Work-family balance among caregivers of elderly people: a systematic review

Abstract

Introduction

Active workers may experience role conflict when trying to reconcile work and caregiving activities with elderly family members.

Objective

To carry out a systematic review of empirical research on work-family balance among caregivers of the elderly.

Method

Scopus, PubMed, Scielo, BVS, Web of Science and PsycInfo databases were consulted to identify research published from 2015 to 2020.

Results

20 articles were identified and categorized as follows: 1. Caregivers of elderly people with dementia and cancer; 2. Gender; 3. Sandwich Generation and Baby Boomers; and 4. Individual and collective coping strategies. It was highlighted that there are specificities in the work-family balance that can favor both positive and negative spillovers; therefore, they must be considered in the planning of individual and collective strategies.

Conclusion

In order to favor work-family balance, the choices between work and family responsibilities should be studied, as well as expanding this narrow framework through the analysis of aspects involving gender, biography, cultural norms, social values, economic aspects and political solutions available to these workers.

Keywords:
Work-life balance; Caregivers; Aged

Resumo

Introdução

Trabalhadores podem vivenciar um conflito de papéis ao tentarem conciliar trabalho e atividades de cuidado com familiares idosos.

Objetivo

Realizar uma revisão sistemática das pesquisas empíricas sobre equilíbrio trabalho-família entre cuidadores de idosos.

Método

Foram consultadas as bases de dados Scopus, PubMed, Scielo, BVS, Web of Science e PsycInfo para identificar as pesquisas publicadas no período de 2015 a 2020.

Resultados

Identificaram-se 20 artigos que foram categorizados da seguinte forma: 1. Cuidadores de idosos com demência e câncer; 2. Gênero; 3. Geração Sanduíche e baby boomers; e 4. Estratégias de enfrentamento individuais e coletivas. Destacou-se que existem especificidades no equilíbrio trabalho-família que podem favorecer tanto o spillover positivo quanto o negativo; por isso devem ser consideradas no planejamento das estratégias individuais e coletivas.

Conclusão

Para favorecer o equilíbrio trabalho-família, deve-se estudar as escolhas entre os trabalhos e responsabilidades familiares, bem como ampliar esse quadro estreito por meio da análise de aspectos que envolvam gênero, biografia, normas culturais, valores sociais, aspectos econômicos e soluções políticas disponíveis a esses trabalhadores.

Palavras-chave:
Equilíbrio trabalho-vida; Cuidadores; Idosos

Introduction

Until the 1960s, much attention was paid to the necessities of workers that needed to reconcile employment and family activities, such as caring for elderly dependents and children. However, with the aging of the population, the intensification of employment for women working outside the home space has increasingly the number of workers who must provide care for an elderly while in the job market. Therefore, it is necessary to pay attention to workers who may have role conflicts when trying to manage work and care functions, leading to a worsening of physical and mental health, in addition to decreased work performance (Sousa et al., 2021).

Work-family conflict is a specific type of role conflict that occurs when the demands of a family role conflict with the demands of a work role, or vice versa. This conflicting experience can lead to emotional problems and/or physical exertion, impairing individuals' well-being and satisfaction with their role and performance (Medeiros et al., 2017). Some causes of work-family conflicts are related to long working hours and work overload. On the other hand, a supportive supervisor and effort in a supportive family environment are related to a reduced degree of conflict (Sousa et al., 2021).

However, recent studies have a more positive perspective, as they question the existence of only negative effects of one sphere on the other. In the spillover model, it is evident that there are not only negative, but also positive effects in the involvement of work on the family, and vice versa. Therefore, the relationship between the professional and family domains can be either positive or negative, or both simultaneously. If it is positive, it is said that the role was promoted (positive spillover). On the other hand, when it is negative, the notion of conflict between work and family (negative spillover) is supported (Depasquale et al., 2018; Medeiros et al., 2017).

In the perspective of positive spillover, the possibility of transferring knowledge and skills, as well as psychological benefits from one sphere to the other is pointed out. Participation in a role can provide skills and resources that can be used to enable development and better functioning in other spheres of life. On the other hand, a high number of working hours and emotional tension can contribute to a negative spillover (Depasquale et al., 2018; Medeiros et al., 2017). Thus, it is essential to investigate how much work can impact the family (self-esteem, informational and emotional support, in addition to financial resources) and how much the family can be beneficial for success at work (support for stress management, financial support spouse and practical help with professional commitments) (Barham & Vanalli, 2012; Matias & Fontaine, 2012).

While in Western Europe in North America there is a broad discussion about family needs of working individuals, in Brazil this is still a recent discussion. In this direction, a systematic collection of data on this topic is scarce, in addition to few studies on the gender effect of care, the impact of care on personal and professional life, and public policies in favor of reconciling work and family (Medeiros et al., 2017). Thus, scientific production is needed to contextualize them as themes with the purpose of reflecting on psychosocial intervention strategies.

Method

Delimitation

Conducting a systematic review implies investigating and integrating a set of studies that have similar or divergent results, so that it is viable to identify possible knowledge gaps for future investigations (Sampaio & Mancini, 2007).

First, a query was carried out on the Health Sciences Descriptors (DeCS) to identify the terminology and speed up the search process in the databases. The following descriptors were identified: work-life balance, caregivers, elderly, work and family. In the next step, consultations were started with these descriptors in Portuguese, Spanish and English, in the following databases: Scopus, Pubmed, Scielo, BVS, Web of Science and PsycInfo.

Inclusion and exclusion criteria

For the selection of articles, the Zotero® app, which helps in the process of reading and storing the selected studies. The reading of the articles took place in three stages: 1) carrying out searches in the selected databases; 2) reading by title and abstract of studies; 3) full reading of the selected articles, remaining only those that presented the eligibility criteria according to the proposed theme. The selection and evaluation of the studies were carried out by professionals in the health field. The level of evidence applied to the selected studies was based on clarity and study justification, methodological design, description of data collection and its instruments (Medina & Pailaquilén, 2010).

We sought to include studies carried out between 2015 and 2020, in which caregivers of the elderly were participants. Articles that provided the full text were included and theoretical and review studies were excluded.

Procedures

After extracting the articles from the databases, the inclusion/exclusion criteria and the removal of duplicate articles were applied. A spreadsheet was used to enter the following information about the articles: study names; authors; year of publication; objectives; method; instruments; synthesis of the results obtained; journal in which the study was published. The international recommendation Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA, 2021) was used in the process of identification, selection and eligibility of articles, in order to have quality criteria.

Data analysis

The titles and abstracts of the articles were read by thematic categorization. Thematic analysis was used to construct categories (Bardin, 2002). In the next step, the full reading of the studies was carried out to write the results.

Results

Figure 1 shows the flowchart of the search, selection and inclusion of articles.

Figure 1
Selection of articles according to PRISMA recommendations. São Carlos, São Paulo, Brazil, 2021. Source: Research Data.

Regarding the research methods consulted, 14 were quantitative studies and 6 were qualitative articles. The participants were caregivers of the elderly, of both sexes; however, the female gender prevailed in the surveys. Table 1 presents the characteristics of each article selected to compose the sample.

Table 1
Presentation of the articles selected for analysis according to their authorship, delimitation, objective, category, instruments used and conclusions. São Carlos, SP, Brazil, 2021.

Author	Delimitation	Objective	Instruments	Conclusions
Honda et al. (2015)	Cross-sectional quantitative study.	To examine the differential impact of various roles associated with psychological distress among Japanese workers.	Kessler Psychological Distress Scale (K10).	Participants who had only one job function had an increased risk of psychological distress.
Hansen & Slagsvold (2015)	Cross-sectional quantitative study.	To assess how work and informal care interact, affecting the psychological well-being of employees according to the working day.	Sociodemographic Questionnaire, Satisfaction with Life Scale, Positive and Negative Affect Schedule, Center for Epidemiological Studies Depression Scale, Loneliness Scale, Short Form Health Survey.	Caring at home is related to lower psychological well-being, but only among women who do not work full-time.
Lee & Tang (2015)	Cross-sectional quantitative study.	To examine the relationship between caregiving roles and workforce participation.	Sociodemographic and current employment status questionnaire.	Women caregivers of parents and/or grandchildren were less likely to be in the workforce than non-caregivers.
Lee et al. (2015)	Longitudinal quantitative study.	To assess the relationship between caring for elderly parents and the financial well-being of caregivers.	Sociodemographic questionnaire, total family income.	Women tend to have negative economic outcomes as a result of caring for elderly parents.
Jolanki (2015)	Cross-sectional qualitative study.	To analyze how working women help their parents or in-laws.	Semi-structured interviews, adapted to the narratives of the interviewees.	While working-women can take on caring responsibilities, most of them reject the idea of leaving work to care.
Lkhoyaali et al. (2015)	Longitudinal quantitative study.	To assess the social, psychological, behavioral and economic impact on family caregivers of elderly cancer patients.	Sociodemographic and economic questionnaire and the Diagnostic and Statistical Manual of Mental Disorders IV.	Even with a great impact on the family members of the elderly with cancer, the benefits of care were observed in 80% of the participants.
Sakka et al. (2016)	Cross-sectional quantitative study.	To examine the differences in family repercussions for work between employed and non-employed women who had care responsibilities for elderly parents.	Sociodemographic Questionnaire, Survey Work-Home Interaction-Nijmegen, Cognitive Caregiving Appraisal Scale and Family Adaptation Partnership Growth Affection.	Being a middle-aged woman, employed and caring for her elderly parents were significant predictors of negative family repercussions for work.
Hwang et al. (2017)	Cross-sectional qualitative study.	To understand how adult offspring of people with dementia support care in their family and formal care contexts in Canada.	Sociodemographic questionnaire, focus groups (separated by gender).	Family values and relationships, distrust of institutional and home care systems and lack of knowledge about how to provide care had an influence on the care offered to family members.
Häusler et al. (2017)	Cross-sectional quantitative study.	To assess the impact of informal care on the risk of burnout among health professionals.	Copenhagen Burnout Inventory; Copenhagen Psychosocial Questionnaire.	Triple-duty caregivers were found to have a significantly higher risk of burnout compared to formal-only caregivers.
Alpass et al. (2017)	Longitudinal quantitative study.	To explore the challenges presented to older New Zealanders who combine paid work with caring responsibilities.	Economic Living Standards Index; Short Form Health Survey; Center for Epidemiological Studies Depression Scale.	Attempts to reconcile work and care responsibilities for older workers can impact mental health and living standards.
Mehta & Leng (2017)	Cross-sectional qualitative study.	To focus on the dynamics of family care for the elderly based on the perspective of working life in Singapore.	Recorded interview.	The findings point to the need for improvements in policies, training and support for caregivers.
Kim et al. (2018a)	Cross-sectional quantitative study.	To compare sociodemographic characteristics that are related to caring for two generations and to identify which factors contribute to the burden of such caregivers.	Sociodemographic and care-related questionnaire; Self-reported overload.	Vulnerable subgroups should be prioritized for policy benefits, such as those with no choice and younger working caregivers.
DePasquale et al. (2018)	Cross-sectional quantitative study.	To examine how women who combine long-term caregiving employment with informal caregiving roles differed from their caregiver peers in terms of performance and job retention.	The Maslach Burnout Inventory; Michigan Organizational Assessment Questionnaire; 2 items reflecting intentions to leave the job role.	Dual and triple-duty caregivers did not differ from workplace-only caregivers in terms of job retention and performance factors.
Eguchi & Wada (2018)	Cross-sectional quantitative study.	To investigate associations between having a person in need of nursing care at home and psychological distress.	Kessler Psychological Distress Scale (K6).	Having a person who needs nursing care at home appears to be positively correlated with worsening mental health.
Kolodziej et al. (2018)	Longitudinal quantitative study.	To estimate how labor force participation is affected when adult children provide informal care to parents.	Questionnaire with information about the individual’s health aspects of care and interpersonal relationships.	The results reveal negative causal effect, indicating that providing care reduces labor force participation by 14%.
Evans et al. (2019)	Cross-sectional quantitative study.	To explore how role characteristics and interactions are related to role balance for women working and caring for children and aging parents.	Sociodemographic and labor aspects questionnaire; Role Balance Scale; The Role Checklist.	Participants tended to role imbalance. Some characteristics intrinsic to the role of mother and family member were related to role balance.
Sakka et al. (2018)	Cross-sectional quantitative study.	To assess the associations between behavioral and psychological symptoms of people with dementia, care burden and family-work conflict of employed family caregivers.	Sociodemographic questionnaire, Zarit Burden Scale-Short Version, Survey Work-Home Interaction-Nijmegen and Dementia Behavior Disturbance Scale.	It is important for employed family caregivers to reduce family work conflicts and maintain their work-life balance.
Fernandes et al. (2018)	Qualitative phenomenological and cross-cultural study	To identify the demands of family caregivers of dependent elderly people.	Two focus groups (one in Portugal and one in Brazil).	Despite the different social and political contexts, caregivers’ needs are similar and converge on the same problems and challenges.
Kim et al. (2018b)	Cross-sectional qualitative study.	To comprehend the experience of paid family care workers for people with dementia in South Korea.	Sociodemographic questionnaire.	The results help to identify the educational needs and the level of support these workers need to improve the treatment of dementia in the home care environment.
Crespo et al. (2019)	Cross-sectional quantitative study.	To investigate the influence of work experience variables on the emotional state of caregivers.	Sociodemographic questionnaire, Center for Epidemiologic Studies Depression Scale, Positive and Negative Affect Schedule, Worry and Strain Scale, Impact of care at work, Caregiver Burden Interview, Role Overload and Captivity Scale and Work-Caregiving Role Conflict.	The effect of perceived work experiences on caregivers’ emotional state is more relevant than work conflicts.

• Source: survey data.

After reading the studies, it was possible to divide them into the following categories: 1) Caregivers of the Elderly with Dementia and Cancer, in which there are articles that address the conciliation between work and family among caregivers of elderly people with dementia or cancer; 2) Gender, which groups themes related to the burden of women in the care of the elderly, as well as notes on the variables that interfere with the balance between work and family; 3) Sandwich Generation and Baby Boomers, which unifies studies that address the conciliation of work and family between caregivers of the elderly and children, concomitantly; and 4) Individual and collective coping strategies, which aggregates research on the skills, resources and adjustments used by caregivers to manage time and stress, in addition to works on public and organizational policies in favor of reconciling work and family.

Caregivers of elderly people with dementia or cancer

In this category, 5 studies are presented that address the care of elderly people with dementia and cancer.

In the study by Sakka et al. (2019), caregiver overload and the presence of family-work conflict were observed, that is, the family's demands were transferred to work, interfering with the performance of work responsibilities, as well as accentuating the degree of stress among caregivers. In short, the role of the family was negatively affecting the role at work. One proposal to balance work-family would be to offer leave to caregivers of elderly people with dementia who are employed as a way of supporting them.

The negative aspects of caring for an elderly person with dementia can be minimized by the positive ones, which cushion the difficulties and burden of care. In this direction, in the study by Hwang et al. (2017), it was observed that the imbalance between personal and care demands was minimized by positive aspects, such as feelings of accomplishment and meaning of the role of caring and development of skills (management of tasks, time and resources).

Likewise, the study by Lkhoyaali et al. (2015) also verified the existence of positive aspects in caring. In the survey, caregivers actively participated in the treatment of the elderly (86%, with 75.3% wanting a maximalist treatment for their relatives). Due to this immersion in the care of an elderly family member with cancer, there were repercussions in various spheres of the caregivers' lives, namely: physical and mental health and in the financial and professional spheres. The consequences at work were mainly in the dismissal of work (54%) and two caregivers were fired due to absences from work. However, even with all these negative impacts on the family members of elderly cancer patients, the benefits of care were observed in 80% of caregivers, with reports of increased personal satisfaction, personality improvement, obtaining meaning in life and a greater appreciation of family.

Similarly, in the study by Kim et al. (2018b), despite the difficulties, care activities for the elderly were encouraged through a sense of responsibility, filial piety and religious beliefs. The authors suggest that paid family care workers have preparation, training, education, regulation and support, regular monitoring and adequate remuneration so that they have satisfaction and quality of life.

In the study by Crespo et al. (2019), it was found the way in which a satisfactory job spills over into other areas and promotes quality of life and well-being. The data showed that most caregivers manage to reconcile work and caregiving, with only 23% reporting having many difficulties in reconciling. However, 94% stated that being a caregiver resulted in some impact at work, such as difficulties in completing work (interruptions by phone, having to leave unexpectedly, being late) and, less frequently, changes in work dedication (decreased working hours or changing shifts).

In the studies by Hwang et al. (2017), Lkhoyaali et al. (2015) and Kim et al. (2018b), it was also observed that, even with the emotional, financial and professional overload to which they were subjected, the offspring felt satisfied and fulfilled with the provision of care. In addition, care provided the development of time, task and resource management skills. Thus, positive effects from work spilled over into care, with an impact on the caregiver's emotional state (Crespo et al., 2019). Therefore, it is inferred that there was a negative and positive spillover from work to the family, and vice versa. In order for the caregiver not to become ill, public policies are needed, such as adequate remuneration for professionals, excellent educational programs, encouraging the participation of other family members in care, flexible working hours, work leave, work technologies, tax benefits and continued security contributions.

Gender

In this category, six articles are presented that discussed the influence of gender on elderly care among employed workers.

The study by Sakka et al. (2016) observed that, among caregivers, there is a greater negative spillover from the family to work, due to time restrictions and interruptions at work. Thus, women experienced significant psychological burden, restrictions, and conflict rather than rewards. However, family support and motherhood of a preschool-age child provided a positive spillover for work among these caregivers. The authors suggested that supervisors and organizations find ways to increase caregivers' positive assessments of caregiving, with support and information about care services. Job options with flexible hours and home office would be possibilities for caregivers so that they can balance work and care.

Providing information to caregivers was also seen in the results of the study by Fernandes et al. (2018), in which caregivers reported a lack of resources to promote care, such as knowledge and skills. Even when resources were available, because access was so complex and difficult, many caregivers gave up using them. Therefore, in view of the caregivers' difficulties, the authors suggested that health professionals should offer support to the caregiver to prevent overload, intervene in family imbalances in order to favor resilience, promote a division of care responsibilities and an ongoing assessment of their needs to provide information about care.

Being employed can also have a dampening effect on a woman's burden. This result was evidenced in the study by Hansen & Slagsvold (2015), carried out in Norway, which observed that employment provides greater opportunity to benefit from everything the role has to offer, including commitment and involvement, higher remuneration and better career prospects. In addition, working can be a necessary break from caring, becoming a distraction. Another advantage would be that, unlike part-time work, being employed full-time could result in greater social and psychological resources.

However, being employed and caring for parents can be negative for women, as demonstrated by the study by Lee & Tang (2015), which shows that caring for parents and grandchildren is negatively related to participation in the labor market for women, but not for men. Chances are that they want to provide maximum care to their families and, so, decide not to be part of the workforce; or they may still feel high tension in reconciling the roles of caregiver and worker and, therefore, withdraw from the labor market. The study further suggests the need to offer flexible working hours, employer support, paid family leave and paid sick leave or vacation days, as well as home and community-based services and programs.

In the study by Lee et al. (2015), as also observed in the research by Lee & Tang (2015) and Jolanki (2015), the financial impact of care, how much it negatively influence family income, was verified. Thus, the research by Lee et al. (2015) found that women with lower household incomes were more likely to be caregivers than those with higher household incomes. Thus, public policies for social security, compensation for financial losses, home care systems and unpaid care leave are necessary so that women do not accumulate disadvantages throughout their lives.

In the study by Jolanki (2015), the analysis showed that most women had the option to continue working and providing care. However, leaving work and becoming a full-time caregiver was not considered a viable option due to financial needs. In addition to being a source of income, work was also a promoter of social contacts and a sense of life. On the other hand, other factors also influence the decision not to work and to dedicate themselves fully to care: advanced age, dissatisfaction with work, lack of meaning at work, workload and intensification of work contributed to the decision making about working and taking on the role of caring.

Therefore, based on the analysis of the six studies focusing on the gender perspective, it became evident that women end up being responsible for most of the care, which culminates in overload. Other relevant data refer to the reconciliation of work and care. If, on the one hand, working full-time and providing care for the elderly favors women’s health, compared to not working or being employed part-time (Hansen & Slagsvold, 2015), on the other hand, care can compromise career development, income and work-family balance (Jolanki, 2015). There is also the significant financial impact of caring, which causes many people to try to balance work with care, but with future disadvantages such as retirement plans (Jolanki, 2015; Lee et al., 2015; Lee & Tang, 2015).

Therefore, gender inequalities in the family and the workplace still exist and create different role experiences for men and women. Middle-aged women can be stuck in their commitments as workers, spouses, relatives and caregivers. Thus, in order for them to continue to work and act as caregivers, those who work, especially women, must be supported to remain in the workforce and benefit from employment that provides an important buffer against the stress and burden of care demands.

Sandwich generation and baby boomers

In this category, 5 studies that aimed to understand the sandwich and baby boomer generation are presented, and composed of individuals who take care of children and elderly parents at the same time.

In the study by Evans et al. (2019), it was observed that, while in the role of mother, women had higher levels of pleasure and competence, which led to a perception of greater work-family balance. Thus, interventions aimed at raising interest in the role of mother can produce positive results in role balance, such as introducing quality time, performing fun activities with children, practicing mindfulness when performing parenting tasks or directed towards joyful moments. In addition, the study recommends improving some social skills, such as self-monitoring, time management, prioritization and increased self-efficacy.

In the study by Depasquale et al. (2018), it was observed that dual and triple responsibility caregivers reported feeling more exhaustion. Child caregivers (dual role) had lower turnover. For those dual or triple-role caregivers, spousal support was essential to not work when they were sick. This support reflected in less marital distress, which may be indicative of less marital conflict, a fairer division of the home, having work, a more fun relationship, and acquiring resources that counteracted negative work experiences. Another hypothesis would be that well-being linked to childcare, together with spousal support, produces benefits that decrease turnover intentions. The study suggests that organizations should consider initiatives that can strengthen employees' marital relationships.

The study by Kim et al. (2018a) noted that baby boomers have additional challenges when compared to post baby boomers: dual care responsibility (parents and children), in addition to unemployment, which leads to financial difficulties. Typically, more hours of care mean a more serious medical condition or functional decline in the care recipient, which is an increasing source of burden. However, post baby boomers spend less time caring than baby boomers, as they rely more on the use of formal health services among the elderly, in addition to using time management strategies. They can be proactive in requesting assistance from secondary caregivers, which lowers the cost of adult care.

Häusler et al. (2017) also observed spousal support as an important stress buffer among triple-role caregivers in their study. In the survey, burnout among participants who care for children and elderly parents concomitantly was higher among women (40.3%) compared to men (37.4%). All care groups had an average burnout score below the 50 cutoff, considered a significant risk for burnout.

It was also observed that triple-duty caregivers (professional care, of a child or an elderly person) had a higher risk of burnout compared to those who performed only professional care. Thus, such triple-burden caregivers struggled to manage professional and informal caregiver roles, which could affect physical and mental health, due to the inability to reconcile work and family domains. It was found that the support of the partner, flexible hours and coexistence centers/day centers for the elderly are important factors to explain the non-existence of work-family conflict, as well as the reduction of stress and the increase of well-being.

Unlike the studies by Häusler et al. (2017) and Kim et al. (2018a), the results of Honda et al. (2015) diverged regarding the quality of life of dual and triple role caregivers. In the research by Honda et al. (2015), it was noted that the proportion of participants with psychological distress was higher in women (17.8%) compared to men (11.5%). Performing three roles significantly decreased the risk of psychological distress (0.37 times in women and 0.4 times in men) compared with just one role. Among women, for those who work and are married, there was less psychological suffering (0.27 times); those with children and care responsibilities for elderly parents had significantly less psychological distress (0.38) than those who only worked. Likewise, men who work and have children or care for elderly parents had significantly less psychological distress (0.41) than those who only worked. The study also showed that participants who only worked had an increased risk of psychological distress. Furthermore, it was found that participants who cared for children or the elderly, and were not married, tended to have high psychological distress compared to those who only worked.

Therefore, if, for some studies, playing many roles can be a source of stress (Häusler et al., 2017; Kim et al., 2018a), for others, it can cause less psychological distress (Honda et al., 2015). One hypothesis would be that, more important than the quantity of functions, is their quality, with their rewards and satisfactions, as well as ways of managing them. Therefore, behavior management is so important for caregivers' quality of life. Thus, for the management of activities aimed at children and parents, social skills are needed to balance work and family, such as self-monitoring, self-efficacy, proactivity, time management, self-care and prioritization. Another hypothesis would be that performing various functions makes it possible to overflow positive and negative aspects from one sphere to the other. Thus, for example, the good mood arising from the relationship with the elderly can spill over into work, and vice versa (Honda et al., 2015; Häusler et al., 2017; Kim et al., 2018a).

Other measures and practices for mitigating conflicts between work and family are: provision of home care for the elderly, flexible work policies, employee benefits, cash or pension for unpaid hours of care, provision of income tax credit for lost work hours due to care, individual or group programs, community support, and outsourcing of housework all contribute to work-family balance (Evans et al., 2019; Kim et al., 2018a). In addition, spousal support is critical for work-family balance, providing quality of life for women and support for working dual and triple-duty jobs, especially when they become ill (Depasquale et al., 2018; Häusler et al., 2017; Honda et al., 2015).

Individual and collective coping strategies

In this category, four texts are discussed that address different collective and individual coping strategies to achieve work-family balance.

In the study by Mehta & Leng (2017), caregivers reported financial, emotional and psychological stress in their roles as caregivers. The relationship between work and family was conflicting, because of the difficulty of managing the demands due to overload. Caregivers were divided between their jobs and care duties, leaving little energy and time for self-care. For coping, they used as individual strategies to say prayers, listen to music, keep a good mood, talk to a friend, share and laugh about concerns, hire someone to help and fulfill the sense of duty to take care of parents. As collective strategies, the study emphasizes the importance of policies that promote training and education about diseases, social skills and symptoms of old age, for example, understanding about Psychology and behavioral aspects of people with dementia.

In the same direction as the research by Mehta & Leng (2017), the study by Eguchi & Wada (2018) also highlighted the importance of policies in favor of work-family balance among employed individuals with responsibilities for caring for the elderly. Thus, in the research by Eguchi & Wada (2018), it was found that, among people who worked and cared for older relatives, 25.3% of men and 32.8% of women reported having quit their jobs due to stress caused by the role of caring. In this sense, the study suggests that companies should promote a balance between work and family of employees with elderly relatives.

As individual strategies, one should reduce the number of people who leave or change their jobs and promote interventions such as stress management and providing information on work-family balance. As collective strategies, support from colleagues and supervisors is suggested for workers to be able to adjust their schedules in order to allow them to continue providing care and mitigate the impacts that home care can generate on mental health (Mehta & Leng, 2017; Eguchi & Wada, 2018).

In the study by Kolodziej et al. (2018), based on the comparison between existing health policies in European countries, relevant information was presented on the effectiveness of collective strategies in the work-family balance. Thus, the research by Kolodziej et al. (2018) showed that support through public policies to informal caregivers produces benefits in favor of work-family balance. In the case of Germany, for example, caregivers who are working can be absent from work for 10 days per episode of care. In addition, caregivers can take six months (without pay) to provide care without putting their jobs at risk. The authors suggest further implementing the “license to provide care”, in which individuals take longer vacations, receive income replacement from long-term care insurance and have a legal request to return to previous work.

Similar to the research by Kolodziej et al. (2018), in the study by Alpass et al. (2017) the flexible public policies in favor of caregivers of the elderly in New Zealand and the informal arrangements existing in work relationships were presented. Despite New Zealand having flexible working relationships and the right of workers over 65 years of age to a full universal state pension, mental illness among caregivers, especially men, was observed, in addition to high financial costs and opportunities among the category. Male worker caregivers report greater negative effects on mental health, which, in turn, may reflect a lack of support for men in traditionally female roles.

Most of the sample did not stop working because of care, which can be explained by the cost of care. In addition, the combination of work and family care can result in opportunity costs such as lower wages, poorer career prospects, and reduced retirement savings. Thus, it is suggested that not only working conditions should be more flexible in order to successfully reconcile work and family care, but also that New Zealand health policies should be reviewed due to the illness and impoverishment of caregivers of the elderly at the same time, throughout care (Alpass et al., 2017).

Thus, the four articles covered in this category discussed individual and collective strategies that can favor work-family balance. Regarding the former, the following stand out: stress management (Eguchi & Wada, 2018), prayers, listening to music, keeping a good mood, talking with a friend, sharing and laughing about worries, hiring someone to help and fulfilling the sense duty of care for parents, in addition to flexible arrangements made with supervisors and co-workers (Alpass et al., 2017). Concerning the seconds, support from colleagues and supervisors for workers to adjust their schedules and provision of information on how to reconcile the demands of work and family (Eguchi & Wada, 2018), training and education about illnesses (Mehta & Leng, 2017), guaranteed return to work after months of foster care, professional outpatient care, “care license” (Kolodziej et al., 2018) and workers over 65 entitled to a full universal state pension (Alpass et al., 2017) were suggested to promote work-family balance.

Discussion

Several studies have shown the positive spillover between family and work (Hwang et al., 2017; Kim et al., 2018b; Lkhoyaali et al., 2015). This concept is based on role enrichment, which proposes that multiple roles bring rewards, such as income, social networking opportunities, and successful experience. Other research in the area (Correia et al., 2018; Cunha, 2011; Noonan & Tennstedt, 1997) also found that, despite the difficulties inherent in role performance, such as physical capacity and emotional management, caregivers obtain satisfaction with life, greater positive affect and well-being in the care of the dependent person, even when the demands are more challenging among the elderly with Alzheimer's disease (Lopes & Cachioni, 2013). In addition, care provided the development of time, task and resource management skills (Barham & Vanalli, 2012; Crespo et al., 2019; Matias & Fontaine, 2012).

On the other hand, the negative family-work spillover is based on the scarcity of roles, in which caregivers limit cognitive resources, time and energy in caring for the elderly family member. Therefore, negative effects and frustration can occur due to an individual's inability to meet the competing demands of family and work, as observed in some studies in this review (Gratão et al., 2012; Jolanki, 2015; Lee et al., 2015; Lee & Tang, 2015).

Some variables influence whether the work-family relationship can be balanced or not. They are: gender, sandwich generation or baby boomers and individual and collective coping strategies. Regarding gender, it was found that, as a result of care, many women feel overwhelmed and leave their jobs (Gratão et al., 2012; Lee & Tang, 2015); those who continue to work, in many cases, compromise career development, income and work-family balance (Hansen & Slagsvold, 2015; Jolanki, 2015; Lee et al., 2015). However, working, especially full-time, has a dampening effect, as they can disconnect from household activities and earn income to finance care (Hansen & Slagsvold, 2015).

Concerning the sandwich generation and baby boomers, studies indicate that caregivers experience more tension and stress, less time for themselves, live on the edge of what they can bear, and feel burdened, physically and emotionally (Häusler et al., 2017; Kim et al., 2018a; Kim et al., 2018a; Lopes & Cachioni, 2013). However, other studies point out that playing multiple roles can favor mental health (Honda et al., 2015; Matias & Fontaine, 2012), as positive aspects overflow from one sphere to the other, for example, good humor in the relationship with offspring for elderly parents. Thus, more important than the quantity of functions is their quality, with its rewards and satisfactions. Another important element for maintaining employment and double or triple care among women was spousal support, which made it possible, for example, for them to miss work when they were sick (Depasquale et al., 2018).

Finally, several studies have addressed individual and collective strategies in favor of work-family balance. Regarding the former, we can mention: praying, listening to music, keeping a good mood, talking to a friend, sharing and laughing about concerns, hiring someone to help, fulfilling the sense of duty to take care of parents, in addition to making flexible arrangements made with supervisors and co-workers (Alpass et al., 2017; Eguchi & Wada, 2018). In this way, one can infer the occurrence of a positive spillover, that is, the transfer of knowledge and skills, as well as psychological benefits from one sphere to the other. Thus, participation in a role can favor the acquisition of skills and resources that can be used to enable development and better functioning in other spheres of life (Barham & Vanalli, 2012; Matias & Fontaine, 2012; Medeiros et al., 2017).

Regarding collective strategies to favor work-family balance, many studies have highlighted countries with public policies that benefit elderly caregivers, such as Norway, New Zealand, Japan, South Korea and Germany (Alpass et al., 2017; Eguchi & Wada, 2018; Hansen & Slagsvold, 2015; Kim et al., 2018b; Kolodziej et al., 2018). Generally speaking, the measures refer to the guarantee of returning to work after months of sheltering the elderly, professional outpatient care, “care leave” and the right of workers over 65 to a full universal state pension (Alpass et al., 2017; Kim et al., 2018b).

However, the need for training courses for caregivers of the elderly was evidenced, as well as the encouragement of greater participation of other family members in the care of the elderly, so that there can be a work-family balance. More than keeping individuals working, it is important that they work while being healthy.

In Brazil, although there are laws that guarantee rights to the aging population, there are no effective measures to fulfill them, in addition to attributing responsibility for care exclusively to the families of the elderly. Thus, it is necessary for the Brazilian government to have as a guideline the protection of dependent elderly people based on the following guidelines: balance between public, private, social and family responsibilities and investments in caregivers through practical and theoretical information, in addition to financial support (Minayo et al., 2021).

Conclusion

In view of the findings of this systematic review, it was understood that, in order to favor work-family balance, the choices people make between work and family responsibilities must be studied; it is also necessary to expand the narrow “work-family” framework and analyze gender in the individual worker, biography, cultural norms, social values, economic aspects and available political solutions.

At the same time, company and state policies such as flexible working hours, work leave, work policies and technologies, tax benefits, continuing social security contributions, and direct payments to replace lost or reduced income are imperative for caregivers. With these interventions, caregivers will be able to gain support in care, with benefits for dealing with the challenges of balancing their needs with those of their parents.

In addition, further studies on work-family balance among caregivers of elderly people in Brazil are recommended, given the increasing aging population in the country and the presence of only one national study found in this systematic review. Therefore, research on this topic is welcome and will make it possible to know, monitor and compare results for decision-making regarding the formulation of health policies for Brazil.

• How to cite: Medeiros, T. J., Barbosa, G. C., Alves, L. C. S., & Gratão, A. C. M. (2022). Work-family balance among caregivers of elderly people: a systematic review. Cadernos Brasileiros de Terapia Ocupacional, 30, e3154. https://doi.org/10.1590/2526-8910.ctoAR241831542

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Edited by

Section editor

Profa. Dra. Marta Carvalho de Almeida

Publication Dates

• Publication in this collection
  17 June 2022
• Date of issue
  2022

History

• Received
  20 Sept 2021
• Reviewed
  23 Nov 2021
• Reviewed
  17 Feb 2022
• Accepted
  24 Mar 2022