Abstract
Introduction
Thailand is experiencing rapid population aging and increasing demand for long-term care (LTC). The proportion aged 80 years and above, a major driver of LTC needs, is estimated to rise 10-fold between 2000 and 2050. Moreover, population cohorts approaching their 70s and 80s have been more exposed to risks related to noncommunicable diseases than previous cohorts, thus making them more vulnerable to disabilities that require LTC (World Bank, 2016). Like other Asian settings, family members have been a linchpin of support for older Thais needing personal assistance with activities of daily living (ADL; Knodel, Teerawichitchainan, Prachuabmoh, & Pothisiri, 2015). However, Thailand’s growing numbers of older persons combined with shrinking family size and increased out-migration of adult children raise concerns about the sustainability of home-based care by family members in the future (Knodel, 2014; Knodel, Prachuabmoh, & Chayovan, 2013).
In Thailand, formal state or paid private LTC services are at an early stage of development. Government efforts to comprehensively address the need to incorporate family based care with community-based and institutional care are limited by a lack of empirical evidence to guide such policy planning. This study attempts to fill that research gap. Based primarily on nationally representative data from the 2014 Survey of Older Persons in Thailand (SOPT), we examine recent patterns and trends in caregiving for frail older Thais in the family context. More specifically, we address the following research questions.
We conclude by discussing the implications for understanding the roles of intergenerational relationships in LTC provision and for improving Thailand’s current programs and policies on LTC.
LTC for Frail Elderly in Comparative Perspectives
Provision of LTC can be carried out in the broadly defined settings that encompass home, community, and institutions and incorporate both health and social care services (World Bank, 2016). Social care involves assistance with ADLs and IADLs as well as social support. In Western settings, LTC provision tends to be dominated by institutional care such as nursing homes (Columbo, Llena-Nozal, Mercier, & Tjadens, 2011; Keenan, 2010). In much of eastern Asia, such formal LTC systems remain in a nascent stage and LTC for older persons is primarily provided informally by family members, who are informally employed women and sometimes elderly themselves (World Bank, 2016).
Adult children in eastern Asia typically hold strong beliefs regarding respect and obligations to assist their parents (Kim, Cheng, Zarit, & Fingerman, 2015). Filial piety, one of the most important cultural ideals, underlies intergenerational relations in many eastern and south Asian societies (Croll, 2006; Slote & DeVos, 1998). It offers guidelines for beliefs and behaviors toward parents, including showing obedience and respect, sacrificing for parents, honoring parents, coresiding with parents, and taking care of parents whether healthy or sick. It is integral to the intergenerational contract under which elderly parents receive support and personal assistance and care from adult children in return for previous sacrifices by the parental generation. Adult children who do not behave consistent with filial piety are likely sanctioned by family members, communities, and sometimes the state. Research in several East Asian settings suggests that aging parents whose children do not behave in appropriate filial ways are at greater risk of adverse psychological well-being (Lim & Kua, 2011; Silverstein, Zhen, & Li, 2006).
Intergenerational coresidence is considered the normative and traditional living arrangement for older persons in much of Asia. It facilitates intergenerational contacts and material and emotional exchanges between generations, particularly aging parents and married children and their families. Coresidence is particularly important for the well-being of Asian elderly given their typical dependence on the family instead of the state to provide old-age LTC (Kim et al., 2015). With changing demographic context, socioeconomic environment and family structure, however, intergenerational coresidence is declining across many Asian countries. Still it remains a prevalent living arrangement for Asian elders and is at higher levels than in Western settings (World Bank, 2016).
Although there is still strong belief that adult children should be supportive of their parents particularly in old age, the behaviors that accompany such belief are in flux (Kim et al., 2015). Evidence indicates that the meanings and practices of filial piety are being modified and reinterpreted by both elderly parents and adult children (Croll, 2006). Caregiving in response to parental care needs is also undergoing transformation. Policies regarding caregiving for older adults may lead to changes in filial behaviors. Recognizing that filial support may have diminished, some governments reform their welfare systems and step in to fill gaps in the safety network for older persons’ income security and care support. Over time, these policies may have altered perception about filial support (Kohli, 1999). For example, after the 1990s welfare reform in China, some formerly government-sponsored elder homes became hybridized (i.e., partially funded by the government), whereas others privatized. A large number of new private and community-run elder homes also opened up for business. This led to competition and improvement in the quality of institutionalized elder care. Institutional care for older persons thus shifted from being considered a stigma to a reinterpretation of filial piety (Zhan, Feng, & Luo, 2008). If adult children are unavailable to provide direct personal care for frail aging parents, they can pay for high-quality institutional care as a way to fulfill their filial duties.
The Thai Context
Changing demographic context across Asia described above characterized Thailand as well and has exposed the limitations of informal LTC for frail older persons particularly by adult children. Moreover, medical advances permit older persons to survive to more advanced ages extending not only periods in good health but also periods of frailty, chronic illness, and disability when routine personal care is required (Murray et al., 2015). Thailand is far from an exception in these respects all of which pose challenges for the role that family members and particularly adult children can play in providing routine personal care for older persons (Knodel et al., 2015).
The current total fertility is estimated at only about 1.5 births per woman down from over six during the 1960s (United Nations, 2015). Thus, in 2014, persons aged 60 to 64 years averaged only 2.5 living children compared with 4.4 among persons aged 80 years and above (Knodel et al., 2015). Already in 2014, persons aged 50 to 54 years who will be entering the older age span within the coming decade averaged only two living children. Unless fertility rises, completed family size of older persons will fall below two children in the foreseeable future.
The provision of personal care requires geographical proximity between caregiver and recipient and is particularly facilitated through coresidence in the same household. Thus, the decline from 77% to 55% between 1986 and 2014 in older persons who live with children further threatens filial caregiving (Knodel et al., 2015). Moreover, non-coresident children are more dispersed. The proportion of adult children who live outside their parents’ province rose from 28% to 39% between 1995 and 2011 (Knodel, Prachuabmoh, & Chayovan, 2013). This further reduces the potential for filial personal care. Hiring paid caregivers to assist older parents with self-care could be one potential solution. However, as the following analysis indicates, resorting to nonfamily paid assistance among older persons remains relatively rare.
In addition to demographic change, social, political, and technological transformation can alter the normative context underlying filial obligations to older-aged parents (Hendricks & Yoon, 2006). So far, however, evidence indicates that the normative context in Thailand has yet to change substantially, although this may occur in the future. There is widespread preference for a family member, especially adult children, over nonrelatives to provide personal care in old age (Knodel, Kespichayawattana, Wiwatwanich, & Saengtienchai, 2013). In addition, the concept that adult children have an obligation to care for aging parents still prevails. However, parental care could be problematic given their children’s obligation to their own conjugal families and the lack of economic opportunities if they return to the parents’ home (Knodel, 2014; Knodel, Kespichayawattana, et al., 2013).
The Thai government is aware of the challenge that LTC poses in the context of decreasing availability of family assistance. The Health Development Strategic Plan for the Elderly (2013-2023) of the Ministry of Public Health clearly spells out a strategy for addressing LTC. The plan is based on the assumption that the quality of life of older persons at advanced ages can be best retained through a combination of assistance within their family and a supporting system of health care and social services within their own community. It emphasizes the need for the community and local administrative organizations to cooperate in implementing the LTC system, including allocating a budget for the purpose. The components of the system include databases on older persons, good-quality clubs for elderly people, volunteers to provide home-based care for older persons, preventive dental services, and a system to ensure care for the elderly who are home- or bed-bound (Foundation of Thai Gerontology Research and Development Institute & College of Population Studies, 2012).
With respect to providing home-based assistance for older persons, the Bureau of Empowerment for Older Persons (now Department of Older Persons) launched the Home Care Service Volunteers for the Elderly Program in 2003. It established a system of community-based care and protection for older persons with chronic illnesses, especially for those who are bedridden, who have no caregivers or who are underprivileged. By 2013, it provided some level of coverage in all communities throughout Thailand and involved over 51,000 elderly home care volunteers who were responsible for nearly 800,000 older persons (Ministry of Social Development & Human Security, 2013). Nevertheless, the extent and quality of services provided by home care volunteers vary greatly across communities. Key challenges include insufficient numbers of qualified and skilled home care volunteers and lack of budget to compensate them for their activities (e.g., transportation expenses; Suwanrada, Pothisiri, Siriboon, Bangkaew, & Milintangul, 2014).
Long-term institutional residences for older persons in serious need of elder care provided by the Thai government are considered only as a last resort for dealing with persons in need of LTC care. Thus, as of 2012, there were only 12 institutional old-age homes supported by the national government with under 2000 residents and 13 others under the supervision of the Department of Local Administration (Foundation of Thai Gerontology Research and Development Institute & College of Population Studies, 2012).
Data and Measurement
The social, economic, and health situations of older persons have been documented in a series of cross-sectional surveys (Teerawichitchainan & Knodel, 2015). The present analysis is based primarily on the 2014 survey, which collected information on all persons aged 50 years and above in each sample household as well as information from their caregivers. Analyses are restricted to 38,695 persons aged 60 years and above, the age range most commonly used when referring to the older-aged population in Thailand. After applying appropriate weights, the sample is nationally representative 2 . Unless otherwise indicated, results in the tables and figures are based on the full sample of persons 60 and above excluding a very small number with missing information. For results presented that are not based on the full sample the unweighted number of cases is shown.
Overall, among persons aged 60 years and above covered in the 2014 survey, 79% provided interviews by themselves, 5% were assisted by another person, and 16% by a proxy (typically another household member). Proxy interviews are important as they allow inclusion of older persons that were particularly frail, had serious hearing difficulty, suffered from dementia, or who were absent at the time of interview.
Relevant to the present analysis, the survey included questions that solicited a variety of information to assess the need for assistance in ADL as well as information on the main care provider for those who received such assistance. Respondents were asked directly if they wanted or needed (tongkarn) someone to help them with their daily living activities. Thus, the 8.5% who gave positive responses reflected either a need or a desire for personal assistance or some combination of the two. Note that this question left the definition of daily living activities up to respondents who likely thought of them in a broad generic sense. Thus, what respondents considered as daily living activities might not have corresponded to the far more narrow set of specific activities that are referred to as such in the gerontological literature and in our analyses.
Respondents were asked to self-assess if they experienced specific difficulties involving four physical functional activities (i.e., lifting 5 kg, squatting, walking 200-300 m, and climbing a few stairs), eight ADL (i.e., eating, using toilet, washing face/brushing teeth, bathing, dressing, grooming self, putting on shoes, and getting up from lying) and three IADL (i.e., taking bus or boat on own, counting change, and taking medicines). 3 Possible answers ranged from 1 (no), 2 (yes with assistance), to 3 (yes without assistance). The three answer categories of each activity were recoded into a dichotomous variable, where 1 indicates yes, and 0 indicates otherwise. Although some of these conditions may be temporary, it seems reasonable to assume that most are unlikely to improve substantially in the future. The total number of difficulties reported is used in the following analysis to measure need for long-term personal care.
Table 1 indicates that these measures correspond well with reported self-assessed physical health during the past 7 days and self-assessed need or desire for help with ADL. Functional, ADL, and IADL difficulties are relatively rare among respondents who assessed their health as very good to fair, averaging a total of just less than 1 of the 15 possible difficulties asked about. In contrast, those who reported their health as poor and even more so those who said their health was very poor reported far more difficulties with the latter averaging more than eight. The results also show a substantially higher mean numbers of functional, ADL, and IADL difficulties for respondents who indicated need or desire for help with ADL than those who did not. Similar stark patterns of differences are evident with respect to the percentages that reported experiencing any of the various types of difficulties.
Mean Number of Functional Limitations and ADL and IADL Difficulties and Percentage With Any Functional Limitation and ADL and IADL Difficulty by Self-Assessed Health and Self-Assessed Need or Desire for Assistance With Daily Living Activities, Persons Aged 60 Years and Above.
Source. 2014 Survey of Older Persons in Thailand.
Note. The four most basic ADL are assumed to consist of eating, using toilet, bathing, and dressing. ADL = activities of daily living; IADL = instrumental activities of daily living.
Older-aged respondents in this survey who received assistance with daily living activities were asked how they were related to their main care provider. 4 Additional information on this was also available from the caregivers themselves. Among the 3,278 caregivers interviewed, 92% were the main caregiver and 8% a minor caregiver. Respondents that said they need or want assistance with daily living activities but report that no one provides such care are considered as having an unmet need.
The main independent variables used in the analysis in addition to the total number of functional, ADL, and IADL difficulties, which indicate need for assistance vary somewhat with the particular dependent variable being analyzed. They include gender, age, area of residence, education of respondent, value of respondent’s total assets and living arrangements. The inclusion of these variables is determined by their likely association with physical difficulties and their availability in the data set.
The main statistical methods used in the present study are cross-tabulation, binary logistic regression and multiple classification analysis (MCA). The binary logistic regression is used when the dependent variable is binary. It provides the odds of a predicted outcome for each category of the independent variables and tests for significant differences between them. The MCA is utilized when the dependent variable is continuous but all the independent variables are categorical, either nominal or ordinal scales. The MCA provides a mean value of the dependent variable for each category of the independent variables that are adjusted for the effects of all other variables included in the model.
Results
Prevalence and Differentials of Self-Care Disability
As Table 2 shows, the extent to which people have functional limitations, ADL difficulties and IADL difficulties varies considerably. Although the survey asked about eight potential ADL difficulties and only four functional limitations and three IADL difficulties, the mean number of ADL difficulties reported is lowest with only 7% of respondents reporting any. This compares to over one third reporting at least one functional limitation and over one fourth an IADL difficulty.
Functional Limitations, Difficulty With ADLs and Difficulty With IADLs by Age, Gender, and Area of Residence, Persons Aged 60 Years and Above.
Source. 2014 Survey of Older Persons in Thailand.
Note. ADL = activities of daily living; IADL = instrumental activities of daily living.
At the same time, the pattern of differences according to age, gender, and residence are similar across the three sets of physical difficulties. Both the mean number of problems and the percentages having at least one of each type of the three categories rise with age. Particularly sharp increases are apparent between those in their 70s and those 80 and above. Women are substantially more likely than men to report these three types of difficulties. Interestingly, with respect to place of residence, older-aged persons in Bangkok appear to be distinctly physically disadvantaged. This is unlikely to be due to difference in age and sex distributions as the percentage of women in Bangkok in the sample is only 1% higher than in the country as a whole and younger elderly (i.e., 60-69 years in age) are more prevalent. Instead, this could reflect a tendency for persons with physical difficulties to move to Bangkok where superior medical facilities are far more common.
Care Providers
Information provided by main caregivers indicated that 94% coreside with the care recipient and most of the remainder lived adjacent or very nearby. As Table 3 shows, based on information from respondents aged 60 years and above, only 11% received assistance with their ADL. This varied substantially according to the level of need for assistance. Only 6% of those who reported that they did not need or want assistance indicate that they received care compared with almost two thirds of those who said that they needed or wanted assistance. 5 Similarly among those who assessed their health as at least fair, only 7% indicated that they received care. In contrast, over one fourth who reported their health as poor and two thirds who said their health was very poor said someone helped them with their daily living activities.
Percentage Receiving Care and Percent Distribution of Main Care Providers Among Those Receiving Assistance, Persons Aged 60 Years and Above (n = 3,857).
Source. 2014 Survey of Older Persons in Thailand.
Note. Care refers to assistance with daily living activities as defined by respondents. Other relatives include grandchildren, siblings, and parents; nonfamily members are primarily employees including servants or health professionals. ADL = activities of daily living; IADL = instrumental activities of daily living.
With regard to the proportion receiving care for functional limitations, and ADL and IADL there is a noticeable difference between those who reported limitations and difficulties and those who reported having none. Moreover, the difference in the proportion receiving care between those who reported one and those who reported multiple limitations or difficulties is particularly striking. Having ADL difficulties is clearly associated with a higher probability of receiving assistance than having either functional limitations or IADL difficulties. This underscores ADL problems as particularly relevant for creating a need for a caregiver. Moreover, as the number of total difficulties reported increases, the likelihood of receiving care increases as well.
Table 3 also reveals that overall children—male and female—are by far the most common main caregiver accounting for over half (55%). However, it is far more likely that the child providing the care is a daughter than a son. Spouses rank second making up almost 30% of main assistance providers with daily living activities. Children-in-law only infrequently serve as the main person providing assistance. However, apparently the large majority of children-in-law who are main caregivers are daughters-in-law. 6 Together, spouses, children, and children-in-law represent about 90% of main caregivers for persons aged above 60 years. Most of the remaining 10% are other relatives with fewer than 2% reporting nonfamily members (mainly employees or professional persons) as their main source of assistance. Although not shown in the table, it is interesting to note that if only currently married recipients with children are considered, spouses account for 61% of the main caregivers and children for 34%. Thus, the situation is almost reversed when respondents have both a living spouse and living children. However, when both a spouse and a child are coresident, they are about equally likely to be the main caregiver (49% and 47%, respectively).
In general, regardless of the measure of need, spouses as main providers of care decline with increasing need while daughters together with children-in-law are commensurately more common. Underlying this relationship undoubtedly is that those with greater need are distinctively older than those with less or no need. For example, the average age among persons aged 60 years and above rises virtually steadily from 67.0 for those with no limitation or difficulty to 79.5 for those with 10 or more (not shown in table). Increased age in turn is related to higher chances of widowhood and thus with no spouse available to provide assistance.
Figure 1 summarizes the relationship between age of care recipients and the role of spouses and children or children-in-law as the main care providers. The percentage of main providers who are a spouse declines steadily and almost linearly with age while the percentage whose main caregiver is a child or child-in-law increases. Among care recipients in their early 60s, spouses account for over 60% of main providers and compared with about half for those in their late 60s. At the same time, children or children-in-law represent only just over one fourth of main caregivers for persons in their early 60s but rises linearly with age reaching just over two fifths for those in their late 60s and almost four fifths for those aged 80 years and above. The role of others besides spouses and children or children-in-law is low and remains almost unchanged at only around 10% of main caregivers regardless of the age of recipients.
Percent distribution of main care givers to persons aged 60 years and above who receive assistance with their activities of daily living (n = 3,857).
Met and Unmet Need for Assistance
An important issue concerning LTC is the extent to which those who need or want assistance receive it. Respondents who reported that they needed or wanted assistance with daily living activities and received it are considered as having a met need for such assistance. The remainder is treated as having an unmet need. As panel A of Figure 2 clearly shows, not only is the desire for assistance in daily living activities strongly related to the total number of functional, ADL, and IADL difficulties, but so is unmet need. Clearly the proportion of respondents who said they needed or wanted assistance increases steadily with the total number of difficulties, slowly at first then sharply starting with six or more difficulties. Unmet need declines fairly steadily with increased numbers of difficulties experienced. Thus, unmet need characterizes over two thirds of those who need or want assistance but experience three or fewer difficulties but declines sharply starting at four dropping from just under half to only 12% of those with 10 or more difficulties.
Unmet need for assistance with ADL, persons aged 60 years and above who report a need or desire for assistance (n = 3,212).
Panel B in Figure 2 examines the association of unmet need with different living arrangements both unadjusted and statistically adjusted using MCA for the total number of difficulties. Although the adjusted results differ modestly from the unadjusted results, the relative ordering of the arrangements are the same. Unmet need is clearly highest among those who live alone and lowest for those who live with children but not a spouse. The latter may reflect that children take into consideration the need for care when making decisions about whether to leave a parent living without a coresident spouse or another coresident child.
Table 4 provides a multivariate analysis based on binary logistic regression of several potentially important covariates of met need. Results are shown as odds ratios unadjusted, adjusted only for the total number of physical difficulties, and adjusted for all covariates included in the analysis. Prior to any adjustment, gender shows virtually no relationship to met need for assistance but women appear disadvantaged compared with men once results are adjusted for the total number of physical difficulties and even more so when adjusted for all covariates. Increased age is clearly associated with higher likelihood of met need for assistance. The degree of association is moderated when the influence of other variables are taken into account, especially when the total number of physical difficulties experienced by the respondent are controlled.
Odds Ratios From Binary Logistic Regression Predicting Met Need for Assistance With Daily Living Activities, Older Persons Aged 60 Years and Above Who Report a Need or Desire for Assistance (n = 3,212).
Source. 2014 Survey of Older Persons in Thailand.
Note. Total number of difficulties is adjusted as a continuous variable. Values of p shown indicate the level of statistical significance of differences within the set categories in the variable. ADL = activities of daily living; IADL = instrumental activities of daily living.
Met need varies to some extent with area of residence and is particularly high in urban areas excluding Bangkok. Education shows relatively little relationship to met need. However, persons with assets are less likely to have met need for assistance than those with no assets although the value of the assets seems to make little difference. Living arrangements clearly are related with those living alone particularly disadvantaged with respect to met need.
Discussion and Conclusions
Our study significantly expands the literature related to the situation of LTC among Thailand’s rapidly aging population. First, the analysis informs the extent and differentials in LTC among older Thais. Consistent with research in other settings, we find that LTC needs (as indicated by prevalence of physical difficulties particularly restriction in ADL) rise sharply with age. Serious needs for personal assistance, however, tend to be concentrated at advanced ages and are more common among older women than men. Furthermore, the study informs the patterns of care provision for older Thais with LTC needs. As in much of developing world, responsibility for care and support of older Thais in need of assistance traditionally rests with the family, especially with their adult children (Knodel, Prachuabmoh, & Chayovan, 2013; National Research Council, 2011). Our empirical results indicate that children and spouses remain predominant sources of informal care support constituting approximately 90% of main caregivers. Extending prior research, we further reveal that the association between having a family member as the main caregiver and socioeconomic characteristics (as measured by education or value of assets) is quite weak once other influences are taken into account. This underscores a strong and virtually universal normative prescription for family to serve as LTC providers as has been documented in numerous previous studies (Cowgill, 1972; Knodel & Chayovan, 2012; Knodel, Saengtienchai, & Sittitrai, 1995).
Importantly, our study investigates the extent to which LTC needs are met in Thailand. We find that experiencing assistance among those needing LTC increases with age, although the extent of the increase is moderated once the extent of physical difficulties is controlled. The importance of filial assistance in meeting LTC needs is also clear from the association implicit in living arrangements, in particular coresidence with adult children. This finding is consistent with substantial previous research on the topic. Furthermore, results indicate that older persons in provincial urban areas compared with those in Bangkok and rural areas are especially likely to indicate their need for assistance with daily living activities is met especially once other variables are controlled. The explanation for this observation is, however, not evident in the present analysis. Additional research is needed to determine the findings’ robustness and their underlying reasons.
We are mindful of study limitations. First, given the cross-sectional nature of the data, we only examine associations between various covariates, physical difficulties, and met need for LTC. We cannot attribute causality to them. Second, our data source undoubtedly is affected by response errors as is true for any survey. The measures of functional limitations, ADL, and IADL difficulties are self-reported and thus subjective. Responses concerning needs or desire for assistance with ADL are likewise subjective and hence might be influenced by whether or not assistance is being provided, thus creating problems of statistical endogeneity.
Despite these limitations, the present study helps guide policy planning on LTC. Empirical findings, for instance, suggest that policy makers need to pay serious attention to gender dimension of LTC support. The present analysis makes clear that daughters and wives are much more likely to be the main care provider compared with sons or husbands. The prospect for this to change remains uncertain. The role of husbands as main caregivers for wives is restrained by the fact they are much more likely to predecease their wife. Husbands are typically older than their wives and thus reach advanced ages sooner where mortality risks are higher. This is somewhat counteracted by the fact that at any given advanced age women tend to be in poorer health than men, at least in terms of self-reported health. With reduced family size, the proportion of persons entering advanced ages that has only sons and no daughters will increase as average family size decreases. This increase is already quite evident. According to the 2014 survey, 22% of persons aged 50 to 54 years have only sons compared with only 9% of those aged 80 years and above. Among persons aged 60 years and above who receive assistance with daily living activities, daughters are the main caregivers in 58% of the cases whereas sons are the main caregivers in only 33%. Given the deeply entrenched normative acceptance of women as the appropriate gender to provide personal care, the extent to which sons will sufficiently take this responsibility is questionable at best.
Furthermore, our analysis demonstrates a very limited role of nonfamily members as care providers, hence more room to grow in the future. To facilitate the roles of paid caregiver and private sector in LTC, policy makers should be mindful of existing norms, expectations, and preference in personal care support. An analysis based on the national surveys of adults aged 18 years to 59 years in 2007 and 2011 shows overwhelming preference for family members as main care providers with two thirds specifically citing children as their preferred choice (Knodel, Prachuabmoh, & Chayovan, 2013). The low reliance on paid persons or other nonfamily members to take main responsibility for caregiving could be due not only to limited availability as well as affordability of such services but also to concern over the quality of care received (Knodel et al., 2015). Attitudes toward paid carers depend in part on the nature of their role (Knodel, Kespichayawattana, et al., 2013). A paid caregiver that fills in when a coresident adult child is at work or assists when the child is present is more acceptable than employing a paid caregiver as a full-time replacement for a child that lives elsewhere.
In assessing the future of family caregiving to frail older persons in Thailand, it is important to recognize that the social, economic, political, and technological context is continually changing. Thailand’s national and local governments not only are well aware of the challenges posed by LTC needs of older persons but are actively participating in ways to ease the burden of LTC on families (Knodel et al., 2015). For example, the Ministry of Public Health clearly spells out a plan that includes establishing databases on older persons, good-quality elderly clubs, volunteer groups to provide home-based care for older persons, preventive dental services, and a system to ensure care for older persons who are home or bed bound. 7 It is very likely that this trend will continue. In addition, assistive technologies are likely to be more commonly used even if only those that are relatively simple and inexpensive such as installation of hand rails and use of walkers with or without wheels will be most common in the foreseeable future. Although empirical data are largely lacking on the role of the private sector, it is likely to play an increasing if mainly supplementary role in LTC of older persons. For example, agencies that provide persons trained in care for frail or disabled older persons are likely to increase. Paid caregivers (including domestic workers) may well become a more common sight in Bangkok and/or other urban areas. Although it is unlikely that any demographically significant segment of the older population in need of LTC will rely on institutional care in the foreseeable future, still it is likely to increase somewhat especially if the economy improves and higher quality institutional care becomes available.
Looking ahead, ongoing demographic change will continue to escalate the challenges of care support. Although the state and local communities are expanding their roles in response to rising demands for LTC, schemes to assist older persons and their families sometimes struggle to keep pace with rapid socioeconomic and technological change within a context of constraints in resources and political will. Clearly continued research into the situation of older persons and the extent to which their LTC needs are being met by their families, communities, and society at large will remain essential.
Footnotes
Authors’ Note
This article was presented at the Conference on Long-term Care for Elderly in ASEAN Plus Three: Research and Policy Challenges, 1-2 March 2016, organized by the Asia Research Institute, National University of Singapore.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.