Considerations of Taiwanese Working Carers on Choosing Long-Term Care Services for Relatives with Disabilities

Abstract

Unpaid carers are a significant support for dependent people with chronic illnesses in most countries. Working carers have specific needs because they face a conflict between employment and care. This study reports on the views of seven working carers in Taiwan to discover the factors they might have considered when arranging publicly funded Long-Term Care (LTC) services for the person they care for to reconcile their work and care. According to the testimony of working carers, the issue of safety for care recipients motivates the application for LTC services. However, LTC services in Taiwan, while affordable, are limited. Working carers have a positive attitude towards home care due to its low price and flexible service time. The constructed barriers to accessing daycare make it difficult for families to use daycare, even though it may be the most suitable service for care recipients. The findings have implications for improvements in LTC services. They show that an extension of opening hours of daycare is needed to meet the employment needs of working carers and that care skill training should be offered for providers of LTC services.

Keywords:

• Working carer
• carer burden
• long-term care
• care service
• informal care
• disability

Introduction

The number of people in need of LTC is expected to grow significantly in all countries due to the increasing ageing population and people living longer with disability (OECD 2011; World Health Organization 2022). Unpaid carers (hereafter carers), primarily women, perform an important role in families to meet the personal needs of individuals (Anokye 2018; Chiou et al. 2009; OECD 2022; Pickard et al. 2018). A feminist approach to family care recognises that women have historically been oppressed within the home and the labour market (Hooyman and Gonyea 1999). The care work carried out in the private space is usually unrecognised (Daly 2002). However, rises in female labour market participation may also decrease the unpaid care that families can undertake (Nguyen and Connelly 2014).

Reports indicated that the majority of carers provide care for 35 or more hours each week (Carers UK 2022; Tooth et al. 2005), although the hours that carers spend on caring vary. The time required to competently care for a relative in need of LTC amounts to a full-time job (Schulz et al. 2003). Therefore, carers must contend with conflicts between work and care that can cause them to be absent from work and less productive (Fujihara et al. 2019), or to leave employment (OECD 2011), adding financial difficulty to the care burden (Lai 2012). Previous studies revealed that working carers tended to have worse health conditions and poorer quality of life than employees who were non-carers (Gupta et al. 2012) and had higher rates of absenteeism, presenteeism, and overall work impairment (Laks et al. 2016). Paid services for care recipients or replacement care for carers has been highlighted as a significant policy to reconcile work and care for working carers. An association between a carer’s employment and care receipt by care recipients has been found. Evidence revealed that working carers who used care services were more likely to have a low carer burden (Huang 2014; Kumamoto, Arai, and Zarit 2006) and to stay in employment (Pickard et al. 2015, 2018).

Since the enactment of the Act to Implement the Convention on the Rights of Persons with Disabilities 2014 and the Long-Term Care Service Act 2015 in Taiwan, there has been a recognition in policy discourses that disability results from the interaction between persons with impairments and attitudinal and environmental barriers. Based on this principle, the Ten-Years Long-Term Care Project 2.0 (LTC 2.0)¹ was introduced in 2017 in Taiwan to establish an accessible, affordable, universal LTC system and services, with the aim of reducing the barriers to access of care services and enhance the ability of people with disabilities to live independently (Hsu and Chen 2019; Ministry of Health and Welfare 2016). LTC 2.0 puts ‘ageing-in-place’ values into practice via multiple and continuous home- and community-based types of care (Chen and Fu 2020). To receive care services under LTC 2.0, care recipients must be assessed by LTC case managers, and a care plan will be made based on the results of the assessment. Under LTC 2.0, care services mainly consist of home-based services (such as home care) and community-based services (such as adult daycare, dementia daycare, and adult foster services²) (Chen and Fu 2020; Ministry of Health and Welfare 2016).

Similar to many countries, Taiwan relies on unpaid care provided by family carers. Yet, after decreases in birth rate and number of family members and an increase in female labour market participation, more caregiving responsibility nowadays falls on people who are also employed (Ministry of Health and Welfare 2016). In the LTC 2.0, there is an emphasis on developing a well-established care system to improve the quality of life of carers to enable them to continue to work. In doing so, carers will be referred to a carer centre by LTC case managers if they have a significant carer burden or need further assistance, such as helping them to make a care plan and reducing their carer burden by attending carer relief events (Chen 2019).

Before the LTC project was introduced, the Taiwanese government attempted to address the crisis of increasing needs for LTC and the lack of Taiwanese care workers joining the LTC industry by introducing a regulation entitled ‘Temporary Measure to Address Shortages of Manpower for Providing Care for Households’ Disabled’ in 1992, aiming to import live-in migrant care workers to fill the needs of families with disabled members. Although the ‘Care Service Industry Development Plan’ was introduced in 2002 to encourage people to use home care provided by Taiwanese care workers, by allowing disabled people with general household income to be able to use home care and offer job opportunities to Taiwanese working as care workers, live-in migrant care workers have been the main labour force in Taiwanese LTC industry (Liang 2023). In 2021, there were 225,423 live-in migrant care workers, in contrast to 74,601 Taiwanese care workers (National Development Council 2021; Executive Yuan Gender Equality Committee 2021). In terms of the type of care services used by disabled people, only 1 in 3 adults in need used care services provided under LTC 2.0, and 28% per cent of them were cared for by live-in migrant care workers (Taiwan Association of Family Caregivers 2019). This may be because of the unavailability and inaccessibility of home care, the fear of using care homes (Chen 2011) and the advantage of live-in migrant care workers in providing 24-hour care at a lower cost (Chen 2016). Undoubtedly, migrant care labour has gradually replaced Taiwanese care workers in the LTC industry (Chen 2016).

The Social Model of Disability asserts that the problems that disabled people face are not caused by their physical, mental or behavioural differences but by the attitudinal, ideological, institutional, and structural barriers within society (Mladenov 2021; Oliver 2004; Shakespeare 2013). Given that the model was recently extended to include carers by redefining the relationship between disabled people and their carers as interdependency (Giri et al. 2022; Larkin and Milne 2014), the ability of disabled people to be included in society will influence the level of care that carers have to undertake. Morris (2001) reminded us that it would be unethical if the care and support did not enable people to share fully in the social life of their community. The idea of the Social Model of Disability was applied in Taiwanese LTC policy, in which the well-being of care recipients and their carers is paid attention to. This study focuses on the experience of working carers who are still in the labour market while caring for their relatives with disabilities and using care services. The concept of the Model can help to understand the accessibility of care services to disabled people, which may influence the considerations of working carers when choosing care services for relatives with disabilities.

Methods

This study is based on a qualitative study of seven working carers located in Taipei City and New Taipei City in Taiwan, who were purposely sampled through gatekeepers in the carer organisation based on the recruitment criteria as follows: (1) participants must be aged 18 years or over and work either as a part-time or full-time job; (2) participants have been involved in caregiving for at least a year; (3) care recipients are currently using care services under LTC 2.0. The gatekeepers approached the potential participants with an information sheet about the study, explaining the risks and benefits of participating and emphasising that they were free to accept or refuse to participate in this research. Details of the participants who consented to be contacted were given to the author via the gatekeepers.

Table 1 presents the details of the participants and the care recipients. Six female carers and one male carer were involved in this study. The duration of involvement in caregiving ranged between 2 years and 12 years. One participant worked part-time and one participant did not live with the care recipient. Although the age of care recipients was not restricted in this study, all of them were aged 65 years old and over. In addition, home care was used by all of them.

Table 1. Information of participants and care recipients.

Working carers					Care recipients
Participant number	Gender	Job	Relationship to relatives	Years of caregiving	The level of disability	The care service used
1	Female	Full time	Daughter	7	Moderate	Home care* Care home
2	Female	Full time	Daughter	3	Moderate	Home care* Dementia daycare Live-in migrant care worker
3	Female	Full time	Daughter	12	Moderate	Adult daycare* Home care
4	Male	Full time	Son	10	Severe	Home care
5	Female	Full time	Daughter	3	Severe	Adult daycare Home care
6	Female	Part time	Daughter	2	Moderate	Home care
7	Female	Full time	Daughter	4	Moderate	Home care

* Previously used.

Face-to-face interviews were conducted between May 2021 and July 2021. Semi-structured interviews were employed to elicit responses about the experience of caring for relatives while using care services. The interviews were conducted in Mandarin or Taiwanese. Participants were asked about the issues in terms of care circumstance, such as what care issues they had faced before they began using care services. They were also asked about their personal perspectives on care services. For example, what made them decide to use the care service they currently use, how they felt about accessing care services, what are the strengths and weaknesses of the service offered for the service user?

Interviews were recorded with the consent of participants and were transcribed by the author. Transcripts were analysed using thematic analysis (Braun and Clarke 2006). In the analysis process, the author specifically focused on the ways in which participants constructed their own considerations on choosing LTC services for care recipients and concentrated on the unique caregiving experience. The transcripts were analysed by the author in their original language, Mandarin. Transcripts were repeatedly read and coded until no new codes were generated. The extracts used in this study were selected from codes that were collated into themes and subsequently translated into English.

Ethics

Ethics approval was obtained through the University of Bath Social Science Research Ethics Committee. The participant information sheet identified the research aim and the benefits and risks of the research, and participants were given the opportunity to ask questions before being interviewed. All participants signed consent forms. As the interview potentially elicited negative experiences of caregiving, each interview ended with a debriefing information sheet, and participants were given information about support services. No remuneration was given for taking part.

Findings

The intention of the study was to explore the aspects considered by working carers in choosing the type of care services for their relative in Taiwan. The aims were not only to understand why working carers had the will to use care services but also to explore how the specific care services under LTC 2.0 were chosen. Five themes emerged, which are explained in the following sections.

The safety of Care Recipients

Most participants indicated that they were concerned about the safety of care recipients at home. Carers decided to apply for LTC services because leaving care recipients alone at home was likely to be unsafe for them. For example, when asked why they decided to apply for the LTC service, one participant explained that her mother had fallen at home several times.

My mum’s physical function was getting worse, and the number of times she fell over at home was slowly increasing. She was alone at home… every day. So sometimes I would phone my mother while I was working. If she did not answer the phone, it was likely that she has fallen over and couldn’t stand up by herself. (Participant 1)

In some instances, although there was another family member who could look after care recipients at home, carers also took into account the ability of an alternative person to provide the necessary care. Participant 2 said:

Initially, my father was responsible for looking after my mother at home. However, my mother had suffered from a stroke again. One month later, she was discharged from the hospital. The consequence of the second stroke was more severe than the first time. I realised that it might not be appropriate to rely on my father to look after my mother by himself. I therefore started considering using home care. (Participant 2)

In other cases, carers checked whether the care service they were considering using was the most beneficial for the safety of care recipients. When Participant 4 was asked why he chose home care as the main LTC service for his mother, he responded:

I have had thoughts about care homes. But there were many cases of older people being abused in the care homes. I felt a bit worried [about sending my mother to a care home] … Also, I don’t think the environment of care homes was suitable for my mother… because my mother had Bacteremia a few years ago. (Participant 4)

For this participant, the decision on which care service under LTC 2.0 to use was determined by comparing all care services in terms of how friendly the environment was to care recipients, even though their severe disabilities made it very difficult, or impossible, for them to be cared for at home. This suggests that, carers are more likely to choose the care service based on the safety of care recipients rather than on type of service that was most appropriate for them.

Affordability of LTC Services

Participants in the research indicated that the cost of care services is one of the factors they have considered when choosing appropriate services for their relatives. Participant 2 took her mother to dementia daycare because the service was free of charge. She explained:

It (dementia daycare) is totally free even now. We don’t have to pay for it and lunch is offered free of charge. (Participant 2)

In other cases, there was reluctance to use a certain care service that care recipients had a high need for, because of the cost. One participant said:

At the beginning, I rarely used this service (home rehabilitation), because it costed 400 (Taiwan) dollars a time (around GBP 10). Of course, I used it very rarely … Recently, the government thought that there were very few people using this service, so the price, it was suddenly reduced. It costs 150 (Taiwan) dollars a time (around GBP 4). I felt that it was so cheap. Then I… I increased the times I use it. I used it four times a month…I think I can afford the price, and I am willing to give my mother a little more help. (Participant 3)

However, most participants made a decision on which care services they wanted to use after comparing the costs of the available options. As mentioned above, Participant 4 had initially considered sending his mother to a care home. However, after comparing the prices of care homes with home care, he ultimately chose home care. He said:

Because she (mother) needed to use a nasogastric tube, and she was unable to sit on a chair or a bed steadily, I was considering sending my mum to a care home. But after I inquired about the price and services that the care home would provide, I found that I could not afford it. It was too expensive. I asked a few care homes where the cost was at least 30,000 (Taiwan dollars) a month (around GBP 800). (Participant 4)

A few participants had thought about hiring a live-in migrant care worker to look after their relative because of the demands of their own employment. They said:

There was no one to prepare meal for my mum and assist her bathing during the daytime (while I was working) (Participant 4).

I had to go home and prepare lunch for her and came back (to work) as soon as possible (Participant 6)

One participant after another explained that due to a lack of financial ability to hire a live-in migrant care worker, they eventually chose home care provided by LTC 2.0 instead. They said:

I had considered it (hiring a live-in migrant care worker) initially. After I evaluated it, I really couldn’t (hire) because of first the price, and second no room at home available for them to live in. (Participant 4)

I couldn’t hire a live-in migrant care worker because I have no ability (to pay). (Participant 6)

The affordable cost of LTC 2.0 was one of its advantages. From the above examples, however, when the families faced the needs for LTC, publicly funded services were not the first choices but live-in migrant care workers. This is because live-in migrant care workers can provide 24-hour care for people with disabilities at home at a lower cost.

Support from Other Family Members

Several working carers pointed out that the extent of support from other family members would influence their choice of care services. The other family members who might help were likely to be the person living with the care recipient or siblings of the carers. When one participant was asked about the reason for choosing home care and whether this service met the needs of the recipient, she responded:

We felt that home care was totally enough for us to care for my mother because the physical functions of my father were still stable. They (home care workers) would only assist my mother with some things that my father cannot cope with. For example, while she needed to go to hospital for rehabilitation it was impossible for my father to take her to the hospital, because my father was also old and frail, we think it was impossible. (Participant 3)

In the above extract, the reference to ‘[home care workers] would only assist my mother with some things that my father cannot cope with’ is used to highlight the caring support from other family members. Notably, this participant’s father was actively involved in some caregiving tasks with minimal formal care service assistance. It appears that working carers may have preferred to maintain caregiving capacity within the family rather than completely relying on formal LTC services. Similarly, another participant had taken into account the assistance her brother could offer when arranging specific caregiving tasks that they wanted the care worker to provide. She said:

For example, we don’t ask the care worker to do some caregiving task, like house cleaning, assisting my parents exercising, accompanying my parents to the hospital. This is because that my brother can drive and pick my parents up at the hospital. He also goes to the pharmacy to collect medicine in the evening. (Participant 6)

However, unlike the cases mentioned above, support from other family members was not always forthcoming. Participant 3 had no other siblings, and her mother was living alone. In this case, she needed LTC services to cover the majority of caregiving tasks. She said:

In fact, at that time, I was naively thinking that my husband would help me to take care of my mother. My husband didn’t help with anything. Additionally, it was not easy to arrange the transportation service that can pick my mother up and take her to the daycare. It was because our house is a little far away from daycare. (Participant 3)

The first two cases show that LTC services are considered a supplementary resource when other family members are willing to help. Otherwise, working carers need to rely heavily on formal care services, where LTC services become the main care resource.

Accessibility of Daycare

The barriers to accessing daycare created by its structure were identified from this study. A few participants explained that daycare was not used by them because of a conflict between the open time of daycare and the working hours of employment. Participants were not able to take their relatives to daycare in the morning and pick them up in the afternoon because the operation of daycare does not align with the working hours of employment, although daycare offers bus services for disabled people. For example:

I had also considered this service (daycare), but the reason for not using the service was that the complimentary bus offered by daycare was not flexible. They could not come to pick up and drop off my mum at the time that we hoped they would… they could only come to pick my mother up after 8 in the morning, but my work starts at 8 am, which means that I have to set off to my office before 8 in the morning. Or they might drop my mother at home at 4 pm, but I finished at 5 pm. (Participant 1)

Some other cases revealed experiences of and worry about being refused access to daycare because of worse physical function of care recipients. Participant 7 mentioned that the receipt of daycare would benefit her staying in employment. Nevertheless, the person she cared for was refused daycare because of concerns about the physical condition of the care recipient, although the LTC disability level was only level 4 (equally moderate level).

Because daycare is very close to my home, then I sent her to…she could still stand up. But daycare day…(said) No, (because) she walked too slow, what if she was knocked down (in daycare)? (Participant 7)

In line with others interviewed, two participants encountered the obstacle of their relatives being withdrawn from daycare centres. One of them explained that her mother’s physical function was deteriorating, and daycare no longer provided adequate care for her mother. She said:

She (my mother) was having tantrums and crying (daycare) there again, but none of the staff came up to help her. In fact, I always knew that her physical function was getting worse… I was always worried about whether the staffs of daycare would think that my mother was not suitable for this service. (Participant 5)

Before participant 3 enrolled her mother in the daycare, she had a sense that her mother would no longer be able to use the service at some point in the future. Therefore, when arranging the care plan for her mother, she applied for both daycare and home care simultaneously to minimise the impact of service disconnection. She said:

But I think my mother will not be able to go to the daycare centre eventually. I think her physical function will become weaker with time. And I know…because…I also participated in some of the carers support groups held by the daycare. I noticed that a few older people haven’t shown up recently in the daycare centre. Shortly after, I found out that it was not because their carers did not let them come (to the daycare). It might be because they were no longer allowed to come and participate at the daycare. I knew that this would happen, so I never just use one service. (Participant 3)

In the above example, the participant utilised two types of care services in anticipation of the possibility that her mother might be rejected from daycare centres. To strike a balance between caregiving and employment, working carers might find themselves compelled to opt for a service that wasn’t their first choice, and this could potentially result in care recipients being denied access to the service.

Difficulties in Participating in the Labour Market

Research investigating the impact of caregiving on the lives of working carers has highlighted that providing care for disabled relatives has a negative impact on the sustainability of employment for these individuals. In this study, two participants’ jobs were adversely affected by their caregiving responsibilities for disabled relatives. One participant explained the dilemma he faced in balancing work and care, particularly the lack of carer-friendly working conditions. Faced with the responsibility of caring for his mother, he ultimately decided to resign from his job due to a lack of support for working carers:

At that time, there was no family care leave or other benefits for working carers. The company didn’t have any policy of ‘leave without pay’, so I was asked to quit my job. I didn’t have much time to negotiate with the employer because I was very anxious about my mother’s health then, and no one in the family could help me. Eventually, I resigned from the job. (Participant 4)

In the above case, after arranging a care plan, the participant was able to re-enter the labour market and secure a job with flexible working hours in an insurance company. However, despite the new job providing him with the flexibility to address the unpredictable needs of care, it does not offer a basic salary. Instead, the amount he can earn is dependent on how many insurance policies he sells to the customers. He expressed:

I got a new job which does not require clocking in, but there is no basic salary. The salary entirely depends on the sales performance. Due to this type of job, I can flexibly arrange my working hours. Otherwise, if I still worked for a job that is similar to my previous job and something happened to my mother, the same situation would surely occur again…being required to quit the job. (Participant 4)

In another case, a participant who was able to keep their job would rather retain a low job position at the company to meet their caregiving responsibilities than get promoted. This participant said:

Anyway, I just wanted to do what I basically need to do for my job, I won’t force myself to do very well for my job because I have no ambition to become an outstanding employee. Thus, I give myself a goal, anyway, it was ok for me to do this job in the same position. I didn’t need to be promoted. Every year, my employer asked me, ‘are you willing to join the business trip?’, and I always said, ‘no’… I refused to go on the business trip. I even… every employee all had to evaluate work performance by us at the end of the year, and I always scored myself a bad performance. (Participant 3)

In contrast to the above example, most participants were able to reconcile work and caregiving, but this was not due to their companies offering flexible, employment-friendly policies. All participants indicated that no such policies were in place in their workplaces. As one participant shared from her experience, she opted for a part-time job as a solution to address the conflict between work and caregiving. She said:

I was thinking about… I don’t need a full-time job. I work when I have time to do so. But there is a disadvantage that I could only get the salary if I achieved the sales performance required by the company. Although the working hours are flexible, I will be financially pressured, which doesn’t satisfy the employer’s expectation. (Participant 6)

Significantly, caregiving responsibilities can have a highly negative impact on the career development of working carers. This study found that, in order to reconcile work and care, working carers might choose to forgo opportunities for career advancement. Most participants made efforts to retain their jobs for various reasons. Gaining understanding and support from their employers proved to be an effective means of balancing work and care, especially in cases where employment-friendly policies had not yet been well-established.

Discussion

The paper concludes with a discussion of implications for practitioners who are involved in the arrangement of care plans and policymakers who design better care services for care recipients in order for working carers to reconcile care and work.

The findings from this study have contributed to the existing literature on the carer burden of working carers. Worrying about care recipients staying at home alone was identified as a significant carer burden (Poon, Joubert, and Harvey 2013). The present study indicates that this worry, identified as a subject burden, causes working carers to use care services to look after their relatives in order to reconcile their care duties with their work. Using care services is a way of reducing the carer burden of working carers. Kim and Choi (2008), who explored caregivers’ willingness to use LTC services in Korea, indicated that the well-being and health conditions of older adults were the priority when choosing LTC services. This finding is consistent with my own, suggesting that working carers choose LTC services after considering whether the services would positively or negatively impact the well-being of their relatives, such as the safety and environment of care homes.

This study highlights that the presence or absence of help from other family members is one of the factors considered by working carers when choosing the type of care service. This may be related to the attitude of carers towards care services. Previous research indicated that carers felt they could manage caregiving themselves, or some managed with the help of other family members (Brimblecombe et al. 2018), which was associated with less use of care services. One finding also highlighted that having available informal support from other family members was a feature of carers who held a traditional caregiving ideology (Lawrence et al. 2008). Carers, along with other family members, coordinated caregiving tasks according to their relationship with care recipients. The caregiving ideology that working carers hold informs their expectations regarding the amount of care service they need to cover the caregiving needs when making a care plan.

The findings also highlighted the financial burden experienced by working carers who struggle to pay for care services. The affordability of care services reflects previous findings in carer research, where carers experiencing higher caregiver burden intended to use community- or home-based care services (Chen and Wu 2006). This was partly because institutional care was more expensive than other options. The findings also indicated that unaffordability leads carers to stop using needed services (Lamura et al. 2008). This research identified participants whose lack of ability to pay for the preferred service drove them to seek alternative care services which might not be suitable for the care recipients. For example, individuals with disabilities who might need institutional care still stayed at home using home care. This research also found that the consideration of hiring live-in migrant care workers might have first emerged in caregiving families at an early stage of making a care plan to meet the needs of carers’ employment. Literature indicates that this might be because live-in migrant care workers can significantly support carers in maintaining employment and meeting the expectation of ‘24-hour one to one home stay caregiving’ (Wu and Chen 2013). Those participants ultimately chose home care under LTC 2.0 because they could not afford to hire a live-in migrant care worker.

All participants in this study who had considered using daycare, had used or were using daycare, experienced barriers to accessing daycare services. This can be explained by the social model of disability, which emphasises that the restrictions faced by disabled people result from the interaction between impairment and the barriers in the environment, that is, socially constructed barriers (Mladenov 2022). Previous findings indicated that publicly funded services were not always accessible due to strict eligibility criteria (Spann et al. 2020). My research further identified the eligibility criteria of care services that directly reduced the ability of care recipients to obtain suitable care services. For example, the opening time of daycare is usually from 9 am to 5 pm which does not meet the employment needs of many working carers. In addition, lack of the professional knowledge oamong daycare workers, resulting in the care recipients being excluded from LTC services, was identified in the present study. The literature highlighted that care service providers might refuse the care recipient where the needs of care are unfamiliar, such as people with mental illness problems (Lin 2020; Lu et al. 2022). This can be partly explained by the fact that to increase the number of care workers in the LTC industry, the Ministry of Health and Welfare still maintains a low threshold for obtaining care worker qualifications (Lee, Hsu, and Wang 2022). Although care workers had positive feedback about the training, the diversity of care recipients may have challenged them in providing professional care services (Chang et al. 2011). The lack of professional skills to meet the specific needs of the care recipient in daycare remains in the Taiwanese LTC system, perpetcuating the constructed barriers to accessing the care service.

Finally, although the participants did not directly indicate that employment status influences their choice of care services, the employment of carers is undoubtedly related to income and family finances (Spann et al. 2020). The interruption of employment may increase their financial burden (Covinsky et al. 2001). Previous findings have highlighted that employment sustainability influences other considerations to care services found in the present study. For example, women with extensive labour market resources may be less willing to leave or reduce employment activities, probably because they are more likely to have the financial means to purchase institutional care (Kelle 2020). Participants in this research chose jobs allowing them to work flexible hours with no salary guarantee or forgo opportunities for career advancement to reconcile work and care. Two types of work that could support working carers to stay in employment were identified: companies offering carer-friendly policies and jobs requiring flexible working hours because of the nature of the work. One research indicated that using home care, a personal assistant, and short-term breaks were associated with employment sustainability (Pickard et al. 2015). It is important that employment sustainability is also one of the factors that may affect the choice of official care services for working carers.

Limitations

Several limitations of this research should be noted. Being a qualitative study, its findings are not completely representative but demonstrate the range of views held by participants. Recruitment of participants was reliant on carer organisations in two cities, Taipei City and New Taipei City, in which the economic and education levels are relatively high among cities in Taiwan. Carers who live in rural areas may have different considerations in choosing care services because the attitude towards the use of care services is associated with the living environment and economic status (Shi et al. 2018). Only one male carer participated in this research. This may be because, apart from the recruitment barriers, male carers were more likely to be hidden (Barber 2013). Last, how the working carers became the key person in charge of making decisions about the care arrangement for care recipients was not explored in this study. Despite these limitations, the findings offer valuable insights into factors influencing choices of care service for older relatives, aiding our understanding of barriers and practical challenges faced by working carers in LTC decision-making.

Conclusion

The findings shed light on the extent to which care services were utilised by working carers under considerations of the needs of employment and care. In line with the carer burden literature, worries about the safety of care recipients staying at home bring a significant subjective burden. This is a good sign that LTC services may have a positive outcome in reducing the burden of working carers to some degree. The focus on the safety of care recipients could help social workers better understand the concerns of working carers.

The literature has identified that home care is commonly used by working carers due to its low cost and flexible service times or the expectations of the recipients to be cared for at home. Notably, barriers to the receipt of daycare relating to the structure of the service may limit the possibilities for care recipients to use daycare, which might be the best service for them, and make it more difficult for working carers to achieve a balance between work and care. However, small-scale multi-function services based on daycare to extend the service times were introduced under LTC 2.0 in 2017. This could benefit working carers who cannot finish work before daycare closes. However, the demands of working carers should not be underestimated before the accessibility of daycare is improved. Future training plans for care workers should be designed to improve their skills in caring for diverse people with disabilities, leading to marked or meaningful improvements and minimising barriers to publicly funded services for LTC service users and their families.

Acknowledgements

The author would like to thank all the participants for sharing their experience, and Dr Jeremy Dixon for useful feedback regarding the interpretation of the data and efforts in reviewing an earlier version of this paper.

Disclosure Statement

No potential conflict of interest was reported by the author(s).

Additional information

Notes on contributors

Yu-Ching Liu

Yu-Ching Liu is a doctoral student in the Department of Social and Policy Sciences at the University of Bath, United Kingdom. His main research interests include long-term care, burden on unpaid carers and mental health. Email: [email protected].

Notes

1 LTC 2.0 is the expanded version of the Ten-Year Long-Term Care Project 1.0 (LTC 1.0). LTC 1.0 was launched in 2007 to provide various care services to care recipients aged 65 years and over with functional limitations in activities of daily living (ADL). LTC 1.0 ended in 2016 when the government considered introducing universal compulsory LTC insurance. After the 2016 presidential election, the new governing party decided to expand the LTC project rather than introducing LTC insurance due to the low coverage of LTC services (Chen & Fu, 2020).

2 According to the Department of Long-Term Care’s definition, adult foster care is provided at the house of care workers who have been working as professional care workers for 500 hours and over. They have restructured their house based on the Standards of the Establishment of Long-Term Care facilities to provide care for a maximum of four people (Department of Long-Term Care, 2022).