European Journal of Ageing (2023) 20:11 https://doi.org/10.1007/s10433-023-00760-3 ORIGINAL INVESTIGATION Cared and uncared populations: understanding unmet care needs of older adults (65+) across different social care systems in Europe Mariana Calderón‑Jaramillo1,2 · Pilar Zueras2,3 Accepted: 20 April 2023 © The Author(s) 2023 Abstract Population care needs are dynamic. They change throughout individuals’ life courses and are related to the population struc- ture. These needs are particularly demanding during population ageing and may vary depending on how societies cope with them. In this study, we explored the unmet social care needs of individuals in twelve European countries with different social care systems. We used data from the seventh wave of the Survey of Health, Ageing and Retirement in Europe (SHARE) to conduct a cross-sectional study of individuals aged 65 and over with care needs (n = 7136). Unmet care needs were meas- ured from an absolute approach. We fitted binomial regression models to explain the relative importance of individuals’ characteristics, health status and different social care systems on unmet needs. The absolute measure shows that 53.02% of the analytical sample faced unmet care needs as they reported limitations and did not receive help. The prevalence of unmet care needs is higher for men than women and for younger than older individuals. Furthermore, we found that individuals living in Mediterranean social care systems have the highest prevalence of these unmet needs. This analysis contributes to the ongoing debate about the challenges posed by ageing populations and their relationship with care. Keyword Social care systems · Ageing · Unmet care needs · Care provision · Europe Background instance, care needs are not the same between populations in the earlier stages of the demographic transition, character- Care is a basic need of human beings throughout their life. ized by high fertility rates where children take up most of the As anthropological and philosophical work has suggested, care and the social services, in comparison with those in the care constitutes individuals’ personhood (Buch 2015) and fourth stage of the transition that are facing ageing processes acts in the foundations of society itself (Fisher and Tronto and challenges regarding caring for older people (Bom and 1990). The most paradoxical aspect of care, however, is that Stöckel 2021; Rechel et al. 2013). it is usually recognized because of the lack of it. People European countries are forerunners in this ageing pro- usually feel they are not receiving enough care when they cess that will affect many countries worldwide (Vaupel and stop being cared for or when new care needs emerge. Fur- Kistowski 2008). Therefore, Europe is a critical scenario for thermore, demographic dynamics fundamentally impact understanding population ageing effects on care provision, social care demand and supply (Spijker et al. 2022). For policies, and welfare systems. Previous literature has high- lighted that care is affected by its gendered provision, as is mainly given by women (Schmid et al. 2012; Uccheddu et al. Responsible Editor: Thorsten Kneip. 2019; Young and Grundy 2008); the central role played by * Mariana Calderón‑Jaramillo the family and informal care provision (Pickard et al. 2007; mcalderon@ced.uab.es Tennstedt et al. 1993); and new changes in the design and use of social services (Cantor 1991; Davey 2017; Spijker 1 Universitat Autònoma de Barcelona, Barcelona, Catalunya, and Zueras 2020). Spain Some authors have suggested that we are facing a care 2 Centre d’Estudis Demogràfics (CED-CERCA) – Cerdanyola crisis driven by demographic dynamics leading to popula- del Valles, Barcelona, Catalunya, Spain tion ageing and changes in family trajectories, household 3 Institute for Social and Economic Research, University units, and social and economic transformations (Pérez of Essex, Colchester, UK 13 Vol.:(0123456789) 11 Page 2 of 14 European Journal of Ageing (2023) 20:11 Orozco 2021). Discussions about care provision have also The literature on social care systems mainly focuses underlined how it is affected by policy changes (Pfau-Effin- on childcare and infants’ care needs; meanwhile, the one ger 2005) and social perceptions about ageing and support referred to the care for the older population is based on dif- that usually shape specific care systems to help people with ferent typologies. These have been built according to theo- disabilities and facing limitations in daily life. However, in retical or empirical perspectives. The theoretical approach many societies, some individuals are not receiving the sup- focuses on the configuration of the welfare state within port they need and are facing unmet care needs that can neg- Europe, where care systems fall on the spectrum of family- atively affect their health, well-being, and life expectancy. centred care (Hrast et al. 2020) and social care-based ser- In this article, we aim to analyse the unmet care needs vices provided by the welfare state (Bergmark et al. 2000; experienced by people aged 65 and over within twelve Euro- Pfau-Effinger 2005). This theoretical framework refers espe- pean countries. We examined the socio-demographic charac- cially to service provision and articulation between informal teristics of middle-age and older adults with care needs and and formal care provision. estimated the prevalence of unmet care needs in the follow- On the other hand, the empirical approach has con- ing social care systems: the Mediterranean, characterized by structed different typologies of social care systems using sta- family-based care provision; the Nordic, where care provi- tistical methods such as clustering and principal components sion is strongly linked to welfare-state services; the Western, analyses. Previous evidence has focused on OECD, high- where care provision is articulated between informal and income and middle-income countries and has emphasized formal care provision, also including the participation of diverse aspects of care provision like service availability, private providers; and, the Eastern, which used to be based public expenditure, care demand, performance, and, regu- on ‘familialist’ care provision but has undergone various lation (Ariaans et al. 2021; Damiani et al. 2011). Despite transformations since the fall of the Berlin Wall. the importance of this approach, one of its main limitations is that the demographic dynamics in care provision remain barely explored. In this article, we focused on the theoreti- Different typologies for understanding social care cal typology to explore unmet care needs in countries where systems social care systems have been shaped by a long-term policy history. Social care is conceptualized as the coexistence of infor- mal and formal care activities that addresses three primary Measuring unmet care needs needs: socialization, activities of daily living and personal needs related to severe disability (Cantor 1991). The dif- Underlying the measurement of unmet care needs is the dis- ferences between social care systems are related mainly to cussion about social care services and how informal and the way informal and formal care is organized. For exam- formal care are articulated through policies, public institu- ple, family-centred systems rely primarily on informal care, tions, households, and families (Broese van Groenou & de whereas welfare-state centred systems emphasize the avail- Boer 2016; Uccheddu et al. 2019). However, research on ability of formal care through its provision by people who this topic has stressed the challenges of measuring unmet are not relatives. care needs among the ageing population (Allen et al. 2014; Theoretically, the configuration of social care systems Bień et al. 2013; Dunatchik et al. 2019; Stein et al. 2020). relates to values (Pfau-Effinger 2005), ancient family sys- These difficulties by and large occur because surveys do not tems (Reher 1998), religion (Damiani et al. 2011), and the usually include enough information about care provision structural socioeconomic context (Ariaans et al. 2021) that and the quality of care received. Consequently, its analysis have shaped care provision itself as well as public policies should be done through indirect estimations based on ques- related to it. The starting point for exploring unmet care tions about experiencing functional limitations that affect needs is the recognition that social care systems may fail the performance of daily life activities. to provide universal coverage, access, and funding for indi- Evidence on the subject has identified different dimen- viduals’ care needs. This idea also emphasizes that the rela- sions of these functional limitations and distinguishes tionship between formal and informal care provision is not between mobility, Activities of Daily Living (ADLs) and always virtuous, that the availability of one of these types Instrumental Activities of Daily Living (IADLs) (Ćwirlej- of care does not guarantee the availability of the other, and Sozańska et al. 2019; Mlinac & Feng 2016; Wolinsky et al. that access to both does not necessarily lead to all care needs 2011). The definition used here is based on previous work being met; for example, there may be times of the day when by Vlachantoni’s (2011), where unmet care needs from an the individuals has no one to help them, or certain tasks for absolute approach refer to the type and amount of support which they do not get the help they need. received by someone who reports functional limitations (mobility, ADL and IADL) and is, consequently, assumed 13 European Journal of Ageing (2023) 20:11 Page 3 of 14 11 Fig. 1  Flow chart for the selection of the analytical sample. Note ADL: Activities of Daily Living; IADL: Instrumental Activities of Daily Liv- ing. Source Survey of Health Ageing and Retirement in Europe, seventh wave (2017) to be in need of help but does not report receiving it. Previ- Data and methods ous evidence has shown the importance of demographic and socioeconomic circumstances on people’s needs and unmet Data care needs and has emphasized that socioeconomic vari- ables like housing tenure and education level may explain This cross-sectional study uses data from the seventh wave the experience of unmet needs (Maplethorpe et al. 2015; of the Survey of Health, Ageing and Retirement in Europe Vlachantoni 2019). It has also called attention to the rela- (SHARE), collected in 2017 (Börsch-Supan 2022). The tionship between unmet needs, health conditions (McGilton SHARE provides harmonized longitudinal data through et al. 2018), and types of limitations faced (Mlinac & Feng eighth waves about individuals aged 50 and older, and 2016). their partners, from 28 participant countries (27 European In this article, we explore two hypotheses about the unmet countries plus Israel). The eighth wave of SHARE, with care needs of people over 65 based on previous literature. more recent data is currently available, but it was collected Firstly, due to women’s greater longevity and likelihood of during the pandemic of COVID-19 when many changes being widowed and living alone (Delbès et al. 2006), as well in older adults’ lives and care provision at the household as the fact that those with worst health and financial cir- level took place (Lebrasseur et al. 2021). In the seventh cumstances have less access to care provision outside home wave, the module about physical health included questions (Dupraz et al. 2020), we hypothesized that women in the about functional limitations and care received by individ- older age group, in poor health and with low educational uals (Börsch-Supan et al. 2013). However, the relevant attainment (Momtaz et al. 2012), would be those that are questions for this study were not available in all countries. most likely to face unmet needs (Hypothesis A). Second, We selected 12 countries based on the availability of in terms of issues related to the functioning of social care the studied variables concerning facing limitations in daily systems, there are concerns about the availability of infor- life and receiving help or not for dealing with these limita- mal care provision and its limits in meeting the increasing tions. The analytical sample was composed of individu- demand for care (Pickard et al. 2007; Tennstedt et al. 1993), als who reported having limitations in performing at least hence, we hypothesized that the propensity to have unmet one activity related to mobility, ADL or IADL. Figure 1 care needs would be higher among middle-aged and older includes the flowchart and questions to illustrate the selec- adults living in countries with family-centred social care sys- tion process of the analytical sample. This sample was tems (Mediterranean) than in countries with other types of composed of 7,136 individuals with complete information state participation (Hypothesis B). 13 11 Page 4 of 14 European Journal of Ageing (2023) 20:11 for the questions about coping any of the previously men- less than three months.”1 On the other hand, for measuring tioned limitations and care received. ADL and IADL, the survey asked: “Please tell me if you have any difficulty with these activities because of a physi- Analytical strategy cal, mental, emotional or memory problem. Again, exclude any difficulties you expect to last less than three months.”2 The analysis of unmet care needs consisted of two steps. In addition, for those who report having problems with any Firstly, we measured the percentage of people with abso- of these types of activities, the survey includes the following lute unmet care needs by type of limitation and analysed question: “Thinking about the activities that you have prob- these measures by age, gender, and social care system. lems with, does anyone ever help you with these activities?”. Secondly, we conducted a multivariate analysis regressing Independent variables were included as follows. Age was the binary dependent variable of absolute unmet need for aggregated into three categories (65–74, 75–84 and 85+); social care (0 = received care; 1 = did not receive care) con- the education level was harmonized through ISCED 1997 sidering socio-demographic and health variables: gender, classification and grouped into low (until primary school), age group, educational level, marital status, housing tenure, mid (secondary education), and high education (college and living arrangements, self-rated health, chronic disease, and above); even though ISCED 2011 is also included in the type of limitations. These variables are ex ante harmonized SHARE, this variable presented higher proportions of miss- through the SHARE, which are also harmonized with simi- ing values than the ISCED 1997. Housing tenure was also lar surveys from other countries like the ELSA (England) regrouped into three categories: (i) owner, (ii) tenant and and the HRS (US) (Börsch-Supan 2017), the variables are (iii) other; this last category includes members of a coopera- measured indirectly through individuals’ responses and were tive, subtenant and rent-free. selected based on available evidence on unmet care needs, in Self-rated health was treated as binary, distinguishing particular on Vlachantoni’s previous study of England with between good health (excellent, very good or good) and data from the ELSA (2019). Finally, given the purpose of poor health (fair or poor self-rated health). Besides, given this study, the variable accounting for the European coun- the information available, we followed the approach used by tries’ clusters by social care systems was also included. Spijker and Zueras (2020) and combined the type of func- Regression models were built using a forward method and tional limitations to create a variable that captures the degree were aligned with the two hypotheses. Model one included of severity depending on the type of limitations reported: (i) the individuals’ demographic and socioeconomic variables, facing only mobility limitations (for those who reported any and the second model added the macro variable identify- mobility limitation but no limitations in performing IADLs ing the social care system. Model three again considered and ADLs), (ii) those who reported limitations in one ADL individuals’ socio-demographic characteristics and included and/or any IADL, (iii) those who reported limitations in two information on the type of limitation, to better understand or more ADLs. Even though the Global Activity Limitation its relationship with unmet care needs. Model four added Indicator (GALI) has been validated as a severity meas- all the health variables, and model five adjusted for hav- ure and is also included in the SHARE, it does not provide ing children as an indicator of potential availability of care detailed information about the type of limitation faced by outside the household. Finally, model six included all the previous variables and, again, the social care system of the country of residence. 1 Activities on card 36 included: i) Walking 100 m; ii) Sitting for about two hours; iii) Getting up from a chair after sitting for long Variables periods; iv) Climbing several flights of stairs without resting; v) Climbing one flight of stairs without resting; vi) Stopping, kneeling, As mentioned above, the dependent variable was the abso- or crouching; vii) Reaching or extending your arms above shoulder level; viii) Pulling or pushing large objects like a living room chair; lute unmet need for social care, measured through the ques- ix) Lifting or carrying weights over 10 pounds/5 kilos, like a heavy tion related to help received by individuals reporting any bag of groceries; and x) Picking up a small coin from a table. mobility, ADL and IADL limitation. Participants were asked 2 The activities asked for were: i) Dressing, including putting on about these limitations through two questions referring to 25 shoes and socks; ii) Walking across a room; iii) Bathing or shower- activities, 10 for mobility and 15 combining ADL (6 limita- ing; iv) Eating, such as cutting up your food; v) Getting in or out of bed; vi) Using the toilet, including getting up or down; vii) Using a tions) and IADL (9 limitations). For mobility limitations, the map to figure out how to get around in a strange place; viii) Prepar- question was: “Please look at card 36. Please tell me whether ing a hot meal; ix) Shopping for groceries; x) Making telephone calls; you have any difficulty doing each of the everyday activities xi) Taking medications; xii) Doing work around the house or gar- on this card. Exclude any difficulties that you expect to last den; xiii) Managing money, such as paying bills and keeping track of expenses; xiv) Leaving the house independently and accessing trans- portation services; and xv) Doing personal laundry. Activities from i to vi refer to ADL, while from vii to xv are related to IADL. 13 European Journal of Ageing (2023) 20:11 Page 5 of 14 11 Table 1  Descriptive statistics of the analytical sample by social care system Mediterranean Eastern Western Nordic Total sample n = 2662 % n = 1160 % n = 2364 % n = 950 % n = 7136 % Age group 65–69 543 20.4 289 24.9 511 21.6 170 17.9 1513 21.2 70–74 588 22.1 301 25.9 497 21.0 226 23.8 1612 22.6 75–79 569 21.4 225 19.4 465 19.7 195 20.5 1454 20.4 80–84 510 19.2 183 15.8 406 17.2 160 16.8 1259 17.6 85+ 452 17.0 162 14.0 485 20.5 199 20.9 1298 18.2 Gender Female 1616 60.7 726 62.6 1460 61.8 615 64.7 4417 61.9 Type of limitation Only mobility 1456 54.7 627 54.1 1223 51.7 508 53.5 3814 53.4 One ADL and/or any IADL 852 32.0 356 30.7 873 36.9 327 34.4 2408 33.7 Two or more ADL 354 13.3 177 15.3 268 11.3 115 12.1 914 12.8 ADL: Activities of Daily Living; IADL: Instrumental Activities of Daily Living Source: Survey of Health Ageing and Retirement in Europe, seventh wave (2017) individuals, moreover, the way in which it is included in the other people but the partner. Secondly, as (i) living alone, questionnaire does not allow to directly connect it with the (ii) living as a couple, with the partner only, (iii) living with measure of unmet care needs that we used. one or more relatives and non-relatives. The results includ- Finally, countries were grouped into four theoretical ing this second way of coding living arrangements, by which regions according to their social care system following a we take into account the availability of care provided by the welfare-state configurations typology (Pfau-Effinger 2005). partner, showed a lower level of statistical significance than The Mediterranean social care system includes Spain, the first one included in the final models. Greece, and Italy; the Nordic considers Sweden and Den- The severity variable aimed to explore how the number mark; the Western has Germany, France, Austria, Swit- and type of limitations explained the experience of unmet zerland, and Belgium; and the Eastern is composed of the care needs. Before including it, we fit the models with the Czech Republic and Poland. Table 1 displays the composi- specific limitations (ADL, IADL, and mobility) and also tion of the analytical sample by age, sex, and type of limita- fitted three different models for individuals by each specific tions by the social care system. limitation but the results were very similar to those pre- sented here and did not include the number of limitations, Sensitivity analysis which is related to the amount of help needed, so we used the severity variable with the categories described earlier, We conducted an alternative analysis exploring different which considered both the type and number of limitations. aggregations of marital status and living arrangements to Finally, we also analysed results by including countries understand how unmet care needs were related to the avail- instead of social care systems, which showed the internal ability of potential informal care within households. Marital coherence of the Mediterranean social care system and the status was grouped in two different ways. First, we consid- differences within the other groups, especially for the Nordic ered three categories: (i) married or with a registered part- and Eastern countries. ner, (ii) ever married, and (iii) never married; secondly, four categories distinguishing: (i) married or with a registered partner, (ii) divorced or separated, (iii) never married, and Results (iv) widowed. However, none of these variables showed sig- nificance and were removed to avoid multicollinearity with We present two types of results: First, the descriptive analy- the living arrangements variable. sis of the analytical sample focusing on the prevalence of We extended sensitivity analysis by grouping living unmet care needs from an absolute approach and the demo- arrangements in two different ways. In the first place, the graphic characteristics of those with any of these needs; following three arrangements: Living arrangements distin- second, binomial regression models, which illustrate how guished people (i) living with their partner, either with or individuals’ demographic and economic characteristics and without other people, (ii) living alone, and (iii) living with health status explain the experience of unmet care needs as 13 11 Page 6 of 14 European Journal of Ageing (2023) 20:11 Fig. 2  Percentage of people 65 + with functional limitations by type presents any type of limitation on these activities. Source Survey of of limitation, age, sex, and social care system. Note ADL: Activities Health Ageing and Retirement in Europe, seventh wave (2017) of Daily Living; IADL: Instrumental Activities of Daily Living; All: well as its relationship with specific social care systems in As expected, the prevalence of care needs is higher and Europe. more severe in older age groups. The most common type of limitation below age 85 is to experience only mobility Who needs care? difficulties, while limitations for performing one ADL and/ or any IADL are the most common for those aged 85 and People with any limitation (mobility, ADLs and IADLs) over. Having only mobility limitations shows the highest were considered to be at risk of having unmet care needs. prevalence across the sample (33.46%, CI 32.60–34.32%), Figure 2 presents the prevalence of each type of limitation exceeding 15% in all the age-sex groups. Also, smaller per- among women and men by age group and social care sys- centages of this population face the other two types of limi- tem. In the four social care systems analysed, women have tations, and differences between men and women regarding more limitations of any type (69.67%; CI 68.54–70.80%) the prevalence of limitations related to ADLs and IADLs than men (53.74%; CI 52.37–55.11%); these percentages are are minor in the younger age groups and in the oldest age also higher in the Eastern region (70.43%; CI 68.22–72.63%) group. However, the gender gap is larger in the Mediterra- for individuals with any type of limitations and for specific nean social care system, and in the Nordic social care sys- type of limitations. tems for people aged 85+ . 13 European Journal of Ageing (2023) 20:11 Page 7 of 14 11 Fig. 3  Percentage of people 65+ facing unmet care needs from an Activities of Daily Living; All: presents any type of limitation on absolute approach by type of limitation, age, sex, and social care these activities. Source Survey of Health Ageing and Retirement in system. Note ADL: Activities of Daily Living; IADL: Instrumental Europe, seventh wave (2017) Relating to the prevalence of unmet care needs, from the (56.87%; CI 57.00–60.73%), which is also the trend by age absolute approach, 53.03% (CI 51.87–54.18%) of the indi- and gender when compared with the other three groups. viduals in the analytical sample (n = 7136) dealt with these. Moreover, Fig. 3 shows the relevance of mobility limitations Therefore, more than half of the population who reported in the experience of this circumstance because the higher at least one limitation did not receive any help. Figure 3 percentages of unmet care needs are experienced by people shows the results by social care system, age, sex, and type with only mobility limitations. Additionally, percentages of of limitation. The main trend is that the percentage of peo- individuals with unmet care needs that face two or more ple with any limitation experiencing unmet care needs is ADL are lower when compared with the other types of limi- lower in the older age groups, and, with some exceptions tations (less than 40% for all the analysed combinations of for the age-sex groups. In general, proportions are higher age and sex groups). for men (56.75%; CI 54.90–58.61%) than women (50.73%; Percentages of unmet care needs also varied across CI 49.26–52.21%), even though the latter experience more countries, Table 2 presents percentages of individuals with limitations than the other. unmet care needs for those with any limitations and by type In general, individuals with any limitation from the Medi- of limitation. Overall, the trend is that more than 30% of terranean group have higher percentages of unmet care needs the population with any limitation is experiencing unmet 13 11 Page 8 of 14 European Journal of Ageing (2023) 20:11 Table 2  Percentage of people 65 + with an unmet care need from an absolute approach by country and type of limitation Social Care System Country Any Only mobility One ADL and/or any Two or more ADL IADL n % n % n % n % Mediterranean Spain 340 49.49 220 80.00 110 42.64 10 6.49 [45.75–53.23] [75.27–84.72] [36.60–48.67] [2.60–10.39] Greece 750 65.85 599 82.50 144 41.86 7 10.14 [63.09–68.60] [79.74–85.27] [36.65–47.07] [3.02–17.27] Italy 477 57.06 379 83.30 82 32.80 16 12.21 [53.70–60.41] [79.87–86.72] [26.98–38.62] [6.60–17.82] Western Germany 179 43.77 150 60.00 27 25.23 2 3.84 [38.96–48.57] [53.93–66.07] [17.00–33.46] [− 1.38–9.07] France 316 57.04 227 81.36 83 38.25 6 10.34 [52.91–61.16] [76.79–85.93] [31.78–44.71] [2.50–18.18] Belgium 347 42.16 251 67.29 89 25.36 7 7.07 [38.79–45.54] [62.53–72.05] [20.80–29.91] [2.01–12.12] Austria 153 50.33 125 81.17 27 24.55 1 2.50 [44.70–55.95] [74.99–87.34] [16.50–32.58] [− 2.34–7.34] Switzerland 135 49.27 102 61.08 29 32.95 4 21.05 [43.35–51.19] [53.68–68.47] [23.13–42.78] [2.72–39.38] Nordic Sweden 309 62.05 243 82.09 60 40.00 6 11.54 [57.79–66.31] [77.73–86.46] [32.16–47.84] [2.85–20.22] Denmark 212 46.90 163 76.89 44 24.66 5 7.93 [43.30–51.50] [71.21–82.56] [18.49–31.22] [1.26−14.61] Eastern Poland 398 62.97 316 89.27 62 37.13 20 18.01 [59.21–66.73] [86.04–92.49] [29.80–44.45] [10.87–25.17] Czech Republic 168 31.81 139 50.92 28 14.81 1 1.51 [27.85–35.79] [44.99–56.85] [9.75–19.88] [− 1.43–4.46] ADL: Activities of Daily Living; IADL: Instrumental Activities of Daily Living. Confidence intervals, in squared brackets, were estimated based on the z value for 95% confidence (1.96) and standard errors from the analytical sample Source Survey of Health Ageing and Retirement in Europe, seventh wave (2017) care needs. Greece has the highest percentage (68.60%; CI 2). In models 3 to 6, we observed the importance of health 63.10–68.60%), and the Czech Republic the lowest (31.82%; status in explaining unmet care needs, in these models CI 27.85–35.80%). However, less than 25% of people with the variables of self-reported health and chronic disease two or more ADL limitations make front of unmet care where included and both showed statistical significance needs in all countries. For example, in Czech Republic and (p < 0.001) for these coefficients in the three versions of Austria, less than the 3% of people that has two or more the models. According to the statistics used (Akaike and ADL limitations have unmet needs (respectively 1.51%; CI Bayesian indexes of goodness of fit, AIC and BIC), model − 1.43–4.46 and 2.26; CI − 2.33–7.33%), while in France, 6 had the best fit. It included demographic, economic and they are the 10.34% (CI 2.51–18.18%). At the same time, health variables, having children (a potential source of these percentages are higher for people facing one ADLs care), and social care systems. and/or one or more IADLs difficulties, ranging between In all models, younger people (65–74) presented higher 14.81% (CI 9.75–19.90%) in Czech Republic and 42.64% risks of dealing with unmet care needs than the 85+ group, (CI 36.60–48.67%) in Spain. but this difference showed a statistically significant reduc- tion of the odds ratio after adjusting for health status from The experience of unmet care needs: individuals vs 8.908 in model 1 to 3.007 in model 6, this reduction is social care systems smaller but also noticeable in the age group from 75 to 84 from 4.971 in model 1 to 2.032 (see Table 4). Also, Table 3 summarizes the results of six regression models. men were statistically significant (p < 0.001) at higher risk Similar results were observed between the first two mod- of experiencing that situation than women in all models. els, which refer mainly to demographic and economic The odds of facing unmet care needs differed depending characteristics (model 1) and social care systems (model on living arrangements: living with other than the partner 13 European Journal of Ageing (2023) 20:11 Page 9 of 14 11 Table 3  Binomial logistic regressions for estimating unmet care needs in different social care systems Model 1 Model 2 Model 3 Model 4 Model 5 Model 6 Intercept 0.418*** 0.612*** 1.298* 1.966*** 2.434*** 3.650*** [0.344, 0.507] [0.493, 0.758] [1.038, 1.623] [1.552, 2.492] [1.782, 3.329] [2.611, 5.112] Age 85+ (Ref.) 1 1 1 1 1 1 65–74 5.555*** 5.461*** 3.030*** 3.127*** 3.113*** 3.009*** [4.768, 6.485] [4.681, 6.385] [2.545, 3.611] [2.620, 3.737] [2.608, 3.720] [2.517, 3.602] 75–84 2.984*** 2.929*** 2.029*** 2.105*** 2.100*** 2.032*** [2.575, 3.465] [2.525, 3.403] [1.714, 2.404] [1.775, 2.500] [1.771, 2.494] [1.712, 2.415] Gender Female (Ref.) 1 1 1 1 1 1 Male 1.239*** 1.227*** 1.366*** 1.427*** 1.413*** 1.410*** [1.115, 1.378] [1.103, 1.365] [1.212, 1.541] [1.264, 1.612] [1.251, 1.597] [1.248, 1.595] Living arrangements Partner in household (Ref.) 1 1 1 1 1 1 Living alone 1.048 1.062 1.322*** 1.321*** 1.277*** 1.302*** [0.933, 1.178] [0.945, 1.195] [1.157, 1.511] [1.155, 1.513] [1.112, 1.468] [1.132, 1.497] In other arrangements 0.607*** 0.596*** 0.784* 0.831 0.816+ 0.801+ [0.496, 0.741] [0.486, 0.729] [0.622, 0.987] [0.658, 1.047] [0.647, 1.030] [0.633, 1.012] Housing tenure Owner (Ref.) 1 1 1 1 1 1 Tenant 1.002 1.112 1.034 1.082 1.081 1.205* [0.863, 1.164] [0.952, 1.298] [0.874, 1.225] [0.912, 1.284] [0.911, 1.283] [1.009, 1.440] Other 0.890 0.985 0.894 0.945 0.953 1.030 [0.756, 1.047] [0.834, 1.164] [0.744, 1.075] [0.785, 1.138] [0.792, 1.148] [0.851, 1.247] Level of Education High (Ref.) 1 1 1 1 1 1 Mid 0.713*** 0.716*** 0.756*** 0.769** 0.772** 0.767** [0.622, 0.818] [0.622, 0.823] [0.648, 0.882] [0.657, 0.899] [0.660, 0.902] [0.654, 0.900] Low 0.806** 0.673*** 1.064 1.116 1.124 0.931 [0.700, 0.929] [0.578, 0.782] [0.906, 1.250] [0.948, 1.315] [0.954, 1.325] [0.782, 1.108] Social care system Mediterranean (Ref.) 1 1 Nordic 0.745*** 0.784* [0.629, 0.883] [0.643, 0.956] Western 0.559*** 0.527*** [0.491, 0.636] [0.453, 0.613] Eastern 0.588*** 0.632*** [0.504, 0.685] [0.528, 0.756] Self-reported health Good health (Ref.) 1 1 1 Poor health 0.708*** 0.707*** 0.662*** [0.626, 0.800] [0.625, 0.800] [0.584, 0.750] Chronic disease No (Ref.) 1 1 1 Yes 0.569*** 0.570*** 0.598*** [0.500, 0.647] [0.501, 0.649] [0.524, 0.682] Type of limitation Only mobility (no ADL nor IADL) 1 1 1 1 One ADL and/or any IADL 0.165*** 0.188*** 0.187*** 0.189*** [0.146, 0.186] [0.166, 0.212] [0.166, 0.211] [0.167, 0.214] 13 11 Page 10 of 14 European Journal of Ageing (2023) 20:11 Table 3  (continued) Model 1 Model 2 Model 3 Model 4 Model 5 Model 6 Two or more ADL 0.039*** 0.052*** 0.051*** 0.051*** [0.030, 0.049] [0.040, 0.066] [0.040, 0.065] [0.039, 0.065] Children No (Ref.) 1 1 Yes 0.804* 0.807* [0.653, 0.990] [0.653, 0.995] Num.Obs 7136 7136 7136 7136 7136 7136 AIC 9187.2 9101.8 7583.7 7436.8 7434.6 7364.0 BIC 9256.0 9191.2 7666.1 7533.1 7537.7 7487.7 F − 4.583.617 − 4.537.907 − 3.779.830 − 3.704.423 − 3.702.311 − 3.663.999 RMSE 68.272 56.848 148.446 129.183 119.964 99.875 +p < 0.1, *p < 0.05, **p < 0.01, ***p < 0.001 Odds ratio are reported with its confidence intervals in squared brackets. ADL: Activities of Daily Living; IADL: Instrumental Activities of Daily Living Source Survey of Health Ageing and Retirement in Europe, seventh wave (2017) reduced the risk of experiencing it (results were statisti- Discussion cally significant with different p values for all the models but the fourth one). This study aimed to understand the unmet care needs of The educational attainment showed similar results across people aged 65+ from different social care systems in twelve models, suggesting that being low- and middle-educated was European countries. Results showed that the most vulner- associated with lower risks of experiencing unmet care needs able individuals (with poor health, chronic disease, older age than higher-educated individuals. However, differences for group, and women) are at lower risk of experiencing unmet individuals in the lower levels of education became non- care needs, rejecting Hypothesis A. This is consistent with significant after controlling for health variables (models 3 previous evidence from England, which suggested that men to 6). Regarding health variables, first, the type of limitation were at a higher risk of experiencing these (Vlachantoni showed that those with ADLs and IADLs were less at risk 2019) and that older people with poor health were more of experiencing unmet care needs than those with mobility likely to report receiving care (Maplethorpe et al. 2015). limitations alone (p < 0.001). In this line, individuals with These results are probably due to social awareness of the self-reported chronic diseases and poor health were not that care and social support needed by older people with health exposed to experience unmet care needs than those without problems, indicating the importance of social imaginaries. chronic disease and good health (p < 0.001). In addition, In contrast, we observed that people living in countries with having children is associated with a more consistent satis- Mediterranean social care systems are at a higher risk of having faction of individuals’ care needs when compared to those unmet care needs than in other systems, in line with Hypothesis who do not have children (p < 0.001). B. These results are indicative of the diverse approaches within Finally, the models showed that the risk of suffering social care systems, as well as of social awareness about the unmet care needs is lower for individuals in other social urgent care needs required by older adults. Additionally, results care systems than the Mediterranean. This risk was lower in show that family-centred systems may face more challenges in the final model for the Western region (0.527, p < 0.001) and meeting individuals’ needs due to its dependence on the avail- higher in the Nordic one (0.784, p < 0.05); however, smaller ability of family members willing and able to provide care p values were observed in the Nordic group (p < 0.001 vs. (Tennstedt et al. 1993), and these may be changing as women’s p < 0.05). Refined analysis including countries instead of engagement in the labour market increases. For example, a study regions, revealed considerable heterogeneity within the ana- in Spain showed that the willingness to care for the older family lysed social care systems, particularly in the Eastern and members was lower among women with a high level of educa- Nordic social care systems. In the former, Czech Republic tion and doing paid work (Zueras et al. 2018). Previous studies had lower than expected odds ratios, and in the later, Swe- have also emphasized that ageing due to demographic changes den odds ratios were not statistically significant different poses challenges on the availability of informal because of low from Spain. In contrast, countries in the Mediterranean and fertility rates and increases in the percentage of dependent elders Western regions had more homogeneous results (Table 5). who are childless (Spijker and Zueras 2020). 13 European Journal of Ageing (2023) 20:11 Page 11 of 14 11 Table 4  Comparison between Estimate OR Std Error z value Pr( >|z|) model 1 (rescaled to the variance) and model 6 Age 65–74 Model 1 2.187 8.908 0.093 23.404 < 2.2e − 16 *** Model 6 1.101 3.007 0.091 12.049 < 2.2e − 16 *** Difference 1.085 0.062 17.385 < 2.2e − 16 *** 75–84 Model 1 1.404 4.071 0.088 157.977 < 2.2e − 16 *** Model 6 0.709 2.032 0.087 80.729 6,87E − 13 *** Difference 0.695 0.057 120.377 < 2.2e − 16 *** Gender Male Model 1 0.294 1.342 0.062 47.326 2,22E − 03 *** Model 6 0.343 1.409 0.062 54.882 4,06E − 05 *** Difference − 0.049 0.034 − 14.43 0.149 Living arrangements Living alone Model 1 0.108 1.114 0.068 15.784 0.114 Model 6 0.263 1.301 0.071 37.012 0 *** Difference − 0.155 0.042 − 36.778 0 *** In other arrangements Model 1 − 0.644 0.525 0.118 − 54.378 5,39E − 05 *** Model 6 − 0.221 0.802 0.119 − 18.539 0.063 Difference − 0.422 0.074 − 57.034 1,18E − 05 *** Housing Tenure Tenant Model 1 0.009 1.009 0.087 0.105 0.915 Model 6 0.186 1.204 0.09 20.602 0.039 Difference − 0.177 0.053 − 33.129 0 * Other Model 1 − 0.143 0.867 0.095 − 15.067 0.131897 Model 6 0.029 1.029 0.097 0.3034 0.761593 Difference − 0.172 0.058 − 29.578 0.003099 ** Level of education Mid Model 1 − 0.431 0.650 0.08 − 53.516 8,72E − 05 *** Model 6 − 0.265 0.767 0.081 − 32.531 0.001 ** Difference − 0.166 0.042 − 39.333 8,38E − 02 *** Low Model 1 − 0.243 0.784 0.083 − 29.196 0.003 ** Model 6 − 0.071 0.931 0.088 − 0.803 0.421 Difference − 0.171 0.052 − 32.761 0.001 ** Source Survey of Health Ageing and Retirement in Europe, seventh wave (2017) The main contribution of this study is its comparative knowledge this is the first study comparing unmet care needs approach to the analysis of this largely unexplored issue. between different social care systems. Results spotlighted that Our findings show that unmet care needs change depending the demographic characteristics like the age group and gen- on the social care systems of the countries where older peo- der, were associated with unmet care needs, i.e., a higher risk ple live. Despite previous research has shown differences in was found for men than women and for younger than older social care systems between regions and countries (Ariaans age groups. In line with previous research, findings showed et al. 2021; Dunatchik et al. 2019; Pfau-Effinger 2005), to our that the type of limitation explained the risk of facing unmet 13 11 Page 12 of 14 European Journal of Ageing (2023) 20:11 Table 5  Odd ratios of model 6 using countries instead of grouping by However, further research about the relationship between social care systems these unmet needs and different social care systems is still Social care system Country OR needed; through the sensitivity check of the models, it was visible that there are differences within the groups of Nor- Mediterranean Spain (Ref.) 1 dic and Eastern countries. For instance, the results for Swe- Greece 0.729 den and Poland may be explained by recent changes in care [0.570–0.933] policies in these two countries. In the Swedish case, changes Italy 0.832 [0.644–1.073] during the last three decades have been orientated towards Western Germany 0.262 enhancing voluntary choices and individuals’ involvement [0.190–0.361] in their own care; however, these measures are taking place France 0.684 in a context where the second demographic transition may [0.514–0.909] affect the availability of care provision by children and part- Belgium 0.298 ners (Edlund and Lövgren 2022; Moberg 2021). Meanwhile, [0.227–0.389] Poland’s history is characterized by an essential differentiation Austria 0.494 between hospice-palliative care, which emerged in the seventh [0.347–0.703] decade of the last century, and home care (Krakowiak 2020), Switzerland 0.287 [0.200–0.411] gaps between these two ways of care provision may reflect the Nordic Sweden 0.763 lower quality of informal care provided in Poland when com- [0.560–1.039] pared to the other countries (Dobrzyn-Matusiak et al. 2014). Denmark 0.404 In any case, this study has some limitations related to the [0.296–0.552] sample and the measure that we used. The most relevant limita- Eastern Poland 1.353 tion is posed by the assumption behind measuring unmet care [1.020–1.796] needs, which supposes that individuals facing any limitation, Czech Republic 0.149 in fact, need help, even though some of them may be able to [0.110–0.203] cope with these limitations without the support of a caregiver. Confidence intervals are provided in squared brackets Another limitation comes from the small sample size and lack Source Survey of Health Ageing and Retirement in Europe, seventh of representativeness of the analysis by countries, which is why wave (2017) we used groups of countries based on theoretical typologies of social care systems, despite there are internal differences care needs, in our results individuals with only mobility limi- between the countries that are part of the Nordic and the East- tations faced lower risk, meanwhile others have shown that ern social care systems. How to construct typologies of social the chance of suffer them is more strongly associated to ADL care systems is still an ongoing debate. Previous evidence says (Vlachantoni 2019). Living with other people in the house- that there may be more appropriate criteria than a regional hold is associated with a lower risk, which may indicate that approach (Ariaans et al. 2021; Damiani et al. 2011). Neverthe- care is being provided by someone other than the couple, less, this study based its theoretical typology on previous work although previous research has shown that partners are still about welfare state configuration (Pfau-Effinger 2005). the main informal care providers (Kaschowitz and Brandt Some relevant aspects come from using SHARE data to 2017; Uccheddu et al. 2019; Young and Grundy 2008). measure unmet care needs. While studies based on the ELSA In addition, people who live with someone other than a usually ask if someone facing a limitation is receiving the partner (compared with living alone or with a partner with help needed for performing a specific activity (e.g., bath- or without another person) and who are neither owners nor ing or eating), the SHARE asks this after all the questions tenants of the house in which they live are less likely to have about limitations for performing these activities are asked, unmet care needs. Previous evidence on the subject comes which makes it impossible to know the specific activities for from England, where it was estimated that about 55% of older which individuals are facing these unmet needs. Likewise, individuals with ADL, 24% of people with an IADL difficulty, we cannot truly know if the individual needs help to cope and 80% of people with a mobility limitation have unmet care with the limitations that s/he is facing. This problem can needs based on ELSA (Vlachantoni 2019). In contrast, this only be solved by adding a new question in the survey that study found lower percentages of unmet care needs by each directly ask if the person needs care from other to perform type of limitation, even for the population with only mobil- these activities.3 Still, the main value of this study lies in ity difficulties, for whom the highest percentage was found in Greece. Nevertheless, these results are not fully comparable as 3 Following the SHARE wording it can be formulated as: “Thinking the estimation comes from similar but not equivalent questions about the activities that you have problems with, do you need help or and filters in the analysed surveys (Ashokkumar et al. 2012). support from someone else for performing these activities? Yes/No”. 13 European Journal of Ageing (2023) 20:11 Page 13 of 14 11 its comparative nature, which makes it possible to provide as you give appropriate credit to the original author(s) and the source, an empirical estimate of unmet care needs in 12 countries provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are and to gain insights into the differences between social care included in the article's Creative Commons licence, unless indicated systems at the regional level, which may be useful for policy otherwise in a credit line to the material. If material is not included in makers interested in care demand and provision in ageing the article's Creative Commons licence and your intended use is not societies. permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://​creat​iveco​mmons.​org/​licen​ses/​by/4.​0/. Conclusions References Care provision within ageing scenarios make front of chal- lenges in assuring people’s rights and well-being. 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