Elderly ethnic Danes´ and immigrants´ use of public care services (DK)
Written by Margit Helle Thomsen
Text reference: “Ældre danskeres og indvandreres brug af pleje- og omsorgsydelser (”Elderly ethnic Danes and Immigrants´ use of public care services”) by Hansen, Eigil Boll and Siganos, Gallatios, KORA, The Danish Institute for Local and Regional Government Research (at the time of publication: The Research Institute for Counties and Municipalities), Working Paper, 2009, pp 1-35.
Elderly people who emigrated from non-Western countries, account for an increasing number of the older population in Denmark. They will increase in number and also constitute a growing proportion of the elderly population, equivalent to a quadrupling by 2030. These demographic and sociocultural changes raise the question about the consequences for the public sector and the demand and distribution of welfare state benefits. One of the key issues is whether elderly immigrants´ lifestyles and living conditions imply that elderly immigrants either make less or more use of social and healthcare services, compared to elderly ethnic Danes. This working paper describes the key findings and conclusions from comprehensive Danish research on this issue.
The purpose of this research was to examine and analyse whether older migrants are using public services to a greater or lesser extent than elderly ethnic Danes. The study primarily focused on elderly immigrants of non-Western origin, but also involved data on immigrants from Western countries. The total population included people aged 65 or over, residing at that time in the City of Copenhagen on January 1st 2007.
The study included three main areas of public and municipal healthcare and social services for elderly citizens:
- Personal care services
- Practical assistance
- Care homes
Personal care services include in the Danish context support for personal care needs at any time of day, for example help to get out of bed, personal wash and body care, help to get to bed, medicine etc. From a cost perspective, this implies that care in the evening and night hours are more expensive than care in the daytime.
Practical assistance includes support for cleaning, laundry and shopping etc. From a cost perspective, the price related to these benefits would be calculated at a price per allocated number of hours. The category care homes covers a range of different types of housing for elderly citizens. This applies for instance to sheltered housing & care homes for people with special needs in relation to diseases, for example special housing for people with dementia etc.
In this research, the three categories were examined separately, but they were also assessed as an overall expression of elderly people´s use of healthcare and social care services.
Theoretical-methodical approach and data sources
With a departure point in these specific healthcare and social services, the research and analysis was based on a specific model framework, called “behavioural model of health service use”. By using this model, the researchers gained insight into factors other than ethnicity that may explain a particular pattern of use in relation to healthcare services. Thus, the model focused on a number of explanatory variables on the individual level:
- Predisposing variables such as gender, age, education and ethnicity
- Variables that may either increase or decrease the use of public service, such as income, alternative care options instead of public services
- Needs-oriented variables such as individual health indicators
These individual variables were transformed into a number of variables in regression analysis in order to illustrate the extent to which ethnicity and immigrant background actually affected the consumption of public healthcare services. The researchers hereby operated with both dependent and independent variables. The categories for municipal healthcare and social service would be the dependent variables and the independent variables would refer to factors dealing with ethnicity.
Thus, the elderly citizens in the population were divided into 1) ethnic Danes, 2) immigrants from a Western country with less than 10 years of residence in Denmark, 3) immigrants from a Western country with more than 10 years of residence in Denmark, 4) immigrants from a non-Western country with less than 10 years of residence in Denmark and finally 5) immigrants from a non-Western country with more than 10 years of residence in Denmark.
Furthermore, the researchers controlled a wide range of variables that may influence the need and use of public healthcare services. These variables would include the demographic, socio-economical and educational data, marital status, family, the fact of living alone or cohabiting, hospitalisation of different lengths etc. In total, the data sources combined institutional data extractions from municipal registers and national statistics, including:
- Data on the individual use of personal care services, practical assistance and care homes within the total population. This data was provided for the research from registrations and data registers on care and institutions in the City of Copenhagen.
- Data on demographic information as well as data on education and occupation from Statistics Denmark
- Data on use of health insurance and number of days of hospitalisation from the National Health Insurance Service
- Through a series of regression analyses, the explanatory factors were investigated for their significance and insignificant factors were gradually excluded. The final estimates only consisted of explanatory factors with strong significant correlation with the dependent variables, i.e. the investigated healthcare services.
The analysis revealed a long list of differences in the use of healthcare services among immigrants, as compared with ethnic Danes. Some examples:
- Background and long-term residence as an explanatory factor
The general use of the investigated healthcare services would differ quite significantly between the population groups at the time of research. Thus, 40% of the ethnic Danes were using one of services in the investigated year compared to 14 respectively i.e. 18% of non-Western immigrants with more than 10 years of residence.
It is worth noticing that the Western immigrants with more than 10 years of residence would be much closer to the Danish pattern. This may indicate that the combination of Western background and long-term residence may influence the use of public healthcare for elderly people. However, the same trend was seen to a lesser extent among non-Western immigrants of more than 10 years of residence.
- Knowledge about healthcare services as an explanatory factor
As shown, the lowest frequency of use was seen among non-Western immigrants with less than 10 years of residence. This could indicate a reduced need and demand despite the fact that all the population groups belonged to the same age groups. Another explanation may be the lack of knowledge about the Danish welfare system and public benefits. The shorter the residence is, the less the knowledge immigrants may have of the system and its benefits. This may also include the lack of knowledge on accessibility and procedures etc. Furthermore, cultural-institutional differences between the Danish system and the health systems in the countries of origin may be quite significant in terms of the nature, extent and access in relation to public services for elderly citizens. Finally, linguistic and communication issues may probably play an important role in the use of services.
- Family-based care as an explanatory factor
Apart from knowledge, the analyses suggested that elderly non-Western immigrants would rely more on the family´s support, especially in the first years of immigration. The results may also indicate that patterns of use over time are adapted more and more to a Danish pattern. It may reflect the fact that awareness of public healthcare services has increased. But it can also show that immigrants increasingly adapt to a Danish lifestyle where generations live apart, and where especially women’s fulltime employment makes it difficult to pursue more traditional family-based lifestyles.
- Age as an explanatory factor
Immigrants of non-Western origin with more than 10 years of residence in Denmark are the largest group after the ethnic Danes in the population, but this group of non-Western immigrants would also on average be younger than the ethnic Danes. Their proportion of under 70 year olds was higher and their proportion of over 80 year olds considerably less, compared to ethnic Danes.
- Household as an explanatory factor
The proportion of citizens living alone was significantly lower among non-Western immigrant with more than 10 years of residence than among all the other groups. This may be surprising considering the fact that the non-Western immigrants generally were younger than the other groups, but it may also indicate less need for public care.
Summary of research results
In summary, the research gave rise to the following results:
- At the time of the research, elderly immigrants received the investigated services less frequently than ethnic Danes within the age group from 65 and over. This applied both generally to all services in total and specifically for each of the investigated types of services.
- In terms of domiciliary care, the practical assistance component of care and assistant services used tended to be less for elderly immigrants than for elderly ethnic Danes. This indicates that a greater proportion of the practical assistance was met from other sources among elderly compared to ethnic Danes.
- In terms of personal component of care services, it turned out that elderly immigrants would not be using these services significantly less than elderly ethnic Danes. Furthermore, elderly from non-Western countries with a long-term residence in Denmark would actually receive a greater volume of personal care services than elderly ethnic Danes.
- Finally, the time factor related to duration of residence obviously played an important role for the use of healthcare and social service. Thus, immigrants who lived in Denmark for more than 10 years, would more frequently receive public care and assistance services than immigrants with a shorter residence time in Denmark.
The research results do not provide a full explanation of the differences observed between elderly immigrants and elderly ethnic Danes in terms of the use of municipal healthcare and social services. However, some of the key findings would certainly indicate that 2 factors are particularly influential in relation to the use of these services:
Firstly, the mere knowledge of the availability of these services seems to be of major importance for the patterns of use. Thus, the longer the residence in Denmark, the more closely the elderly resembled the elderly ethnic Danes in their pattern use.
Secondly, the tradition to undertake care of elderly family members within the family frame also seems to be very important for the use – or rather non-use – of public healthcare and social services for elderly citizens.
By linking these trends, it can be concluded that in terms of the usage of public healthcare and social services among elderly people, the long term residence may in several respects affect the usage and thereby also the lifestyles. Knowledge and overview of available services is built over time for newcomers. However, at the same time, general socio-cultural and socio-economic conditions have a great impact on the pattern usage, while traditional family patterns are difficult to maintain. This especially includes the socio-cultural and socio-economic tradition where female family members stay at home in order to take care of the family in general, and in particular the elderly family members. In the Danish context, immigrant families need an earned income from both male and female family members. This condition increases the need for using public care services for elderly family members, thus speeding up the process of change in lifestyles and adapting to a Danish usage pattern in relation to public services.
One may conclude that there is a strong need to disseminate knowledge about the Danish welfare system – and of the specific benefits for elderly citizens – among immigrant families. At the same time, it would be important to enhance the intercultural understanding among healthcare and social professionals concerning the lifestyles, needs and expectations found among immigrant families in general, and among elderly immigrants in particular.