1. Health Impacts of Caregiving: FINDINGS FROM THE SINGAPORE INFORMAL CARE SURVEY Authors: Angelique Chan, Chetna Malhotra, Rahul Malhotra, Truls Ostbye Institution: Program in Health Services and Systems Research, Duke-NUS Graduate Medical School Singapore

2. Introduction Singapore is one of the most rapidly aging countries in Asia, by 2030, 19% of the population will be aged 65+ Caregiving is primarily provided by the family Use of institutional care very low Caregiving causes chronic stress How is “stress” defined? (Revised Pearlin et. Al. 1990) Self-reported stress

3. Objectives To identify the predictors of self- reported stress among family caregivers of older adults with ADL limitations To assess whether predictors of stress vary by type of caregiver (spouse or adult child)

4. METHODS

5. Dataset Singapore Survey on Informal Caregiving (N=1,290 dyads) National survey of community dwelling Singaporeans >75 years receiving human assistance for at least 1 ADL limitation and their self-identified primary caregiver

6. Sampling Target sample: 1500 care recipient caregiver dyads Random sample of 20,000 Singaporeans >75 years drawn from national database of dwellings 5,613 administered ADL screener 1211 met the criteria of being a care recipient and identified a caregiver 1190 caregivers also gave consent for survey 655 (55%) care recipients used a proxy due to health reasons

7. Measures Dependent variable – Caregiver stress “On a scale of 1 to 10 where 1 is not much stress at all, and 10 is a great deal of stress, how much stress do you have in your daily life?” Independent variables Caregiver characteristics Demographics: Age, gender, ethnicity, educational status, type of housing Amount of care provided (in hours) Caregiver Reaction Assessment Scale (Given et al) Disrupted schedule and health problems due to caregiving Financial Problems due to caregiving Lack of family support in caregiving Self-esteem of the caregiver

8. Measures Caregiver characteristics (contd.) Perceived emotional support Number of chronic diseases Help received from a foreign domestic worker/maid Care recipient characteristics Demographics – age, gender ADL limitations Revised Behavior and Memory Checklist Memory problems Problem behaviors Depressive symptoms

9. Statistical analysis Descriptive statistics – overall sample and by type of caregiver (spousal/ adult child) 39 other caregivers excluded (other than spouse or adult child) Ordinary least squares regression model Unadjusted estimates Main effects model Interaction of type of caregiver (spousal/adult child) with other independent variables

10. RESULTS

11. Table 1: Caregiver characteristics, by type of caregiver (N=1,151, Mean & SD) Caregiver characteristics TotalSpouseAdult child Age (in years)55.5 + 12.4 75.7 + 7.451.5 + 8.7 Female 59.7% 73.2% 57.0% Educational status Primary education or lower Lower secondary/secondary Greater than secondary education 32.6 37.7 29.7 76.8 12.6 10.5 23.8 42.7 33.5

12. Caregiver characteristics TotalSpouse Adult child Type of housing 1-2 room public housing 3-4 room public housing > 5 room public housing Private apartments Bungalow/semi-detached/terrace house 6.8 59.3 22.3 3.4 8.2 15.3 59.5 15.3 3.2 6.8 5.1 59.3 23.7 3.4 8.4 Amount of care provided (in hours) (0-133)30.9 + 24.842.5 + 27.128.6 + 23.7 Disrupted schedule and health problems due to caregiving (8-39) 21.1 + 5.123.1 + 4.820.7 + 5.0 Financial problems due to caregiving (2-10)5.4 + 1.85.9 + 1.75.3 + 1.8 Lack of family support in caregiving (5-25)10.7 + 3.210.8 + 3.110.7 + 3.2 Table 1 (contd.): Caregiver characteristics, by type of caregiver

13. Caregiver characteristics (Contd..) TotalSpouseAdult child Self-esteem (11-30)23.1 + 3.523.1 + 3.827.1 + 3.8 Perceived emotional support (9-67) 24.6 + 3.724.3 + 4.524.7 + 3.5 Number of chronic diseases (0-18) a 1.1 + 1.52.4 + 1.60.8 + 1.3 Help received from a foreign domestic worker/maid 53.237.456.3 Stress (1-10)4.2 + 2.24.2 + 2.34.2 + 2.2 a Table 1 (contd.): Caregiver characteristics, by type of caregiver

14. Care-recipient characteristics TotalSpouseAdult child Age (in years) 75-79 80-84 >85 83.5 + 5.5 29.7 32.1 38.2 81.0 + 4.3 47.4 31.6 21.1 84.0 + 5.6 26.2 32.2 41.6 Gender Males Females 31.9 68.1 73.2 26.8 23.7 76.3 ADL limitations (0-13)5.4 + 4.44.7 + 4.35.5 + 4.4 Memory score (0-28)7.3 + 7.06.8 + 6.87.4 + 7.1 Disruptive behavior score (0-36)2.4 + 4.02.1 + 3.12.5 + 4.2 Depressive symptoms score (0- 32) 3.7 + 4.83.3 + 4.33.8 + 4.9 Table 2: Care recipient characteristics, by type of caregiver

15. Table 2: Standardized regression estimates for stress scores on various caregiver and care-recipient characteristics (N=1150) Caregiver characteristicsUnadjusted estimates Model 1 (Main effects model) Model 2 (Interaction model) Age (in years)-0.02-0.12*-0.11 * Gender(ref: males) Females 0.04 -0.02 -0.01 Ethnicity (ref: Indians & others) Chinese Malays -0.06 -0.16 ** -0.06 -0.06 Educational status(ref: greater than secondary education) Primary education or lower Lower secondary/secondary -0.01 -0.04 -0.03 -0.01 -0.03 -0.02 Type of housing (ref: 1-2 room public housing) 3-4 room public housing > 5 room public housing Private apartments Bungalow/semi-detached/terrace house -0.10 -0.09 -0.05 -0.13** -0.08 -0.09 -0.04 -0.12 * -0.08 -0.09 -0.05 -0.12* **p<0.001; *p<0.05

16. Table 2 (contd.): Standardized regression estimates for stress scores on various caregiver and care-recipient characteristics (N=1150) Caregiver characteristicsUnadjusted estimates Model 1 (Main effects model) Model 2 (Interaction model) Relationship with care-recipient (ref: adult child) Spouse 0.002 -0.01 -0.18 Amount of care provided (in hours)0.004-0.02 Disrupted schedule and health problems due to caregiving 0.41**0.29**0.26** Financial problems due to caregiving0.33**0.15**0.14** Lack of family support in caregiving0.26**0.02 Self-esteem-0.09*-0.07* Perceived emotional support-0.16**-0.02 Number of chronic diseases0.16**0.13** Help received from a foreign domestic worker/maid0.020.04 **p<0.001; *p<0.05

17. Table 2 (contd.): Standardized regression estimates for stress scores on various caregiver and care-recipient characteristics (N=1150) Care-recipient characteristics Unadjusted estimates Model 1 (Main effects model) Model 2 (Interaction model) Age (in years)0.02 ADL limitations0.12**0.04 Memory score0.12**-0.005-0.006 Disruptive behavior score0.22**0.050.06 Depressive symptoms score0.28 **0.15** Spouse caregiver X Disrupted schedule and health problems due to caregiving --0.30 * **p<0.001; *p<0.05

18. SUMMARY Lower caregiver stress: Caregivers are older, have higher SES and self- esteem Higher caregiver stress: Caregiver disrupted schedule and health problems Depressed care recipient Spousal caregivers more stressed due to disrupted schedule and health problems compared to adult child caregivers

19. CONCLUSION Caregiver stress can be identified in several ways: self- reported stress, depression, health care utilization and labor force participation Spousal caregivers are under particular stress and will require caregiving support to manage their schedules and health Lower fertility  increasing number of spousal caregivers Reliance on foreign domestic care workers is not sustainable Promote caregiving in the community Need to understand the dynamics of use of LTC services in Singaporean community