[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]

Thu Oct 28 14:54:52 CEST 2021

Dear Stefania, dear all,

That was quite a laundry list of comments. I think we should be able to address or contest most of them, but it will take some work. Skimming through the comments of reviewer #1, it seems to me that themain question is whether we want to adapt the analyses to the research questions or the research questions to our analyses. I would think that the latter is more tractable, but let's talk about it.

All the best,

Stefan

Från: Futuregen <futuregen-bounces at euro.centre.org> För Stefania Ilinca
Skickat: den 27 oktober 2021 14:50
Till: futuregen at euro.centre.org
Ämne: [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]

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><mailto:em at editorialmanager.com>
Reply-To:
Marja J. Aartsen <maraar at oslomet.no><mailto:maraar at oslomet.no>
To:
Stefania Ilinca <ilinca at euro.centre.org><mailto: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/<https://eur01.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.editorialmanager.com%2Fejoa%2F&data=04%7C01%7CStefan.Fors%40ki.se%7C0ee1a4c35e074da3aabf08d99948564e%7Cbff7eef1cf4b4f32be3da1dda043c05d%7C0%7C0%7C637709359012348040%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C3000&sdata=A8a5WOqcIIgZ9esVzyM69VG4kcjeOYarvdapRibpZw0%3D&reserved=0> 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<https://eur01.safelinks.protection.outlook.com/?url=http%3A%2F%2Fwww.share-project.org%2Ffileadmin%2Fpdf_documentation%2FWorking_Paper_Series%2FWP_Series_41_2019_Bergmann_et_al.pdf&data=04%7C01%7CStefan.Fors%40ki.se%7C0ee1a4c35e074da3aabf08d99948564e%7Cbff7eef1cf4b4f32be3da1dda043c05d%7C0%7C0%7C637709359012358034%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C3000&sdata=Ui0gmiwx3wlzTaAnR8ZioZzmck4locQyFxGn2EWwJto%3D&reserved=0>).

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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