In this study, 62.38% of the participants whose parents or parents-in-law needed to be taken care of in daily life and shopping, did not provide informal care. We added the number of siblings of caregivers as a control variable to eliminate the impact of care provided by siblings, and the regression results show that the number of siblings had no statistical significance. Regarding the impact of formal care, formal care is not the first preference for older adults who need care in China. Previous studies have shown that formal care is a supplement rather than a substitute for informal care among older Chinese adults [37, 38]. In most cases, formal care is used only when adult children do not have time to provide informal care . 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 small proportion of formal care exists, informal care remains indispensable and cannot be replaced by formal care in China. Understanding the determinants of informal care is crucial in designing long-term care financing programmes.
SES is one key determinant affecting both caregivers and care-recipients in the caregiving context. It is crucial to develop targeting measures by analysing the SES of female caregivers, to design welfare programmes for informal care in China. To our knowledge, this is the first study to investigate the SES of married females who provide 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 included only married women, so we need to be careful when extrapolating our findings. One of the key conclusions drawn from our findings is that high-SES females were more likely to provide informal care for their older parents compared with low-SES females, which is in agreement with the study of 48 LMICs by Louis et al. . Specifically, those with high educational attainment, high economic status and urban hukou were more likely to provide high-intensity care, and females who were employed and had urban hukou were more likely to provide low-intensity care.
The current study showed that females with high educational attainment were more likely to be high-intensity caregivers, but this education effect was not found to be statistically significant in low-intensity informal caregivers. This finding is in agreement with the conclusion of Petra et al. that a higher educational level was associated with a higher probability of being a caregiver in Poland, although the authors did not focus on females . One important reason for this finding might be due to the “feedback theory” proposed by Xiaotong Fei . This “feedback theory” suggested that children have the responsibility to support their parents 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 who have attained higher education may view caregiving as a way to provide for their parents and repay them for their investment . In addition, females with high educational levels tend to be motivated by traditional Chinese culture, according to which it is a virtue to support one’s parents, especially when they are in need of care [43, 44].
Surprisingly, the employed women in this study were found to be more inclined to provide low-intensity informal care, whereas this association was not statistically significant for high-intensity informal care. To further explain this phenomenon, we performed an in-depth analysis to examine the correlation of the different SES (see Appendix Table S1). We found a positive correlation between education, income, and hukou, while employment status was only negatively correlated with hukou. Based on this result, we speculate that there may be a selection effect involved, especially for those with low SES. In recent decades, awareness of work and economic participation has increased ; thus, low-SES women also have to find a job for their basic livelihoods. It may be that when women are weighing decisions to find a job versus to take care of their parents or parents-in-law who need care, they will consider the intensity of the care their parents need. If the parents or parents-in-law only need a low-intensity care, they may prefer to work. However, high-intensity care requires a certain amount of time and effort, and thus high-intensity caregivers have to spend much time providing informal care for their parents or parents-in-law, regardless of their employment status.
Consistent with previous studies, we also found that women with urban hukou were more likely to provide informal care than those with rural hukou [40, 46]. Because we excluded those who did not live in the same city or county as their parents, the impact of living distance for rural respondents moving to urban areas for better job opportunities was eliminated. As we mentioned in the introduction, individuals with urban hukou receive higher benefits than 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 are in need. In addition, compared with rural women, urban women have a higher educational level, and higher education was found to be associated with more informal caregiving. The association is also demonstrated in the Appendix Table S1.
A negative association between caregiver SES and informal care has been found in some previous studies, which are inconsistent with the current study. However, these studies mainly focused on high-income countries. For example, in Germany, those who provided high-intensity informal caregiving tended to have low educational attainment and unemployment status . A study in Belgium found that women who were not formally employed were more likely to be informal caregivers . Another study in Japan found that women with lower education were more likely to be informal caregivers . Agree and Glaser  suggested that SES may have different effects across societies and countries. One of the explanations for the inconsistent results may be due to the difference in the long-term care system between China and other countries. In high-income countries, economic and social development is ahead of population ageing, which allows for the establishment of a good economic and social foundation to address population ageing. Consequently, as the United States, Germany, Japan and other high-income countries have gradually established a relatively complete long-term care service system and social services in conjunction with health services to provide care for dependent older people, but in many LMICs, social services do not exist or remain dysfunctional . Thus, in the abovementioned high-income countries, women with higher SES have a greater capacity to pay for formal institutional care for their older parents instead of informal care. Although the study in Poland reported findings consistent with our findings , this consistency may be due to the lack of a public insurance fund for long-term care for older people. In contrast, in China and many other LMICs, long-term care system are still in their infancy, and informal care remains dominant. Women with low SES may be less able to provide care for their older parents, which may be because they have to prioritize paid jobs due to financial needs and, for rural hukou holder, lower levels of social security.
As seen from trends over time, 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 , the proportion of the population over 65 years has been rapidly increasing since 2000, which has generated a higher need for high-intensity care for elderly people. However, the Chinese government has not been well prepared for coping with this challenge, and the supply of formal care is not sufficient. Instead, an increase in informal high-intensity care has been observed. Second, even though we used the clustering robust standard error to avoid individual autocorrelation across eight waves of the data, the increase in high-intensity care in recent waves might be partly because the care recipients were older with each wave, and 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. Finally, the respondents were not asked what kind of care was being provided or whether other forms of caregiving (such as spousal care or paid formal care) were being used, and information on the specific age of the care recipient was not available in the database, making the analysis less comprehensive.