[Futuregen] Fwd: 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]

Wed Oct 27 14:49:58 CEST 2021

Dear all,

Below the decision on our manuscript from the European Journal of Ageing 
- resubmit with major revisions.

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.

I have replied to the editor asking for an extension of the 
re-submission deadline for end of year.

I look forward to discussing our revision strategy and the main comments 
with you.

Best, Stefania

-------- Forwarded Message --------
Subject: 	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]
Date: 	25 Oct 2021 07:37:43 -0400
From: 	Marja J. Aartsen <em at editorialmanager.com>
Reply-To: 	Marja J. Aartsen <maraar at oslomet.no>
To: 	Stefania Ilinca <ilinca at euro.centre.org>

Ref.:
Ms. No. EJOA-D-21-00215
Gender Differences in Access to Community-Based Care A Longitudinal 
Analysis of the Effects of Widowhood and Living Arrangements
European Journal of Ageing

Dear Ms. Ilinca,

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.
For your guidance, reviewers' comments are appended below.

Please submit a list of changes or a rebuttal against each point which 
is being raised when you submit the revised manuscript.

Your revision is due by 06-12-2021.

To submit a revision, go to https://www.editorialmanager.com/ejoa/ and 
log in as an Author. You will see a menu item call Submission Needing 
Revision. You will find your submission record there.

Yours sincerely,

Marja J. Aartsen, PhD
Editor
European Journal of Ageing

COMMENTS TO THE AUTHOR:

Reviewer #1: "Gender Differences in Access to Community-Based Care A 
Longitudinal Analysis of the Effects of Widowhood and Living Arrangements"

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.

MAJOR COMMENTS:

1. Discrepancy between the stated aims, the methodology, and claims to 
causality:
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.

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.

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.

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
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.

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
(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).

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.

2. Care receipt indicator:

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).

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.
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.

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).
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.

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).

3. Inclusion of longitudinal information from wave 7:
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
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.

4. Discussion of human and financial capital.
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.

5. Analysis of cross-context differences.
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,
the division into four clusters feels slightly like an after-thought.

MINOR COMMENTS:

6. Inclusion / exclusion of covariates: I wonder whether the authors 
could describe and clarify their model covariates.

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.

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?

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.)?

7. Greater emphasis on gender differences in the background.
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.
8. Structure: Finally, I have some suggestions regarding the structure 
of the paper:

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).

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.

Reviewer #2: The study is well-designed and relevant in the field. Few 
comments:

- 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;
- 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;
- 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);
- 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;
- 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 
(http://www.share-project.org/fileadmin/pdf_documentation/Working_Paper_Series/WP_Series_41_2019_Bergmann_et_al.pdf).

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.

-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)
-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)

-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

-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

-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

-check reference list: Saraceno 2016 is missing, Leveille et al. (2014 
in text), (2000 in bibliography)

-p. 14 (line 1-16): very general and descriptive statement, no 
discussion with literature sources, no effort to explain the findings
-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:
what is new in the debate, based on this analysis?

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