Urban-rural comparisons of outcomes for informal carers of elderly people in the community: a systematic review

Study protocol for a hybrid effectiveness-implementation trial of the Building Better Caregivers online workshop for rural family/friend caregivers of people living with dementia

INTRODUCTION

Dementia caregiving is complex and disproportionally burdens caregivers living in rural areas due to fewer resources and formal support systems. There is an immediate need to identify effective, scalable, and accessible online programs to support rural caregivers' well-being. Building Better Caregivers (BBC), a possible solution, is an asynchronous online 6-week, interactive, and skills-building workshop developed for caregivers of persons with dementia. This research aims to assess the effectiveness and implementation of the BBC workshop when delivered among rural dementia caregivers in the United States.

METHODS

A hybrid effectiveness and implementation trial applying mixed methods will be conducted in collaboration with local, state, and national partnering organizations. Eligible participants live in a rural area of the United States, give care at least 10 h a week for a family member or friend with dementia, and have internet access. Evaluation is based on the RE-AIM framework. Effectiveness outcomes are assessed using a randomized control trial. Caregivers are randomly assigned to the BBC workshop (intervention) or attention control group. Implementation outcomes are assessed using surveys and debriefing interviews from partnering organizations and participants. The study protocol including the study design, methods of recruitment and assessment, and outcomes are described.

CONCLUSION

This is the first known study to evaluate both the effectiveness and implementation of a caregiver support intervention under real-world conditions in rural areas. If successful, this online workshop will be a practical and acceptable approach for promoting the health and well-being of geographically isolated rural dementia caregivers.

Needs Detection for Carers of Family Members with Dementia

Aim: To determine the perceived needs of carers of non-institutionalized family members that suffer from dementia. Methods: Two-steps qualitative study by focus groups of relatives in three centres of different characteristics from the Girona Health Region (step 1) and two in-depth interviews with significant professionals in dementia care (step 2). The analysis was performed based on the interpretation of the transcribed data and the bottom-up coding of categories and themes. The information was triangulated and coding was agreed upon. Results: There were three groups, 26 main carers of community-dwelling relatives with dementia in step 1 and two in-depth interviews with dementia-specialised healthcare and social care professionals in step 2. The demands were categorised according to three main themes: whether they were addressed to the members of care services for more direct and close care, to the agencies for a better joint working and less fragmented system, or to society for better comprehension and social recognition. We emphasize the need for a consultation-liaison reference figure throughout the process both for aspects of greater efficiency in the management of resources and for greater empowerment of carers.

The effect of socioeconomic status on informal caregiving for parents among adult married females: evidence from China

BACKGROUND

Married female caregivers face a higher risk of an informal care burden than other caregivers. No study has explored the effect of socioeconomic status (SES) on the intensity of informal care provided by married female caregivers in China. The purpose of this study is to empirically examine how the SES of married female caregivers affects the intensity of the informal care they provide for their parents/parents-in-law in China.

METHODS

The data for this study were drawn from 8 waves of the China Health and Nutrition Survey (CHNS). The respondents were married women whose parents/parents-in-law needed care and lived in the same city as them. SES was defined based on four indicators: education, economic status, employment status, and hukou (China's household registration system). Informal caregivers were divided into three categories: non-caregivers (0 h/week), low-intensity caregivers (less than 10 h/week), and high-intensity caregivers (10 h/week and above). Multinomial logistic regression analysis was used to examine the relation between SES and the likelihood of a low- and high-intensity caregiving among married female caregivers, adjusting for age, family characteristics and survey wave.

RESULTS

Of the 2661 respondents, high-intensity and low-intensity caregivers accounted for 16.35 and 21.27%, respectively. The multinomial logistic regression results showed that the likelihood of being a high-intensity caregiver versus (vs. a non-caregiver) increased as the caregiver's educational attainment increased (p < 0.05), and that high economic status was related to the likelihood of being a high-intensity caregiver, but this relationship was only significant at the 10% level. Urban females were 1.34 times more likely than their rural counterparts to provide low-intensity care vs. no care (p < 0.05) and were 1.33 times more likely to provide high-intensity care vs. no care (p < 0.05). Employed females were 1.25 times more likely than those unemployed females to provide low-intensity care vs. no care (p < 0.05).

CONCLUSIONS

Differences in SES were found between high-intensity caregivers and low-intensity caregivers. Women with high educational attainment and urban hukou were more likely to provide high-intensity informal care, and women who were employed and had urban hukou were more likely to provide low-intensity care.

The Transition From Spousal Caregiver to Widowhood: Quantitative Findings of a Mixed-Methods Study

BACKGROUND: The number of persons diagnosed with dementia is projected to triple to 14 million by 2050. The significance of these projections is particularly relevant to older women (>65 years), who are more likely to provide dementia caregiving for a husband than vice versa. Research has identified consistent themes around the impact of caregiving during the caregiving experience, yet there is limited research exploring the ongoing impact during the transition to widowhood. Moreover, there is a paucity of research examining differences between rural and urban spousal dementia caregivers. AIMS: The aims were to compare differences between older rural and urban spousal caregivers on physical and mental health factors affecting the transition from caregiver to widow and to identify resources the women used during this transition over 12 months. METHOD: This mixed-methods longitudinal study recruited 13 urban and nine rural female spousal caregivers. Participants were interviewed three times over 12 months. The dependent variables were depression (measured using Center for Epidemiologic Studies Depression Scale), physical and mental functioning (measured using the 12-item Medical Outcomes Study-Short Form Health Survey Version 2). RESULTS: No statistically significant differences were detected between rural and urban female caregivers on the dependent variables. However, rural caregivers scored higher on depression and lower on both physical and mental functioning compared to their urban counterparts. CONCLUSIONS: The findings have clinical and research implications. Psychiatric nurses are well positioned to provide education related to dementia information deficits; implement interventions that facilitate bereavement, resilience, self-care, and identity; advocate for additional services; and conduct larger scale studies with a more diverse sample of female spousal caregivers.

The care receivers perspective: How care-dependent people struggle with accepting help from family members, friends and neighbours

In many countries in north-western Europe, the welfare state is changing, and governments expect a great deal of informal care. In the Netherlands, citizens are also increasingly expected to rely on informal instead of professional care. In this study, we aim to determine to what extent Dutch care-dependent people want to rely on social network members and what reasons they raise for accepting or refusing informal care. To answer this question, we observed 65 so-called 'kitchen table talks', in which social workers assess citizens' care needs and examine to what extent relatives, friends and/or neighbours can provide help and care. We also interviewed 50 professionals and 30 people in need of care. Our findings show that a great deal of informal care is already given (in 46 out of 65 cases), especially between people who have a close emotional bond. For this reason, people in need of care often find it difficult to ask their family members, friends or neighbours for extra assistance. People are afraid to overburden their family members, friends or neighbours. Another reason people in need of care raise against informal care is that they feel ashamed of becoming dependent. Although the government wants to change the meaning of autonomy by emphasising that people are autonomous when they rely on social network members, people who grew up in the heyday of the welfare state feel embarrassed and ashamed when they are not able to reciprocate. Our findings imply that policymakers and social professionals need to reconsider the idea that resources of informal care are inexhaustible and that citizens can look after each other much more than they already do. It is important that social policymakers approach the codes and norms underlying social relations more cautiously because pressure on these relations can have negative effects.

Caregiving for Older Adults Requiring Hemodialysis: A Comparison Study

This study examined differences in caregiving appraisal between primary family caregivers of disabled older adults receiving hemodialysis (PFCGs-wHD) and disabled older adults not receiving dialysis (PFCGs-woD). A total of 242 PFCGs-wHD and 335 PFCGs-woD were included in the analyses. We used adjustment by propensity score to control for bias by confounding factors. Caregiving appraisal was measured in terms of role strain, emotional exhaustion, and caregiving satisfaction. On the first task, PFCGs-wHD demonstrated significantly worse levels on all three appraisal indicators than did PFCGs-woD. On the second task, only higher emotional exhaustion was significantly mediated by higher role strain in PFCGs-wHD. Further, PFCGs-wHD status directly influenced lower caregiving satisfaction without mediation by higher role strain. Caregiving for disabled older adults receiving HD may be associated with significant challenges for caregivers.

Providing Care for Persons with Dementia in Rural Communities: Informal Caregivers' Perceptions of Supports and Services

Dementia is one of the costliest and most time-consuming diseases among older persons. Although informal caregivers provide the majority of care for persons with dementia, little is known about the self-perceived need for social services of caregivers of persons with dementia within rural areas. This pilot study examined the knowledge, access and intent of the practice-oriented service model of caregivers of persons with dementia in rural communities in the Midwest U.S. After a systematic training, researchers interviewed 11 rural caregivers of persons with dementia (n = 11). Data were analyzed using thematic analysis. Although similarities with other caregivers of persons with dementia were found, important differences suggesting unique issues among these rural caregivers of persons with dementia. Many participants found strength in their community, which often served as a safety net of support. Consistent with existing literature, participants expressed financial concerns, geographic barriers and lack of dementia-specific services when using formal services. The need for more specialized formal services in rural areas to supplement existing informal care networks is discussed. Policies and services based on rural caregivers' unique concerns and challenges and that build upon their existing care networks are recommended.

The relationship between geographical and social space and approaches to care among rural and urban caregivers caring for a family member with Dementia: a qualitative study

Knowledge about family caregivers in rural areas remains sparse. No studies to date have addressed the sociocultural aspects in caregiving, thus neglecting potentially significant data. This study aimed to explore and better understand family caregivers’ experiences in rural and urban areas and the sociocultural spheres that these two areas represent. How do family caregivers approach their caregiving situation? A hermeneutical approach was chosen to uncover the underlying meanings of experiences. Open-ended in-depth interviews were conducted. The ontological and epistemological roots are based on hermeneutic philosophy, where a human being’s existence is viewed as socially constructed. The study followed a purposeful sampling. Semi-structured in-depth interviews were conducted with 12 rural and 11 urban family caregivers to persons with dementia. These were then analyzed in accordance with the hermeneutical process. The findings provide insight into the variations of family caregiver approaches to caregiving in rural and urban areas of Sweden. There seemed to be a prevalence of a more accepting and maintaining approach in the rural areas as compared to the urban areas, where caregiving was more often viewed as an obligation and something that limited one’s space. Differences in the construction of family identity seemed to influence the participants approach to family caregiving. Therefore, community-based caregiving for the elderly needs to become aware of how living within a family differs and how this affects their views on being a caregiver. Thus, support systems must be individually adjusted to each family’s lifestyles so that this is more in tune with their everyday lives.

Health related lifestyle and preventive medical care of rural Spanish women compared to their urban counterparts

The objective of this work is to study the differences in health related behavior, habits and preventive health care attendance between women living in rural areas and their metropolitan counterparts in Spain. We analyzed health related behavior (such as leisure time physical activity, smoking, alcohol use and other health related dietary patterns) and preventive medical attendance (gynecological attendance, mammography frequency, flu vaccinations, cholesterol and blood pressure checks) in a total of 17,833 women older than 16 from the Spanish National Health Survey 2006. A multinomial logistic regression model was employed to compare groups (adjusted for age and social class). The main findings of this study is that the likelihood of receiving and attending to preventive public health care services was significantly lower for women in medium-sized urban or rural and remote locations than those living in metropolitan areas, as well as differences in health-related lifestyle behaviours.

Family caregivers' assessments of caring for a relative with dementia: a comparison of urban and rural areas

AIM

This study aimed to describe and compare urban and rural family caregivers' reactions to caring for a relative with dementia and to examine the associations between caregiving and socio-demographic factors.

BACKGROUND

Most studies on family caregivers' experiences caring for older people with dementia have been conducted in urban areas, and little is known about the experiences of family caregivers living in rural areas.

DESIGN

A cross-sectional study design was used.

METHODS

A total of 102 caregivers (response rate 85%) from urban (n=57) and rural (n=46) areas completed the Caregiver Reaction Assessment (CRA) Scale and demographic information. Data were analysed using descriptive and inferential statistics and linear regression models.

RESULTS

Overall, family caregivers reported high satisfaction even if they also reported high impact on finances and daily living. Rural caregivers experienced a higher negative impact on finances but reported more support from family members than urban caregivers. Age, gender and relationship were significantly associated with four of the five CRA subscales. Educational level and geographical setting were not associated with any of the CRA subscales.

CONCLUSIONS

The results of the study raise questions about the financial situation of older female caregivers and on the expectations of built-in family structures in urban and rural areas. Further studies focusing on the meaning and constitution of a family would help us to understand how these factors influence family caregiving both in rural and urban areas.

IMPLICATIONS FOR PRACTICE

To provide person-centred care and to avoid stereotyped caregiving, a better picture of traditions in family caregiving can improve a more differentiated and appropriate professional caregiving pliable with the cultural context in which it is carried out.

Degree of rurality is not related to dementia caregiver distress, burden, and coping in a predominantly rural sample

Earlier research suggests that geographic location matters for informal caregivers of persons with dementia: rural caregivers tend to rely on more informal supports and may report more psychological distress and burden than urban caregivers. Differential access to services may underlie these findings, but degree of rurality is typically measured with population size. In contrast, the current article measured degree of rurality with standardized scale of access to metropolitan centers. In a large sample we found nonsignificant and trivial associations between metropolitan access with self-reported caregiver distress, (N = 272; Brief Symptom Inventory), burden (N = 234; Zarit Burden Interview), and coping (n = 46; Jalowiec Coping Scale). The null findings were likely related to the use of a proxy variable for dementia-related caregiver supports (i.e., degree of access to metropolitan centers). In future research, direct measures of access to appropriate dementia related services should be used to study caregiver outcomes.