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<p>Dear all, <br>
</p>
<p>Below the decision on our manuscript from the European Journal of
Ageing - resubmit with major revisions. <br>
</p>
<p>I see many of the comments as difficult to address so this
revision will take quite a bit of effort, I fear. What is more, I
am not at all convinced we can address all of rev 1's comments
satisfactorily so we run a non-indifferent risk of rejection after
the revision.<br>
</p>
<p>I have replied to the editor asking for an extension of the
re-submission deadline for end of year. <br>
</p>
<p>I look forward to discussing our revision strategy and the main
comments with you.</p>
<p>Best, Stefania<br>
</p>
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<th valign="BASELINE" nowrap="nowrap" align="RIGHT">Subject:
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<td>EJOA: Your manuscript entitled Gender Differences in
Access to Community-Based Care A Longitudinal Analysis of
the Effects of Widowhood and Living Arrangements -
[EMID:7358ca9ec4cf1965]</td>
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<th valign="BASELINE" nowrap="nowrap" align="RIGHT">Date: </th>
<td>25 Oct 2021 07:37:43 -0400</td>
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<th valign="BASELINE" nowrap="nowrap" align="RIGHT">From: </th>
<td>Marja J. Aartsen <a class="moz-txt-link-rfc2396E" href="mailto:em@editorialmanager.com"><em@editorialmanager.com></a></td>
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<th valign="BASELINE" nowrap="nowrap" align="RIGHT">Reply-To:
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<td>Marja J. Aartsen <a class="moz-txt-link-rfc2396E" href="mailto:maraar@oslomet.no"><maraar@oslomet.no></a></td>
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<th valign="BASELINE" nowrap="nowrap" align="RIGHT">To: </th>
<td>Stefania Ilinca <a class="moz-txt-link-rfc2396E" href="mailto:ilinca@euro.centre.org"><ilinca@euro.centre.org></a></td>
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<br>
<br>
Ref.:<br>
Ms. No. EJOA-D-21-00215<br>
Gender Differences in Access to Community-Based Care A
Longitudinal Analysis of the Effects of Widowhood and Living
Arrangements<br>
European Journal of Ageing<br>
<br>
Dear Ms. Ilinca,<br>
<br>
I have now received the very informative reviews of three
reviewers who have now commented on your paper. You will see that
they see merit in your work but have detailed and overall
suggestions to improve the work. I invite you for a major revision
of your work. If you decide to revise your work, which I hope,
please be as forthcoming as possible to all comments raised by the
reviewers. <br>
For your guidance, reviewers' comments are appended below.<br>
<br>
Please submit a list of changes or a rebuttal against each point
which is being raised when you submit the revised manuscript.<br>
<br>
Your revision is due by 06-12-2021.<br>
<br>
To submit a revision, go to <a class="moz-txt-link-freetext" href="https://www.editorialmanager.com/ejoa/">https://www.editorialmanager.com/ejoa/</a>
and log in as an Author. You will see a menu item call Submission
Needing Revision. You will find your submission record there.<br>
<br>
Yours sincerely,<br>
<br>
Marja J. Aartsen, PhD<br>
Editor<br>
European Journal of Ageing<br>
<br>
COMMENTS TO THE AUTHOR:<br>
<br>
Reviewer #1: "Gender Differences in Access to Community-Based Care
A Longitudinal Analysis of the Effects of Widowhood and Living
Arrangements"<br>
<br>
Thank you for the opportunity to read and review this manuscript,
which aims to disentangle the effects of gender, widowhood and
living arrangements on the probability of receiving domiciliary
care using SHARE data. The manuscript is well written and asks an
interesting and relevant research question. It aims to fill a
clear gap in the literature on the determinants of care use.
However, I have serious concerns regarding the methodological
approach and, more specifically, about the indicator of
community-based care used in the study, which potentially limit
the extent to which the empirical analysis reflects the aims set
by the authors. In particular, I do not believe the paper is
publishable unless the following "major points" are carefully
addressed, preferably through additional/alternative analyses.<br>
<br>
MAJOR COMMENTS:<br>
<br>
1. Discrepancy between the stated aims, the methodology, and
claims to causality: <br>
Overall I notice a discrepancy between what the study "promises"
in terms of aims, and what it can actually achieve due to data and
method limitations. I think the authors could be more open about
the methodological limitations of the study, as follows.<br>
<br>
i) A stated objective of the study (e.g. in the abstract and
introduction) is to disentangle the effects of gender, widowhood
and living arrangements on the probability of receiving care.
However, all analyses are conducted separately by gender, and
stratifying is not equivalent to testing or disentangling gender
differences in the probability of care. Given that separate models
assume that the data come from different/unrelated populations,
all the authors can do is qualitatively comment on differences in
the coefficients between men and women. "Intersectionality" is
also mentioned at various points in the manuscript, but to the
best of my knowledge this can only be tested through interactions
of gender with the relevant independent variables in a regression
framework.<br>
<br>
ii) similarly, it is unclear how the authors disentangle the
associations of marital status and living arrangements from each
other in a regression framework. Is it simply by controlling for
each other? If so, are there potential for collinearity should be
discussed.<br>
<br>
iii) to my understanding, the authors use hybrid between/within
multilevel models to study associations between time-varying as
well as time-invariant factors and the probability of care use. I
believe that this is an appropriate strategy for capturing
associations. However, I do not think there are the grounds to
interpret those associations in terms of "effects" - a term which
implies and requires causal identification methods. I think
greater consideration needs to be given to the presence of
time-varying unobserved heterogeneity. This may derive from a
variety of sources: two important ones that come to mind are
unmeasured health changes (health deterioration among individuals
with care needs); and unmeasured changes in family circumstances
(concerning the living or family situation of adult children, for
instance). In terms of language, at various points in the study
the authors refer to "longitudinal effects" (e.g. in the "study
objectives" section). Given the likely<br>
presence of time-varying confounders, I do not think this
terminology is appropriate. As a reader I would rather see these
referred to in terms of longitudinal or within-individual
associations.<br>
<br>
iv) The authors limit the analytic sample to individuals with
"care needs" for at least two consecutive waves, assessed by the
presence of 1+ ADL, 1+ IADL, 3+ mobility limitations, or diagnosed
cognitive impairment (Alzheimer's or dementia). I believe this is
a sensible strategy. However, at p.7, the authors state: "by
focusing on those older individuals who experience sustained
functional limitations we are able to identify the effect of
changes in marital status and living arrangement, not confounded
by changes in care needs status". This seems to me like a very
strong claim, given that the health of respondents who are
classified as having "care needs" may deteriorate over time. For
example, someone may go from having 1 IADL limitation at time t to
a combination of 1 IADL + 1 ADL + cognitive impairment at time
t+1. Such an individual's care needs have not remained constant
over time, and the possibility of confounding due to worsening
care needs has not been accounted<br>
(not even in a fixed-effects framework). As the author themselves
note, only about half of the individuals in the sample receive
care despite being classified as having a care need (p.10).
Besides, there may be unobservable/unmeasured changes in health
that are not captured by the controls (see above).<br>
<br>
As a general suggestion, I would recommend getting rid of all
causal claims from the text, and restating the objectives in terms
of what they are - cross-sectional (between) and longitudinal
(within) associations. At best, some sensitivity analysis should
be provided to convince the reader about the potential direction
of causality. For example, if sample size allows, the authors
could restrict the sample to individuals whose health status based
on IADL, ADL, mobility and cognition variables and remains the
same. At the very least, some appropriate discussion of
confounding based on time-varying unobservables should be
included, especially with respect to worsening health and changing
family circumstances.<br>
<br>
2. Care receipt indicator:<br>
<br>
I have a series of concerns regarding the main outcome of the
study, a binary indicator of whether an individual receives any
type of domiciliary care (informal or formal).<br>
<br>
i) I believe that the third question listed at p.8 ("during the
last twelve months, did you receive … any professional or paid
care services due to a physical, mental, emotional or memory
problem?") was not asked at wave 4. This is important because it
means that the wave 4 outcome is not comparable the variable coded
from the other waves. <br>
ii) the substantive focus of this study is on personal care,
commonly defined as care with tasks such as bathing, dressing,
eating, etc. However, the authors include domestic tasks as well
as housework in the definition of the variable. I understand this
is due to data limitations, i.e., the fact that in SHARE waves 4
and 5 it is not possible to distinguish between personal care and
domestic tasks for help received from individuals outside the
household. However, I think this is a serious issue that should be
given greater/more explicit consideration. In particular, the
death of a spouse or a change in living arrangements may
substantially impact the receipt of help with domestic tasks and
have nothing to do with care needs.<br>
<br>
iii) Overall, I am not fully convinced by the strategy of
combining informal care, informal help with domestic tasks, and
formal care into a single binary indicator, as these are
substantially different forms of support that may have different
associations with the main independent variables of interest
(widowhood, living arrangements, and gender). Moreover, the large
variation in the availability of formal care across European
countries implies that formal care receipt may have substantively
different interpretations across country clusters (e.g., it may be
common and affordable in some countries and very rare in others).
<br>
iv) I would like the authors to specify in the text how they
assigned the care receipt variable between cohabiting partners in
waves 1, 2, 4 and 5, where the question on informal care provided
by someone living outside the respondent's household is only asked
to the "family respondent". This is important because the question
in those cases is: "Thinking about the last twelve months, has any
family member from outside the household, any friend or neighbour
given you AND/OR YOUR HUSBAND/WIFE/PARTNER any kind of help [with
personal care or domestic tasks]?" When studied in association
with widowhood, bereavement and living arrangements, a potential
risk is to assign care to both partners while actually only one of
them is receiving it. Then, of course, bereavement may be
longitudinally associated with lower care receipt for a group of
individuals, even though there has been no change in their care
use status.<br>
<br>
In general, I believe the authors should be more straightforward
in the text about the important limitations of the outcome
variable. Potential (partial) solutions should be provided, such
as restricting the analysis to informal care only; or conducting
separate analyses for formal and informal care (excluding wave 4
from the formal care model); or, even further, restricting the
analysis to personal care and considering waves 1, 2, 6, and 7
only (regarding wave 7, see point 3 below). At the very least the
limitations of the present approach should be carefully discussed,
and sensitivity to different specifications of the care variable
should be provided. It is surely not enough to state in the
discussion that "a limitation arises from the inability to control
for the intensity of care received" (p.14).<br>
<br>
3. Inclusion of longitudinal information from wave 7: <br>
I wonder why the authors decided to exclude wave 7 from the
analysis. At p.7 they state that this is due to waves 3 and 7
containing retrospective data and life histories. While it is the
case that wave 3 (SHARELIFE) includes only retrospective data,
wave 7 includes over 13,000 observations from individuals who were
previously interviewed about their life histories at wave 3, and
therefore completed the regular panel modules in wave 7. I think
it would be highly beneficial for the analysis to include those
observations. Most of those individuals were also interviewed at
waves 6, 4 and 5, so this would add substantially to the
longitudinal dimension of the analysis. Moreover, as pointed out
above (point 2), some of the other waves (especially waves 4 and
5) suffer from serious limitations in the way the dependent
variable was coded. By contrast, in wave 7, it is possible to
distinguish between personal care and household help, and all
regular questions about formal care<br>
receipt were asked. I would therefore recommend that wave 7 is
included (i.e. only its regular panel section with around 13,000
observations), unless the authors give a good justification for
its exclusion.<br>
<br>
4. Discussion of human and financial capital. <br>
At p.6, the authors list three interrelated study objectives. 1)
to examine if widowhood and living alone are independent
predictors of the probability of using care; 2) to investigate
gender specific patterns in the association of marital
status/living arrangements with care use; 3) to account for the
effects of financial and human capital, and reflect on how
disadvantage in these dimensions can intersect with sex to
influence patterns of care use. While the first two objectives are
reasonably justified and introduced in the background section,
objective 3) comes as a surprise as the potential
moderation/mediation by financial/human capital is not introduced
as a relevant gap in the literature. I wonder if the authors could
better elaborate on the potential role of human and financial
capital for the associations between widowhood/living arrangements
and care receipt, with reference to previous empirical/theoretical
literature.<br>
<br>
5. Analysis of cross-context differences. <br>
At p.12, the authors split the sample of countries into four
clusters (Nordic, Continental, Southern and Eastern) for the
analysis, with the aim of exploring contextual moderation in the
associations. However, in the background section I could not find
any prior mention of this objective. It is not anticipated to the
reader why one would expect contextual differences in these
associations. Moreover, the classification into four country
clusters is not theoretically justified. From my understanding,
the Carrieri et al (2017) and Albertini & Pavolini (2017)
papers do not propose new classifications but use existing ones.
There is a large literature on welfare regime classifications and,
while I appreciate that an accurate description of each context is
beyond the scope of this paper, I believe that the manuscript
would benefit from acknowledging where the current distinction
comes from and what sort of macro-level institutional/cultural
factors it is based upon. At present,<br>
the division into four clusters feels slightly like an
after-thought.<br>
<br>
<br>
MINOR COMMENTS:<br>
<br>
6. Inclusion / exclusion of covariates: I wonder whether the
authors could describe and clarify their model covariates.<br>
<br>
i) I can see from the tables' footnotes that age is included as a
control in all models - this is obviously very important as it may
confound all associations of interest, especially widowhood/care.
However, this was not clear to me from the text. In the section on
"Independent variables" (p.8/9), age is not mentioned.<br>
<br>
ii) the authors control for mental health in the models - could
they comment on the potential endogeneity of mental health
deterioration to both care use and widowhood? Are the results
consistent if mental health is excluded from the models?<br>
<br>
iii) given that informal care is the most important component of
the care use outcome, why not control for family characteristics
that proxy the availability of informal caregivers, such as the
number of children/daughters, or other potential caregivers (e.g.
siblings etc.)? <br>
<br>
7. Greater emphasis on gender differences in the background. <br>
The discussion of gender differences in care use and its
association with the background of the study could be better
developed. The authors highlight the existence of gender
differences in the experience of ageing, widowhood, and care
needs. However, the subsection on "widowhood, living arrangements
and care resources in later life" does not emphasise the gendered
nature of empirical evidence, even when some of the previous
studies cited are explicitly gendered (e.g. Bertogg & Strauss,
2020). I would suggest better emphasising the gendered nature of
the associations throughout the review of the literature. <br>
8. Structure: Finally, I have some suggestions regarding the
structure of the paper:<br>
<br>
i) some sentences in the "study objectives" section sound more
appropriate for the introduction: "… this analysis is rendered
both timely and highly relevant by changing patterns of
co-habitation among future older age cohorts…/ In addition, it is
important to understand whether transitions into widowhood…/ A
case in point are eligibility criteria to long-term care services:
whereas in some European countries…" (p.5/6).<br>
<br>
ii) in the discussion, I would recommend giving more space to the
limitations of the study (see points 1 and 2 above), and their
potential implications for the validity/generalisability of the
results. The lengthy final paragraph on equity and covid-19 is
interesting, but I have found it to be somewhat unrelated to the
analysis and the results. As such, it could be substantially
condensed.<br>
<br>
<br>
<br>
<br>
<br>
Reviewer #2: The study is well-designed and relevant in the field.
Few comments:<br>
<br>
- introduction: it would be good to include a paragraph with a
summary of available evidence of country differences/similarities
in Europe concerning widowhood, living arrangements, care needs
and resources;<br>
- methods: lines 57-61, p. 7, and lines 1-25, p. 8, should be
moved at the beginning of results, as they are basically
descriptive statistics of observations and individuals;<br>
- dependent variable (p. 8): I am not sure about the convenience
and robustness of merging three different types of care in the
same variable. Authors might want to justify this choice in the
article or try to have e.g. two dependent variables in the
statistical analyses (e.g., informal care - item 1 vs.
formal/professional care - items 2 and 3);<br>
- independent variables: in the statistical analyses it would be
interesting, if possible, to explore differences between
widows/widowers whose partners had the same gender and
widows/widowers whose partners had a different gender;<br>
- limitations: an underestimated limitation to mention is the use
of SHARE data, whose response rates are not fully optimal and have
quite big differences across surveyed countries
(<a class="moz-txt-link-freetext" href="http://www.share-project.org/fileadmin/pdf_documentation/Working_Paper_Series/WP_Series_41_2019_Bergmann_et_al.pdf">http://www.share-project.org/fileadmin/pdf_documentation/Working_Paper_Series/WP_Series_41_2019_Bergmann_et_al.pdf</a>).<br>
<br>
<br>
Reviewer #3: -despite the strong statement on p. 3 (l. 26-27),
referring implicitly to the in sociology and social policy
sciences wellknown concept 'Matthew effect', the article remains
very descriptive; it is mainly a report of the statistical
analysis, but I would appreciate to go (at least one step) beyond
and reflect more in depth about the results and the possible
policy-related consequences/implementation suggestions.<br>
<br>
-the text would benefit from adding some facts and figures (or
percentages) in the literature analysis (one example, but not
exhaustive: p. 5 (l. 20) % informal care giving spouse)<br>
-the text would benefit from adding some concrete examples of
policy measures decided for by various countries regarding
requirements for getting acces to formal care services (it would
also be a concrete illustration of the large variety of hurdles
people can meet, depending on their country of residence)<br>
<br>
-p. 7: add the explicit arguments why the waves 3 and 7 were
excluded (especially wave 7: the most recent one, 2017): the
analysis contains data 2004-2015, but given the quick changes in
social policy measures and in (in)formal care policy in some
countries, more recent data would be welcome<br>
<br>
-p. 7, line 30: it is uncommon to consider the Netherlands as a
'Nordic country' in the typology of welfare regimes. Please add
explicitly the arguments to do so in the text (references to
literature are insufficient here, the concrete explanation is
needed). For readers familiar with welfare regime typologies, the
current information is doubtful. I know that especially related to
elder care, the Netherlands did develop a strong policy of
intervention and support in the past. I assume this is the reason
why the Netherlands are considered 'Nordic' in this analysis. But
one should notice also the tendency towards a more liberal social
policy system and the risk of 're-familialization', also related
to elder care, in more recent years, in the Netherlands<br>
<br>
-the text started with a strong statement, and ends with a strong
statement (p. 15, 20-52): I would recommend to develop these
statements more indepth, proven by findings of your analysis and
other recent literature sources; e.g. the concept of 'systemic
inequalities' needs to be refined, related to the variety of
country clusters in the analysis<br>
<br>
-check reference list: Saraceno 2016 is missing, Leveille et al.
(2014 in text), (2000 in bibliography)<br>
<br>
<br>
-p. 14 (line 1-16): very general and descriptive statement, no
discussion with literature sources, no effort to explain the
findings <br>
-p. 14: the limitations described are indeed serious limitations
of this study; the very general and descriptive approach, with
limited attention given to country (or within country)
differences, raises the question what the added value of this
analysis to the yet existing literature could be. This added value
could be mentioned at the end, but not in very general terms
('research as added value'), but related to the specific debate:<br>
what is new in the debate, based on this analysis?<br>
<br>
__<br>
<br>
<br>
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