Caregivers, lifegivers: drawing attention to the costs of health care in the home and its impact on women's work.
Chile is one of the countries that has committed to improving social determinants of health equity and is already developing some policies and pilot programs to promote this transformation. In this effort, valuing women's time is key for making appropriate decisions and avoiding the aggravation of inequalities.
In Chile, as in other Latin American countries and elsewhere in the world, institutional healthcare systems have always relied on support from the home and the family for healthcare and caregiving efforts. In other words, the healthcare system is based on two fundamental realms: the domestic system and the institutional system. The domestic healthcare system operates within the homes and interacts with the surrounding community (Galvez and Matamala, 2002).
Health within the home is achieved as the result of remunerated work outside the domestic sphere by which women and men ensure the economic sustainability of the household and as the result of domestic work--performed primarily by women--which provides nutritious food, a clean home, personal hygiene, clothing and comfort for the family group. At the same time, good health is encouraged in the younger generations through the instruction of habits, practices and behavior. In this fashion, women promote health and emotional wellbeing. They also serve as mediators between people and the institutional healthcare system, making sure that their families have the immunizations, information and interventions needed to prevent and treat illness; they also care for ill, elderly and disabled family members, even providing hospice care for dying relatives. As Galvez and Matamala (2002) explain, women historically have played a central role in supporting community-based health efforts, such as prevention campaigns, support for health teams and organization and action during crises. Indeed, there is widespread consensus among researchers that women perform most of the unremunerated health care.
Provoste and Berlagoscky (2002:9) also point out that "the healthcare model cannot be adequately explained if it is only understood as an aspect of public health as an institution. On the contrary, the linkages between the institutional system and the domestic health system are sociologically key to understanding the way in which the healthcare model works. In fact, we can assert that the viability of this model is dependent on the domestic health system, which in turn relies on the division of gender roles that operate within the family and society."
An exploratory study on family care of the sick by Reca and colleagues (2002) showed that the main caregivers were overwhelmingly women and also relatives of the ill. The caregivers were, for the most part, very closely related to the ailing family member, as mothers, wives or daughters.
Overwhelmingly, the economic implications of this process are ignored, and the market value of these services goes unrecognized (Galvez and Matamala, 2002; Provoste, 2002). Some measures of structural adjustment or health system reform that aim to reduce costs and cut services--reduction of hospital stays, institutional care for the elderly and care for the mentally ill--are based on the assumption that the family will provide the services (preventive care, accompaniment, treatment, etc.), which implies an increase in the domestic production of health. In general, the need for family-based health care also increases because the number of outpatient treatments and interventions has also increased. According to Provoste and Berlagoscky (2002), the participation of the family in health care is explicitly associated with "joint responsibility in health care." As the Pan American Health Organization (2004) also indicates, terminal, chronic and transitory illnesses--including mental illness, addiction and accidents--demand family-based care and cause serious problems and high costs for the families. Degenerative illnesses related to age and disabilities in general also require constant health care in the home.
These measures are based on the notion that women's time is infinitely flexible and free of charge and on the expectation that they are always available, willing and morally obligated to provide care in the home for dependents, the ill, the elderly and the disabled. For example, community projects relieve hospitals of responsibility for rehabilitation by teaching mothers to provide physical therapy for their children as way of ensuring ongoing treatment in the home: "Fifteen mothers were trained by Penalolen's Community Rehabilitation Center to give physical therapy to their children and thus ensure an ongoing and more effective recovery" (El Mercurio, 2005). On the other hand, allowing the terminally ill and elderly to die at home is increasingly common, which reorganizes the family routine around this end-of-life care (El Mercurio, 2005).
In Chile, a considerable portion of the population needs health care in the home. Several sub-groups each have specific concerns: children; the elderly (2); the disabled who cannot care for themselves (3); some chronic and terminal ill; those suffering from acute, disabling episodes; those recovering from serious injuries; those undergoing treatment for addiction; and women who have recently given birth (PAHO, 2004). (4)
The current healthcare models are based on the complementary nature of the institutional and domestic health systems, following the most traditional social division of gender roles. Nonetheless, increasing numbers of women are looking for employment and the opportunity to earn independent income, which decreases the availability of the fulltime workforce inside the home performing domestic and caregiving tasks. (5) The increasing incorporation of women into the paid workforce is one of the factors that has a negative impact on this interaction between the institutional and domestic systems, as described by Provoste and Berlagoscky (2002).
The constant incorporation of women into the labor market, plus women's special dedication to caregiving and their responsibility for domestic work actually intensifies gender inequalities. Women have had to assume work within both spheres, confronting on an individual basis the complications and conflicts of performing unpaid and paid labor simultaneously. The total workload may not increase, but caring for the sick can imply other hazards: the loss of gainful employment; economic dependence; emotional difficulties; sacrifices in one's social life; and a physical and psychological toll (Duran, 2002).
Unremunerated healthcare activities in the home are not visible, and they are not included in National Accounts. Calculations of spending on health and healthcare financing only include institutional, private and public systems, but they do not count the time that families invest in health care, the additional indirect costs and expenditures or lost wages, nor is there any sort of social compensation for these caregivers. Likewise, there are no proposals for benefits or support for the caregivers (PAHO, 2004).
On this same subject, Galvez and Matamala (2002:3) explain that "there has been an economic and cultural omission of the work involved in unpaid domestic health care, despite the impact that these actions have on social and individual health.... This situation has given rise to serious macroeconomic inequities in regard to health and gender, because while most housewives are responsible for the domestic production of health ... they are not recognized for their efforts, nor to they enjoy benefits, technical support or adequate compensation from society.... This situation makes us question the basis for the economy of health and the way in which our society is disposed to examine, value and compensate the assurances for wellbeing in the domestic healthcare system."
Gomez (2002) stresses that the failure to recognize the economic contribution of women's unremunerated work in health care is a covert form of discrimination. As a result, even seemingly neutral policies like cost reduction, the shrinking of the State apparatus and decentralization often hide a serious gender bias because they imply the shifting of costs from a paid economy to an economy based on the unpaid work of women.
When some services are transferred from the public sector to the private sector, most of them end up as the responsibility of families and become part of the non-market production of the home. Urdaneta-Ferran (2002) observes that since women mostly carry out this non-market production, ignoring it effectively underestimates women's contribution to the country's economy.
Economic statistics on work and production are normally used to frame public policy and business decisions. Therefore, it is important to know what activities we understand, define and measure as "work" and "leisure," not only because this informs our daily discourse but also because the reports on these "variables" affect our lives through these very decisions (Ironmonger, 1996). As a result, there is a longstanding demand for recognition of the limitations of the definition of "the economy" under the statistics of the National Accounts. With rare exceptions, these systems only include market transactions and ignore the contributions of unpaid work by women and men.
In Chile, as in other countries of the region, the National Accounts only include "all the goods and services produced and able to be sold on the market or which at least have the ability to be provided from one unit of production to another, for a fee or free of charge. This definition includes the production of goods for use within the home, since once they have been generated, their destination could change and they could be sold on the market, but it does not include the services--such as health care or caregiving--produced in the household, which are consumed immediately at the moment of their production and therefore could not be sold to a third party. These accounts also exclude services generated through volunteer work for community or nonprofit organizations" (Galvez and Matamala, 2002:4). These criteria leave unremunerated reproductive work--which includes the domestic system of healthcare production--outside the limits of production and, therefore, beyond the scope of the National Accounts.
In light of this exclusionary situation, a number of different national and international institutions have been working in different fora for several years to promote the creation of Satellite Accounts. In this regard, the United Nations Statistics Commission has recommended that the national departments of statistics prepare accounts on economic activities beyond the current limits of production, accounts for the domestic (household) sector or separate "Satellite" Accounts that are also consistent with the current National Accounts. The sector-based Satellite Accounts (which would include an account on health) employ a broader understanding of production and producers, including services offered to other members of one's own household and volunteer work. In other words, it includes households not just as consumers of goods and services but also as producers of non-market healthcare services. This approach would quantify an estimated monetary value added for the unpaid work performed within the household and the capital of the household, thus contributing to the value of the household's efforts as a product and generating information that could be compared with other National Satellite Accounts (Ironmonger, 1996; Carrasco et al., 2004; Duran, 2003; PAHO, 2005; Urdaneta-Ferran, 2002; Araya, 2003). In the case of the health sector, the Satellite Account would include healthcare activities performed in the house by another member of the household as a "subcontractor" (see PAHO, 2005).
In the specific case of health care in Chile, this issue is extremely relevant. In coming years, the country must adopt social policies to cover the needs for care and wellbeing that are the growing and legitimate right of a wide spectrum of people who demand or require this care. In other words, healthcare services must be provided in keeping with a new socio-demographic reality.
In Chile, between 1992 and 2002, the percent of the population age 64 and older increased from 7.4 to 9.1 in the case of women and the 5.7 to 7.0 in the case of men (INE, 1992 and 2003); and life expectancy during this time increased from 77 to 79 for women and from 71 to 73 for men. The gradual aging of the population is transforming and increasing the burden of unremunerated caregiving performed in the home. This work, which until recently was focused on childcare and care for members of the household with some degree of disability, is currently being extended to include a growing population of older people. For this reason, the public health objectives proposed by Chile's Ministry of Health for 2000-2010 (Ministerio de Salud, 2002) seek to broaden the section on health care in the National Accounts, incorporating the calculation of the unremunerated production of health by gender.
The domestic activities of health care, as well as domestic work itself, are essential for people's physical and social wellbeing. Nonetheless, the fact that these activities are not remunerated makes it even more likely for them to be ignored, not taken into consideration and unequally distributed.
Drawing attention to unremunerated caregiving performed in the home recognizes situations of inequity between women and men. It also allows for the improvement of statistical and accounting instruments used in the analysis and design of economic and social policy. It would also promote proposals for support programs, laws and policies for caregivers working in the home.
In the search for gender equity, determining the costs of unremunerated care is of the utmost importance, so that this work can be measured and compared to remunerated work.
To draw attention to the economic contribution of unremunerated healthcare performed in the home (and the time that this work entails), we must begin with the statistics, as Ironmonger (1996) indicates. Current statistics offer a distorted and incomplete perspective on the real role of the household in the provision of care, childrearing and other services of considerable value.
Time-use surveys are a highly useful instrument for revealing the unremunerated work performed in the home. They shed light on the way in which remunerated and unremunerated work is distributed in society and generate data for developing public polices that are more effective in the reduction of inequalities and for supporting the implementation of these policies. The usefulness of time-use surveys were clearly demonstrated in experts' meetings on the subject held by ECLAC in 2003 and 2005. The most recent of these meeting specifically addressed the issue of Satellite Accounts on Health and Time-Use Surveys and looked at the inclusion of the production of unremunerated healthcare services in the home. (6)
In Chile, studies and surveys on the distribution of unpaid domestic work and paid employment between men and women, as well as the measurement of time invested by both genders in the various domestic tasks have not gathered detailed information on healthcare performed in the home (see for example, Sharim and Silva, 1998; Progenero, 2003; SERNAM, 1998). In some of these studies, the activities related to health care were exclusively caregiving for the sick (Nieto, 1999). Research by CEM on women workers from different economic sectors looked at the total time of work performed in some specific groups of workers. (7) For example, women who worked in the garment industry, seasonal agricultural labor and the fishing industry, as well as domestic workers and housewives, have long workdays in a paid job plus domestic work in their own homes and childcare responsibilities, which places a very heavy burden on these women. In the case of women who take in piecework for the garment industry, the time they dedicate to their paid work is even more exhausting than the labor of the factory workers in the same trade because they also work at night after they have met all the family and domestic needs.
Chile's Instituto Nacional de Estadisticas (National Statistics Institute) is developing an Experimental Survey on Time Use in Greater Santiago (INE, 2008) that will later be applied at a national level. The initial results show a clear differentiation in the use of time among women and men, as well as different participation in caregiving tasks according to gender. For example, far fewer men say that their primary activities are "household tasks" or "caregiving" as compared to women (respectively, 33.6% and 77.3% in the first case and 7.8% and 32.8% in the second). With regard to the average daily time spent performing these tasks, women dedicate an average of 2.4 hours each day, while male caregivers spend only 1.6 hours on these tasks.
In our study, the data confirm that in the case of unremunerated healthcare provision, a gender bias is also manifest in a similar fashion to that observed in relation to domestic work: there are proportionally far more women in caregiving roles than men. Of all those surveyed who reported performing healthcare work in their home during the previous week, 86.1% were women.
This finding confirms the hypotheses and results of other researchers in Chile, some of which have already be indicated above. This situation is no exception in our country or, for example, in Spain, where Duran (2004) reports that the 1990 survey on healthcare demand found that 72% of all those surveyed who had performed unremunerated caregiving during the previous week were women.
Since the overwhelming majority of caregivers are women, this article will only make reference to them. Following this introduction, the first section addresses the general aspects of research and methodology. The second section shares the main findings regarding efforts to draw attention to healthcare activities and the time that caregivers invest in them; this section includes a brief profile of the caregivers. The third section addresses issues related to the overall workload, the impact that having to dedicate time to unremunerated health care has on people's personal and professional lives, and the value that the caregivers themselves assign to healthcare work. The fourth and final section shares some conclusions.
General Aspects of the Study: Objectives and Methods
This article is based on the results of a study that had three central objectives: a) to draw attention to unremunerated caregiving; b) to estimate the time invested in healthcare work; c) and to comprehend the overall workload entailed in providing unremunerated health care in the home and the professional and personal impacts on the caregivers.
These objectives are framed in a broader concern related to the invisibilization of unremunerated work, which is performed primarily by women in the home and the community, under a double standard that only perceives the market sphere of the production of goods and services (hiding most of the processes of reproduction without which this "market" could not subsist) and insists on its separateness from the sphere of emotional wellbeing preserved by the silent and invisible work of women in the home (Carrasco, 2001). The traditional economic analysis of work only explores the market-based dimension, turning a blind eye to other forms of hard-to-measure efforts, like the time dedicated to unremunerated work performed by women in the home and volunteer work.
Since these activities are not acknowledged, their contribution to the country's economy and development is not valued and those who perform these services are bereft of economic and social benefits, such as protection in their old age.
In a context of increased healthcare needs of older people who cannot care for themselves and the shifting of healthcare services to the homes--care for the chronically and terminally ill and those with some degree of disability--we must take a closer look at what these new demands mean for the family members who meet the growing healthcare needs of other family members. This analysis implies drawing attention to the caregiving activities being performed, estimating the time dedicated to these tasks, identifying who carries them out and what this work implies for the caregivers in terms of their total workload and the changes that they must make in their professional and personal lives to fulfill these responsibilities. Generally, unremunerated caregiving is not viewed as work or an investment of time, much less as a contribution to the national economy, as we described earlier.
The information for this study was gathered by means of a survey given to a sample of 252 households in different neighborhoods throughout Greater Santiago, with the objective of including households from different social economic levels under the hypothesis that unremunerated health care, as well as domestic work and paid employment are not only influenced by gender but also by social economic factors. (8)
To be included in the survey, the household must meet the basic requirement of having at least one member who had performed some task of unremunerated health care (from a list provided by the researchers) for a resident of the household or for someone who did not live in the home (but generally a relative) who was ill, had some disability or was elderly and could not take care of him/herself. (9)
While the central objective of the survey was to gather information on the unremunerated health care performed within the home of the respondent, the survey also recorded information on such services performed for other people, usually relatives, who lived in other households, because this situation is very common in other countries. In fact, in 11.5% of the households surveyed, the caregiving was performed outside of the respondent's home.
The questionnaire was applied first to the household head, defined as the member of the household who performs and/or administers and/or distributes most of the unremunerated household tasks and therefore knows all the activities of each member of the household. [Ed. note: This term does not imply that this individual is the economic head of household, although this aspect will be addressed later.] This person is often a "housewife," and she identified the members of the household who performed the unremunerated healthcare.10 The individual questionnaire was given to all those who were identified as "caregivers." (11)
The list of healthcare activities to be considered was based on our revision of several studies. (12) These selected activities were divided into four groups: a) specific professional care; b) support care; c)
accompaniment; and d) other activities.
Specific professional care includes activities such as performing specific medical treatment, changing bandages or cleaning wounds, giving injections, controlling manifestations of illness and encouraging intellectual development or stimulation. Support care refers to activities such as feeding, bathing, giving medicine, organizing or arranging the person's living quarters, organizing their routine, cooking special meals for them. Accompaniment includes going with them to recreational activities, providing transportation or moving them from place to place within the home, entertaining them, taking them to the doctor for check-ups or treatments or helping them do paperwork. Other activities include doing paperwork, shopping or running other errands for the person who needs care.
By far, most of the people who undertake caregiving tasks related to health are women, as seen in Figure 1.
Nearly all the women caregivers have the greatest responsibility and invest more time than the rest of the family in performing these unremunerated healthcare activities through their lives as adolescents and as adults. At the same time, most of these women are also household head (86.4%).
This noteworthy participation by female household heads in unremunerated healthcare activities observed in our study was also underlined by Duran (1988:87), who reported that in the process of preserving one's own health or the health of another, the household head also assumes the responsibility of interacting with the institutional healthcare system in representation of the rest of the family and "in addition to making decisions with regard to the medical visit, the women of the household usually go with the sick person to the doctor and makes sure that they get the medicine and care prescribed."
A third of all caregivers have a paid job in addition to their unremunerated domestic responsibilities (household chores and caregiving tasks). This combination of paid and unpaid labor is most common among women caregivers aged 45 to 54, with 48.7% of this age group gainfully employed.13 Provoste and Berlagoscky (2002) suggest that the greater proportion of caregivers in this age group working in paid and unpaid labor could be explained by the fact that there are fewer extended families in which older women assume all the caregiving work while the younger women work outside the home. (14)
Domestic work is the primary activity of most women caregivers, regardless of their socio-economic class, with between 72% and 64% of all caregivers dedicating themselves exclusively to unremunerated work. Most of the women who work both in the home and at a paid job are from the middle-income sector: 34.7% as compared to 27.3% in the lower-income sector and 28.3% in the higher-income sector.
The information gathered in our survey does not directly explain the differences observed among the social sectors. However, we can infer that in the case of the women from upper-income groups--who have a high rate of participation in the labor market according to national statistics--those women who work for pay are not directly responsible for the healthcare activities in their household, but rather they delegate these tasks to paid domestic workers. On the other hand, a lower proportion of caregivers in the lower-income sectors may be able to have gainful employment because they are unable to pay someone else to carry out these tasks in their absence.
Finally, over 15% of these caregivers are not only responsible for the upkeep of the household, but they are also the economic heads of household, in other words, they make the greatest monetary contribution to the household. Figure 2 clearly shows the multiple and simultaneous responsibilities of the women caregivers.
[FIGURE 2 OMITTED]
In sum, women perform unremunerated health care in the home throughout the course of their adolescent and adult lives. Most of these caregivers are responsible for overseeing their households and a third of them are gainfully employed in addition to their unremunerated domestic and caregiving efforts. Over 15% of these women caregivers are also heads of household with the primary economic responsibility for the family as well as being responsible for the upkeep of the home. Very few caregivers are men. Thus, in this article we have chosen to focus our analysis exclusively on the situation of the women caregivers.
Drawing Attention to Unremunerated Health Care
One of the central objectives of our study was to draw attention to the production of unremunerated health care performed within the home. In this effort, we asked the caregivers (of both genders) to list the healthcare-related activities that they had undertaken in the previous week and the weekly time invested in these tasks, differentiating weekdays from the weekend. The activities spontaneously identified by the subjects surveyed were classified as "visible activities." Next, they were read a list of activities related to health care, and they were asked which ones they had performed in the previous week. This allowed the researchers to register many more activities than had actually been performed, but which had not been identified by the caregivers themselves. These tasks were classified as "invisible."
The spontaneous identification of certain caregiving tasks indicates that the caregiver recognizes these actions as demanding of their time. On the contrary, the recognition of these caregiving tasks only when mentioned or shown in a list provided by another person indicates that the caregiver does not perceive them as specific activities, but quite possibly lumps them in with other household tasks.
In only one out of ten household surveyed were all of the unremunerated healthcare activities visible. Most of the households gave evidence of a varied combination of visible and invisible tasks. In other words, the caregivers clearly identified some of the tasks as health care, while others are not identified as such nor seen as separate from the rest of the housework that is part of the regular unremunerated domestic work.
In general, healthcare activities are more visible in the middle-income sectors. All of the caregiving tasks were visible to 11% of the caregivers in this group as opposed to 6% of lower-income caregivers and 2.1% of the caregivers in the higher-income sector.
Our study found that nearly equal proportions of women and men perceived their efforts in health care. These results contradict to some extent the hypothesis of other studies, such as the work of Carrasco and Dominguez (2001), who report that women are more likely to "naturalize" unremunerated work and therefore tend to invisibilize these activities. On the contrary, men would invisibilize them less since these activities are not a "natural" part of their responsibilities, and therefore, they are very aware of performing these tasks and see them for what they are. Our study found that the visibility or invisibility of a task is related more to the sort of work that it is rather than the gender of the person performing it.
For example, Table 1 shows that the healthcare tasks less perceived as such were: entertaining the sick person, providing transportation for the sick person, organizing the routine; and arranging the sick person's living quarters. (15) Given that, in general, these tasks don't take very long to perform, it is very likely that they are done fairly simultaneously with other domestic activities, and so they tend to go unnoticed.
The caregivers were least likely to recognize the actions of "entertaining the sick person," "organizing the daily routine" and "organizing the sick person's living quarters" as health care. In 80% to 95% of the cases, the caregivers did not mention these activities spontaneously. The fact that entertaining the sick person is not visible is very interesting, since this task clearly interrupts the routine of domestic chores.
Initially, we thought that other activities would "disappear" more easily, camouflaged as daily domestic tasks, since many healthcare activities could be carried out simultaneously with the regular household activities (such as "feeding" or "cooking special foods"). Nonetheless, these tasks are much more visible, compared with "entertaining the sick person." The invisibility of this action could be explained by the fact that it implies a loving relationship between two people, the caregiver and the person being cared for, and so it is not recognized as "work" nor is it perceived as health care. Another reason could be the minimal time allocated to this activity each day.
The degree of visibility among the unremunerated healthcare activities also varies according to whether the caregivers dedicate themselves to domestic work full time or if they also have a paid job. Generally and considering only the most often-mentioned healthcare activities, the first group is less likely to perceive the health care as opposed to the second group (65% and 55% of the tasks are invisible, respectively). It is likely that women who have paid employment have to organize their time much more precisely and therefore more clearly identify the time they dedicate to these activities.
On the other hand, while the middle-income sector pays more attention to the healthcare activities as a whole, as we indicated earlier, when we look at the most frequently performed activities, the degree of visibility changes: these tasks are more visible in the lower-income sectors. This result is interesting because one might think that the caregivers from the lower-income sectors might have tended to incorporate these healthcare activities into their daily routine, since more than half of them state that they are exclusively dedicated to domestic work, which would tend to hide some of the healthcare tasks. Nonetheless, because the healthcare activities increase their work and complicate the domestic routine, they are perceived and recognized by the caregivers.
Time Dedicated to the Production of Unremunerated Health Care
The second main objective of our study was to estimate the time that the caregivers dedicated to healthcare activities. Just like domestic work or a paid job, health care makes demands on the caregivers' time and cannot be avoided, which has repercussions on their total workload and may force them to make changes in their lives.
The results of this study reveal that women dedicate a total of 20.5 hours on average each week to unremunerated healthcare activities in the home and that this time is distributed among an average 9.4 tasks. The averages vary according to when the activities are performed, i.e., during the week or on weekends. During the week, the caregivers work about 3.5 hours each day on healthcare-related tasks and during the weekend only about an hour a day. The difference is explained by the fact that some of these activities must be done on weekdays, such as running errands, taking the sick person for medical visits or treatments outside the home--which often takes up considerable time.
On the other hand, while there is a similarity in the average time invested in health care by all the socioeconomic groups, the differences are striking. Only 30% of the women in the highest-income sector dedicated over 21 hours a week to unremunerated health care, while 44% of the caregivers in the lowest-income bracket spent that much time performing these tasks.
The daily average of time dedicated to unremunerated healthcare activities also depends on the type of task. Some activities are brief, like giving medicine or transporting the person from one place to another within the home--12 and 24 minutes on average, respectively--and they can be performed simultaneously with other domestic tasks. However, other activities demand more specific dedication, such as taking the sick person to regular medical visits, taking them for medical treatments or doing their paperwork. These tasks take, on average, 1.5 hours to 2.5 hours and tend to take more time for the lowest socioeconomic sector.
Studies undertaken in other countries on time use indicate in the case of Nicaragua, for example, that women and men dedicate 2.6 and 2.2 hours daily, respectively, caring for sick people (INEC, n.d.). In Costa Rica, the time-use survey shows that women invest about 3 hours each day in caring for the ill, children and others (Sandoval, 2005). In Mexico's 2002 time-use survey, 70% of the respondents who performed healthcare activities in the home were women, who invested 4 to 11 hours each week (Nigenda et al., 2005).
Another important finding regarding time dedicated to unremunerated healthcare activities is the working conditions of the caregivers. As seen in Table 3, women who list domestic work as their primary activity invest nearly 22 hours on average each week to healthcare tasks, while those who also work in a paid job still manage to put in 16 hours each week to healthcare activities.
In sum, the data gathered by our survey reveals the existence of a high degree of unremunerated caregiving activities that are not visible and that are mixed up with domestic work, which is, of course, essential.
At the same time, the caregivers invest considerable time in these tasks, and there are only so many hours in a day. The following section explores how caregivers are often obligated to make changes in their personal and professional lives in order to perform these unremunerated healthcare activities.
The Overall Workload and Its Impact on Professional and Personal Lives
The time invested in the many tasks related to unremunerated health care, a paid job, domestic activities and other caregiving results in a very heavy workload, especially in the case of women, and sometimes forces them to make changes in their personal or professional lives.
In our study, the total workload was estimated based on the weekly time invested in unremunerated work (healthcare activities and domestic chores) plus the time dedicated to remunerated work (when the woman also had a paid job).
The methodological problem that crops up in these sorts of measurements involves the possibility that certain tasks can be performed simultaneously, especially unremunerated tasks (domestic work and healthcare tasks), although there may also be an overlap in remunerated and unremunerated activities in the case of those who work at home. In this case, we performed a simple aggregation of the time dedicated to the different tasks (an aggregated index), which very probably results in a workday with more hours than a real day.
There have been many attempts to overcome this problem of overlapping tasks. Usually, studies like the one carried out by Madrid's Direccion General de la Mujer (2003) have tried to solve this problem by attempting to establish an approximate time for the workday based on an estimation by the survey respondents (a synthetic index), measuring the difference in time between the sum of all the activities registered in the study and the overall estimate provided by the respondents, which allows the calculation of the amount of overlapping time.
We attempted to use this methodology to solve the problem of overlapping work, however, we found that the estimates the respondents made of their total workload (paid employment plus unremunerated work) was either significantly over or under estimated. Clearly, we needed another way of estimating the overlap, and so we decided to add the time they dedicated to all the activities implied in health care and the time dedicated to domestic work and we compared these results to those obtained by other studies carried out in Chile and elsewhere in the region, in order to estimate the range in the differences in time, as we will explain shortly.
In general, the total workload of the caregivers was an average of 70 hours a week, however, the total hours worked varied among the caregivers. Indeed, caregivers who have paid jobs in addition to their unremunerated work put in an average of 87 a week, over 12 hours a day. On the other hand, the caregivers who are dedicated exclusively to domestic work have a total workload of 63 hours a week, nearly 9 hours daily.
The highest total workload--nearly 94 hours a week on average--was found among low-income caregivers who also have paid jobs. This means that they work over 13 hours a day.
The time dedicated to domestic work and healthcare tasks by caregivers who only worked as "housewives" was very close to the average time invested in domestic work and caregiving tasks as estimated by the study carried out by Schlaen, Diaz and Medel (1998) on housewives in Chile: 11 hours daily.
The Encuesta Experimental sobre Uso del Tiempo en el Gran Santiago (Experimental Survey on Time Use in Greater Santiago), carried out by Chile's National Institute of Statistics (INE) in 2008, aimed to quantify the total workload (paid and unpaid), the distribution by gender of unremunerated domestic work in the home and the estimate of the use and distribution of time dedicated to activities related to caregiving. The results of the first sample indicated that the total workload of women who simultaneously perform paid and unpaid work is over 10.4 hours a day, of which 2.9 hours are dedicated to unremunerated efforts. (16)
The results of the second sample revealed that women are responsible for 68.2% of all unremunerated work. They spend an average 3.5 hours a day caring for others in the household, which drop to 1.1 hours a day when they also have paid work and their total workload is over 8 hours a day. (17)
In a study by Duxbury and Higgins (2002) on the conflicts between personal life and work in Canada, the subjects surveyed reported dedicating about 17 hours a week to tasks unrelated to their paid jobs. This study also revealed that workers who are responsible for providing care for children, older persons and the disabled must also meet more demands on their time in comparison with their colleagues who don't have such responsibilities and that they spend twice as much time on tasks unrelated to their professional lives (23 hours a week versus 10 hours a week); they also have 3 hours less leisure time each week.
Impact on Caregivers' Professional and Personal Lives
One of the possible consequences of dedicating time and effort to unremunerated healthcare activities in the home is the fact that caregivers are obliged to make changes in their professional or personal lives. (18) In fact, during the 2004 commemoration of International Women's Day, the Director of the Pan American Health Organization, Dr. Mirta Roses Periago, observed assumptions implying that providing health care to the family has no personal, family or social consequences were unfair, unrealistic and dangerous for public health policies. (19)
Caregivers make changes in their personal and professional lives because allocating a portion of time every day to unremunerated health care often implies abandoning activities that they once performed. As Mauro and Yanez (2005) demonstrate, in order to balance their paid work with caregiving responsibilities women must often choose jobs that are part time, have no formal contract, are poorly paid, have no benefits and which they must frequently perform in their own homes. The alternative is not having any form of remunerated work: nearly 50% of women have irregular work histories, with periods of employment, underemployment and unemployment during the ten years considered in Mauro and Yanez's study.
Over half the caregivers we interviewed reported that they had to make some sort of change in their personal or professional plans. (20) These changes varied widely, but a significant percentage were related to their paid work: either they had to quit their job, work fewer hours, change their schedule or work at home. They also reported other impacts on their professional lives, such as earning less or being concerned about their performance evaluation or possibilities for promotion (due to frequent absences or because they had to work fewer hours).
These changes also vary according to the age of the caregiver. For example, many of the women aged 35 to 64 reported earning less, and this impact was especially notorious among the women aged 55 to 64. We can surmise that this drop in income is linked to working fewer hours or to having to quit a paid job altogether. Leaving the labor market was also a change reported by women aged 25 and older and is most serious among the women aged 55 to 64 (18%). Among the younger women, the most important changes were dropping out of school, working fewer hours at a paid job, earning less and losing friends.
It is important to stress that while both women and men make changes in their personal and professional lives in a similar proportion, the sort of impact that these changes have in their lives is very different. Women had to quit their jobs, earned less money or lost friends. Men felt some repercussions in their professional lives, but they didn't quit their jobs; they just worked fewer hours or changed their schedules or shifts (see Table 4).
In this regard, Galvez and Matamala (2002) warn that when women have paid employment outside the home, healthcare work in the domestic sphere often interferes, complicates or interrupts this participation in the labor market. The Canadian study of Duxbury and Higgins (2002) also found it likely that caregivers of older persons would have to make changes in their lifestyle: since they are providing care, they have less time for their families, for their own health care and for vacations. They also found that while only about 10 percent of the caregivers had to quit a job to take care of an older person (usually a parent), 20 to 40 percent had to make changes in their work schedules, reduce their work hours or take unpaid vacation time.
The consequences of providing healthcare services in the lives of the caregivers were also observed in a survey carried out by Spain's Centro de Investigaciones Sociales (CIS, Center for Social Research) (cited in Delicado et al., 2004). In this survey, the caregivers acknowledged a reduction of leisure time, being tired, not taking vacations, not seeing friends, feeling depressed, health problems getting worse, not being able to work outside the home, not having time to take care of themselves, having economic problems, having to work fewer hours at a paid job or having to quit work altogether. The caregivers in our study mentioned some of these same consequences.
As we explained in the introduction, women are perceived as morally obligated to fulfill these caregiving responsibilities. This is very likely the reason why women caregivers often quit their jobs or put off personal activities.
On the other hand, the situation of caregiving also can have repercussions on the family if the household head becomes ill, disabled or dependent. When the woman who usually takes care of the domestic work and caregiving in the household becomes ill, domestic production comes to a standstill, and if her illness is chronic, there may be a reorganization of the family, with dependent children being sent temporarily to other households, explains Duran (1988). In our study, several of the male caregivers who stated that they were the household heads lived in a household comprised of only two people, the respondent and his spouse/partner, who received the health care. If the illness is transitory, it is possible that men may temporarily take responsibility for the domestic chores.
Value Given to Unremunerated Caregiving Work
Our survey also gathered information on the value that the caregivers placed on these activities.
In regard to this issue, Duran (1988:83) indicates that: "Maintaining the health of oneself or another person has become a very economic matter, and the decisions that affect care are determined by whether or not they are cost-effective. Even though the right to health is recognized in the legal realm as a basic right, all economic entities--be they individual, family, business, local clinic, institution or national political/administrative system--includes health in their calculations of risk, costs and benefits." On the other hand, Carrasco (2001) indicates that "the criteria of a third person" is general used to evaluate the value of unremunerated work. However, these efforts generally underestimate the worth of domestic work in the family by measuring domestic production using market criteria and trying to establish a universal standard as the value of all work performed in the household. This work is not only an activity that meets the needs of the production and reproduction of human life based solely on the logic of market relations. On the contrary, it also includes reciprocity, solidarity, feelings and care, the basic values of domestic work. Therefore, valuing domestic work--and unremunerated health care--means becoming aware of the economic and social contribution made by these activities, taking into account the time and the cost (both emotional and economic) that they entail.
One of the problems involved in trying to set a value on domestic work and unremunerated caregiving--which includes health care--is related primarily to the fact that many of the activities also incorporate a considerable subjective/emotional burden (the activities are inseparable from the emotional relationship, and there are no substitutes available on the market). In addition, domestic activities related to management and organization often do not necessarily demand much in the way of time but they do require a great deal of energy. Therefore, addressing this issue implies focusing on at least two dimensions: one is based on quantification, creating a system of value based on time or money; and the other is based on a qualitative perspective that captures the complexity of these different classifications of healthcare activities, which are very difficult to pin down and specify. Our study does not attempt to estimate the monetary value of the healthcare activities performed by the caregivers surveyed but rather to record their perceptions with regard to this issue. (21)
The responses to our question on this matter were divided into two groups. The first group, in which most of the caregivers fell (76%), were those who believed that the healthcare work had monetary value, the other group didn't assign an economic value to the work.
Among the caregivers who do not recognize a monetary value in these activities, a significant percent (39.3%) make clear reference to family reasons for performing these caregiving tasks, such as, "he's my son," "he's my father," "he's my husband," "she's a relative," or "it's her duty."
In this regard, in their study on unremunerated caregivers in Mexico, Nigenda, Matarazzo and Lopez-Ortega (2005:12) report: "In their analysis, some studies have concluded that the expectations, cultural meaning and values that people assign to caregiving are one of the reasons why these activities are perceived as less stressful and onerous than they really are (Chadiha et al., 2004). Therefore, while negative impacts of informal caregiving are perceived, they are also eclipsed by the positive impacts."
In sum, dedicating part of their daily time to healthcare activities could increase people's total workload. While it is true, as we will see shortly, that some of the unremunerated healthcare activities imply a reduced use of daily time and can be carried out almost simultaneously with other domestic tasks, there are other healthcare activities that cannot be performed in parallel with other tasks but demand the dedication of a specific amount of time and considerable time at that. We refer, for example, to regular medical visits, specific treatments, accompanying the sick person to do errands or paperwork or taking care of these things for the ailing member of the household.
At the same time, women not only assume the family domestic work, but also the unremunerated health care. Often, the immediate cost of carrying out the activities is to have to quit their job or receive less income and, in some cases, lose friends. The caregivers in our survey also used subjective arguments related to their emotional connection with the person for whom they are providing the care or they express socio-cultural values such as responsibility or a sense of duty to their family, and therefore, it is difficult for the subjects to set an economic value on these activities because they transcend the logic of the market.
Summary and Conclusions
The exploratory study on unremunerated healthcare work in households of Greater Santiago discussed in this article allowed us to estimate the degree to which these tasks are perceived by those who perform them, especially in the case of women (the majority of the caregivers are female). In second place, this study allowed for an estimate of the time that the caregivers dedicate to healthcare activities, as well as their total workload and the impacts that carrying out the unremunerated caregiving has on their lives. Finally, this study revealed the value that the caregivers placed on this work and the arguments they used to justify this appraisal.
All this information allows us to put forth some general conclusions. In the first place, we should stress the importance of and the need to support unremunerated caregivers, especially women of middle- and lower-income sectors, who dedicate so much time to the activities and have such a heavy workload. In addition, in certain circumstances, they have been forced to quit their jobs or work fewer hours at their paid jobs, which implies a decrease in income among other consequences. In second place, we find it fundamental to extend and broaden the debate on strategies and public policies that aim to improve caregivers' situations.
In this regard, Nigenda, Matarazzo and Lopez-Ortega (2005) present a concise and very interesting summary of different strategies of support for unremunerated, informal caregivers implemented in European countries, the United States and Canada. These strategies offer economic incentives through subsidies or fiscal measures to provide the direct provision of care or the hiring of external care services, while others help caregivers to have more time by reducing or reorganizing their work schedule through leave or by allowing them to work shorter days, among other measures. A third set of strategies focuses on caregiving services outside of the family, so that others perform the work; and finally, the last set of strategies provides training and information to caregivers, like counseling and psychological support, short breaks and support services in the household.
The study by Nigenda and colleagues also addressed the problem of public policies in relation to unremunerated healthcare activities in the home and long-term caregiving (for the chronically ill, for older persons who cannot take care of themselves or for the disabled), which can have negative impacts on the professional and personal lives of the caregivers, as the results of our study also clearly revealed.
With regard to the best course of action, different documents, studies, seminars and meetings have asked a number of questions. Is it better to provide support for the person being cared for or the caregiver? Should subsidies to pay for services be given to the families or the people who need care or would it be better to support and certify state providers? What is the nature and the scope of the right to care? How do we provide support for the informal, unremunerated caregivers without turning family relations into a market good? What impact would providing support to unremunerated caregivers have on the public budget? And finally, to what extent is reproducing the role of women as primary caregivers a valid act?
Concerns such as these bring us to the matter of who is and who should be responsible for providing health care in Chile: the State, society, the individual and/or the family, especially in the light of data provided by our study and other research and experiences from other countries on ways to address this problem and the policies and strategies that have been implemented.
We also believe that it is important to undertake new studies, both qualitative and quantitative, on care for older persons who are unable to care for themselves, a need that can last for a long time. These studies would allow for the identification of other impacts of unremunerated health care. This aspect was not analyzed in our research but is relevant for the promotion of actions and policies, given the aging of the Chilean population and society's scant preparation for confronting this trend, which is especially significant because the care of this population will continue to fall on women's shoulders.
It will also be important to study how much time the caregiver spends on the caregiving activities, as well as whether or not they have paid help. First of all, such a study would allow us to more precisely comprehend the contribution by unremunerated caregivers to the healthcare system, which would be useful for promoting actions and policies targeting "long-term" caregivers. Secondly, this sort of research would allow us to discover the sort of care that unremunerated caregivers perform, since not all the healthcare activities are the same. Some of these tasks need more knowledge or specialization than others, for example accompanying the older person as compared to having to give injections or perform a specific treatment. Clearly, untrained unremunerated caregivers cannot take on all healthcare activities, and also, the estimated market value of these activities varies widely.
Finally, all proposed actions, programs or policies on unremunerated health care should bear in mind the fundamental role that women play in caregiving and what these efforts mean for their economic autonomy and their physical and mental health.
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(1.) WHO, 2008.
(2.) In Chile, "between 1992 and 2002, the population age 64 and older increased by 340,000 individuals, a growth rate of 3.3%. The total volume of the senior population that would potentially benefit from social policies grew in 2002 to over 1.2 million people. Women comprise the greater proportion of this population, a trend that increases with age" (Bravo 2004:52).
(3.) At the time of the 2002 Census, there were 334,400 people with some mental or physical disability in Chile, 2.2% of the nation's total population (Bravo, 2004), and 116,853 were living in the Metropolitan Region, representing 1.9% of the total inhabitants of this part of the country (INE, 2003).
(4.) Health care is becoming more important as time goes on, reports Roses (2005): "At the beginning of the 21st century, there were some 2,228,900 people age 90 and over living in the Americas, and 90,400 of them were centenarians. By mid-century, these figures will have reached nearly 13,903,000 and 689,000, respectively." This situation implies a growing population of older persons who will rely on family to meet their healthcare needs, and most of these caretakers will be women.
(5.) According to census data from Chile in 1992, women's rate of participation in economic activity was 28.1%, which increased to 35.6% by 2002. In that year, the national rate of participation was 52% for women aged 25 to 39 and 49% for women aged 40 to 44. In the Metropolitan Region, women's rate of economic activity was higher than the rate among women for the country as a whole for 1992 and 2002, reaching 34.5% and 42%, respectively.
(6.) As of 2005, very few countries in the region have undertaken time-use surveys; they include Cuba, Mexico, the Dominican Republic, Nicaragua and Uruguay. It should also be noted that these surveys don't disaggregate the healthcare tasks. In some cases, they consider caring for the sick and the disabled as different activities within the sphere of domestic work. See Aguilar and Espinoza, n.d.; Universidad de la Republica, 2003; Aguirre, 2004; Alvarez, et al., 2003; Gomez, 2003; Oficina Nacional de Estadisticas, 2003.
(7.) See Diaz and Medel, 2002; Medel et al., 1998; Diaz et al., 1996; Medel and Riquelme, 1994; Diaz and Schlaen, 1994; Diaz and Schlaen, 1992; and Medel et al., 1989.
(8.) The survey was given to permanent residents of private homes in Greater Santiago, excluding persons in collective living situations, such as care facilities, convents or jails. The sample unit was a home with one or more members. The sample of 36 sectors was extrapolated from the total number of city blocks (or manzanas) in Greater Santiago, 34,661 manzanas, distributed in 34 comunas (boroughs), and based on the results from the 2002 Census, using a simple two-step random sample, divided by socio-economic groups.
(9.) In taking down the information, the tasks performed the week prior to the survey served as a reference.
(10.) If there were more than one caregiver in the household, the main caregiver was identified at the person who dedicated the most time to the unremunerated healthcare activities, while those who helped the caregiver perform these tasks (but spent less time doing this work) were classified as "support care." Of those surveyed, 92% were the main caregiver.
(11.) When the questionnaire was being designed, we had set a minimum age of 15 for the subjects being interviewed. As a result of meetings held by the team of investigators with the team implementing the survey in the field, we decided to not establish an age limit, since especially in the lower-income sectors, healthcare tasks might be assigned to the younger members of the family.
(12.) PAHO/WHO, 2004; Duran, 2004; Reca et al. 2002; Provoste and Berlagoscky, 2002; Carrasco, 2001. See also The United Nations Statistic Division, Allocation of Time and Time Use, available online at http://unstats. un.org/unsd/demographic/ sconcerns/tuse/. The activities included were adapted to the context in which the survey was applied.
(13.) According to data from the 2002 Census, throughout Chile 2,671,639 women performed unremunerated work (women aged 15 and older who declared "housework" as their main activity). Women's dedication to unpaid domestic work varies with the stage of their life cycle, and the proportion increases with age: from 37% of 20- to 24-yearold women, the proportion leaps to 52% among 25- to 39-year-old women, with much gradual increases thereafter: 54% among 40- to 49-year-old women and 59% among 50- to 64-year-old women. See Bravo, 2004.
(14.) In 1992, 27% of the families were extended or compound families (with one or two parents); in 2002, this percentage dropped to 25% (Bravo, 2004:16).
(15.) The degree to which a task is invisible depends on the number of times it appears only when attention is called to it (by the list provided by the survey team) with respect to the total number of times the task is spontaneously named.
(16.) The sample was comprised of 1,571 households in urban areas in the 34 comunas (bouroughs) of Greater Santiago.
(17.) The second sample incorporated a sub-sample of 261 households based on records provided by the Ministry of Health from its Program for Caregivers of the Prostrate.
(18.) It should be noted that our study did not examine the impact of this dedication on the physical or mental health of the caregivers themselves.
(19.) Roses, 2004.
(20.) The question used to discover this sort of change took as a reference the twelve months prior to the application of the survey.
(21.) The interviewers were asked to transcribe verbatim the subject's response to the question, "How much (monetarily speaking) do you think that the unremunerated healthcare tasks you mention earlier are worth?" This response might include the criteria used by the subjects to appraise this work, which was of fundamental importance for our study. We were more interested in the arguments that they used than in the amount of money.
by Amalia Mauro and Julia Medel, with contributions from Ximena Diaz
The authors are researchers at Chile's Centro de Estudios de la Mujer (Center for Women's Studies). This article summarizes the findings from the FONIS project no. sa04i4047, entitled "Visibilizacion de los costos de la produccion de salud en el hogar. Impacto sobre el trabajo total de las mujeres" (Drawing Attention to the Costs of Health Care Production in the Home and Its Impact on Women's Total Workload).
Table 1. Healthcare Activities According to Visibility Activities Visible Invisible % % Running errands or doing paperwork 55.8 44.2 Monitoring the illness 62.7 37.3 Encouraging intellectual development 16.7 83.3 Feeding 46.5 53.5 Cleaning 42.2 57.8 Giving medication 67.4 32.6 Organizing the sick person's belongings 26.4 73.6 Organizing and/or arranging the sick person's living quarters 14.5 85.5 Organizing the sick person's routine 12.5 87.5 Cooking special foods 34.1 65.9 Accompanying the sick person in recreational activities 18.7 81.3 Transportation 10.2 89.8 Entertaining the sick person 7.6 92.4 Taking the sick person to regular medical visits 63.1 36.9 Taking the sick person for specific medical treatments 65 35 Accompanying the sick person to do errands or paperwork related to health 31.6 68.4 Running errands or doing paperwork for the sick person 25.6 74.4 Buying medicine 48.6 51.4 Buying food 24.1 75.9 Buying other supplies for the sick person 27.8 72.2 Other (specify) 75 25 Activities Total % N Running errands or doing paperwork 100 86 Monitoring the illness 100 193 Encouraging intellectual development 100 18 Feeding 100 198 Cleaning 100 147 Giving medication 100 361 Organizing the sick person's belongings 100 159 Organizing and/or arranging the sick person's living quarters 100 207 Organizing the sick person's routine 100 120 Cooking special foods 100 147 Accompanying the sick person in recreational activities 100 91 Transportation 100 88 Entertaining the sick person 100 132 Taking the sick person to regular medical visits 100 165 Taking the sick person for specific medical treatments 100 40 Accompanying the sick person to do errands or paperwork related to health 100 76 Running errands or doing paperwork for the sick person 100 39 Buying medicine 100 181 Buying food 100 83 Buying other supplies for the sick person 100 18 Other (specify) 100 4 Source: CEM (2005) Encuesta sobre visibilizacion y medicion del tiempo dedicado a las tareas de cuidado de salud no remuneradas. Table 2. Degree of Invisibility of Most Frequent Unremunerated Healthcare Activities, According to Type of Work Performed by Caregivers Activities % of Invisibility Only Unremunerated Unremunerated & Remunerated Work Work Feeding 56.2 49 Giving medication 34.1 33.3 Organizing the sick person's belongings 77.2 73 Organizing and/or arranging the sick person's living quarters 85.1 84 Organizing the sick person's routine 85 69 Cooking special foods 65.7 55.9 Entertaining the sick person 91.5 52.8 Total of all frequent activities 65 55 Source: CEM (2005) Encuesta sobre visibilizacion y medicion del tiempo dedicado a las tareas de cuidado de salud no remuneradas. Table 3: Average Weekly Time Dedicated to Unremunerated Health Care, According to Type of Work Performed by Caregivers Gender Time Caregiving by Type of Work Unremunerated Unremunerated & Work Only Remunerated Work Hrs. Min. Hrs. Min. Women 22 15 16 32 Source: CEM (2005) Encuesta sobre visibilizacion y medicion del tiempo dedicado a las tareas de cuidado de salud no remuneradas. Table 4: Primary Personal and Professional Changes Made by Caregivers, by Gender Gender Changes * Women N % Dropped out of school 18 6 Quit work 42 13.9 Worked fewer hours 22 7.3 Changed work schedule 20 6.6 Changed work shift 14 4.6 Began to work at home 27 8.9 Earned less 54 17.9 Saw an impact in job evaluation or possibilities for promotion 21 7 Saw an impact in possibilities for making decisions in group work 13 4.3 Lost friends 33 10.9 Other impacts in personal life 15 5 Other impacts (family conflicts; going to live in the home of the person needing care or bringing them into the household; having to get a job; having to work more hours) 23 7.7 Total changes 302 100 Gender Changes * Men N % Dropped out of school 0 0 Quit work 4 9.3 Worked fewer hours 8 18.6 Changed work schedule 7 16.3 Changed work shift 6 14 Began to work at home 4 9.3 Earned less 8 18.6 Saw an impact in job evaluation or possibilities for promotion 2 4.6 Saw an impact in possibilities for making decisions in group work 0 0 Lost friends 3 7 Other impacts in personal life 0 0 Other impacts (family conflicts; going to live in the home of the person needing care or bringing them into the household; having to get a job; having to work more hours) 1 2.3 Total changes 43 100 Gender Changes * Total N % Dropped out of school 18 5.2 Quit work 46 13.3 Worked fewer hours 30 8.7 Changed work schedule 27 7.8 Changed work shift 20 5.8 Began to work at home 31 9 Earned less 62 18 Saw an impact in job evaluation or possibilities for promotion 23 6.7 Saw an impact in possibilities for making decisions in group work 13 3.8 Lost friends 36 10.4 Other impacts in personal life 15 4.4 Other impacts (family conflicts; going to live in the home of the person needing care or bringing them into the household; having to get a job; having to work more hours) 24 6.9 Total changes 345 100 * multiple-choice question Source: CEM (2005) Encuesta sobre visibilizacion y medicion del tiempo dedicado a las tareas de cuidado de salud no remuneradas. Figure 1: Unremunerated Caregivers, by Gender Women 86.1% Men 13.9% Source: CEM (2005) Encuesta sobre visibilizacion y medicion del tiempo dedicado a las tareas de cuidado de salud no remuneradas. Note: Table made from bar graph.