Informal Caregiving and Its Hidden Cost to National Economy- With a Toronto Case Study

More than eight million Canadians are providing care for their aging family members, relatives, neighbours, or friends. Due to staff shortage, eldercare facilities are also relying on their residents’ families to fill the gap of the care needs. Caregiving responsibilities have forced many employees to take time-off from work or take early retirement, which is a heavy loss of productivity of Canada’s national economy. This study employed a mixed method strategy, and with both qualitative and quantitative data collection methods: interview, focus group discussion, and a questionnaire survey. It shows that Canadians must take time off from work or to leave jobs for providing care to their loved ones, even when they are residing in a longterm care setting. This seemingly private matter is a very public one in the other side of the coin: family caregivers’ lost time in employment is affecting Canada’s national economy significantly. Government should work with stakeholders to develop a national strategy to tackle the issue. COVID19 outbreak has revealed long-term care institutions’ struggle with severe staff shortage in Canada.


I. INTRODUCTION
In Canada, elders aged 65 and over has reached 17.2% of its total population. Around 7% of the Canadian seniors are living in a collective dwelling facility, while the rest are residing at their respective private homes. Considering many older elders are with chronic illnesses and/or disability, caregiving burden to their families can be significant. In fact, caregiving has become a national hot topic in Canada in recent years, because the nation's high life-expectancy and its rapid aging trend have been driving the eldercare demand.
Many Canadians are making private arrangements to care for their spouse, parents, or grandparents. Such private arrangements include take time off from work and retire early, which is causing the loss of national productivity and population health.
The objective of this study is to examine the issues relating to family caregivers' eldercare burden and explores a societal and long-term solution for reducing informal caregiver burden in Canada. Particularly, learn the common and specific problem areas that affect informal caregivers and their families' quality of life, and how caregiving burden on the families are affecting Canada's national economy. It explores the caregiving needs and challenges in both institutions and private homes through learning lived experiences of informal caregivers and eldercare centre staff members. Since the fieldwork of this study was conducted prior the global COVID-19 pandemic, it also shed lights on why so many long-term care homes were unable to protect their residents from being infected by the virus.

II. LITERATURE REVIEW
A. Aging and Informal Caregiving Burden in Canada 17.2 percent of Canada's population was aged 65 and older on 1 July 2018 [1]. The life expectancy in Canada has reached 82.05 years in 2019 [2]. As the Canadian population gets older, it puts greater pressure on its healthcare system, pension system, and eldercare system. There is an estimate that approximately 10.4 million of Canadians will become senior citizens by 2036 [3]. Fig. 1 shows the aging trend of Canada, which indicates the percentage of elder population will grow rapidly. Thus, family caregiving is a major social issue in Canada. More than eight million Canadians have been providing care to a family member who is disabled or chronically ill [5].
Nearly 46% of Canadians aged 15 and older have been providing care to their family members. This number is expected to increase considerably since the proportion of Canadians who require care is forecasted to double over the next three decades [6], [7]. This upward trend is troubling given the extensive commitment of time, financial resources, psycho-emotional and physical investment that is required of caregivers [8]. There is a high prevalence of dementia and other illnesses that require intensive care among seniors in long-term care homes; and the prevalence rate of chronic conditions of longterm care residents is also high (see Table I). Both of which indicate how much care demand is there among the elders. However, there is a severe staff shortage in institutional care settings; thus, informal caregivers are increasingly providing caregiving duties to fill the service gap [10], [11]. Family members' increased participation resulted positive effects in staff burnout and residents' wellbeing, but there are also shortfalls and challenges [12].
Caregiving involves much sacrifice on family caregivers' part. It impacts caregivers' lives in multiple aspects, namely, physical, emotional, financial, and social. Many Canadians engaged in providing some aspect of informal care for a family member with chronic illnesses or disability. The intensity of care has a greater impact on the caregivers' health [13]- [16]. Therefore, caregivers experience higher than normal levels of stress, which can lead to mental, physical, emotional, and financial health costs; and more importantly, it affects their quality of life [13], [15].

B. Personal Support Workers in Canada
Personal support workers (PSWs) make up 73% of the home care workforce in Canada. "PSWs" means either educational qualifications or the caregiving role they perform. Unlike nurses and therapists, PSWs are unregulated workers that no one oversees their ongoing professional development [17]. In other words, PSWs are mostly defined by their caregiving role.
PSWs are providing both physical and emotional services to elders. However, most of these workers' working conditions are not reasonable. Namely, a) heavy workload, b) high risk of injury, c) lack of respect, d) low pay, and f) parttime or hourly based job. The precarious nature of their employment also made the current PSWs workforce unstable [18], [19]. They are predominantly women, and immigrant and racialized minorities are overrepresented in the sector [20], notable large groups include Filipinos and Black people [21]. Indeed, the LTC sector is very much feminized, and it employs predominately racialized workers, "Home care PSWs often provide physical care in isolated settings with no in-person supervision. In home and community health care, complaints about PSWs can be scattered among different service providers or client files not linked to or searchable by PSW name" [22]. An Ontario study found staff shortage is the underline cause of sickness absenteeism among nurses and PSWs [23].
The Personal Support Network of Ontario estimates that while 7,000 PSWs are trained annually, 9,000 leave the PSWs workforce [24]. The Canadian Research Network for Care in the Community estimates that 45% of the PSWs (i.e., the group aged 50-59 years and the group aged 60+ years) may retire within the next 15 years; and predicts there may be an imminent PSWs human resource deficit, likely accompanied by a knowledge and experience drain as long-serving PSWs leave the workforce over the next 15 years [25].
COVID-19 pandemic exposed the otherwise hidden crisis in various elderly collective dwelling settings: severe caregiver staff shortage and substandard services. Mainstream media outlets' report of COVID-19 cases and death made aware that it is necessary to have "policy measures to ensure the adequate staffing, the limitation of movement of healthcare workers between multiple sites, access to personal protective equipment and ensuring that staff know how to use it properly are key in helping to prevent the continued spread of COVID-19 and associated mortality in Canadian long-term care home residents" [26]. In which, care staff is the key. "Adequate staffing" points out the severe shortage of caregivers in these settings; "limitation of movement of healthcare workers between multiple sites" states a fact that most PSWs are parttime or hourly-based workers that they have to work at different facilities each day to make up a fulltime job's wage.

C. The Cost of Informal Caregiving to the Canadian Economy
Three-quarters of informal caregivers in Canada were employed while providing care, which account for 35% of total employed Canadians [15]. For some caregivers caring duties became equivalent to full-time employment, with one in ten indicating that caregiving duties accounted for 30 or more hours per week [8]. And 43% of caregivers reported providing care to multiple family members or friends at one time [6], [8], [16]. According to the General Social Survey [27], Canadian seniors received an average of 21.9 hours per week of unpaid care; almost 55% of informal caregivers who had provided over 20 hours or more of care per week had experienced work disruptions, and this cohort of caregivers had the highest rate of work disruptions and accommodations [16]. For the projected 11.6 million unpaid caregivers to offer a similar level of care from 2011 to seniors in 2046, it is estimated that the informal caregivers will have to contribute over 2.6 billion hours of unpaid work [28].
Among caregivers, about 50% of them are caring for their parents or parents-in-law. Since 44% of caregivers are between 45 to 64 years of age, they are in the prime of their careers [29]. Approximately 30 percent of caregivers for elders took time off work at 450 working hours per year, or about 8.5 hours per week, in average. Employers across Canada lose an estimated $5.5 billion annually in lost productivity due to caregiving-related absenteeism [6], [30]. Some scholars [31] suggest that caregivers are 25% more likely to retire early. On an average, they retire 8 years earlier than their non-caregiver counterparts. Scholars have found the relationship between caregiving and paid employment is substantial. Their studies show that the economic burden that emerges from caregiving causing employees lose income and/or their jobs; while businesses lose productivity and a significant share of their workforce [16], [28], [31].
According to the Canadian Life and Health Insurance Association [32] the cost to support long-term care for the baby boomers is $1.2 trillion in the next 35 years. Current government's funding can only cover approximately half this cost. This gap would likely to be filled by unpaid caregivers [33]. E: Use with caution †: Reference category *: significantly different from reference category -disruption in work routine for 2-4 hours of caregiving per week P<0.05 **: significantly different from reference category -reducing regular weekly work hours for 2-4 hours of caregiving per week P<0.05 Note: Includes caregivers whose main activity was working at a paid job or business. Questions on the impact of caregiving responsibilities on employment were only asked of those caregivers providing care for 2 or more hours per week. Fig. 3 shows that many employed family caregivers have to reduce their regular work hours and disrupt their work routines for fulfilling their caregiver duties. Meanwhile, due to the severe shortages of funding and professional caregivers at Ontario long-term care facilities, family caregivers took early retirement or find personal arrangement in order to attend the needs of their elders, and family caregiving burden is particularly heavy on women [11].
When adding informal caregivers' health and quality of life to their time off from work, the overall cost of informal caregiving is indeed impossible to estimate. Therefore, informal caregiving burden is an important issue for us to tackle. It matters to our socioeconomic development and the health and quality of lives of tens of millions, if not all.

III. METHODOLOGY
Research ethics: all participants of the project were provided the project's information letter and signed their consent form before they took part in the project. This study received the University of Waterloo's ethics review clearance (#22276). The design of the project and all of its data collection instruments had undergone its Office of Research's rigorous review.

A. Setting
The case site is Toronto Gerontological Centre (TGC, coded name). It is a not-for-profit eldercare institution with over eight hundred long-term care beds and various community support services for over fifteen thousand seniors annually. The TGC has multiple outlets in the great Toronto area.

B. Data Collection
This study employed a mixed method strategy, with both qualitative and quantitative data collection methods. In the qualitative research part, the main data collection methods were face to face interviews, and telephone follow-up interviews, and focus group discussions. The quantitative method used was questionnaire surveys.

C. Sampling Method
This study used stratified purposive sampling method coupled with voluntary principle in recruiting participants and respondents.

1) Qualitative Data Collection
Interview: N = 38. Participants: a) Elders -Adult Day Program participants and community dwelling elders b) Family caregivers -family member provide care to their spouse or parents in long-term care and/or as Adult Day Program participants c) Staff -staff members with different responsibilities. d) Managers e) Volunteers Focus group discussion: 8 groups, N=88. Participants: a) Family caregivers b) Adult Day Program participants c) Staff and managers d) Community dwelling elders e) Volunteers Voice recording and transcription: Participants were asked whether they agree to have their voices recorded prior to interview and focus group discussions. All recruited participants agreed and signed their consent forms. Therefore, a recording device was used during each interview and focus group discussion. These recordings were transcribed to notes for analysis and writing up study report.

2) Quantitative Data Collection
Questionnaire survey: N= 84 Respondents: TGC independent living tenants and community residing elders.
Main variables: Daily life assistance needs, transportationseeing doctors, cutting grass, shovel snow, meals, cleaning home, transportation-shopping.
The above-mentioned first-hand data collection has been analyzed with the following research questions: 1. What is the current informal caregiving burden in Canada in relation to aging? What is such caregiving burden's impact on informal caregivers' lives? 2. Does TGC's long-term care services meet the needs of its senior residents? If not, how the service gaps were filled? Would the residents' families feel obligated to volunteer their time and energy there? 3. Would working age informal caregivers' caregiving duties interrupt their employment and professional career? Do such interruptions mean the loss of productivity to national economy? How to address the issue and promote a healthy economy?

IV. FINDINGS' DISCUSSIONS
Long-term care homes in Canada are relying on informal caregivers to care for the residents. Informal caregivers provide "account for up to 30% of care including feeding, washing, toileting, social, emotional and memory support, and mobilization" [10]. Thus, many Canadians sacrifice their mental health, quality of life, as well as job and career when performing their caregiving duties.
This study found there is a severe shortage of formal or trained caregivers, which causing reduced quality of care and relying on family caregivers for unmet needs of the residents; care for a loved one reduces the family caregivers' quality of life; providing care to a loved one would cost informal caregivers' health; informal caregivers' employment and career disruptions is a cost to productivity in national economy; elders' care needs require a sustainable strategy; and the government pays less in eldercare, but it costs the nation more.
1) There is a severe shortage of formal or trained caregivers, which causing reduced quality of care and relying on family caregivers for unmet needs of the residents The shortage of professional caregivers in long-term care homes made caregivers' caregiving burden particularly heavy. Meanwhile, unmet care hurts elder residents' health. Following are some participants' words that reflect the reality they face: "About one staff for eight patients. In the evening, 2 PSWs take care of 32 patients. During the day, the fifth floor has more staff than the other floors. Usually there are 2.5 staff on each floor. During busy times, there will be an extra staff, but when it calms down, that staff will leave. So, it's really busy." -A son "I found the most common complaints of the families is the caregivers didn't change diapers soon enough and often enough. One staff has to care for more than 6

" -A LTC staff
Providing care to residents with high prevalence rate of dementia makes caregiving work more difficult and challenging. With the shortage of PSWs, the workload would be particularly heavy for each PSW. Unmet care needs would cause resident' health deteriorating and experience high risk of injury, which would cause otherwise unnecessary utilization of healthcare. Thus, hire less than enough PSWs can cost a lot more to the nation. Shortage of caregivers à substandard care à declining of elders' health àmore healthcare cost 2) Care for a loved one reduces the family caregivers' quality of life One person's long-term illness can make their entire family's lives difficult. Many primary family caregivers ignored their own health conditions and sacrificed their normal lives for their caregiving duties. One gentleman in his eighties takes care of his wife with dementia said that he has not had a night long sleep for many years, because "She would get rid of blanket from time to time, I have to check nearly hour by hour to make sure that she is covered by the blanket". "I have been taking care of my wife for a very long time. She's got dementia. I care for her eat, drink, sleep and everything else." Another caregiver who provides care to her husband in the long-term care said: "I'm actually quite busy. I need to take care of my three grandsons. I have a busy schedule. I get up at 6am, prepare their breakfast, and I go swimming for an hour after they go to school. When I get home, it's about 10 o'clock. I eat breakfast. Before 11 o'clock, I come here to chat and watch TV with my husband. Then I help him have lunch. After lunch, I clean his denture, wash his face, then I go back home around 1pm. I go grocery shopping and drop off my grandson at the place where he volunteers. Then I need to pick up my other grandsons around 5 pm and prepare their dinner. And my daughter would go to help her father with dinner and help him go to bed." Both caregivers were quite emotional when sharing their daily life experiences. It was obvious that they care about their spouses' wellbeing deeply and full heartedly. Meanwhile, they found the responsibility quite daunting and feel helpless. They tradeoff their own quality-of-life to care for their loved ones. Since they are in 80s and 70s respectively, their heavy caregiving burden is likely to cause them health issues, mentally and physically. Consequently, they would need medical attention themselves, and more healthcare expenditure will be spent on top of their unnecessary suffering. They truly need effective support, immediately.
3) Providing care to a loved one would harm informal caregivers' health Many family caregivers sacrificed their own health in the process of caring for their loved ones in Canada. 46% of aged 15 and over have provided care to a loved one. 57% of informal caregivers are women, and more than 40% of caregivers experienced depression [34].
An informal caregiver in her 70s shared her experience as career to her husband with dementia. She hurt her back severely in the process and had to be hospitalized, which was the "last straw" for her to finally arrange for her husband to be a resident of the TGC long term care home. However, the shortage of PSWs at the TGC kept her busy. Like other family caregivers, she has to visit the long-term care residence daily to help her husband eat meals, assist him for other daily needs. This family caregiver's story shows that caring for someone at home is a heavy-duty task. It can cause harm to the caregiver. This story also shows that the long-term care home does not have enough professional caregivers that provide appropriate care to its residents. In order to meet the care needs of their loved ones, many family caregivers would have to provide their assistances at long-term care facilities, especially during the mealtimes. In other words, although eldercare facility is helpful to family caregivers when compared to taking care of their loved ones at home, the caregiving burden is not lifted entirely from them. Considering a lot of family caregivers have been providing care for a long time, their physical and mental health status tend to decline, which is another reason that shortage of professional caregivers would increase healthcare expenditure of the nation.

High intensity of work High injury & illness risk
Shortage of caregivers à low quality of care à to elders and caregivers àmore healthcare cost

4) Informal caregivers' employment and career disruptions is a cost to productivity in national economy
The shortage of caregivers affects many working age family caregivers' employment and career development. Facing immediate family caregiving duties, some of them have to take early retirement, some have to take time off from work regularly.

Now I understand why she is always in a bad mood." -A daughter (her mother is the primary family caregiver)
These family caregivers' real-life struggles have become norm in many households in Canada. They are gaggling between their personal career at paid work and their caregiving duties for their loved ones at home or at long-term care home. Since no one can replace them with private responsibilities, most of them have to sacrifice their career if they are employed [35], [36].

Early retirement/High work absence for family caregiving responsibilities à costing national economy
In Canada, about 93 percent elders are living in their own private homes [37]. In order to improve this population's quality of life, we need to develop a national strategy. This study's questionnaire survey learned what are the main assistance the community dwelling elders' need for their daily lives (Table II). Cleaning home 1 4 Transportation-shopping 3 5 Shower 7 Note: 1 -7 is ranked from most to least number of persons' choices among the respondents. Same ranking number means a same percentage of respondents selected the item.
The elders from a city with 110 thousand population in Ontario found they need daily life assistance in the areas of transportation-seeing doctors, cutting grass, shovel snow, meals, cleaning home, transportation-shopping, and shower. While the elder tenants in a collective dwelling community responded in a similar way, but with slightly different need. For example, it is understandable that the group residing in apartment buildings have less people found they require assistance for shovel snow and cutting grass.
These findings show that there is a need to develop accessible and affordable services in these areas. A previous study also found that the tenants at an active elder adults' community long for on-site medical care, on-site social workers, and subsidized meals [37]. This means certain services are urgently needed for meet many elders' daily lives, and they can help the seniors living at their private homes longer. They can also support family caregivers with reduced caregiving burdens.
6) Currently, the government pays less in eldercare, but it costs the nation more Informal caregivers' reduced hours at workplaces cost our national economy around $5.5 Billion annually [38]. When there is an apparent funding shortage on long-term care and other eldercare facilities from the government, Canadians and the entire nation is paying a cost. Like prior studies have found, while informal caregiving is affecting individuals and families with financial and other difficulties in life, it also has implications to broader national economy [15], [28], [31]. The rate of seniors who require care in Canada is projected to increase to over 3.3 million by 2046, and it is expected that approximately 11.6 million unpaid caregivers will be required to meet the needs of the elders [28]. For the projected 11.6 million unpaid caregivers to offer a similar level of care from 2011 to seniors in 2046, it is estimated that the informal caregivers will have to contribute over 2.6 billion hours of unpaid work [28]. Thus, there needs to be a sustainable strategy to tackle this pressing issue. Fig. 4 is this study's analytical framework, which shows the root cause of current long-term care and caregiving issues is lack of funding. It has been decades that the Canadian government has not paid enough attention to eldercare and caregiving pitfalls. The inadequate eldercare system reduced family caregivers' opportunity to contribute to the national economy, increased healthcare cost of the nation, increased unnecessary suffering and death, and decreased quality of life of the elders and their family caregivers. The COVID-19 pandemic outbreak in many long-term care homes and the high proportion of COVID-19 death among long-term care residents exposed Canadian government's lack of care to its senior citizens. "Canada had the worst record among wealthy nations for COVID-19-related deaths in long-term care facilities for older people, many observers referred to it as a 'national disgrace'. At that time, as the first wave of COVID-19 in Canada began to subside, its 2039 homes for older people accounted for about 80% of all COVID-19-related deaths." [39].
The military Joint Task Force released a report on the conditions inside five long-term care facilities in Ontario after it was deployed to fight the humanitarian crisis in the longterm care homes. The 15-page report issued on 20 May 2020 highlighted that long-term care facilities were in "urgent and immediate need of personnel to provide humanitarian relief and medical support" [40]. The headlines of Canada's major media on 26 May 2020 reads: "Ford faces blowback after military report reveals 'horrific' conditions at Ontario long-term care homes" (CBC); "'Gut-wrenching' military report sheds light on grim conditions in Ontario nursing homes" (CTV); "The military's report details the horrors of Ontario long-term-care homes" (The Star); and "Ontario long-term care homes in scathing report could face charges, says Ford" (CBC). Experts in Canada have called for the transformation of long-term care system: the "conditions of work for staff must be dramatically improved", and "tens of thousands of new staff must be hired across the country". "Overcrowded living conditions for residents must also be dramatically improved", and "better infection control and better medical care are also urgently needed" [39].

V. CONCLUSION AND POLICY RECOMMENDATIONS
Canada's eldercare system cannot meet the needs of its growing elder population. Severe resource constrains limited eldercare services' quality and effectiveness. Thus, family caregivers have to fill the gaps, including take time off from work and retire early to care for their loved ones, which has cost our national productivity and overall economy dearly.
More community-based services are required for aging at home seniors. Beside seven percent of Canadian elders living inside of elder collective dwelling communities including long-term care homes, most elders are living in their respective homes. When the crisis at long-term care homes is out in the open due to the pandemic, attention should also be paid to those who relying on their family members or caregivers for assisting their daily lives. How to make aging at home easier in order to emancipate family caregivers' time for a healthy national economy should be a priority of the government funding plan. Including provide long-term care homes with necessary financial support for them to hire sufficient number of caregivers.
Only when our long-term care homes stop relying on family caregivers, their quality of services can be trusted. Only when our employees do not need to take time off from work regularly to care for their loved ones, our nation's economy would be healthy. Only when our seniors' wellbeing became the responsibility of the entire society, this population group and their families' quality of life can be ensured. Canadian government should work with relevant stakeholders in the following areas:

A. Investing in Age Friendly Community Development
Most elders prefer to age at home, in Canada as well as around the world. Enabling infrastructure include various services' availability and accessibility are key to the aging populations' quality of life. Some services are already in operation but need to be integrated into an effective network. By asking the following questions and act on the needs and gaps, the goal of age friendly community could be met. a) What are the main services family/informal caregivers providing to their loved ones? Can these services be provided by others who are not a relative or family? Are there service stations providing assistances? What are the ways in which the service sector could be developed to meet the needs? b) How social resources and available and/or potential technology can be integrated to assemble pathways to an agefriendly society? What would be an ideal network that can lift informal caregivers' burdens and provide optimal service?

B. Developing Quality Personal Support Workers' Training Programs
Quality train programs for PSWs shall include all techniques and relevant knowledge the occupation require. The train program shall include a coop term for the trainees to practice their skill set and test their competency. Such programs can supply the needed facilities with professional caregivers and improve the quality of care. PSWs' training certificates and degrees can ensure the quality-of-care PSWs provide; and earn them the respect from the public they deserve. Government needs to support relevant educational institutions' initiatives.

C. Improving Personal Support Workers' Working Conditions
Making PSWs a respectable occupation can improve PSWs' working condition, and their jobs' security and fulltime employment will be ensured. PSWs' income should be regulated and with a reasonable level that is comparable to that of the nurses and other care workers. Like other professions, PSWs should also have the prospects of promotion with a bright career path.

D. Investing in Long-Term care and Other Elders' Collective Dwelling Facilities
It is time to invest in aging related infrastructure, including support long-term care institutions. There needs a national standard for resident-PSWs ratio, equipment, and other necessary facilities. Encourage and enable eldercare sector to use technology and enabling devices in performing their care work and reduce workplace injury risks.

E. Accommodating Informal Caregivers with Work Flexibility
Before age friendly community arrives, informal caregiving burden is a reality many must face. Employers should care for their employees' well-being by accommodating their hard needs. Instead of letting them retire early or take time off regularly from work, making flexibility a possibility for employees with caregiving roles can reduce productivity loss. Meanwhile, provide necessary tangible and intangible support for their overall wellbeing.

VI. LIMITATIONS
Firstly, the case setting, TGC, is an excellent and culturally competent eldercare center known to locals. This means the findings from this case is not representative of average level eldercare institutions. In other words, informal caregivers would have heavier burden if the elders they care for were residing at other eldercare facilities, their pains and sacrifices would be even more compelling.
Secondly, this study collected field data prior to the global pandemic. COVID-19 must have changed much practice in eldercare centers' practice dramatically. Thus, a follow up study would capture post pandemic realities. This facility successfully safeguarded its elders from being infected with the deadly virus during the pandemic, which is the outcome of the dedication of its staff team and effective measures they created and implemented.

INFORMAL CAREGIVING IN CANADA
• 28% of Canadians (or 8.1 million) report having provided care to a family member or friend with a long-term health condition, disability, or aging need in the past year. • 3/4 of family caregivers (or 6.1 million) were employed, accounting for 35% of all employed Canadians. • 44% of employed caregivers report having missed an average 8 to 9 days of work in the past 12 months because of their caregiving responsibilities. • 36% of young caregivers arrived to work late, left early or took time off due to their caregiving responsibilities. • $5.5 billion in lost of productivity due to caregiving-related absenteeism annually.
• Each year Canada loses the equivalent of nearly 558,000 full-time employees from the workforce due to the inability to manage the conflicting demands of paid work and care. • 2.5 million caregivers report that they try to balance caregiving with paid employment. • 30% caregivers for elders took time off work 450hrs/year, or about 8.5 hrs/week. • 44% of them are between 45 to 64 years old and in the prime of their careers [6]. A Snapshot of Family Caregiving in Canada.

TERMINOLOGY
Caregiver: a person who provides assistance in meeting the daily needs of another person. Caregiver is often referred to as either "formal caregiver" or "informal caregiver".
Formal caregiver: those caregivers who are paid for their services and have had training and education in providing care. This may include services from home health agencies and other trained professionals.
Informal caregiver, also called "family caregivers", are people who give care to family or friends usually without payment. A caregiver gives care, generally in the home environment, for an aging parent, spouse, other relative, or unrelated person, or for an ill, or disabled person. These tasks may include transportation, grocery shopping, housework, preparing meals. Also giving assistance with getting dressed, getting out of bed, help with eating, and incontinence [41].

ETHICS APPROVAL
This study received the University of Waterloo's ethics review clearance (#22276).
ACKNOWLEDGMENT Staff members of the TGC provided full field access and support. Participants of the project contributed their experience, insight, and knowledge. Lily Wu transcribed interview and focus group discussion data; Adam Mursal, Ivy Li, and Lily Wu provided fieldwork assistances. This study could not be done without their kind and generous help.