Improving Long-Term Care in Croatia

Annex A. Methodology of the field questionnaire and the focus groups

Under the Croatian Ministry of Labour, Pension System, Family and Social Policy guidance, the OECD designed the survey design and prepared the questionnaire, while the agency Kvaka conducted the survey on the field. The field work in Croatia took place between March and July 2020. The project is aligned with data privacy laws in the EU and in Croatia.

The OECD developed the sampling design, with the support of the Croatian Ministry of Labour, Pension System, Family and Social Policy. The sampling follows a two-stage procedure that has the advantages of: 1) providing a good coverage of the counties; 2) being simple enough to implement; and 3) making the sample representative of family carers and care recipients receiving visiting nurses’ care.

In the first stage, the probability of selecting a nurse from a given county was calculated based on the percentage of Croatians aged 65 years old and over by county. In the second stage, in each county, nurses are selected under the constraints of maximising the number of different health centres within each county, while maintaining proportionality to the size of each health centre. The questionnaires were sent by mail to the health centres, which forwarded the questionnaires to visiting nurses.

In January, three working visiting nurses were randomly selected among visiting nurses working in Zagreb to provide feedback on the questionnaires. The three visiting nurses were excluded from the final sampling procedure and did not take part further in the survey.

Targeted sample size and response rates

The data collection follows a two-stage procedure to ensure an optimal response rate with a targeted sample size of two hundred nurses. In the first stage, three hundred questionnaires were sent to visiting nurses by mail on 9 March 2020, with 1 April 2020 as the deadline for completion (extended to 8 April if necessary). However, the COVID-19 outbreak slowed down the data collection as visiting nurses were not allowed to visit vulnerable populations or were heavily involved in the COVID-19 health efforts. On 1 April, only twenty completed questionnaires had been collected and a reminder was sent to prolong the deadline. As only sixty-seven questionnaires were received on 22 June, it was decided that the agency Kvaka would send an additional fifty questionnaires in June, with 31 July as the deadline. The selection of the additional visiting nurses considered the previous response rate in each county to maximise the country coverage.

When the data collection stopped, 220 questionnaires were collected, out of 350. The number of questionnaires was considered sufficient to make the sample representative of family carers of older people receiving care from both visiting nurses and family carers. The completion rate was good in terms of number of questionnaires collected (63%, out of 350) and in total 33% of visiting nurses completed the questionnaire in Croatia (see table below). However, no information was collected in four counties.

Table A A.1. Completion of the questionnaire by county

County	Number of visiting nurses in Croatia	Number of nurses who completed the questionnaire	% of nurses who completed the questionnaire
Sisak-Moslavina	12	9	75%
Vukovar- Srijem	23	16	70%
Šibenik-Knin	9	5	56%
City of Zagreb	76	41	54%
Varaždin	12	6	50%
Krapina-Zagorje	24	11	46%
Karlovac	22	9	41%
Osijek-Baranja	30	12	40%
Zadar	14	5	36%
Slavonski Brod-Posa..	37	13	35%
Split-Dalmatia	93	32	34%
Koprivnica-Križevci	22	7	32%
Istria	38	11	29%
Virovitica-Podravina	20	5	25%
Primorje-Gorski kotar	63	14	22%
County of Zagreb	105	20	19%
Bjelovar-Bilogora	24	3	13%
Dubrovnik-Neretva	13	0	0%
Lika-Senj	7	0	0%
Međimurje	7	0	0%
Požega-Slavonia	5	0	0%
Total	656	219	33%

Note: One observation was dropped because of the inability to match the ID with the county. The list of visiting nurses by county was provided by Croatian authorities.

Source: OECD 2020 questionnaire to visiting nurses and carers in Croatia.

Each questionnaire for visiting nurses was associated with six questionnaires on informal family carers, care recipients and the care situation. The quantitative analysis was performed on a much larger sample. Analysis was carried on a sample of 1 126 family carers (see table below).

Table A A.2. Number of observations by county

County	Number of observations	Percent
Bjelovar-Bilogora	17	1.51
City of Zagreb	194	17.23
County of Zagreb	108	9.59
Istria	59	5.24
Karlovac	50	4.44
Koprivnica-Križevci	37	3.29
Krapina-Zagorje	55	4.88
Osijek-Baranja	65	5.77
Primorje-Gorski kotar	62	5.51
Sisak-Moslavina	46	4.09
Slavonski Brod-Posavina	65	5.77
Split-Dalmatia	177	15.72
Varaždin	34	3.02
Virovitica-Podravina	29	2.58
Vukovar- Srijem	77	6.84
Zadar	25	2.22
Šibenik-Knin	26	2.31
Total	1,126	100

Source: OECD 2020 questionnaire to visiting nurses and carers in Croatia.

The questionnaire

The questionnaire booklet is composed of three parts:

• one questionnaire for visiting nurses, focusing on the tasks and type of care they provide.

• six questionnaires for visiting nurses, one per household, each one focusing on one care recipient.

• six questionnaires for family carer, one per household, each one to be filled by only one care recipient.

The first part for visiting nurses enquires on their caring activities, including the monitoring tasks and the medical tasks, the care co‑ordination activities, the physical care activities, and the emotional and communication activities.

The second part for visiting nurses enquires on the care recipient socio-economic status (gender, marital status, income, children, wealth, accommodation), health status, functional health status (such as ADL or IADL limitations) and their public benefits.

The last part for family carer enquires on health and living conditions, care tasks performed, tenure, number of hours per week for the care tasks per week, their care relationship (relative, neighbour, friends etc.), their socio-economic status and the challenges that they meet. It also collects data on potential compensations received with a view to estimate the share of informal carers hired by families in the grey market.

The questionnaire was provided by mail to the visiting nurses, who completed their sections and shared the questionnaire with a family carer. For care recipients with more than one family carer, the family carer was the respondent.

• Process review

The OECD developed the questionnaire in late 2019 and early 2020, under the guidance of the Advisory Group (AG) of the project. The OECD presented a draft questionnaire to the AG in Zagreb on the 21^{st of} November 2019 for feedback. Following AG’s suggestions, the questionnaire was reviewed and validated for the pilot survey.

The agency Kvaka conducted a questionnaire with three nurses, in Zagreb on 20 January 2020, to receive feedback. The questionnaire was amended accordingly.

Methodology for the focus groups

Four focus groups and eleven in-depth phone interviews took place between September and October 2020 to provide an in-depth analysis about the provision of care and complement the answers of the questionnaire. The participants were selected in their counties among those who signalled their interest at the end of the questionnaire.

Targeted counties, selection of participants and length of focus groups

About thirty-one family carers and fifty-four visiting nurses were interested in participating in focus group discussions in Croatia (see figure).

Figure A A.1. About thirty-one family carer and fifty-four nurses were interested in participating to focus groups

Note: IC refers to family carers and nurses to visiting nurses.

Source: OECD 2020 questionnaire to visiting nurses and carers in Croatia.

Based on the number of older people, the number of older people with LTC need and the need to cover well the country, the counties targeted were Grad Zagreb, Splitsko-dalmatinska, Osjecko-baranjska, Istarska, Brodsko-posavska, Vukovarsko-srijemska, Primorsko-goranska, Koprivnicko-križevacka A total of 34 people were interviewed (see table).

Table A A.3. Selection of counties and groups

Focus group	Counties covered	Details
1 (16 September)	Zagreb	Six visiting nurses
2 (22 September-24)	Zagreb	interview by telephone. Six family carers
3 (18 September)	Koprivnicko-križevacka	Six visiting nurses
4 (22 September-24)	Brodsko-posavska	interview by telephone. Five family carers
5 (6 October)	Splitsko-dalmatinska, Primorsko-goranska, Istarska	Five visiting nurses (2 Split, 2 Pula, 1 Rijeka)
6 (1 October)	Osjecko-baranjska, Vukovarsko-Srijemska	Six visiting nurses (4 Osijek, one Županja, 1 Vinkovci)

Each focus group was composed of five or six participants. The focus groups were monitored by the moderator, Tamara Kraus from the company Kvaka. Individual responses were anonymised. The focus groups were held on Zoom due to COVID-19 pandemic. When participants did not know how to use Zoom or equivalent technologies, one-to-one in-depth interviews were conducted by telephone.

Topics covered

The three main topics that the focus groups covered were 1/ the profile of family carers, the 2/ caregiver monitoring and support and 3/ the most appropriate form of care.

The first part covers questions about family carers (directly or indirectly through visiting nurses). Questions enquire about the relationship to the care recipient, the employment status, the number of hours of care provided weekly, the balance between care, work and family responsibilities, and support. There are also questions about the reasons for providing care and challenges met (which ones, how do they deal with, who could solve them). The first part also includes a subsection on care recipient needs (what are the needs, whether they manage to meet the needs, what they bring most to care recipients).

The second part covers monitoring and support of family carers. Questions enquire whether and why they should be supervised, whether and to which extent family carers could be mentored. They also include questions about the support needed for family carers and the form that support should take.

The third part aims to understand the type of care that are preferred and why (nursing homes, carer status, home care, foster care). Questions enquire about advantages and disadvantages of each type of care, what works best and what should be developed to expand the preferred type of care.