FUNCTIONAL DISABILITY AND INFORMAL CARE FOR OLDER ADULTS IN MEXICO Mariana López-Ortega National Institute of Geriatrics, Mexico Flavia C. D. Andrade Dept. of Kinesiology and Community Health, University of Illinois UNIVERSITY OF SOUTHERN CALIFORNIA / LOS ANGELES, CALIFORNIA / SEPTEMBER 20 22, 2017
BACKGROUND Rapid population ageing in Mexico Gains in life expectancy at birth - 76.9 years (women 77.8, men 72.6) (INEGI 2015) Life expectancy at age 60 is 22 years, but 12 of those years will be lived with disability, which adds burden to health care and families (Global AgeWatch Index 2015) Increasing number of disabled older adults living in the community and vulnerable to unmet support needs. INTERNATIONAL CONFERENCE ON AGING IN THE AMERICAS 3
BACKGROUND Informal care for older adults in Mexico is mostly provided by women - 63 percent of the elder caregivers (Lopez-Ortega 2014) Women are the primary source of assistance for diverse activities such as preparing meals and feeding, personal care, medical care and rehabilitation, among other domestic activities (Lopez-Ortega 2014). Men s support appears mainly limited to financial support. Largest gender disparities are focused around daily activities that require the greatest time commitments, such as keeping an eye on the elderly or providing special therapies. Women suffer the double burden from caregiving older adults as they take on additional responsibilities related to raising their children (Montes de Oca, 1999, Lopez-Ortega 2014). INTERNATIONAL CONFERENCE ON AGING IN THE AMERICAS 4
BACKGROUND One of the most important health policy issues that we face then is how to provide support to elderly people with disabilities living in the community (Katz et al. 2000). Unfortunately, Mexico lacks well developed/funded health and social care systems that can respond to these increasing and differentiated demands. At the same time, the provision of care for older adults which currently relies mostly on family care and within families on women is decreasing its availability as a result of demographic, social and economic changes. Mainly: smaller families, changes in household arrangements, migration of children, increasing participation in the labour force UNIVERSITY OF SOUTHERN CALIFORNIA, LOS ANGELES, CALIFORNIA, SEPTEMBER 20 22, 2017 5
AIM To explore the extent to which adults with functional disability receive informal care and if such care varies according to socioeconomic and health characteristics. UNIVERSITY OF SOUTHERN CALIFORNIA, LOS ANGELES, CALIFORNIA, SEPTEMBER 20 22, 2017 6
Data: Mexican Health and Aging Study, MHAS MHAS is a prospective two-wave panel study of a nationally representative cohort of Mexicans born on or prior to 1951 (50 and older). Baseline interview was conducted in 2001 (9,000 hh & 15,402 individual interviews. Follow-up interviews in 2003, 2012 and 2015. Response rate equal or close to 90% in all waves. The survey has national representation. Spouses of selected respondents, regardless of their age, are also interviewed. 8
STUDY VARIABLES OUTCOME/Dependent VARIABLES Help with Activities of Daily Living (ADL) Help with Instrumental Activities of Daily Living (IADL) CONTROL/Independent VARIABLES Difficulty with Activities of daily living (ADL): dressing, bathing, eating, getting in and out of the bed (transferring), and toileting. Instrumental activities of daily living (IADL): preparing a hot meal, money management, shopping, and taking medication. Conditions were summed creating a summary score ranging from 0 to 6 in the case of ADL scale, from 0 to 4 in the IADL score Number of chronic diseases Falls Smoking Drinking Depressive symptoms Age, sex, marital status, number of children
STATISTICAL ANALYSES Descriptive statistics of sample characteristics. Random-effects and fixed-effects logistic regression models to compare informal care across periods and to identify factors associated with unmet needs. Model 1 focus on the full sample Model 2 focus on those with at least one disability UNIVERSITY OF SOUTHERN CALIFORNIA, LOS ANGELES, CALIFORNIA, SEPTEMBER 20 22, 2017 10
MAIN CHARACTERISTICS OF THE FULL SAMPLE AT BASELINE Mean age 62 years 53% female Mean number of ADL: 0.28 Mean number of IADL: 0.25 61% with health insurance 68% married Mean number of children 5.5
COMPARED TO THOSE NOT RECEIVING HELP, THOSE RECEIVING ADL HELP Are older (mean 71 vs 66 years old) Have higher number of ADL and IADL Have higher number of chronic conditions Have lower depressive symptoms Are less likely to drink Are more likely to be widowed Baseline Restricted to having ADL limitations
COMPARED TO THOSE NOT RECEIVING HELP, THOSE WITH IADL HELP Higher number of limitations in ADL & IADLs Less likely to drink More likely to be married Baseline Restricted to having IADL limitations
As age increases, mean number of ADL / IADL limitations. Women present higher functional disability (ADL) than men through the study period. For IADLs similar levels for men and women over time Mean number of ADL limitations Mean number of IADL limitations mean 0.1.2.3.4.5.6.7.8.9 1 mean 0.1.2.3.4.5.6.7.8.9 1 2001 2003 2012 2015 Years 2001 2003 2012 2015 Years Male mean Female Male mean Female
In the full sample, the proportion of adults receiving help with ADLs increased from 5% to over 10% Among those reporting disability in ADL, the proportion receiving help increased in the first two years of observation from 50% to 60% of the sample, decreasing to 40% by 2012 and levelling at 50% by 2015 Proportion of adults receiving ADL help Proportion of adults with ADL receiving help mean 0.1.2.3.4.5.6.7.8.9 1 mean 0.1.2.3.4.5.6.7.8.9 1 2001 2003 2012 2015 Years 2001 2003 2012 2015 Years Male mean Female Male mean Female
In the full sample, the proportion of adults receiving help with IADLs increased over time Among those reporting disability in IADL, the proportion receiving help is higher than for ADL, with relatively constant levels among women, but declining levels among men Proportion of adults who receive IADL help Proportion of adults with IADL receiving help mean 0.1.2.3.4.5.6.7.8.9 1 mean 0.1.2.3.4.5.6.7.8.9 1 2001 2003 2012 2015 Years 2001 2003 2012 2015 Years Male mean Female Male mean Female
Models for ADL For both fe and re models, number of activities with disability has stronger effect on informal care Having 2 or more falls is also associated with receiving help (entire sample) In re models, older age and women are positively associated with receiving help In re models, being divorced or separated is associated with lower help Variables Entire sample Restricted Fixed Random Fixed Random b 95% CI b 95% CI b 95% CI b 95% CI Fixed effects Age omitted 1.05*** 1.04,1.06 1.00 1.00,1.00 1.04*** 1.03,1.05 Sex omitted Male 1.00 1.00,1.00 1.00 1.00,1.00 1.00 1.00,1.00 Female 1.28* 1.06,1.55 1.00 1.00,1.00 1.31** 1.08,1.58 Number of disabilities 4.72*** 4.15,5.36 5.96*** 5.44,6.52 1.88*** 1.68,2.11 2.30*** 2.14,2.48 Number of chronic conditions 1.07 0.90,1.28 1.27*** 1.16,1.40 0.90 0.73,1.11 1.05 0.96,1.14 Number of falls None 1.00 1.00,1.00 1.00 1.00,1.00 1.00 1.00,1.00 1.00 1.00,1.00 1 1.36 0.99,1.88 1.15 0.93,1.42 1.34 0.88,2.03 1.01 0.81,1.25 2 or more 1.39* 1.08,1.79 1.27** 1.08,1.50 1.38 0.99,1.93 1.03 0.87,1.21 Depression score 1.05 1.00,1.10 1.04* 1.01,1.07 0.98 0.92,1.04 0.97 0.94,1.00 Smoking Current smoker 1.00 1.00,1.00 1.00 1.00,1.00 1.00 1.00,1.00 1.00 1.00,1.00 Past smoker 1.05 0.61,1.82 1.29 0.97,1.72 1.22 0.58,2.55 1.18 0.87,1.59 Never smoker 1.25 0.68,2.30 1.32 0.99,1.75 1.61 0.70,3.69 1.19 0.89,1.60 Drinking (yes vs. no) 0.74 0.53,1.03 0.75** 0.61,0.92 0.85 0.52,1.39 0.83 0.67,1.03 Years of schooling omitted 0.97* 0.95,0.99 1.00 1.00,1.00 0.99 0.97,1.01 Health insurance (yes vs. no) 1.43* 1.04,1.98 1.21 1.00,1.45 0.83 0.53,1.31 0.85 0.70,1.03 Urban (vs. Rural) omitted 0.98 0.83,1.16 1.00 1.00,1.00 0.99 0.84,1.17 Marital status Single 1.84 0.62,5.48 1.03 0.59,1.80 1.54 0.41,5.71 0.84 0.48,1.47 Married 1.00 1.00,1.00 1.00 1.00,1.00 1.00 1.00,1.00 1.00 1.00,1.00 Divorced or separated 1.56 0.84,2.90 0.69* 0.51,0.93 0.92 0.42,2.01 0.61*** 0.46,0.81 Widowed 1.42 0.94,2.15 1.02 0.85,1.22 0.90 0.53,1.55 0.87 0.72,1.04 Number of children omitted 1.00 0.98,1.03 1.00 1.00,1.00 1.00 0.98,1.03 Intercept 0.00*** 0.00,0.00 0.01*** 0.00,0.02 Random effects lnsig2u _cons 2.19*** 1.76,2.72 1.03 0.68,1.58 N 5025 34357 1238 5369 BIC 1458.991 8541.367 772.8415 6113.651
Models for IADL For both fe and re models, number of activities with disability has stronger effect on informal care In re models, having additional chronic conditions was positively associated with help In re models, being a women is associated with receiving help In re models, being single, divorced or separated is associated with lower help (restricted and entire sample, respectively) Variables Entire sample Restricted Fixed Random Fixed Random b 95% CI b 95% CI b 95% CI b 95% CI Fixed effects Age omitted 1.01* 1.00,1.02 1.00 1.00,1.00 1.01** 1.01,1.02 Sex omitted Male 1.00 1.00,1.00 1.00 1.00,1.00 1.00 1.00,1.00 Female 1.39*** 1.20,1.61 1.00 1.00,1.00 1.83*** 1.52,2.21 Number of disabilities 69.91*** 53.40,91.51 108.24*** 95.19,123.07 2.41*** 1.86,3.14 2.15*** 1.92,2.42 Number of chronic conditions 0.86 0.68,1.10 1.16*** 1.07,1.26 0.80 0.60,1.05 1.14** 1.04,1.25 Number of falls None 1.00 1.00,1.00 1.00 1.00,1.00 1.00 1.00,1.00 1.00 1.00,1.00 1 1.02 0.67,1.54 1.06 0.89,1.27 1.09 0.67,1.77 1.16 0.94,1.44 2 or more 0.85 0.60,1.22 1.03 0.90,1.18 0.77 0.52,1.16 0.94 0.80,1.10 Depression score 1.01 0.94,1.08 1.03* 1.01,1.05 1.01 0.93,1.09 1.03* 1.00,1.06 Smoking Current smoker 1.00 1.00,1.00 1.00 1.00,1.00 1.00 1.00,1.00 1.00 1.00,1.00 Past smoker 0.70 0.37,1.35 1.14 0.93,1.40 0.79 0.37,1.68 1.18 0.93,1.48 Never smoker 0.68 0.32,1.41 1.24* 1.02,1.51 0.59 0.25,1.37 1.28* 1.02,1.61 Drinking (yes vs. no) 1.01 0.69,1.48 0.96 0.82,1.11 0.98 0.64,1.50 0.92 0.78,1.10 Years of schooling 1.00 1.00,1.00 0.99 0.97,1.01 1.00 1.00,1.00 0.99 0.97,1.01 Health insurance (yes vs. no) 1.35 0.90,2.02 1.08 0.93,1.25 1.13 0.73,1.76 1.04 0.87,1.24 Urban (vs. Rural) omitted 0.98 0.86,1.12 1.00 1.00,1.00 0.95 0.81,1.11 Marital status Single 0.96 0.21,4.44 0.68 0.42,1.11 1.15 0.22,6.01 0.52* 0.30,0.91 Married 1.00 1.00,1.00 1.00 1.00,1.00 1.00 1.00,1.00 1.00 1.00,1.00 Divorced or separated 1.54 0.59,4.00 0.74* 0.59,0.93 1.75 0.54,5.63 0.65** 0.49,0.85 Widowed 1.68 0.90,3.13 1.10 0.94,1.27 1.62 0.71,3.69 1.05 0.87,1.26 Number of children omitted 1.01 0.99,1.04 1.00 1.00,1.00 1.01 0.98,1.04 Intercept 0.00*** 0.30*** Random effects lnsig2u _cons 0.000 0.00,5.61e+33 0.25 0.05,1.26 N 10022 34262 809 6036 BIC 1007.252 8372.21 584.5538 5583.924
INFORMAL CARE IN MEXICO Main determinant seems to be number of limitations (severity) Other demographic factors such as age and being a woman also play a role Some health conditions such as falls, number of chronic conditions also tend to increase help Marital status also play a role Number of children was not associated with receiving help UNIVERSITY OF SOUTHERN CALIFORNIA, LOS ANGELES, CALIFORNIA, SEPTEMBER 20 22, 2017 21
NEXT STEPS Determine the core of the analyses entire vs. restricted sample Explore who is providing help spouse or other Explore which activities are the main drivers of help Explore some potential interactions e.g. sex, marital status and number of limitations, number of chronic conditions particularly for IADL UNIVERSITY OF SOUTHERN CALIFORNIA, LOS ANGELES, CALIFORNIA, SEPTEMBER 20 22, 2017 22
THANK YOU Mariana López-Ortega marianalopezortega@googlemail.com Flavia Andrade fandrade@illinois.edu UNIVERSITY OF SOUTHERN CALIFORNIA, LOS ANGELES, CALIFORNIA, SEPTEMBER 20 22, 2017 23
Table 1. Descriptive statistics at the baseline (2001) for the full MHAS working sample Variables N Mean or % sd Age 13,462 62.30 9.63 Sex 13,462 Male 6,271 46.58 Female 7,191 53.42 Number of Activities of Daily Living (ADL) 13,336 0.28 0.95 Number of Instrumental Activities of Daily Living (IADL) 12,400 0.25 0.71 Number of chronic conditions 13,087 0.52 0.71 Number of falls 13,326 0.58 0.83 None 8,553 64.18 1 1,803 13.53 2 or more 2,970 22.29 Depression score 12,106 3.55 2.67 Smoking 13,446 Current smoker 2,365 17.59 Past smoker 3,609 26.84 Never smoker 7,472 55.57 Drinking 13,452 No 9,248 68.75 Yes 4,204 31.25 Years of schooling 13,444 4.47 4.42 Health insurance 13,421 No 5,169 38.51 Yes 8,252 61.49 Urban 13,462 No 4,604 34.2 Yes 8,858 65.8 Marital status 13,039 Single 526 4.03 Married 8,866 68 Divorced or separated 1,125 8.63 Widowed 2,522 19.34 Number of children 12,712 5.51 2.92 UNIVERSITY OF SOUTHERN CALIFORNIA, LOS ANGELES, CALIFORNIA, SEPTEMBER 20 22, 2017 24
Table 1. Descriptive statistics at the baseline (2001) for the MHAS sample, by receiving or not ADL help among those with ADL limitations Variables N Total No ADL help With ADL help Mean or % sd N Mean or % Number of children 1,493 5.91 3.09 700 6.00 3.20 793 5.84 2.99 0.323 UNIVERSITY OF SOUTHERN CALIFORNIA, LOS ANGELES, CALIFORNIA, SEPTEMBER 20 22, 2017 25 sd N Mean or % sd p-value Age 1,574 68.74 11.74 831 66.37 10.80 743 71.38 12.19 Sex 0.326 Male 38.56 37.42 39.84 Female 61.44 62.58 60.16 Number of Activities of Daily Living (ADL) 1,574 2.38 1.62 831 1.69 1.13 743 3.15 1.73 Number of Instrumental Activities of Daily Living (IADL) 1,341 1.21 1.37 790 0.67 0.97 551 1.98 1.49 Number of chronic conditions 1,555 0.97 0.88 820 0.88 0.84 735 1.06 0.92 0.0001 Number of falls 0.404 None 46.15 47.24 44.95 One 14.48 14.97 13.93 2 or more 39.37 37.79 41.12 Depression score 1,299 5.49 2.52 529 5.71 2.47 770 5.34 2.54 0.011 Smoking 0.010 Current smoker 11.90 14.2 9.31 Past smoker 31.36 29.96 32.93 Never smoker 56.74 55.84 57.76 Drinking <0.0001 No 81.88 76.29 88.14 Yes 18.12 23.71 11.86 Years of schooling 1,571 3.15 3.62 740 2.98 3.57 831 3.30 3.67 0.087 Health insurance 0.827 No 38.69 38.43 38.97 Yes 61.31 61.57 61.03 Urban 0.557 No 34.12 33.45 34.86 Yes 65.88 66.55 65.14 Marital status Single 4.02 4.25 3.75 0.037 Married 57.25 59.1 55.04 Divorced or separated 7.71 8.62 6.63 Widowed 31.03 28.03 34.58
Table 1. Descriptive statistics at the baseline (2001) for the MHAS sample, by receiving or not IADL help among those with IADL limitations Total No IADL help With IADL help Variables Mean or Mean or Mean or N sd N sd N % % % sd p-value Age 1617 67.46 11.37 255 67.23 10.80 1362 67.50 11.47 0.729 Sex 0.532 Male 51.14 52.94 50.81 Female 48.86 47.06 49.19 Number of Activities of Daily Living (ADL) 1599 1.29 1.85 254 0.88 1.48 1345 1.37 1.90 0.000 Number of Instrumental 1617 Activities of Daily Living (IADL) 1.76 0.98 255 1.45 0.74 1362 1.81 1.01 <0.0001 Number of chronic conditions 1592 0.79 0.85 246 0.70 0.83 1346 0.80 0.85 0.097 Number of falls 0.291 None 54.15 58.7 53.31 One 12.75 11.74 12.94 2 or more 33.10 29.55 33.75 Depression score 1523 4.68 2.78 241 4.66 2.85 1282 4.69 2.76 0.908 Smoking 0.081 Current smoker 14.35 15.69 14.10 Past smoker 31.48 36.47 30.54 Never smoker 54.17 47.84 55.36 Drinking 0.003 No 73.89 66.27 75.31 Yes 26.11 33.73 24.69 Years of schooling 1616 3.34 3.93 255 3.56 4.33 1361 3.30 3.85 0.347 Health insurance 0.060 No 40.20 45.49 39.20 Yes 59.80 54.51 60.80 Urban 0.885 No 33.33 33.73 33.26 Yes 66.67 66.27 66.74 Marital status <0.0001 Single 3.34 8.24 2.42 Married 66.11 57.65 67.69 Divorced or separated 6.12 10.59 5.29 Widowed 24.43 23.53 24.60 Number of children 1531 5.81 3.11 231 6.08 3.21 1300 5.76 3.09 0.148 UNIVERSITY OF SOUTHERN CALIFORNIA, LOS ANGELES, CALIFORNIA, SEPTEMBER 20 22, 2017 26