A National Examination of Caregiver Use of and Preferences for Support Services: Does Rurality Matter?

Caregiving Outcomes of Sub/Urban and Rural Caregivers: The Powerful Tools for Caregivers Program

OBJECTIVES

The research aimed to investigate the effectiveness of the Powerful Tools for Caregivers (PTC) program for rural caregivers.

METHODS

A total of 160 caregivers participated in the program. Exploratory factor analysis was performed to identify latent caregiving outcomes. Paired samples t-tests were conducted to investigate changes in caregiving outcomes before and after the program. To examine geographical differences in the caregiving outcomes, independent samples t-tests were performed. Qualitative responses of the participants were also analyzed.

RESULTS

Self-care and positive coping strategies were identified as latent caregiving outcomes. When comparing these two outcome scores before and after the program, the scores significantly improved. The changes in the caregiving outcomes of rural caregivers were greater than those of sub/urban caregivers. Although rural and sub/urban caregivers qualitatively reported similar themes, there were geographical differences in the percentages of caregivers reporting each theme.

CONCLUSIONS

The PTC program was effective in improving self-care and positive coping strategies, but the effect of the program was more pronounced in rural areas. Our findings suggest that interventions focusing on self-care and positive coping strategies may beneficially impact rural caregivers.

CLINICAL IMPLICATIONS

The PTC program appears promising to improve self-care strategies and enhance self-efficacy of rural caregivers.

Building on and tailoring to: Adapting a cancer caregiver psychoeducational intervention for rural settings

INTRODUCTION

Rural cancer caregivers experience obstacles in accessing services, obtaining respite, and ensuring their care recipients receive quality care. These challenges warrant opportunities to participate in evidence-based behavioral intervention trials to fill support gaps. Adaptation to rural settings can facilitate appropriate fit, given higher caregiver service needs and unique challenges. We present findings from the adaptation process of a psychoeducational intervention designed to support cancer caregivers in rural settings.

METHODS

We adapted Reblin's CARING intervention, designed for neuro-oncology, to target caregivers of rural cancer patients across cancer sites. First, we conducted formative work to determine the unmet social and supportive care needs rural cancer caregivers faced. We used the Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies (FRAME-IS) to guide the modifications. To conduct the adaptation, we elicited feedback through qualitative interviews of seven caregivers and three cancer hospital staff and thematic analysis to inform intervention modifications. Our qualitative study was guided by the Consolidated Criteria for Reporting Qualitative Research (COREQ).

RESULTS

Interviews revealed that service access was a pressing need, along with financial (e.g., treatment costs, employment challenges) and geographic barriers (e.g., distance to treatment, road conditions). We modified content, training, and context using the FRAME-IS steps. Changes enhanced fit through the following adaptations: changes to social support domains, session content, interventionist training, resource offerings, screening and recruitment processes, and virtual delivery.

DISCUSSION

Challenges to establishing successful psychosocial oncology interventions may be improved through participant-centered approaches and implementation science. Additional systemic challenges, including lack of systematic documentation of caregivers, persist and may especially disadvantage under-represented and underserved groups, such as rural dwellers. The enCompass intervention is undergoing ongoing single-arm pilot of rural cancer patient/caregiver dyads targeting caregiver coping self-efficacy and patient/caregiver distress (Clinical Trials #NCT05828927).

Improving Transitions in Care for Patients and Family Caregivers Living in Rural and Underserved Areas: The Caregiver Advise, Record, Enable (CARE) Act

In this Perspective, we contend bold action is needed to improve transitions from hospitals to home for aging patients and their family caregivers living in rural and underserved areas. The Caregiver Advise, Record, Enable (CARE) Act, passed in over 40 US states, is intended to provide family caregivers of hospitalized patients with the knowledge and skills needed for safe and efficient transitions. It has broken important ground for family caregivers who assist with transitions in patient care. It may fall short, however, in addressing the unique needs of family caregivers living in rural and underserved areas. We contend that to realize the intended safety, cost, and care quality benefits of the CARE Act, especially for those living in rural and underserved areas, states need to expand the Act's scope. We provide three recommendations: 1) modify hospital information systems to support the care provided by family caregivers; 2) require assessments of family caregivers that reflect the challenges of family caregiving in rural and underserved areas; and 3) identify local resources to improve discharge planning. We describe the rationale for each recommendation and the potential ways that an expanded CARE Act could reduce the risks associated with transitions in care for aging patients.

Conceptualizing Family Caregivers' Use of Community Support Services: A Scoping Review

BACKGROUND AND OBJECTIVES

Only a fraction of the 53 million caregivers in the United States use available formal community services. This scoping review synthesized the literature on the barriers and facilitators of community support service utilization by adult caregivers of a family member or friend with an illness, disability, or other limitation.

RESEARCH DESIGN AND METHODS

We searched PubMed, CINAHL, PsycInfo, and Web of Science for quantitative and qualitative articles assessing barriers and facilitators of caregivers' access to and utilization of resources, following Preferred Reporting Items for Systematic Review and Meta-Analysis scoping review guidelines. Thematic analysis, drawing on an initial conceptualization, informed key insights around caregivers' resource navigation process.

RESULTS

The review provides support for individual factors affecting service use. Notably, some factors-such as time restrictions and increased caregiving demands-appear to function as barriers to accessing services even as they increase caregivers' need for support. Additionally, contextual barriers including cultural factors and support of friends/family can affect caregivers' access to resources. Finally, experience with health systems and structures and the intersection with other factors can affect service utilization.

DISCUSSION AND IMPLICATIONS

Suboptimal access to and utilization of community support services can be addressed at both the person and system level to mitigate potential inequities. Ensuring that caregivers are aware of, eligible for, and have the capacity and support to access the appropriate resources at the right time is essential for improving caregiver outcomes, reducing burnout, and supporting continued care.

Orchestrating Care: A Grounded Theory Study of Family Caregiving for Older Adults in Rural Areas

Family caregivers provide the majority of long-term care and support of older adults as they age or approach the end of life. Studies often refer to family caregivers as invisible because the American healthcare system, public policy, and society do not support or recognize their work. Family caregivers who provide care to older adults who live in rural areas face unique challenges due to the rural environment. The purpose of this study was to inductively develop a theoretical framework that explains the process of family caregiving to older adults who live at home in rural areas and require daily assistance while exploring their experiences regarding access, utilization, challenges, and effectiveness of patient healthcare services and caregiver resources in rural areas. The grounded theory method of Strauss and Corbin was used for sampling, data collection, and data analysis. Fifteen family caregivers who oversaw and/or provided care on a daily basis to an older adult living in two rural counties of New York State participated in the study. Data were collected through two semi-structured interviews with each participant, yielding 30 interviews. Findings revealed that family caregivers engaged in the process of orchestrating care by growing into caregiving, integrating technology, and utilizing networks when providing and managing caregiving. Understanding caregiving from the perspective of family caregivers engaged in the process can inform healthcare practice, healthcare education, and public policy and can support better outcomes for both older adults and their family caregivers.

Vigilance, risk, and service use among caregivers of people living with dementia

OBJECTIVE

The purpose of this investigation was to understand the dynamics among dementia caregiving, vigilance, and home and community-based service use.

METHODS

This paper is derived from a larger, mixed-methods study on caregiving. We used a descriptive qualitative approach to analyze interview data of 30 family caregivers of relatives with dementia.

RESULTS

We found five domains of vigilance in which caregivers felt "on duty": ensuring attentiveness, ensuring safety, ensuring resources, ensuring healthcare, and ensuring closeness. Formal service use did not necessarily give caregivers relief from vigilance, with the language of risk often employed by caregivers.

CONCLUSION

Because service use could contribute to feelings of vigilance, rather than give caregivers a break from a sense of watchfulness, these findings support calls for dementia-specific training for service providers. In future caregiving research, the relationship between vigilance, caregiver distress, and role captivity should be explored.

Caregivers to older adults require support: A scoping review of their priorities

The vast majority of older adults who are chronically ill rely on informal caregivers for support. Caregivers often require additional support to facilitate their role. To the best of our knowledge, there has yet to be a collation of caregiver-identified priorities for support. Using existing research, this scoping review provides a comprehensive picture of what caregivers have indicated as priorities for support. Arksey and O'Malley's scoping review framework guides this review. We searched MEDLINE, CINAHL and PsycINFO databases on July 2, 2021. We selected databases based on their relevance to nursing, health and social science. Inclusion criteria were peer-reviewed research of any design, a sample population of caregivers to older adults (>55 years), manuscripts published in English and the priorities for caregiver support identified by caregivers themselves. We screened a total of 3591 records, and 33 articles met the inclusion criteria. These studies were from geographic settings across the globe and used various quantitative, qualitative and mixed-method study designs. In our synthesis, we quantified the identified priorities within the studies using coding and content analysis. We present the following list of caregiver-identified priorities: (1) orientation to the caregiving role; (2) self-care and respite; (3) adapting healthcare; (4) improved supports; (5) information needs; (6) access to resources; (7) financial assistance. Policymakers, healthcare professionals and non-profit organisations can use evidence from this review to guide decisions when developing support services and interventions for caregivers.

Dementia Family Caregiving in Rural Appalachia: A Sociocultural Model of Care Decisions and Service Use

OBJECTIVES

Examinations of cultural variations in caregiving experiences and practices tend to focus on racially and ethnically diverse family caregivers. We extended this research by exploring the role of place-based cultural constructs on care decisions of family caregivers for persons living with dementia in rural Appalachia whose experiences and backgrounds dwell outside the lines of dominant culture.

METHODS

Guided by our sociocultural conceptual model of service use and a descriptive qualitative study design, we conducted in-depth interviews with 30 caregivers for persons living with dementia to understand how predisposing and enabling factors influence caregiving decisions, including the use of services to care for persons living with dementia.

RESULTS

Three predisposing factors reflecting the culture of rural Appalachian counties in Virginia (reasons for becoming a caregiver, previous caregiving experience, and deference to the person living with dementia) shaped decisions about caregiving responsibilities and service use. Three place-based enabling factors (a personal sense of belonging, knowledge of services, and family support for service use) played an important role in facilitating access to services.

DISCUSSION

Findings revealed subtle variation across caregivers in this study and in comparison, to caregivers' experiences more generally. We interpret these variations in light of culturally influenced attitudes, family norms, and sources of information about formal services. Place-based cultural experience influenced dementia family caregivers' behaviors and choices regarding formal service use, suggesting that investigators should pay more attention to cultural influences in future caregiving research.

Interventions for Rural Caregiver Health: An Integrative Review

Few health behavior interventions exist for rural caregivers of persons with dementia (PWD) in the United States. Of interventions that have been studied, little is known about health outcomes that are included in interventions and which interventions are most effective on health outcomes. An integrative literature review of intervention studies for rural caregiver health throughout the United States was undertaken with an emphasis on concepts related to health promotion, self-management, self-care, and/or self-efficacy. Findings from this review indicated multicomponent interventions that included self-care strategies were associated with improvements of caregiver psychosocial health outcomes of depression, burden, self-efficacy, social support, and self-rated health. Sleep problems and endurance potential were the only physical health outcomes measured. To prevent adverse physical health outcomes, interventions with attention to rural context are needed that emphasize health promotion with a focus on health behaviors and health outcome measurement in rural caregivers of PWD. [Research in Gerontological Nursing, xx(x), xx-xx.].

Improvements of Disability Outcomes in CAPABLE Older Adults Differ by Financial Strain Status

The Community Aging in Place-Advancing Better Living for Elders (CAPABLE) program reduces disability in low-income older adults. In this study, we used CAPABLE baseline and 5-month data to examine whether its effects in reducing activities of daily living (ADLs) and instrumental ADLs (IADLs) difficulties differed by participants' financial strain status. At baseline, participants with financial strain were more likely to report higher scores on depression (p < .001), have low energy (p < .001), and usually feel tired (p = .004) compared with participants without financial strain, but did not differ in ADL/IADL scores. Participants with financial strain benefited from the program in reducing ADL (relative risk [RR]: 0.61, 95% confidence interval [CI]: 0.43, 0.86) and IADL disabilities (RR: 0.69, 95% CI: 0.54, 0.87), compared with those with financial strain receiving attention control. Individuals with financial strain benefited more from a home-based intervention on measures of disability than those without financial strain. Interventions that improve disability may be beneficial for financially strained older adults.

Family Caregivers in Rural Appalachia Caring for Older Relatives With Dementia: Predictors of Service Use

BACKGROUND AND OBJECTIVES

Residents of rural Appalachia tend to experience poorer health and greater economic distress than rural dwellers elsewhere in the United States. Although family is the first line of support for older adults needing care, it is unclear whether dementia caregivers in Appalachia assume these care responsibilities because of strong informal networks that support them in their caregiving role, underresourced formal services for persons with dementia, or culture-based reluctance to accept help from outsiders. This research examines how rural residents of Appalachia manage the care of relatives with dementia.

RESEARCH DESIGN AND METHODS

The study was grounded in the Andersen Behavioral Model, supplemented with culturally relevant variables. Family caregivers from rural Appalachian counties in Virginia caring for community-dwelling relatives with dementia participated in a structured phone interview (N = 163). Generalized structural equation models were estimated, with predisposing, need, and enabling variables as predictors. Use of support services (e.g., meal delivery) and personal services (e.g., home health nurse) by family caregivers to care for the person with dementia were the dependent variables, and caregiver's rural community identity and attitude toward services were moderators.

RESULTS

Approximately half the sample utilized at least one support service and one personal service. Predisposing and need factors predicted the use of support services, whereas predisposing, need, and enabling factors predicted personal services. Caregivers who strongly identified with their cultural roots were less likely to use personal services unless they held a generally positive view of formal services.

DISCUSSION AND IMPLICATIONS

Although the extent of needs and the caregiver's economic situation were essential influences on formal service utilization, the main drivers were the caregiver's identification with rural Appalachian culture and attitude toward services. Findings point to within-group heterogeneity that requires differential approaches to delivery of community-based services accounting for varying attitudes, preferences, and family resources.

Caregiver resource utilization: Intellectual and development disability and dementia

BACKGROUND

Adults with intellectual and developmental disabilities and their families have high need for support services. This study assessed resource utilization among caregivers of intellectual and developmental disabilities and other conditions.

METHODS

We assessed 366 caregivers of adults with intellectual and developmental disabilities, dementia or other conditions Regressions assessed group differences in number of agency contacts and frequency of service use. A secondary analysis assessed reasons for underutilization of services.

RESULTS

Caregivers of individuals with dementia contacted twice as many agencies as other caregivers and were more likely to report using suggested services. Agency contact and service utilization were similar among caregivers of adults with intellectual and developmental disabilities compared to other caregivers. Caregivers of adults with intellectual and developmental indicated that suggested services were unavailable to them.

CONCLUSION

The findings of this study shed light on challenges with access to and utilization of support services.

Rural-Urban Differences in Caregiver Burden Due to the COVID-19 Pandemic among a National Sample of Informal Caregivers

The objective of this exploratory study was to explore potential associations between changes to caregiver burden (CB) due to the COVID-19 pandemic and rural-urban status using a nationally representative sample of 761 informal caregivers. Tertiles of two measures of rural-urban status were used: Rural-Urban Commuting Areas (RUCAs) and population density. Bivariate and multivariable binary and ordinal logistic regression were used to asses study objectives. Using RUCAs, rural informal caregivers were more than twice as likely as urban informal caregivers to report a substantial increase in CB due to COVID-19 (OR 2.27, 95% CI [1.28-4.02]). Similar results were observed for population density tertiles (OR 2.20, 95% CI [1.22-3.96]). Having a COVID-19 diagnosis was also significantly associated with increased CB. Understanding and addressing the root causes of rural-urban disparities in CB among informal caregivers is critical to improving caregiver health and maintaining this critical component of the healthcare system.

Predictors of Depressive Symptoms in Heart Failure Caregivers

Heart failure is a serious and complex chronic illness and family caregivers often assist these individuals in performing self-care. Unsurprisingly, caregivers often are overwhelmed by daily activities associated with heart failure management and frequently have depressive symptoms. This study examined predictors (i.e., sociodemographic and clinical characteristics, social support, social problem-solving, family functioning, and objective and subjective burden) of depressive symptoms in 530 informal caregivers of individuals with heart failure in a large cross-sectional, descriptive study in the community. Younger caregivers who provided care for longer periods of time, lived in rural areas, and had less social support and lower problem-solving skills were more likely to have depressive symptoms. These findings emphasize the need for further studies to develop dynamic and innovative approaches that incorporate multiple components to lessen caregiving challenges. Social support and problem-solving skills training may be useful components to lessen depressive symptoms in these younger, rural caregivers.