Introduction
As England’s population ages and formal social care services struggle under growing policy and funding pressures, family caregivers—especially spouses—have taken on an increasingly central role (Glasby, 2021). Among adults aged 50 and over, more than half rely solely on their spouse for care (Ornstein et al., 2019). Against this backdrop, our recent study published in Social Science & Medicine takes a dyadic perspective, examining how the relational and individual characteristics of spouses influence whether care needs are adequately met among older couples in England.
What are Unmet Care Needs and How are they Measured?
Unmet care needs refer to situations where people have difficulties with everyday tasks due to health or functional limitations, but do not receive the support they need. These needs can include anything from getting out of bed to managing medication or preparing meals. However, unmet care needs are difficult to tackle. To address this, most studies approach the question in two parts (García-Gómez et al., 2015): 1) What counts as a care need? and 2) When is that need considered “unmet”? However, as researchers have noted (Dunatchik et al., 2019), there is no universal agreement on what constitutes a care need, or when a need is considered unmet.
The most common framework for identifying care needs comes from a person’s ability to carry out what are termed Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs), along with mobility tasks. ADLs refer to basic self-care tasks, such as bathing, dressing, eating, using the toilet, walking across a room, getting in and out of bed. IADLs include more complex tasks that are necessary for independent living, such as preparing meals, shopping, managing medications, handling finances, using maps or navigating unfamiliar areas. Mobility tasks include getting around outside the home, climbing stairs, or using public transport.
Once care needs are identified, the next question is: Are those needs being met? In the literature, researchers typically use one of two approaches: objective or subjective assessments. Objective assessments (the absolute approach) focuses on whether a person receives any help with a task they have difficulty to do on their own (Vlachantoni, 2019). If they report difficulty but get none, they are considered to have an unmet need. This is sometimes referred to as the “all-or-nothing” approach, because it doesn’t consider whether the help they do receive is adequate, just whether it exists at all. As per subjective assessments (the relative approach), people are asked how they feel about the support they receive (Spiers et al., 2022). Even if they do get help, they may feel it’s not enough or not appropriate. This approach captures perceived insufficiency and is generally broader in scope.
While the distinction between objective and subjective assessments of unmet care needs provides a useful framework, both approaches have important limitations particularly when applied through large-scale survey data (Vlachantoni, 2019). Objective measures define unmet need as the presence of a care need and the complete absence of help. However, this binary logic oversimplifies the complexity of real-life care situations. For instance, an individual may report difficulty bathing, but whether they require external support depends on context, such as their ability to use aids. The objective measure does not distinguish between difficulty and actual dependency. As such, the lack of help does not always equate to unmet need, and the presence of help does not confirm that the need is fully met.
Subjective assessments, on the other hand, ask individuals whether the support they receive is adequate. This captures perceived insufficiencies that objective measures may miss. However, subjective assessments are inherently shaped by personal expectations, cultural norms, emotional states, and relationship dynamics. Two people with identical levels of support may rate their experiences very differently: one feeling content, another frustrated. Therefore, while more inclusive, subjective measures may not accurately reflect the specific scope or practical adequacy of support needed.
Moreover, both types of assessment rely on structured survey questions, which often simplify complex realities into checkboxes. Surveys usually ask about a predefined list of tasks (such as dressing or shopping), which may miss other relevant domains of need like emotional support, supervision, or coordination of multiple services. These gaps mean that survey-based measures may underrepresent the true diversity and severity of unmet care needs in practice.
Given these limitations, researchers increasingly advocate for using both objective and subjective measures in tandem, acknowledging that each captures different aspects of the care experience. This dual approach offers a more balanced and nuanced understanding of unmet needs, which recognises both the presence or absence of help, and the individual’s perception of its adequacy. In practice, these two approaches can produce very different estimates of how many people have unmet needs. Our study used both to provide a more comprehensive view.
Spouses Matter
We analysed data from the English Longitudinal Study of Ageing (ELSA), focusing on 3,439 person-years of observations from couples where one partner had care needs. We found that a spouse’s own health, employment, and emotional relationship with their partner significantly influenced whether the partner’s care needs were met. For instance, individuals whose spouses had more physical or functional limitations were more likely to experience unmet needs themselves. In practical terms, if both members of a couple are in declining health, the ability to provide care within the household becomes severely limited. Depressive symptoms in a spouse also played a role. Those whose partners had more symptoms were significantly more likely to report that the care they received did not meet their needs. This was true for both men and women. Poor mental health may reduce the energy and attention caregivers can offer, affecting the perceived quality of support.
Gender Shapes the Care Equation
One of the most insightful aspects of the study lies in its exploration of gender differences in caregiving dynamics. While previous research has shown that women are more likely to provide care (Glauber, 2017), this study unpacks how gender influences the impact of spousal characteristics on unmet needs.
Men were more likely to experience unmet needs if their wives were in paid work. For men with more severe care needs, having a working spouse doubled their risk of receiving no help with basic tasks. In contrast, women’s unmet care needs were unaffected by whether their husbands were employed. This finding supports the idea that caregiving remains heavily gendered, with women bearing the brunt of hands-on support even when juggling other responsibilities.
Interestingly, we also found that emotional closeness mattered more for women. Women who reported very close relationships with their partners were significantly less likely to have unmet needs, both objectively and subjectively. For men, this emotional factor had no measurable impact on whether their needs were met. These gender differences point to deeply embedded social norms. Women often view caregiving as part of their identity and may continue to provide care regardless of relationship quality (Bertogg and Strauss, 2020). Men, on the other hand, may not see caregiving as a natural or expected role, which could limit their involvement even when needed.
Implications
This study challenges us to rethink how we assess care needs and design support systems. Too often, assessments focus on the individual in isolation. But as this research shows, care needs and whether they’re met, are deeply embedded in interpersonal relationships, particularly in later life. It also raises questions about how we define and measure unmet needs. The study used both objective and subjective measures, revealing that different factors predict each of these domains. For example, a spouse’s depressive symptoms influenced subjective (perceived) care shortfalls, while employment status was linked to objective gaps in care provision. This dual lens is essential for a fuller understanding of where and why care breaks down.
The findings suggest that care policy needs to evolve from an individual-based model to one that considers the couple or household unit. Support should be tailored not only to the person needing care but also to the capacities and constraints of their primary support, often their spouse. Gender-sensitive approaches are also vital. The findings show that men and women experience care gaps differently, and that spousal roles in caregiving are shaped by societal expectations. Interventions should account for these dynamics if they are to be truly effective.
Conclusion
In a society where ageing in place is increasingly promoted, understanding the household context of care is more important than ever. This study offers a timely reminder that behind every statistic on unmet needs is a relationship—sometimes strained, sometimes strong—that plays a critical role in determining how people age. As we look ahead to the challenges of supporting an ageing population, the lesson is clear: effective care policies must think beyond the individual and physical needs. Only then can we build a care system that meets the needs of real people in real households.
About the Authors
Dr Yanan Zhang is a Senior Research Fellow at the Oxford Institute of Population Ageing.
Opinions of the blogger is their own and not endorsed by the Institute
Comments Welcome: We welcome your comments on this or any of the Institute's blog posts. Please feel free to email comments to be posted on your behalf to administrator@ageing.ox.ac.uk or use the Disqus facility linked below.
