In this study, 62.2% of the participants whose parents or parents-in-law need to be taken care of in daily life and shopping, do not provide informal care. Theoretically, this condition may result from other siblings taking care of their parents or the use of formal care. We add the number of siblings of caregivers as a control variable in order to eliminate the impact of sibling care, and the regression results show that the number of siblings have no statistical significance. Regarding the impact of formal care, we don't know whether formal care exists due to the limitations of the database, but formal long-term care still in its infancy in China [38], only in a few countries like Denmark (which has the one of the most extensive systems of home care services) do a large proportion of older people receive regular help or assistance from public social services [39]. Moreover, Chinese people attach great importance to the concept of family affection, and informal care given by adult children can provide the necessary emotional support for older people. Thus, even if a degree of formal care exists, informal care remains indispensable and cannot be replaced by formal care. This is also one of the significance of this study.
SES is one key indicator affecting both caregiver and care-recipient in the caregiving context. It is crucial to develop targeting measures by analyzing the SES among female caregivers, so as to design welfare programs for informal care in China. To our knowledge, this is the first study to investigate the SES of married females who providing intensity informal care for their parents/parents-in-law in need of care in China, and this study contributes to the literature on the 'supply side' of informal care. However, what we should highlight in the study is that this sample only include married women (including married, widows and divorced), so we need to be careful when extrapolating our findings. One of the key conclusion can be drawn from our findings is that high SES females are more likely to provide informal care for their older parents compared with low SES females, which is in agreement with the study from 48 LMICs by Louis et al. [40]. To be specific, those with high educational attainment, high economic status and urban Hukou are more likely to provide high-intensity care, and females who are employed and with urban Hukou are more likely to provide low-intensity care.
The current study finds that the females with high educational attainment are more likely to play the role of be high-intensity caregivers, while this education effect is not found to be statistically significant in low-intensity informal caregivers. This finding is in agreement with the conclusion of Petra et al. that high education was associated with a higher probability of being a caregiver in Poland, though they did not particularly focus on females [21]. One important reason for this finding might be due to the “feedback theory” proposed by Xiaotong Fei [41]. The “feedback theory” pointed out that children have the responsibility to support their parents in order to repay for their upbringing and education. Education has long been an important factor in social and personal development, and attaining higher education requires greater parental and household investment. Those have attained higher education may view caregiving as a way to provide for parents and repay them for their investment [42]. In addition, females with high education tended to be motivated by Chinese traditional culture that it is a virtue to support parents, especially when they are under need of care [43, 44].
Surprisingly, the employed women are found to be more inclined to provide low-intensity informal care, whereas this association is not statistically significant in high-intensive care. In order to further explain this phenomenon, we did an in-depth analysis to examine the correlation of the different variables of SES (See the Appendix Table 1). We find that there is a positive correlation between education, income, and Hukou, while employment status is only negatively correlated with Hukou. Based on this result, we speculate there may be a selection effect involved, especially for those with low SES. In recent decades, the awareness of work and economic participation has increased [45], thus, low SES women also have to find a job for basic livelihood. It may be that when they are weighing decision to find a job versus to take care of their parents or parents-in-law who need care, they would consider the care intensity the parents need. If the parents or parents-in-law just need a low-intensity care, they would prefer to work. But high-intensity care required a certain amount of time and effort, respondents have to spend much time providing informal care for their parents or parents-in-law, regardless of the employment status.
Consistent with previous studies, we also find that women with urban Hukou are more likely to provide informal care than those with rural Hukou [40, 46]. Because we have excluded those who do not live with their parents in the same city or county, so the living distance caused by rural respondents moving to urban areas for better job opportunities is eliminated. As we have mentioned in the introduction, respondents with urban Hukou receive higher benefits compared with their rural counterparts. Thus, one of the potential explanations for the urban-rural disparity observed in this study may be that rural Hukou holders have limited time to care for their parents due to livelihood or lack the awareness of care for their parents who in need. In addition, compared with rural women, urban women have higher educational level, and higher education was found to be associated with more informal caregiving. The association was also demonstrated in the Appendix Table 1.
The negative association between SES of caregivers and informal care has been found in some previous studies, which are inconsistent with the current study. However, these studies have mainly focused on high-income countries. For example, in Germany, those who provide high-intensity informal caregiving tend to have a low educational attainment and an unemployment status [18]. A study in Belgium finds that women who are not formally employed are more likely to be informal caregivers [15]. Another study in Japan finds women with lower education are more likely to be informal caregivers [17]. Agree & Glaser [47] suggested that SES may behave in different ways across societies and countries. One of the explanations for the inconsistent results may be due to the difference of long-term care system between China and those countries. The economic and social development of high-income countries is ahead of the occurrence of population aging, which has a good economic and social foundation to deal with population aging. Consequently, like the United States, Germany, Japan and other high-income countries have gradually established a relatively complete long-term care service system, some social services work with health services to provide care for dependent older people, but in many LMICs, social services do not exist or remain dysfunctional [48]. This thus, the women with higher SES have a greater capacity to purchase formal institutional care for their older parents instead of informal care in the above mentioned high-income counties. Although the study in Poland is consistent with our findings [21], it may be due to its lack of a public insurance fund for long-term care for older people. By contrast, in China and many other LMICs, the long-term care system is still in its infancy, and informal care remains the dominant. Women with low SES may be less able to provide care for their older parents, which may be due to the fact that they have to prioritize a paid job due to financial needs and lower levels of social security in rural Hukou holders.
As can be seen from time trends, the number of people providing high-intensity informal care has been increasing over the last two decades. There are two possible reasons for this finding. First, according to the National Bureau of Statistics [4], the proportion of the population over 65 years has been entering into a rapid increasing period since 2000, which brings a higher need for high-intensity care for the elderly. However, the Chinese government has not been well ready for coping for this challenge, and the supply for the formal care is not sufficient. As an alternative, an increase in the informal high-intensity care is observed. Second, even though we used clustering robust standard error to avoid individual autocorrelation across eight waves of the data, the increase of high-intensity care in recent waves might be partly due to the fact that the care recipients are older, and also the need for high-intensity care increased.
The present study has several limitations. First, since the sample only includes married women aged 52 and below who participated in the supplementary survey on intergenerational linkages to parents, we may have underestimated the results of informal caregiving. Second, owing to the cross-sectional nature of the study, we cannot exclude the possibility of reverse causation. For example, the intensity of informal caregiving could conversely affect the employment status or income. Third, the sample size is not very large. There is no difference in marital status may be since a great majority is married. Finally, respondents were not asked what kind of care was being provided and whether a formal caregiving was being used, and the information of the specific age of care recipient were not available in the database, making the analysis less comprehensive.