegated almost entirely to the family, mostly to women in the private sphere.2 Care is predominantly provided by women, based in traditional gender stereotype and the gendered division of work.

There is evidence that family care negatively affects the caregiver's quality of life, with an impact on both physical and psychological health.3 The stress produced by caregiving can lead to physical and emotional problems, and even death.4 The responsibility of care is also linked to a deterioration in self-perceived health, pain, depression.5 Caring for others also affects other aspects of life, undermining personal development and opportunities to enjoy leisure time and a social life.6 These health effects are due to the conditions under which care is given, rather the care itself, and are likely modulated by the amount of time devoted to caregiving,7,8 the type of activities carried out,9 social support,10 and formal and informal networks to complement care activities.7,11 In addition, cultural norms and motivation to provide care could also influence the burden.12 Family care is assumed according to a social hierarchy that is related to gender and socioeconomic level. Informal care is distributed in families according to gender, age, relationship, and cohabitation status. Thus, caregivers are usually women aged ≥50 years who are the mother, daughter or wife of the care-receiver, who live in the same home as the care-receiver, and who are not in paid employment.13,14 Due to its unequal social distribution, caregiving is a determinant of health inequalities.8

Spain has one of the highest proportions of elderly people of all OECD countries, with 17.6% of the population aged >65 years. In 2008, there were 3,850,000 people with functional diversity (8.5% of the population), of which more than half were in a situation of dependence, i.e. needing personal assistance to carry out activities of daily living.15 The Dependency Law passed in 2006 (Ley 39/2006 2006; LAPAD, from its acronym in Spanish) was an important turning point because it introduced the notion that all citizens have a right to be cared, and that the State is obliged to provide care for people in situations of dependence. LAPAD contemplates social benefits in the form of services and economic compensation when a person is cared by family members. Reports and studies of LAPAD have highlighted budget difficulties since its implementation,16 with the most important reductions in July 2012 due to budget cuts in the context of government austerity policies.17 Some authors have argued that LAPAD does not sufficiently integrate all the perspectives of the various actors involved, and that this could reinforce care-related social inequalities.1,12,18 To date, studies analysing the impact of LAPAD have mainly focused on the economic aspects, and on satisfaction among people in situations of dependence.16 To our knowledge, no population-level studies have examined the influence of LAPAD on caregivers’ health and health inequalities with respect to non-caregivers.

The aim of this paper is to analyse time trends in health inequities due to caregiving for elderly people or those in situations of dependence in the context of LAPAD, taking gender and caregiver status into account.

The proportion of caregivers decreased slightly between 2006 and 2012; however, there were only minor changes in their socio-demographic characteristics. In both surveys, the largest group of caregivers was that of women who provided care alone (Table 1).

Caregivers who give care alone were generally older than non-caregivers and the differences were greater among men. In both surveys and for both sexes, caregivers were less generally well educated and more likely to belong to more disadvantaged social classes (IV and V) than non-caregivers.

We observed a change in employment status between the surveys, with a generalized increase in unemployment in 2012. Those who provided care alone were more likely to be homemakers or retired (women and men, respectively) than non-caregivers, with differences decreasing in 2012. The percentage of women lone caregivers who were in paid employment increased in 2012, and was also greater (29.6%) than for women who shared caregiving (27.7%), but was still lower than that among non-caregivers (41.4%). In both editions of the survey, caregivers were more likely to be married and to live in urban areas. Caregivers were more likely to have poor social support, especially among men who provided care alone, with all proportions decreased in 2012 with respect to 2006, except for women who provided care alone.

In both surveys, men tended to present better health indicators than women. Between 2006 and 2012, women showed a decrease in the age-standardized proportion of illness for all four health indicators (Fig. 1). Only the proportion of lower back pain increased slightly among those who provided care alone (39.1% to 42.0%). The decrease in poor health was more pronounced among women who shared caregiving, in whom self-rated poor health decreased from 61.0% in 2006 to 42.3% in 2012, poor mental health decreased from 44.2% to 29.5%, and the use of psychotropic drugs decreased from 32.2% to 21.2%. The decrease in poor health indicators were less remarkable among men, except for self-rated poor health in lone carers, which decreased from 59.1% to 42.3%. Notably, we observed an increase in the proportion of poor mental health among men who were non-caregivers (14.2% in 2006, 16.7% in 2012) and those who shared caregiving (21.7% to 27.1%), but a decrease among men who were lone caregivers (from 29.4% to 27.3%).

Figure 1.

Age-standardized prevalences of health outcomes by caregiver status, sex and survey year. Residents in Spain aged 16 or more.

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In 2006, the likelihood of poor self-rated health was higher among caregiving than non-caregiving women (PR=1.29 and 1.19 for those giving shared and lone care, respectively) (Fig. 2). In 2012, this gap disappeared among those giving shared care (PR=0.89) but increased among lone caregivers (PR=1.26). The greatest difference between caregiving and non-caregiving women in 2006 was in the proportion of poor mental health (PR=1.69 and 1.51 for those giving shared and lone care, respectively). These differences decreased considerably in 2012 among individuals providing shared care (PR=1.04), but not among lone carers (PR=1.54). According to the adjusted models, the other health indicators, lower back pain and use of psychotropic drugs, followed the same pattern. In both surveys, men lone carers showed a higher probability of poor health than other groups, except in terms of the use of psychotropic drugs. The only significant differences in the 2006 survey were between lone carers and non-caregivers for poor self-rated health (PR=1.43) and poor mental health (PR=2.00). All inequalities tended to decrease for both groups of caregivers in the 2012 survey, and none of were statistically significant.

Figure 2.

Multivariate-adjusted Prevalence Ratio (PR) and 95% confidence interval for health outcomes for persons who share the care and persons who care alone with respect to persons who don’t care by sex and survey of year. Residents in Spain aged 16 or more. PR are adjusted by age and educational level. PR=1 No caregiving. WOMEN 3.0.

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This study shows that the social profile of caregivers in Spain has remained largely unchanged in recent years, and caregiving continues to be linked to gender and social class. Between 2006 and 2012, there was a decrease in health inequalities between individuals providing shared care and non-caregivers, and an increase in inequalities among the largest group of caregivers, women who provide care alone.

Our results show that caregiving is mostly undertaking by women, with similar percentages to those from previous studies in our context.8,9,13 Also consistent with these studies, caregiving women and men generally tend to have a low educational level. These data indicate the persistence of social inequalities in the system of informal care.

Stratifying our analysis by gender allow us to interpret the poorer health indicators among caregiving women than caregiving men in a gender based framework. Differences between caregiving men and women could be explained in terms not only of the higher proportion of women, but also of the types of tasks and time devoted to caregiving, which disrupt women's daily life much more than that of men, thus affecting their health.14 Women more often care for psychological and physical needs, such as assistance with personal hygiene, in contrast to men who have a greater tendency to perform activities in the public sphere.9 Previous research also shows that men faced with a highly demanding caregiving situation are more likely to seek external support, thus experiencing lower stress levels than women.24

In contrast with previous studies,10 we found that social support does not appear to be a main modulator of the burden of care and health problems. One explanation for this could be the fact that we stratified our analysis according to whether care was shared or undertaken alone, where shared care partly accounts for this support.

The difference in time trends in heath inequalities between the two groups of caregiving women may be due to differences in how they use the economic compensation offered for providing care at home. This economic benefit becomes the rule, 54% of the total benefits in 2012, and 93% of the caregivers who received it were women.25 As some authors have suggested,18 the economic benefit for women who provide care alone may condemn them to take a role that excludes them socially. Literature shows that economic benefits in Mediterranean countries may allow families to hire non-professional caregivers,26 many of whom are immigrant women.27,28 This situation may reduce the burden of care on those who share caregiving, as they feel accompanied and relieved.12,29 Receiving help from someone outside the family is associated not only with a reduced burden, but also with a less negative reaction to care,30 which may also explain the health improvement, but maybe moving health inequalities to inmigrant caregivers. Notably, the decrease in mental health inequalities in men is also due to the increased prevalence of poor mental health in non-caregiving men. This is consistent with previous analyses of the same surveys, which showed that the prevalence of poor mental health has increased among men during the economic crisis, especially among middle-aged male main-earners due to their change in employment status.31 The economic crisis in Spain has affected mental health more than other health indicators, such as self-rated health or all-cause mortality.32,33

According to our results, the general structure of the care model, characterised by gender and class division, remains largely unaltered. We observed different trends according to gender and care-sharing, with the health of women who provide care alone remaining the most markedly affected by caregiving.

Based on the findings of the current study, we believe that it is necessary to redesign and implement policies to reduce inequalities related to caregiving that take into account the most affected groups, such as female lone caregivers. It is important to improve the implementation of LAPAD, and in parallel to invest in new solutions that promote a fairer social distribution of care.

M.a Felicitas Domínguez Berjón.

The corresponding author on behalf of the other authors guarantee the accuracy, transparency and honesty of the data and information contained in the study, that no relevant information has been omitted and that all discrepancies between authors have been adequately resolved and described.

M. Salvador-Piedrafita, D. Malmusi and C. Borrell were involved in the conception and design of the work, carried out the analysis and interpretation of data. The first version of the manuscript was written by M. Salvador-Piedrafita and was subsequently improved by all authors, with important intellectual contributions. All authors have approved the final version and are jointly responsible for adequate revision and discussion of all aspects included in the manuscript.

This research was partially supported by the European Community's Seventh Framework Programme (FP7/2007-2013, grant agreement number 278173): Evaluating the impact of structural policies on health inequalities and their social determinants and fostering change (Sophie) project.

C. Borrell belongs to the Gaceta Sanitaria editorial committee, but was not involved in the editorial process of the manuscript.