Socioeconomic and Demographic Disparities in Caregiving Intensity and Quality of Life in Informal Caregivers: A First Look at the National Study of Caregiving

Older Caregivers: Who They Are and How to Support Them

Caregivers play a crucial role in providing health and social supports to their family and friends. Older adults who take on caregiving roles are themselves uniquely vulnerable to negative health and financial effects due to their age and underlying health risks. Many caregivers do not receive adequate support - either formally or informally - exacerbating the strains of providing care. Racial and ethnic minority caregivers may be less likely to report receiving support in their role and face additional challenges. We describe these caregivers over 65 and the burdens they face. We recommend community health workers, direct compensation, and normalization of respite care to support these essential care workers in their role and as they age.

The influence of spirituality on caregiver burden and quality of life in older adult informal caregivers

BACKGROUND

Caregiver burden (CB) reduces quality of life (QOL) and causes poor health outcomes. Spirituality impacts this relationship.

AIMS

To determine prevalence of CB and investigate relationships among CB, spirituality, and QOL in older U.S. adult informal caregivers (n = 754).

METHODS

This was a cross-sectional, descriptive secondary analysis of data from the 2020 Health and Retirement Study using GLM and SEM.

RESULTS

Caregiver mean age was 65.93 (SD=8.37). Caregivers were primarily female (n = 456, 54.0%), White (n = 500, 79.5%), and married (n = 469, 65.3%). Most caregivers had moderate CB (n = 369, 49.8%). Black caregivers who were spiritual (p=.031) and caregivers with a high school diploma/GED who were spiritual (p=.021) had lower CB. Lower CB was correlated with higher QOL (p=< 0.001). SEM depicting an influencing effect of spirituality revealed good model fit (NFI=0.988; IFI=0.993; TLI=0.983; PCFI=0.397, RMSEA=0.043; χ2=9.577, p=.048, DF=4) CONCLUSIONS: Fostering spirituality in older adult caregivers could reduce CB and improve QOL.

Habitual Sleep Duration and Health-Related Quality of Life in Family Caregivers: Findings from the Behavioral Risk Factor Surveillance System

BACKGROUND

Insufficient sleep duration is associated with poor health-related quality of life (HRQoL). However, this relationship has not been studied in family caregivers, a group at high risk of insufficient sleep duration and poor HRQoL.

OBJECTIVE

To examine the associations between habitual sleep duration and HRQoL measures in family caregivers.

METHODS

This cross-sectional study used data from 23,321 caregivers in the 2016 Behavioral Risk Factor Surveillance System. The HRQoL measures were health status and poor mental and physical health days. A multivariable logistic regression model was used to assess the association between sleep duration (<7, 7-9, >9 hours) and health status (fair or poor versus good to excellent). Zero-inflated negative binomial models were used to analyze the association of sleep duration with poor mental and physical health days.

RESULTS

Fair or poor health status was significantly higher in caregivers with short (odds ratio [OR], 1.40; 95% CI: 1.12, 1.74) and long (OR, 2.07; 95% CI: 1.34, 3.21) sleep duration. Short sleep duration was associated with a higher number of poor mental health days (IRR [incident rate ratio], 1.17; 95% CI: 1.04, 1.31) and poor physical health days (IRR, 1.26; 95% CI: 1.10, 1.45). Long sleep duration was associated with more poor mental health days (IRR, 1.31; 95% CI: 1.08, 1.60).

CONCLUSION

Extremes in sleep duration were associated with lower HRQoL. These findings point to the need for interventions that promote adequate sleep and address factors underlying extremes in sleep duration in the context of family caregiving.

Older adults with overlapping caregiving responsibilities and care needs in a U.S. national community-based sample

BACKGROUND

Community-dwelling older adults often serve as caregivers despite having their own health concerns and disabilities, yet little is known about their care needs.

METHODS

Cross-sectional analysis including community-dwelling U.S. adults over age 60 years who self-identified as caregivers in the National Social Life, Health, and Aging Project in 2015-2016. Caregiving was defined by self-reported assistance of another adult with day-to-day activities due to age or disability; overlapping care-receiving was defined by simultaneous receipt of help for at least one activity of daily living (ADL) or independent ADL (IADL). Multivariable logistic regression models examined attributes associated with overlapping care-receiving among older caregivers, adjusted for caregiver characteristics (age, gender, spousal caregiving, self-reported physical and mental health, cognitive function, and household assets).

RESULTS

Among the 444 caregivers, the mean age was 67.8 (SD 0.29) years, 55.8% were women, 78.1% were non-Hispanic White, 54.7% self-identified as primary caregivers, and 30.7% were caring for a spouse. Thirty-two percent of older caregivers were caregiving while themselves receiving assistance with at least one ADL or IADL. Thirty-four percent of caregivers reported <$50,000 in household assets and 10% did not answer the question. Given prior research that supports that most nonrespondents fall into the low-income group, subjects were combined. Analyses with and without nonrespondents did not substantially change the results. Compared to caregivers who were not simultaneously receiving care, caregivers reporting overlapping care-receiving had greater odds of being older (AOR 1.30, 95% confidence interval [CI] [1.14, 1.48] per each 5-year age increase), caregiving for a spouse (AOR 1.93, 95% CI [1.20, 3.13]), having limited household assets (AOR 2.10, 95% CI [1.17, 3.80], for <$50,000 compared to ≥$50,000), and having poor or fair self-reported physical health (AOR 2.94, 95% CI [1.43, 6.02]).

CONCLUSIONS

Over 30% of older adult caregivers report simultaneously receiving care for their own daily activities. Older caregivers who receive care are more likely to be older, spousal caregivers, and have limited assets and worse physical health. Targeted strategies are needed to support older caregivers who are uniquely vulnerable due to their overlapping care needs.

Associations Among Family Caregivers' Perceptions of Loneliness, Choice, and Purpose: a Comparative Analysis Between Non-Hispanic Black Caregivers and Non-Hispanic White Caregivers in a Population-Based Sample

BACKGROUND

Loneliness is a frequent experience among family members engaging in caregiving responsibilities and may vary across racial and ethnic groups. This study aimed to examine (a) the difference in loneliness between non-Hispanic Black and non-Hispanic White caregivers, (b) the associations between loneliness and perceptions of choice and purpose in caregiving, and (c) whether those associations with loneliness differ by caregivers' race.

METHOD

Descriptive statistics and ordinal logistic regression were conducted in a population-based sample of 1000 caregivers (Black caregivers, n = 199; White caregivers, n = 801) from the 2020 Caregiving in the U.S.

STUDY

The survey design was properly addressed. Key variables included loneliness (level of feeling alone about being a caregiver), choice (whether or not reporting a choice in taking on the caregiver responsibility), sense of purpose (level of purpose/meaning in life from caregiving), and race (Black/White). Models adjusted for caregiving characteristics (e.g., hour of caregiving) and sociodemographic characteristics (e.g., age and education).

RESULTS

Black caregivers had lower odds of reporting a higher level vs. a lower level of loneliness than White caregivers (aOR = 0.67, 95%CI = 0.47, 0.96). Reporting having no choice was associated with higher odds of a higher level of loneliness (aOR, 0.77, 95%CI = 0.67, 0.88). Higher sense of purpose scores were associated with lower odds of a higher level of loneliness (aOR = 0.81, 95%CI = 0.71, 0.93). No significant moderation effects of race were found.

CONCLUSION

Black caregivers reported lower loneliness scores than White caregivers. Reporting no choice and lower sense of purpose were associated with higher loneliness in both racial groups.

Structural Inequities in the Kin Safety Net: Mapping the Three-Generational Network throughout Early Adulthood1

Research in the intergenerational transmission of socioeconomic status (SES) consistently shows that the SES of one generation benefits the next. Demographic processes shape the kin structures that serve as conduits for the transmission of SES. Few studies have examined these trends together to describe experiences in evolving kin structures throughout the life course and across generations. This article applies demographic techniques to fertility, marital, and mortality data from three generations in the Panel Survey of Income Dynamics to simulate the amount of time young adults would spend within consequential kin structures. High-SES adults spend more years of their young adulthood in advantageous kin structures with greater potential for kin support and capital accumulation, while low-SES adults spend a larger portion of their young adulthoods as single parents, sandwiched between widowed parents and children, and as adult orphans. The kin network inequities have grown since the 1980s, driven by lagging mortality improvements and increasing single parenthood among low-SES families.

The Experience of Informal Newcomer Cancer Caregivers with Limited Language Proficiency: A Scoping Review

This scoping review explored what is known about the experiences of informal cancer caregivers (CGs) who are newcomers with limited language proficiency. A literature search was performed in seven databases and the search yielded 11,289 articles. After duplicate removal and title and abstract screening, 216 articles underwent full text review and 57 articles and were synthesized. Most studies (n = 41, 72%) were qualitative and were published in North America (n = 35, 61%). Most CG participants were female (69%) and only 19 studies explicitly identified the CG country of origin. Of those that did, 26% originated from Asia, with most migrating from East Asia. Significant challenges were experienced by newcomer CGs and chief among these were related to communication challenges with HCPs that were exacerbated by a lack of availability of medical interpreters and the complexity of oncology health information. Efforts are needed to better integrate newcomer CGs into cancer care.

Correlates of caregiver well-being: The National Study of Caregivers

Background

The literature demonstrates an association between aspects of caregiving and support with caregiver burden and differences by race. Our objective was to examine correlates of caregiver wellbeing, and if the effect is moderated by race.

Methods

The National Study of Caregiving (NSOC) is a survey of unpaid and familial caregivers affiliated with participants in the National Health and Aging Trends Study, a nationally representative survey of Medicare beneficiaries. A total of 899 participants were examined cross-sectionally with logistic and multinomial logistic regression models to obtain adjusted odds ratios (aOR) and 95% confidence intervals (CI) for NSOC Round 3 (2017), stratified by race, to determine the association between aspects of caregiving and support variables with the two outcomes, three-level caregiving gains, and response to the statement "life has meaning and purpose."

Results

Among black caregivers with no family or friends to help, there were lower gains compared to very high gains (aOR: 2.82, 95% CI: 1.18, 6.77). Black and white caregivers who endorsed lower ratings regarding being appreciated by the care recipient had lower gains for "life has meaning and purpose" (aOR: 2.46, 95% CI: 1.00, 6.02; aOR: 1.65, 95% CI: 1.06, 2.56). Black caregivers with lower ratings regarding being appreciated had lower gains compared to very high gains (aOR: 5.04, 95% CI: 1.48, 17.17). White caregivers endorsing lower ratings to the same question had lower gains compared to very high gains (aOR: 3.27, 95% CI: 1.77, 6.04), and those with more help had lower gains (aOR: 0.81, 95% CI: 0.70, 0.93).

Conclusion

The relationship between various correlates and positive aspects of caregiving is moderated by black and white races. Further study on the impact of aspects of caregiving and support networks for caregivers may shed light on factors contributing to racial differences and areas for intervention.

Associations between volunteering and cognitive impairment: The moderating role of race/ethnicity

Although volunteering has been shown to benefit cognitive health, there is a paucity of evidence on informal volunteering and subjective measures of cognitive impairment. Also, little is known about whether such relationships vary by race/ethnicity. This study aimed to examine the associations of both formal and informal volunteering with older adults' objective and subjective cognition and explore the moderating role of race/ethnicity in such associations. Using data from the Health and Retirement Study in the United States (2010-2016), 9941 older adults (51+) who were cognitively unimpaired in 2010 and alive through 2016 were included. Ordered logistic regression models were performed to assess the relationships among volunteering, cognitive impairment and race/ethnicity. Findings showed that more years of formal and informal volunteering significantly reduced the odds of objective cognitive impairment; neither volunteering type was significant for subjective cognitive impairment. The relationship between informal volunteering and objective cognition varied by race/ethnicity. Compared to non-Hispanic Whites, non-Hispanic Black older adults who engaged in more years of informal volunteering had a significantly higher odds of cognitive impairment over time. The current study is one of the first to look at the associations between informal volunteering and cognition. The inclusion of subjective cognitive impairment, paired with objective measures of cognition, also adds value to the knowledge body. Our findings indicate any type of volunteering is a viable approach to prevent cognitive impairment for older populations. However, more research is needed to better understand why racial/ethnic minority, particularly non-Hispanic Black older adults, do not benefit from informal volunteering.

The Landscape of State Policies Supporting Family Caregivers as Aligned With the National Academy of Medicine Recommendations

Policy Points In the absence of federal policy, states adopted policies to support family caregivers, but availability and level of support varies. We describe, compare, and rank state policies to support family caregivers as aligned with National Academy of Medicine recommendations. Although the landscape of state policies supporting caregivers has improved over time, few states provide financial supports as recommended, and benefit restrictions hinder accessibility for all types of family caregivers. Implementing policies supporting family caregivers will become more critical over time, as the reliance on family caregivers as essential providers of long-term care is only expected to grow as the population ages.

CONTEXT

In the United States in 2020, approximately 26 million individuals provided unpaid care to a family member or friend. On average, 60% of caregivers were employed, and they provided 20.4 hours of care per week on top of employment. Although a handful of patchwork laws exist to aid family caregivers, systematic supports, including comprehensive training, respite, and financial support, remain limited. In the absence of federal supports, states have adopted policies to provide assistance, but they vary in availability and level of support provided. Our objectives were to describe, compare, and rank state policies to support family caregivers over time.

METHODS

We used publicly available data from the AARP Long-Term Services and Supports State Scorecard, the National Academy for State Health Policy, and Tax Credits for Workers and Families for all 50 states and the District of Columbia (2015-2019).

FINDINGS

We found that states had increased supports to family caregivers over this five-year period, although significant variability in adoption and implementation of policies persists. Approximately 20% of states had enacted policies that exceed the federal Family and Medical Leave Act requirements, and 18% offered paid family leave. However, most states had not improved spousal impoverishment protections for Medicaid beneficiaries. For example, from 2016 to 2019, 24% of states provided fewer or no protections, while 71% of states did not improve spousal impoverishment protections over time. Access to training for caregivers varied based on eligibility criteria (e.g., select populations and/or only co-residing caregivers).

CONCLUSIONS

Overall, state approaches to support family caregivers vary by eligibility and scope of services. Substantial gaps in support of caregivers, particularly economic supports, persist. Although the landscape of state policies supporting caregivers has improved over time, few states provide financial supports as recommended by the National Academy of Medicine, and benefit restrictions hinder accessibility for all family caregivers.

The impact of care-recipient relationship type on health-related quality of life in community-dwelling older adults with dementia and their informal caregivers

PURPOSE

To assess whether there was an association between care-recipient relationship type and health-related quality of life (HRQL) of older persons living with dementia (PLWD) and their informal caregivers, and whether this association was affected by PLWD' dementia severity.

METHODS

This was a secondary data analysis study. PLWD (n = 1230) and caregivers (n = 1871) were identified from participants in the National Health and Aging Trends Study (NHATS) Round 5 and the National Study of Caregiving (NSOC) II, respectively. A series of bivariate and multivariable regression models examined the associations among relationship type and HRQL in PLWD and caregivers, adjusted for socio-demographic variables and dementia severity.

RESULTS

PLWD and caregivers' HRQL outcomes varied by relationship type. PLWD cared for by an adult-child caregiver, or multiple caregivers experienced higher functional limitations than those cared for by a spousal caregiver (β = .79, CI [.39, 1.19]; β = .50, CI [.17, .82], respectively). "Other" caregivers, such as extended family members or friends, had lower odds of experiencing negative emotional burden and social strain than spousal caregivers (β = .79, CI [.39, 1.19]; β = .50, CI [.17, .82], respectively). Lower odds of experiencing negative emotional burden were also found with multiple caregivers. The effect of an adult-child caregiver on social strain was no longer significant when the dementia severity of PLWD was included in the analysis.

CONCLUSION

The type of care-recipient relationship impacts the HRQL in both PLWD and their informal caregivers. Dementia severity of the PLWD appears to affect this association.

What are we doing to support informal caregivers? A scoping review of caregiver education programs in cancer care

OBJECTIVES

The cancer system is experiencing a rise in cancer prevalence, a workforce shortage, and is resource-stretched. In this environment, informal caregivers (unpaid family caregivers of cancer patients) are required to take on expanded care roles and experience the debilitating effects of caregiver burden. Education programs are increasingly being developed to support caregivers. The aim of this review is to summarize what is known about these programs.

METHODS

A scoping review was conducted from May 2019 to January 2020. The literature search yielded 34,906 articles.

RESULTS

119 articles were included, and ninety-two (77%) were focused on in-person psychoeducational programs.

CONCLUSION

Most caregiver programs have a unidimensional focus on psychoeducational training, demonstrating a need for more comprehensive programming to address the full spectrum of caregiver needs.

PRACTICE IMPLICATIONS

Clinicians and educators must collaborate to create accessible, equitable education programs that comprehensibly address the needs of unpaid family caregivers beyond addressing psychological aspects of cancer care. This will ensure that a broader range of patients and caregivers are equipped with the knowledge and skills needed to cope with a cancer diagnosis, navigate the health system and to maintain their quality of life.

Associations Between Family Member Involvement and Outcomes of Patients Admitted to the Intensive Care Unit: Retrospective Cohort Study

BACKGROUND

Little is known about family member involvement, by relationship status, for patients treated in the intensive care unit (ICU).

OBJECTIVE

Using documentation of family interactions in clinical notes, we examined associations between child and spousal involvement and ICU patient outcomes, including goals of care conversations (GOCCs), limitations in life-sustaining therapy (LLST), and 3-month mortality.

METHODS

Using a retrospective cohort design, the study included a total of 858 adult patients treated between 2008 and 2012 in the medical ICU at a tertiary care center in northeastern United States. Clinical notes generated within the first 48 hours of admission to the ICU were used with standard machine learning methods to predict patient outcomes. We used natural language processing methods to identify family-related documentation and abstracted sociodemographic and clinical characteristics of the patients from the medical record.

RESULTS

Most of the 858 patients were White (n=650, 75.8%); 437 (50.9%) were male, 479 (55.8%) were married, and the median age was 68.4 (IQR 56.5-79.4) years. Most patients had documented GOCC (n=651, 75.9%). In adjusted regression analyses, child involvement (odds ratio [OR] 0.81; 95% CI 0.49-1.34; P=.41) and child plus spouse involvement (OR 1.28; 95% CI 0.8-2.03; P=.3) were not associated with GOCCs compared to spouse involvement. Child involvement was not associated with LLST when compared to spouse involvement (OR 1.49; 95% CI 0.89-2.52; P=.13). However, child plus spouse involvement was associated with LLST (OR 1.6; 95% CI 1.02-2.52; P=.04). Compared to spouse involvement, there were no significant differences in the 3-month mortality by family member type, including child plus spouse involvement (OR 1.38; 95% CI 0.91-2.09; P=.13) and child involvement (OR 1.47; 95% CI 0.9-2.41; P=.12).

CONCLUSIONS

Our findings demonstrate that statistical models derived from text analysis in the first 48 hours of ICU admission can predict patient outcomes. Early child plus spouse involvement was associated with LLST, suggesting that decisions about LLST were more likely to occur when the child and spouse were both involved compared to the involvement of only the spouse. More research is needed to further understand the involvement of different family members in ICU care and its association with patient outcomes.

The Effect of Support from Secondary Caregiver Network on Primary Caregiver Burden: Do Men and Women, Blacks and Whites Differ?

OBJECTIVES

Many older adults receive informal care from multiple caregivers, including support from a primary caregiver and a secondary caregiver network (SCN). This study examined the association between SCN support and primary caregiver burden, and whether the association varies across women and men, Black and White.

METHODS

Data came from the 2015 National Health and Aging Trend Study (NHATS) and the National Study of Caregiving (NSOC), including non-Hispanic White and Black men and women who were identified as primary caregivers (n = 967) and their secondary caregivers (n = 2,253). SCN support was indicated by (a) care domain overlap, and (b) proportion of caregiving by SCN. Multiple regression models were estimated for the analyses.

RESULTS

Both SCN support variables were found to reduce primary caregiver burden, and the effect of proportion of caregiving by SCN was found to vary by gender-race groups. With the increase of the proportion of caregiving by SCN, both Black and White women caregivers tend to experience faster decrease in caregiver burden than Black men.

DISCUSSION

Our findings support the role of SCN in reducing primary caregiver burden and demonstrate that the benefit of SCN support varies across the four gender-race groups. The results indicate that it is imperative to further examine caregiving experience and protective mechanisms of SCN support using an intersectional perspective.

Care-giver wellbeing: exploring gender, relationship-to-care-recipient and care-giving demands in the Canadian Longitudinal Study on Aging

The three-way intersection of gender, relationship-to-care-recipient and care-giving demands has not, to our knowledge, been examined in relation to the wellbeing of family care-givers. We explore inequalities in depressive symptoms and life satisfaction, comparing wives, husbands, daughters and sons providing very-intensive care (36+ hours/week) with those providing less care and disparities between these groups in the factors related to disadvantage. Data from the Canadian Longitudinal Study on Aging (N = 5,994) support the existence of differences between the groups. Very-intensive care-giving wives report the most depressive symptoms and lowest life satisfaction; less-intensive care-giving sons report the fewest depressive symptoms, and less-intensive care-giving daughters report the highest life satisfaction. However, group differences in life satisfaction disappear among very-intensive care-givers. Drawing on Intersectionality and Stress Process theories, data from regression analyses reveal a non-significant gender–relationship–demand interaction term, but, health, socio-economic and social support resources play a strong mediating role between care demand and wellbeing. Analyses of the eight groups separately reveal diversity in the care-giving experience. Among less-intensive care-givers, the mediating role of resources remains strong even as differences are evident. Among very-intensive care-givers, the role of resources is less and differences in wellbeing between the groups are magnified. Policy implications emphasise the imperative to personalise services to meet the varied needs of care-givers.

Social Isolation Among Spousal and Adult-Child Caregivers: Findings From the Canadian Longitudinal Study on Aging

OBJECTIVES

The caregiving outcomes of spousal and adult-child caregivers are widely studied since they are the most common source of support provided to adults. However, the literature on social isolation among spousal and adult-child caregivers is very limited. In order to further elaborate and specify unique caregiving outcomes, this study focuses on social isolation, both longitudinally and comparatively between spousal and adult-child caregivers.

METHODS

This study was based on the Baseline and Follow-up 1 data from the Canadian Longitudinal Study on Aging. A total of 5,226 participants (1,293 spousal caregivers and 3,933 adult-child caregivers) were selected. The Linear mixed models were used to examine the effect of caregiver type and caregiving intensity on social isolation over the course of survey.

RESULTS

Spousal and adult-child caregivers reported greater social isolation over time, and spousal caregivers exhibited a steeper increase in social isolation from Baseline to Follow-up 1 than adult-child caregivers. Also, an increase in caregiving hours resulted in greater social isolation. Finally, male spousal or adult-child caregivers were more likely to be socially isolated over time than their female counterparts.

DISCUSSION

The findings of this study contribute to the existing literature on caregiving outcomes by demonstrating an association between family caregiving and social isolation. The results indicate a strong need for intervention programs that aim to enhance social connectedness among family caregivers, and especially for those who perform intensive caregiving, are older age, and are from a lower socioeconomic status.

Differences in Caregiving Intensity Among Distinct Sociodemographic Subgroups of Informal Caregivers: Joint Effects of Race/Ethnicity, Gender, and Employment

More than 40 million informal caregivers in the United States provide essential care to older adults. Recent research has identified substantial differences in caregiving intensity by gender, race/ethnicity, and employment status. Using intersectionality theory, the current study extends the existing literature by exploring the relationship between caregiving intensity and the unique experiences of individuals with different intersections of gender, ethnicity, and employment. We used generalized linear models to estimate multivariate associations between caregiving intensity assessed by three different measures (hours of caregiving per month and number of activities of daily living and instrumental activities of daily living [IADLs] assisted with) and the three sociodemographic factors of interest (race/ethnicity, gender, and employment status). Unemployed White males provided, on average, 77 fewer hours per month of care (p < 0.001) and assisted with 1.9 fewer IADLs (p = 0.004) than unemployed Black males. Employed White females provided 42.6 fewer hours per month of care (p = 0.002) than employed Black females and 49.2 fewer hours per month (p = 0.036) than employed females of other races. Study findings suggest that examining racial/ethnic or gender differences in isolation does not provide a true picture of differences in caregiving intensity. There is a critical need to understand how the intersections of race/ethnicity, gender, employment, and other sociodemographic factors shape the experiences of caregiver subgroups. [Journal of Gerontological Nursing, 47(7), 23-32.].

Disparities in Palliative and Hospice Care and Completion of Advance Care Planning and Directives Among Non-Hispanic Blacks: A Scoping Review of Recent Literature

OBJECTIVES

Published research in disparities in advance care planning, palliative, and end-of-life care is limited. However, available data points to significant barriers to palliative and end-of-life care among minority adults. The main objective of this scoping review was to summarize the current published research and literature on disparities in palliative and hospice care and completion of advance care planning and directives among non-Hispanc Blacks.

METHODS

The scoping review method was used because currently published research in disparities in palliative and hospice cares as well as advance care planning are limited. Nine electronic databases and websites were searched to identify English-language peer-reviewed publications published within last 20 years. A total of 147 studies that addressed palliative care, hospice care, and advance care planning and included non-Hispanic Blacks were incorporated in this study. The literature review include manuscripts that discuss the intersection of social determinants of health and end-of-life care for non-Hispanic Blacks. We examined the potential role and impact of several factors, including knowledge regarding palliative and hospice care; healthcare literacy; communication with providers and family; perceived or experienced discrimination with healthcare systems; mistrust in healthcare providers; health care coverage, religious-related activities and beliefs on palliative and hospice care utilization and completion of advance directives among non-Hispanic Blacks.

DISCUSSION

Cross-sectional and longitudinal national surveys, as well as local community- and clinic-based data, unequivocally point to major disparities in palliative and hospice care in the United States. Results suggest that national and community-based, multi-faceted, multi-disciplinary, theoretical-based, resourceful, culturally-sensitive interventions are urgently needed. A number of practical investigational interventions are offered. Additionally, we identify several research questions which need to be addressed in future research.

Prevalence of Informal Caregiving in States Participating in the US Patient Protection and Affordable Care Act Balancing Incentive Program, 2011-2018

Importance

The Balancing Incentives Program (BIP), established under the 2010 Patient Protection and Affordable Care Act provided federal funding for states to shift long-term care out of institutional settings and into the home. However, the association of its implementation with informal caregiving is not known.

Objective

To evaluate the association between BIP participation and the prevalence and frequency of informal caregiving and socioeconomic disparities among caregivers.

Design, Setting, and Participants

The cohort study included respondents to the 2011-2018 American Time Use Survey in BIP-adopting states and non-BIP-adopting states.

Exposure

Living in a state that had implemented the BIP after program implementation had begun (April 2012 to April 2018).

Main Outcomes and Measures

Prevalence of caregiving among all respondents, frequency of caregiving, and minutes of daily sleep, a marker of well-being. Differences-in-differences (DID) regression analysis was used to compare these outcomes between BIP-adopting states and non-BIP-adopting states.

Results

The study included 38 343 respondents in BIP-adopting states (median age, 47 years [interquartile range (IQR), 31-61 years]; 51.9% women), of whom 7428 were caregivers (median age, 51 years [IQR, 37-61 years]; 55.6% women), and 26 437 respondents in non-BIP-adopting states (median age, 48 years [IQR, 32-62 years]; 52.7% women), of whom 5527 were caregivers (median age, 52 years [IQR, 38-62 years]; 57.9% women). There was no change in the prevalence of caregiving between BIP-adopting and non-BIP-adopting states after program implementation (DID, 0.00%; 95% CI, -0.01% to 0.01%). Caregivers in BIP-adopting states were more likely to provide daily care after implementation (DID, 3.2%; 95% CI, 0.3%-6.0%; P = .03) and report increased time sleeping (DID, 15.6 minutes; 95% CI, 4.9-26.2 minutes; P = .005) compared with caregivers in non-BIP-adopting states. This association was more pronounced among caregivers with more education (DID, 25.1 minutes; 95% CI, 6.5-43.8 minutes; P = .01) and higher annual family income (DID, 16.9 minutes; 95% CI, 5.9-27.9 minutes; P = .004) compared with caregivers in non-BIP-adopting states who had the same education and income levels, respectively.

Conclusions and Relevance

In this cohort study, the BIP was associated with increased daily caregiving and improved caregiver well-being. However, it may have disproportionately benefited caregivers of higher socioeconomic status, potentially exacerbating disparities in caregiver stress. Future policies should aim to mitigate this unintended consequence.

Stress and well-being of unpaid carers supporting claimants through disability benefit assessments

This study assessed the subjective well-being and perceived stress of unpaid carers of disability benefit claimants. A total of 129 carers from the UK were surveyed between July and September 2017, using a cross-sectional design. Carers, who provided unpaid support to sick or disabled friends, family or neighbours in a non-professional capacity, reported here as unpaid carers, were asked to complete a web-based questionnaire comprising of the Perceived Stress-10-item Scale (PSS-10), the Personal Wellbeing Index-Adult (PWI-A), sociodemographic characteristics, the time they spent caring per day and the number of Personal Independence Payment and Work Capability Assessment interviews prepared for and attended by the person they cared for. Hierarchical regression analyses were performed to assess the effects of the number of benefit assessments on stress and well-being scores, controlling for carers' sociodemographic characteristics and the time they spent caring. Analyses revealed that the number of times that claimants were exposed to benefit assessments significantly and negatively predicted unpaid carers' well-being and was positively related to their stress levels. After controlling for sociodemographic characteristics and hours supporting per day, benefit assessments predicted 8.1% of perceived stress and 4.3% of well-being variance. Being a female unpaid carer of a disability benefit claimant negatively predicted 7.5% of well-being variance. The results offered unique evidence of the negative psychological effects of disability benefit assessments upon unpaid carers, while adding to the evidence of female carers facing increased risks of psychological distress.

Effects of a Telehealth Early Palliative Care Intervention for Family Caregivers of Persons With Advanced Heart Failure: The ENABLE CHF-PC Randomized Clinical Trial

IMPORTANCE

Family caregivers of persons with advanced heart failure perform numerous daily tasks to assist their relatives and are at high risk for distress and poor quality of life.

OBJECTIVE

To determine the effect of a nurse-led palliative care telehealth intervention (Educate, Nurture, Advise, Before Life Ends Comprehensive Heart Failure for Patients and Caregivers [ENABLE CHF-PC]) on quality of life and mood of family caregivers of persons with New York Heart Association Class III/IV heart failure over 16 weeks.

DESIGN, SETTING, AND PARTICIPANTS

This single-blind randomized clinical trial enrolled caregivers aged 18 years and older who self-identified as an unpaid close friend or family member who knew the patient well and who was involved with their day-to-day medical care. Participants were recruited from outpatient heart failure clinics at a large academic tertiary care medical center and a Veterans Affairs medical center from August 2016 to October 2018.

INTERVENTION

Four weekly psychosocial and problem-solving support telephonic sessions lasting between 20 and 60 minutes facilitated by a trained nurse coach plus monthly follow-up for 48 weeks. The usual care group received no additional intervention.

MAIN OUTCOMES AND MEASURES

The primary outcomes were quality of life (measured using the Bakas Caregiver Outcomes Scale), mood (anxiety and/or depressive symptoms measured using the Hospital Anxiety and Depression Scale), and burden (measured using the Montgomery-Borgatta Caregiver Burden scales) over 16 weeks. Secondary outcomes were global health (measured using the PROMIS Global Health instrument) and positive aspects of caregiving.

RESULTS

A total of 158 family caregivers were randomized, 82 to the intervention and 76 to usual care. The mean (SD) age was 57.9 (11.6) years, 135 (85.4%) were female, 82 (51.9%) were African American, and 103 (65.2%) were the patient's spouse or partner. At week 16, the mean (SE) Bakas Caregiver Outcomes Scale score was 66.9 (2.1) in the intervention group and 63.9 (1.7) in the usual care group; over 16 weeks, the mean (SE) Bakas Caregiver Outcomes Scale score improved 0.7 (1.7) points in the intervention group and 1.1 (1.6) points in the usual care group (difference, -0.4; 95% CI, -5.1 to 4.3; Cohen d = -0.03). At week 16, no relevant between-group differences were observed between the intervention and usual care groups for the Hospital Anxiety and Depression Scale anxiety measure (mean [SE] improvement from baseline, 0.3 [0.3] vs 0.4 [0.3]; difference, -0.1 [0.5]; d = -0.02) or depression measure (mean [SE] improvement from baseline, -0.2 [0.4] vs -0.3 [0.3]; difference, 0.1 [0.5]; d = 0.03). No between-group differences were observed in the Montgomery-Borgatta Caregiver Burden scales (d range, -0.18 to 0.0). Differences in secondary outcomes were also not significant (d range, -0.22 to 0.0).

CONCLUSIONS AND RELEVANCE

This 2-site randomized clinical trial of a telehealth intervention for family caregivers of patients with advanced heart failure, more than half of whom were African American and most of whom were not distressed at baseline, did not demonstrate clinically better quality of life, mood, or burden compared with usual care over 16 weeks. Future interventions should target distressed caregivers and assess caregiver effects on patient outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02505425.

Differences within Differences: Gender Inequalities in Caregiving Intensity Vary by Race and Ethnicity in Informal Caregivers

Among the 50+ million informal caregivers in the US, substantial gender, racial/ethnic, and socioeconomic disparities in caregiving intensity are well-documented. However, those disparities may be more nuanced: gender disparities in caregiving intensity may vary by race/ethnicity (White, Black, and Hispanic) and socioeconomic status (SES). We used data from the 2011 National Study of Caregiving and applied generalized linear models to estimate associations between three measures of caregiver intensity (ADLs, IADLs, and hours caregiving/month) and the three sociodemographic factors with their interaction terms. Black female caregivers provided significantly higher levels of care than White females and males for both IADL caregiving and hours/month spent caregiving. Black caregivers spent an average of 28.5 more hours/month (95%CI 1.7-45.2) caregiving than White caregivers. These findings highlight the need to understand the complex disparities within population subgroups and how intersections between gender, race/ethnicity, and SES can be used to develop effective policies to reduce disparities and improve caregiver quality-of-life.

Longitudinal changes on the quality of life in caregivers of type 2 diabetes amputee patients

PURPOSE

To explore changes in the quality of life of caregivers of amputees due to type 2 diabetes ten months after amputation.

METHODS

This is a longitudinal study with three moments of evaluation (T1: one month after surgery, T2: 7 months, T3: 10 months). The sample comprised 110, 101, and 84 caregivers of amputated patients with type 2 diabetes. Caregivers answered a Socio-demographic questionnaire; the Self-Assessment Caregiver; the Family Disruption from Illness Scale; and the Short Form Health Survey (SF36).

RESULTS

Stress levels were not significantly reflected in changes on mental quality of life over time, except in the caregivers who presented less stress, emphasizing the adverse role of stress when experienced on a continuous basis for ten months on the caregivers' mental well-being. Caregivers presented greater number of physical symptoms at T2 that decreased at T3.

CONCLUSIONS

According to the results, in order to promote caregivers' physical and mental quality of life, it would be important to evaluate stress levels especially in patients who presented somatic complaints.

Informal Grandmother Caregivers of Co-Resident Young Adult Grandchildren

Although primary caregivers of young adult grandchildren are generally not older women, a limited number of aged grandmothers assume this critical role. It is beneficial for the public to understand the lived experiences of these caregivers. For many different reasons, older grandmother caregivers freely provide valuable, person-centered care in their homes. They respond, on an ongoing basis, to the many care needs of their young adult grandchildren. Over time, their caregiving experiences can be satisfying and challenging. Because their services are provided to their young adult grandchildren at home, the collaborative efforts of health professionals, caregivers, and care recipients are essential. Therefore, researchers and health professionals can use conceptual models that emphasize wholeness, unity, and collaborative decision making to frame their understanding of the phenomenon of older grandmother caregivers, consider the influential factors, and determine the practice implications for this population. [Journal of Psychosocial Nursing and Mental Health Services, 56(10), 15-19.].

Challenges to and Strategies for Formal Service Utilization among Caregivers in an Underserved Community

Family caregivers face enormous challenges when attempting to oversee the medical, legal, financial, and daily affairs of loved ones with chronic or life-limiting illness. While formal services and agencies exist to assist caregivers with some of these tasks, caregivers in underserved communities do not utilize these services, or utilize them with unsatisfactory results. This study used focus groups (N = 5 groups) with underserved, minority caregivers (N = 22) to explore their experiences related to care provision, including barriers to support service use and challenges navigating systems related to the broad spectrum of caregiving demands. Thematic content analysis revealed three main themes: (1) prior difficulties with formal service use, (2) difficulties navigating financial, legal, and medical systems, and (3) caregivers' personal strategies to address challenges associated with formal service use and systems navigation. Findings from this study identify underserved caregivers' challenges in utilizing formal services, as well as caregiver-identified strategies for supporting their caregiving activities.

Sociodemographic Disparities in Adult Child Informal Caregiving Intensity in the United States: Results from the New National Study of Caregiving

The objective of the current study was to assess socioeconomic and demographic disparities in caregiving intensity among informal caregivers. Using a randomized, nationally representative sample of 1,014 adult child informal caregivers from Medicare enrollment databases, the associations between informal caregiving intensity and age, race/ethnicity, and income were examined using binary and ordinal logistic regression. Caregiving intensity varied by demographics. Activities of daily living (ADL) caregiving was highest among Black, non-Hispanic caregivers. Instrumental ADL caregiving and number of hours spent caregiving was highest in female and non-White caregivers. Although the overall association between caregiving intensity and income was not significant, when stratified by race/ethnicity, this association was positive for White caregivers and negative for non-White caregivers. Health care providers frequently interact with informal caregivers and should be aware of trends in caregiving and the needs and supports available to ameliorate caregiver burden. To protect caregivers, policies and programs should be designed to promote well-being and mitigate the potential harms of caregiving to health. [Journal of Gerontological Nursing, 44(9), 15-20.].

Socioeconomic and demographic factors modify observed relationship between caregiving intensity and three dimensions of quality of life in informal adult children caregivers

Background

The relationship between informal caregiving intensity and caregiver health is well-established, though research suggests this may vary by caregiver demographics. The aim of this exploratory study is to assess the association between caregiving intensity and three dimensions of quality of life outcomes, and determine how caregiver sociodemographics change the nature of this relationship among informal adult children caregivers.

Methods

Using the 2011 National Study of Caregiving, associations between caregiving intensity and quality of life were examined in caregivers providing care to an aging parent (n = 1014). Logistic regression was used to model caregiver quality of life on caregiving intensity using an ordinal composite measure of caregiving activities, including Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL), hours per month, and length of caregiving, stratified by race/ethnicity, gender, age, and family income. Odds ratios and corresponding 95% confidence intervals were calculated.

Results

Associations between caregiving intensity and quality of life varied substantially by race/ethnicity, gender, age, and annual family income. White caregivers were significantly more likely to experience negative emotional burden when providing high intensity care (ADL: 1.92, Hours: 3.23). Black caregivers were more likely to experience positive emotions of caregiving (ADL: 2.68, Hours: 2.60) as well as younger caregivers (Hours: 8.49). Older caregivers were more likely to experience social burden when providing high ADL, IADL, and monthly hours of care.

Conclusions

These findings demonstrate the complex and multi-dimensional nature of caregiving, and emphasize the need to develop approaches that are tailored to the specific health needs of subpopulations of informal caregivers.

Income-based inequalities in caregiving time and depressive symptoms among older family caregivers under the Japanese long-term care insurance system: A cross-sectional analysis

AIM

Long-term care systems may alleviate caregiver burdens, particularly for those with fewer resources. However, it remains unclear whether socioeconomic disparity in caregiver burdens exists under a public, universal long-term care insurance (LTCI) system. This study examined income-based inequalities in caregiving time and depressive symptoms in Japanese older family caregivers. We further compared inequality in depressive symptoms with that of non-caregivers to evaluate whether family caregiving exacerbates this disparity.

METHODS

Data were obtained from a cross-sectional, nationwide survey conducted by the Japan Gerontological Evaluation Study in 2013. Participants were functionally independent older adults aged ≥65 years (N = 21,584). Depressive symptoms were assessed using the Geriatrics Depression Scale (GDS); caregiving hours per week, household income, and other covariates were also assessed.

RESULTS

Family caregivers occupied 8.3% of the total. A Poisson regression model revealed that caregivers in lower income groups (compared to those in the highest) were 1.32 to 1.95 and 1.63 to 2.68 times more likely to engage in ≥36 and ≥72 hours/week of caregiving, respectively. As for the GDS (≥5), an excess risk was found in the caregivers in lower (compared to higher) income groups (adjusted prevalence ratio: 1.57-3.10). However, an interaction effect of income by caregiving role indicated no significant difference in inequality between caregivers and non-caregivers (p = .603). The excess risk for GDS (≥5) in the caregivers compared to non-caregivers was observed across income groups.

CONCLUSIONS

Our findings revealed a possible disparity in family caregivers under the public LTCI system. Further studies should examine factors associated with longer caregiving hours in lower income households. Our findings also suggest the necessity for more efforts to alleviate depressive symptoms in family caregivers under the LTCI system regardless of income level, rather than exclusively supporting those with a low income.