When Sons and Daughters Care for a Parent
An Analysis of Gender Differences
Abstract
Abstract: This study examines gender differences in offspring primary caregivers. We compared baseline data from 26 caregiving sons and 244 caregiving daughters. Caregiving sons had higher incomes, were less likely to be married, and provided care to parents less limited in their cognitive functions and instrumental activities of daily living. Daughters matched via propensity score matching to the sons regarding these variables did not differ significantly in coping and most other outcomes, though daughters did show more depressive symptoms and perceived fewer positive aspects of caregiving. This suggests that, although caregiving sons and daughters might differ in demographic variables as well as in caregiving intensity and stressors, they cope with caregiving similarly when the caregiving situation is comparable.
One central aspect of sociodemographic change is the growing share of older people in the population (European Commission, 2020; He et al., 2016; Hirayama, 2011). In 2019, more than 20% of the European population and about 17% of the population in the countries of the Organisation for Economic Cooperation and Development (OECD) was aged 65 or over, and this number is still growing (Eurostat, 2020; OECD, 2021). In the European Union, Germany is one of the countries in which sociodemographic change is advancing the most, with 19% aged 67 and 6% aged 80 or over in 2019 (Federal Statistical Office, 2016, 2019). The need for long-term care increases sharply with age for the very old population. In Germany, 77% of those in need are cared for at home, mainly by their relatives, a percentage that is 9 points higher than the OECD average (Ehrlich, 2019; OECD, 2019, 2021). About 7% of the adult population in Germany regularly provide such informal care, the majority of whom are women (Ehrlich, 2019; Wetzstein et al., 2015). Only about one-third of these caregivers are men, and this gender gap is even wider for people providing care for two hours per day or longer (OECD, 2021; Rothgang & Müller, 2018; Wetzstein et al., 2015). On the other hand, there is also evidence that in Germany this gender gap is narrowing (Ehrlich, 2019): While in 1998 only 5% of people in need of long-term care received care from their son, this number more than doubled to 11% in 2016 (Schneekloth et al., 2017). The number of caregiving sons may continue to grow because of the increasing number of people in need of care, decreasing family sizes, greater sibling mobility, and an increasing number of daughters employed (Collins, 2014; Federal Statistical Office, 2016, 2019).
Previous research on caregiving was often implicitly or explicitly limited to female caregivers, probably because of the existing gender gap in assuming these responsibilities (Bom et al., 2019; Campbell, 2010). Moreover, many studies focused on male caregivers or investigated gender differences in care without distinguishing between spouse and child caregivers (Xiong et al., 2020; Yee & Schulz, 2000). However, a more differentiated consideration of caregiving sons is necessary because of the increasing need for offspring caregivers and their specific relationship with the care recipient (Campbell & Carroll, 2007). Furthermore, caregiving sons often are employed and have a family, so their motivation for eldercare and their caregiving situation can differ greatly from those of spousal caregivers (Campbell & Carroll, 2007). Meta-analytical results suggest that, for some characteristics of the care recipient, gender differences might be more pronounced for offspring caregivers than for spouse caregivers, possibly because offspring caregivers have more choices in selecting the caregiving tasks they assume (Pinquart & Sörensen, 2006). Only few studies have focused specifically on sons as caregivers, most of which are qualitative (Campbell, 2010; Collins, 2014; McDonnell & Ryan, 2014; Novy, 2018). In the following, we present an overview of the quantitative studies on gender differences in offspring caregivers with a specific focus on caregiver characteristics, characteristics of the care recipient, and caregiving outcomes and coping.
Two US studies based on a nationally representative sample of informal caregivers primarily focused on gender differences in various measures of caregiving intensity and their association with different dimensions of quality of life (Cohen et al., 2019; Cook et al., 2018). The offspring caregivers in this sample (about 31% sons) were indicated by Medicare beneficiaries, aged 65 and over, as one of up to five individuals who provided care (Cohen et al., 2019). Cohen et al. analyzed gender differences regarding different characteristics of the caregiver and showed that caregiving sons were younger and provided assistance in fewer instrumental activities of daily living (IADLs, e.g., shopping, household chores, paying bills) than caregiving daughters, and that this gender difference in IADLs was more pronounced for Whites. They found no gender differences in the assistance provided in activities of daily living (ADLs, e.g., bathing, eating, toileting), income, marital status, number in household, number of comorbidities, hours per month spent caregiving, race/ethnicity, employment, coresidence with the care recipient, and whether or not the care recipient has dementia. Cook et al. (2018) found that the effects of different measures of caregiving intensity on caregiving outcomes like social strain, negative emotional burden, and positive emotional benefit differ depending on demographic variables and are, in some cases, higher for caregiving daughters than for sons. This study did not report gender differences in the level of these outcomes.
Kikuzawa (2016) studied social support in Japan in adult children caring for a parent who lives in the same household. She used an online announcement for recruitment and sampled 109 sons and 138 daughters. Kikuzawa found no gender differences in caregivers’ age and care recipients’ functional limitations and cognitive impairments. Regarding caregiving outcomes and coping, caregiving sons had fewer caregiver burdens and received slightly more formal general instrumental support but less informal general emotional support than daughters. Kikuzawa found no gender differences for caregiver distress and all means of instrumental and emotional support closely related to caregiving.
In a longitudinal study in Norway, Romoren (2003) studied 78 male and 149 female primary caregivers providing care for their parents aged 80 years or above. While the author obtained the medical and nursing records from formal care services, the caregivers were interviewed after only their parents had died. The results showed gender differences in caregiver characteristics, as caregiving sons were more often married and employed full-time, shared the household with the care recipient less often, provided less personal care during the escalation phase, and had, on average, a shorter duration of informal home care than daughters. Regarding coping and caregiver outcomes, there were no gender differences in formal home help, but caregiving sons got more help from secondary caregivers.
Liu et al. (2019) used a representative Chinese database of individuals 45 years and older, identifying 403 men and 679 women who reported themselves or their spouses as caregivers for their parents or parents-in-law. For this sample selection, gender differences reported for caregivers’ characteristics and caregiving outcomes should be interpreted with caution since some of the subjects were not providing care to their parents themselves. While there were no gender differences in the caregivers’ age and total caregiving time, female caregivers were more likely to be educated below high school level and unemployed; female caregivers were also less likely to be married than the employed and unemployed men. In the study, depressive symptoms did not differ by gender or working status. However, given the same amount of caregiving time, female caregivers were less depressed than male caregivers.
Summing up this research, caregiving sons may differ from daughters in some demographic variables, such as marital status and working hours as well as the duration and intensity of care, but only in some caregiving-related support measures. Furthermore, there is some evidence for a lower caregiver burden for sons, but, when controlled for caregiving intensity, they also had more depressive symptoms. Less research, however, has been carried out on caregiving stressors in this specific group of caregivers, like functional and cognitive impairments of the care recipient, as well as on caregiver self-efficacy, coping with problems, and positive resources. Since these variables are more closely related to coping with the caregiving situation, they are especially relevant for public health and intervention research (Hernández-Padilla et al., 2021; Pinquart & Sörensen, 2006; Yee & Schulz, 2000). In addition, some of the results reported on gender differences in offspring caregivers are inconsistent or fail to align with other research. Delgardo and Tennstedt (1997), for example, in a qualitative study, found in contrast that Puerto Rican caregiving sons are even less likely to be married than caregiving daughters. Moreover, in their meta-analysis on gender differences in caregiver health, Pinquart and Sörensen (2006) found that caregiving women scored higher on depression than men. The same meta-analysis found evidence for gender differences in caregiver variables to be smaller in more recent studies and younger samples. Thus, gender differences may be subject to social change. Since studies focusing on gender differences in offspring caregivers stem from very diverse countries, so cultural differences could account for their inconsistencies, as Cohen et al. (2019) found for IADLs. In Germany, long-term care insurance provides care services or cash benefits to pay for an informal caregiver. Although only 8% of those 65 and older live in the same household with family members of another generation, the share of people giving informal care to a relative is much higher than the OECD average, and the homecare service usage is comparatively low (Eurostat, 2020; OECD, 2021). For this reason, specifically in Germany, it is essential to examine gender differences.
The first aim of this study was to examine gender differences in offspring primary caregivers’ characteristics, like demographic variables and measures of caregiving duration and intensity, and in the respective care recipients’ characteristics, like care needs and functional and cognitive impairments, in the German context. Since coping with the caregiving situation and caregiving outcomes (such as depression and caregiver burden) may depend on demographic variables, caregiving intensity, and stressors (Liu et al., 2019; Pinquart & Sörensen, 2003, 2006; Theurer et al., 2019), the second aim of this study was to examine gender differences in coping and caregiving outcomes, controlling for these pre-existing differences between caregiving sons and daughters.
Methods
Sample
This study is based on baseline data from the ReDiCare project, a randomized controlled trial with caregivers of older adults receiving benefits from a participating German long-term care insurance (Pfeiffer et al., 2021). Among other eligibility criteria, the caregivers had to provide care and assistance in IADLs, ADLs, or supervision for at least 1.5 hours per day on average or 10.5 hours per week (including travel time) and report distress associated with caregiving. The care recipient had to be 60 years or older and categorized into a care degree (“Pflegegrad”) from 1 to 5, indicating the degree of self-reliance restrictions according to the German Long-Term Care Act (Pfeiffer et al., 2021). For further information on sampling strategy, refer to the study protocol of ReDiCare (Pfeiffer et al., 2021).
The entire sample in this baseline dataset included 445 informal caregivers. Of these, 20 (4.5%) were husbands or male partners, 135 (30.3%) wives or female partners, 26 (5.8%) sons or sons-in-law, 244 (54.8%) daughters or daughters-in-law of the care recipient, and 20 (4.5%) had any other relationship to the care recipient. Compared with a representative sample of German caregivers, the current sample included considerably fewer sons or sons-in-law (5.8% compared to 12%) and husbands or male partners (4.7% compared to 14%) (Schneekloth et al., 2017). For the current study, we used only data from offspring caregivers, restricting our sample to 270 (26 male, 244 female). Of these, 33.2% lived in the same household with the care recipient, and 59.5% cared for a parent with dementia. Both numbers did not differ significantly between caregiving sons and daughters.
Ethical Considerations
Ethical approval was obtained from the Ethics Committee of the Faculty of Social and Behavioral Sciences of the Friedrich Schiller University Jena, Germany (committee’s reference number: FSV 18/08). All participants received information leaflets and gave written informed consent. Data security officers of the participating long-term care insurances (AOK Bavaria, AOK Baden-Württemberg), the University of Jena, and the Robert Bosch Hospital as well as the two ministries for social affairs of the two states involved agreed to the data management and security protocol as well as to the participant information and consent form.
Measures
For all measures included in this study, we used self-reports by the caregiver. We sent the questionnaires to the participants by mail and discussed any unanswered or unclear questions with a member of the project team by phone. The questionnaires included questions about demographics such as caregivers’ age, marital status, working hours, income, duration of caregiving, and usage of professional support services. Further, we employed different scales to measure caregiving intensity, number of IADLs and ADLs the parent needs assistance with, functional and cognitive impairment of care recipient, caregivers’ depressive symptoms, caregiver burden, coping with problems, psychosocial benefits of caregiving, and utilization of psychosocial resources. Table 1 shows the number and range of items and Cronbach’s α.
Caregiver and Care Recipient Characteristics
We measured the number of IADLs and ADLs the parent needs assistance with as well as caregiving intensity using questions adapted from the Resource Utilization in Dementia Questionnaire (Wimo et al., 2013). First, we asked the participants whether the care recipient needs assistance in six different ADLs (e.g., eating, dressing/changing clothes, toilet visits) and six IADLs (e.g., shopping, housekeeping, managing financial matters). We then summed the activities in each category to get total scores for ADLs and IADLs. To evaluate caregiving intensity, we asked participants how many days in the last 4 weeks and how many hours on an average day they assisted their parent on these activities and spent time on supervision. We calculated and summed the hours per day assisting in IADLs and ADLs as well as supervising to determine caregiving intensity.
Functional and cognitive impairment of the care recipient was assessed with the Barthel Index (Mahoney & Barthel, 1965) and the Extended Barthel Index (Prosiegel et al., 1996), respectively. Higher values in the Barthel Index indicate lower impairment in ADLs, and higher values in the Extended Barthel Index indicate higher cognitive functioning (e.g., comprehension, problem-solving) of the care recipient.
Coping and Caregiving Outcomes
We measured depressive symptoms with the Centre for Epidemiological Studies Depression scale (CES-D; Hautzinger et al., 2012; Radloff, 1977; e.g., “During the past week, I felt depressed”). Total scores range from 0 to 60, with higher values indicating more depressive symptoms and a score of ≥ 16 indicating caregivers at risk for clinical depression.
We assessed caregiver burden and self-efficacy with the subscales “Consequences of Involvement in Care for the Caregiver’s Life” (e.g., “I feel that my health has suffered because of my involvement with my relative.”) and “Satisfaction with One’s Own Performance as a Caregiver” (e.g., “I feel that, in the past, I haven’t done as much for my relative as I could have or should have.”) of the abbreviated German version of the Sense of Competence Questionnaire (SCQ-AV; Pendergrass et al., 2015). The subscales were pooled so that higher values meant higher self-efficacy and lower caregiver burden.
To assess coping with problems, we included the subscale “Negative Problem Orientation” of the Social Problem Solving Inventory – Revised QuikScore Form (SPSI-R:S; e.g., “I usually feel threatened and afraid when I have an important problem to solve.”) in the questionnaire (D’Zurilla et al., 2002; Graf, 2003). Higher values meant a more negative problem orientation.
We assessed the psychosocial benefits of caregiving for the caregivers with six items of the Positive Aspects of Caregiving (PAC) scale (Tarlow et al., 2004; e.g., “Made me feel more useful”). Higher scores signify more psychosocial benefits perceived by the caregiver.
We measured the utilization of psychosocial resources with two adapted subscales (“Utilization of resources related to well-being” and “Utilization of resources related to coping with daily hassles”) of the Psychosocial Resource Utilization Questionnaire for Family Caregivers of People with Dementia (PRUQ; Töpfer & Wilz, 2018). Participants indicated the frequency with which they had utilized each resource (e.g., to do something for one’s own health and physical fitness) in the last 4 weeks to achieve a motivational goal (e.g., to feel good).
Data Analysis
To test for gender differences in caregivers’ demographic variables (age, marital status, hours of employment, and income), we computed the duration and intensity of caregiving as well as care recipients’ care needs and functional and cognitive impairment; the descriptive statistics and inferential statistical analyses were carried out at a significance level of α = .05. For the dichotomous variable, marital status (married vs. not married), we utilized the χ2-test. For the interval-scaled variables, we calculated t-tests when the normality criterion was fulfilled. Otherwise, we used the Mann-Whitney U-test.
In a second step, we analyzed gender differences between caregiving daughters and sons in measures of coping (e.g., psychosocial resource utilization) and caregiver outcomes (e.g., depressive symptoms), taking pre-existing differences in the characteristics of the caregiver and the care recipient into account. Since the sample size of both groups was notably unequal, with 244 daughters (-in-law) but only 26 sons (-in-law), we used propensity score matching to identify those 26 daughters most similar to the caregiving sons regarding some background variables (age, marital status, hours of employment, income, duration and intensity of caregiving) and characteristics of the care recipients (care needs and functional and cognitive impairment). We then analyzed the matched groups with t-tests or Mann-Whitney U-tests to examine gender differences in caregivers’ depression, burden, self-efficacy, negative problem orientation, psychosocial benefits of caregiving, utilization of resources related to well-being and coping with daily hassles. Since variables for measuring the usage of professional support were dichotomous, we used χ2-tests to analyze differences between the matched groups in the use of home care and daycare services. We used RStudio for the propensity score matching with the nearest neighbor method. All other analyses were computed with IBM SPSS Statistics 27.
Results
Table 2 shows the results of the analyses on the interval-scaled demographic variables, duration and intensity of caregiving of the caregiver as well as care recipients care needs, and cognitive and functional impairment. There were no significant differences between caregiving sons and daughters in age, caregiving intensity, functional impairments of the care recipient measured with the Barthel Index, and the number of ADLs the care recipient needs assistance with (p > .10). Furthermore, the duration of being a caregiver and the hours of employment were not significantly different between caregiving sons and daughters. However, there was a tendency toward more years of caregiving by daughters than by sons and sons working slightly more hours than daughters. Caregiving sons had significantly higher income and assisted less cognitively impaired care recipients (according to the Extended Barthel Index) who required less assistance with IADLs (see Table 2).
The χ2-test of marital status revealed a significant gender difference, χ2(1, N = 269) = 8.10, p < .01. While 66.7% of caregiving daughters were married, for caregiving sons, this number was only 38.5%.
The propensity score matching led to a sample of 26 caregiving sons and 26 matched caregiving daughters. None of the variables mentioned above significantly differed between the two groups after matching (p > .30). When we examined the measures of coping and caregiving outcomes, only depressive symptoms and psychosocial benefits of caregiving differed significantly between caregiving sons and caregiving daughters (see Table 3). Caregiving sons had lower values in the CES-D than daughters. The values in the PAC were higher for caregiving sons than for daughters. There were no gender differences in caregiver burden and caregiver self-efficacy measured with the subscales of the SCQ-AV, negative problem orientation, and utilization of resources related to well-being and coping with daily hassles (p > .10). Moreover, caregiving sons (34.6%) and daughters (36.0%) did not differ in the use of home care for their parents, χ2(1, N = 51) = 0.11, p > .10. The use of daycare services for their parents was only slightly lower for caregiving sons (7.7%) than for daughters (26.9%) using Pearson’s χ2-test, χ2(1, N = 52) = 3.36, p = .07. However, this difference was not significant, and there were only two cases in one of the cells. When we used Fisher’s exact test, this tendency decreased (p = .14).
Discussion
This study examined gender differences in offspring caregivers regarding demographic variables, measures of caregiving duration and intensity as well as their care recipients’ care needs and functional and cognitive impairments in the German context. The analyses showed that there were some differences regarding income, marital status, cognitive impairment of the care recipient, and the IADLs the care recipient needed assistance with. Caregiving sons had higher incomes than caregiving daughters, possibly because they cared for parents with better cognitive performance and IADL functioning and therefore experienced less conflict between work and family roles arising from eldercare, as described by Cheng et al. (2020). This result aligns with results from Norway showing that male caregivers are more likely to be employed full-time (Romoren, 2003), but it differs from the U.S. study by Cohen et al. (2019), which found no significant gender difference in caregivers’ income. The finding that sons take care of parents less needy than daughters corresponds to Cohen et al.’s (2019) finding concerning IADLs but not the finding in the Japanese study by Kikuzawa (2016) for cognitive impairment of the care recipient, which possibly can be explained by cultural differences. In the current study, caregiving sons were less likely to be married than daughters, contrasting findings from other countries, some of which show sons to be even more likely to be married (Cohen et al., 2019; Liu et al., 2019; Romoren, 2003). However, in contrast to the current study, these studies also included caregivers with only a minimal amount of caregiving – and one even included subjects only having a spouse providing care (Liu et al., 2019). Thus, probably some of the married caregiving sons in these samples only assisted their spouses in providing care for the parents (-in-law), while the sons in the current study were primary caregivers who often having no assistance from a spouse. This explanation for the differing results is even more plausible in light of a study by Delgardo and Tennstedt (1997), showing sons to be more likely to give “no one else was available” as a reason for caregiving and analyses conducted by Wetzstein et al. (2015), demonstrating the gender gap in caring to be wider for people providing care for 2 hours per day or longer.
Second, this study looked at gender differences in coping and caregiving outcomes while controlling for pre-existing differences in caregiver and care recipient characteristics. Propensity score matching created comparable groups. The matched groups did not differ in most coping and caregiving outcome measures. Thus, the caregiving daughters that were comparable to the caregiving sons regarding demographics, duration and intensity of caregiving, as well as functional and cognitive impairment of the care recipient were also quite similar in caregiver burden, self-efficacy, negative problem orientation, utilization of resources related to well-being and coping with daily hassles, and usage of professional support. This corresponds to other findings showing that gender differences in caregiver outcomes are small to very small, especially when controlled for demographics, duration and intensity of caregiving, and functional and cognitive impairment of the care recipient (Pinquart & Sörensen, 2006; Theurer et al., 2019). Thus, the results from other studies showing lower caregiver burden in sons might be attributable to differences in the caregiving situation not controlled for in these studies. Another explanation for the current study not finding the gender differences in caregiver burden shown in former studies might be a closing gender gap in caregiver experiences, as Pinquart and Sörensen (2006) argued in their meta-analysis. One of the two caregiver outcomes differing between the matched groups was depressive symptoms, which were lower for caregiving sons. This effect contradicts Liu et al. (2019), who showed lower depressive symptoms in daughters in a Chinese sample given the same amount of caregiving time. However, this could stem from cultural differences, since Pinquart and Sörensen (2006), in their large meta-analysis, also found lower depressive symptoms in caregiving sons. Although representative (noncaregiver) samples showed higher depressive symptoms for women in general, the gender difference in depression is much higher in the current study examining offspring caregivers (d = 0.62 compared to 0.19 for the 50–59 years age group in the meta-analysis of Salk et al., 2017). This suggests that the gender differences in depressive symptoms are at least partially related to the caregiving situation, especially since there is evidence for caregiving increasing the prevalence of depressive symptoms (Bom et al., 2019). Furthermore, it deserves attention that, in our sample, caregiving daughters and sons had mean sum scores above the cut-off value of ≥ 16 suggested by Radloff (1977). This is also in line with an earlier German study on offspring caregivers of people with dementia showing high depression scores for sons and daughters (Theurer et al., 2019). Although the gender difference was not significant in this smaller former study, the descriptive statistics regarding depression scores pointed in a similar direction as the current study. Another caregiver outcome differing between the matched groups was positive aspects of caregiving. Caregiving sons perceived more psychosocial benefits from their caregiving than daughters, which might also explain lower depression scores. Although Pinquart and Sörensen (2006) found higher subjective well-being for male than female caregivers in their meta-analysis, there is a lack of research on gender differences in the positive aspects of caregiving (Yee & Schulz, 2000). Filling this research gap and thus adding a resource perspective on gender differences in caregiving could help explain differences in negative caregiver outcomes and foster intervention planning and development (Quinn & Toms, 2019).
Limitations
There are several limitations to consider when interpreting the results of the current study. First, the small sample size, especially that of the group of caregiving sons, is a limitation. There were only 26 caregiving sons in the sample, reducing the power of the analysis; some of the nonsignificant differences might be significant in a larger sample. The percentage of sons in this caregiver sample was also much lower than in more representative German caregiver samples (5.8% compared to 11% in the 2016 data of Schneekloth et al., 2017). However, this might result from the selection criteria of the current study focusing on primary caregivers exceeding a minimal caregiving time, thus excluding many sons who often provide care only occasionally (Wetzstein et al., 2015). Furthermore, all the results are cross-sectional and should therefore not be interpreted causally. For the analyses on coping and caregiver outcomes, we matched the groups of daughters and sons regarding relevant variables and were thus more comparable. However, further confounders not controlled for are possible. For example, different prior or current childcare responsibilities might explain gender differences in depression or positive aspects of caregiving. Therefore, results should be interpreted carefully. Finally, there is the alpha error accumulation to consider. There were 10 variables and thus statistical tests concerning the first study aim (four were significant) and nine referring to the second study aim (two were significant). Correcting for this alpha error accumulation, however, would have minimized the test power for the already quite small sample.
Conclusions
The current study revealed some gender differences in caring regarding income, marital status, cognitive impairment of the care recipient, and the IADLs the care recipient needs assistance with. However, compared with caregiving daughters similar in these variables, sons do not differ much in caregiver outcomes and coping. Thus, policies and programs focusing specifically on these potential stressors might also reduce gender differences in caregiver burden. Only regarding depressive symptoms and psychosocial benefits of caregiving do sons seem to be less negatively and more positively affected by the caregiver role than daughters. A more positive perception of caregiving might prevent a higher amount of depressive symptoms, but further research is needed to explore the reasons for the gender difference in depressive symptoms more deeply, especially since depression scores seem to be high for both caregiving daughters and sons. Since the current study included only much fewer caregiving sons than daughters, another issue for future studies is the motivation of adult sons to care for their elder parents. Why are so few sons motivated to care for their elders, what leads caregiving sons to take on these responsibilities, and what could be done to increase the engagement of adult sons in caring? Finding answers to these questions would help to improve the situation of caregivers and care recipients in the future.
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