Challenges Experienced by Rural Informal Caregivers of Older Adults in the United States: A Scoping Review

Attention to Rural Populations in Social Work Journals: Findings from a Scoping Review

PURPOSE

The study aimed to examine social work's scholarly attention to rural populations in a global context, given the paucity of rural social work literature in professional journals and earlier reviews showing the dominance of material emanating from the United States of America.

MATERIALS AND METHOD

The researchers used a scoping review of articles published in social work journals listed in the Journal Citation Reports for the Social Science (hereafter JCR) (n = 90) between 2009 and 2024.

RESULTS

The study found 152 articles on rural social work published in 48 of the 90 JCR social work journals, 71% of which were research-based. Most publications came from the Asia-Pacific (n = 60), 25 of which were from China, followed by 61 from North America, including 58 from the USA and three from Canada, along with 18 from Africa and 10 from Europe and the UK. There were only three from South America, possibly due to the study's restriction to English-language journals. The main themes related to rural social work practice, health, professional issues, and context.

DISCUSSION

The paucity of publications on rural issues contributed to minimal understanding of the complexity and diversity of rural poverty. The findings revealed remarkable similarities in knowledge shaping rural social work practice worldwide, despite regional differences.

CONCLUSION

The study suggested a consistent lack of focus on rural populations within the social work profession and underscored the importance of understanding and addressing pressing issues facing rural communities across diverse global contexts.

Unmet Needs and Factors Impacting Home- and Community-Based Service Use Among Rural Appalachian Caregivers of People With Alzheimer's and Dementia

Family caregivers of persons with Alzheimer's disease and related dementias (ADRD) living in rural areas face significant health and healthcare challenges. Limited research, however, has explored factors shaping their use of home- and community-based services (HCBS). This study identifies unmet needs among caregivers of people with ADRD in rural Western North Carolina and highlights contextual factors that facilitate HCBS use. Nineteen qualitative interviews were conducted with 21 family caregivers and 1 person with ADRD between 2021 and 2022. Thematic analyses revealed unmet needs among caregivers for information, service navigation, and caregiving support. HCBS use was shaped by multiple factors including illness needs, cultural beliefs, preferences for home-based care, and place-based resources. These findings suggest that culturally tailored HCBS are needed to support people with ADRD and their caregivers in rural Appalachian communities, especially those which facilitate access to paid caregiving, clearly communicate program eligibility requirements, and emphasize service availability.

Patient and Caregiver Perceptions of Caregiving Contributions During Cancer Clinical Trials: A Mixed-Methods Study

OBJECTIVE

Caregivers play crucial roles in cancer treatment and outcomes. However, little is known regarding how caregivers support patients during cancer clinical trials. The aim of this study was to gain insight into the caregiver experience of rural and urban patients enrolled in cancer clinical trials.

METHODS

As part of a quality improvement study, 21 patient-caregiver dyads were interviewed using closed and open-ended interview questions. We analyzed quantitative and qualitative data on patient and caregiver perceptions of caregiver contributions and explored differences in the reported caregiving experience between rural and urban participants.

RESULTS

While patient-caregiver dyads showed significant disagreement in the symptoms/medication management domain, with caregivers tending to acknowledge the contribution while patients did not (χ2 (1, 21) = 5.82, p = 0.016), both groups generally showed agreement in their perceptions of caregiver involvement and reported similar levels of involvement across the other six assessed domains. Qualitative analysis revealed three themes: patient independence, invisible support, and accepted forms of support. Despite patients valuing independence, patients benefited from caregivers' unseen support, and providing emotional support and attending appointments were widely accepted forms of support among patients. No meaningful differences in caregiver contributions were found between rural and urban patient-caregiver dyads.

CONCLUSION

Our study revealed that caregivers are assisting patients in often unseen and underestimated ways during cancer clinical trials, highlighting their multifaceted role. Cancer clinical trials should implement a family-centered approach, especially for rural caregivers, to enhance patient retention and outcomes.

Perceived helpfulness of caregiver support resources: Results from a state-wide poll

Objective

Our goal was to identify specific types of services desired by caregivers and determine subgroups most interested in each service type.

Methods

Caregiving questions were added to a state-wide poll conducted in a majority-rural state. Those who identified as caregivers (n = 428) were asked to report on the helpfulness of 6 domains of services. Descriptive analysis and logistic regressions were conducted.

Results

Top resources caregivers identified as potentially helpful included hands-on services (33.9%), help coordinating care from multiple providers (21.5%), help with finances (18.9%), and help managing emotional stress (17.8%). Only 15% indicated no caregiver resources would be helpful. Younger caregivers endorsed several service domains as more helpful than older caregivers; caregivers reporting higher stress were more likely to endorse most domains as helpful.

Conclusion

Data reinforces the overwhelming need to offer caregiver services. Navigation and integrated and tailored service models may be beneficial to help caregivers identify and access appropriate services within healthcare systems.

Innovation

This study uses an innovative approach to identifying needs of caregivers, who are often invisible within the healthcare system. Our findings suggest a paradigm shift is needed to broaden the scope and depth of services offered to caregivers.

Caregiving Intensity, Duration, and Subjective Financial Well-Being Among Rural Informal Caregivers of Older Adults with Chronic Illnesses or Disabilities

INTRODUCTION

Rural informal caregivers (IC) experience major financial and economic constraints in caring for their older family members. Rurality combined with increased caregiving demands and intensity, poor economic opportunities, and limited financial resources and policies create multiple financial stressors and can lead to poor financial well-being. A cross-sectional survey was conducted to understand how caregiving demands, intensity, and duration impact the subjective financial well-being of rural caregivers of older adults.

METHODS

Informal caregivers (N = 196) residing in 12 rural counties in the central North Region of the Midwestern US participated in the survey. Ordinary Least Squares and Linear Probability Model regressions were conducted to measure the association among the study variables.

RESULTS

Our findings showed a moderate level of subjective financial well-being among informal caregivers (average = 51.62; SD 14.52). Caregiving intensity negatively affected financial well-being (β = -1.470, p < 0.05). More than half of informal caregivers (58%) were not satisfied with their household income, and 30% found it difficult to meet their family's needs with their current income status.

DISCUSSION AND CONCLUSIONS

Longer hours of care are associated with financial burden and insecurity and can significantly influence the financial health and well-being of rural informal caregivers of older adults. Older caregivers were found to manage their financial constraints more effectively. Future comparative and longitudinal studies with a more diverse sample are required to infer long-term interactions among the different variables in this study.

Rural-urban and regional variations in aspects of caregiving, support services and caregiver health in the USA: evidence from a national survey

OBJECTIVES

Due to substantial regional variability in available caregiving services and supports, culture and health status among informal caregivers in the USA, the study objective was to explore how rural-urban differences in aspects of caregiving-caregiving intensity, distance to care recipient, caregiver burden, caregiver health and caregiving support-vary by US Census region (Northeast, South, Midwest and West) after accounting for other social determinants of health.

DESIGN

This study was a secondary analysis of multiwave, cross-sectional study data.

SETTING

The data were collected on a representative sample of informal, unpaid caregivers to older adults.

PARTICIPANTS

A sample of n=3551 informal caregivers from the National Study of Caregiving identified by older adult care recipients from waves 1 (2011) and 5 (2015) of the National Health and Aging Trends Study.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome measures were caregiving intensity (provided support for/with the number of activities of daily living (ADLs) and instrumental ADL (IADLs)) caregiver assisted with, hours of caregiving per month), caregiver burden (physical, emotional and financial), support services sought (types and total number), caregivers' self-reported health and health status (individual comorbidities and a total number of comorbidities). Analyses were stratified by US Census region and rural-urban status, as defined by the US Census Bureau, of census tract of caregiver residence.

RESULTS

Urban caregivers provided higher levels of ADL support in the Northeast (beta=0.19, 95% CI 0.03, 0.35) and West (beta=0.15, 95% CI 0.05,0.26) regions. Urban caregivers provided significantly higher levels of ADL support (p=0.020), IADL support (p=0.033) and total ADLs plus IADLs (p=0.013) than rural caregivers. Caregivers living in the South had higher amounts of monthly hours spent caregiving, ADL support, IADL support and combined ADLs plus IADLs and were more likely to have obesity, report poor or fair health, have heart conditions and experience emotional difficulty from caregiving (all p<0.001).

CONCLUSIONS

Study findings underscore caregiving's multifaceted and complex nature and identify important urban-rural and regional differences in caregiving in the USA. Healthcare providers and healthcare organisations can have an important role in identifying and mitigating the negative impacts of caregiving on caregivers' overall health. Interventions and support should be tailored to caregivers' demographic backgrounds, addressing regional differences.

Rural unpaid caregivers' experiences in northern Aotearoa, New Zealand during the Covid-19 pandemic: A qualitative study

OBJECTIVE

Rural unpaid caregivers experience different opportunities and challenges than their urban counterparts. Our aim was to understand rural unpaid caregivers' experiences of challenges and opportunities during the Covid-19 pandemic in New Zealand.

SETTING

Rural northern New Zealand during the Covid-19 pandemic.

PARTICIPANTS

A convenience sample of 10 unpaid rural caregivers, most supporting an older person living with dementia.

DESIGN

A qualitative descriptive design. Data included interviews and online workshops, and a thematic analysis.

RESULTS

Rural unpaid caregivers observed that some aspects of living in a rural context were helpful during the Covid-19 pandemic. However, tasks such as shopping and long-distance travel and communication (both telephonic and digital) became more complex. Abrupt changes to routine and closure of resources and support groups created challenges. Unpaid caregivers worried about what would happen if they were hospitalised themselves. There was a diversity of experience both across caregivers, of familiar routines and rural context as resources, increased challenges requiring resourcefulness to adapt, and experiences of crisis. Many experienced all three states at different times.

CONCLUSION

This research provides valuable insights into challenges and opportunities experienced by rural unpaid caregivers during the Covid-19 pandemic and may help policy-makers and healthcare professionals develop improved emergency preparedness. Multilevel, multisector responses are needed to ensure effective health and social support and access to resources including health care, access to groceries and medication, transport, and communications (telephone and digital). Enhancing rural access to effective and inexpensive online services is particularly important, as is recognition of the value of rural sites or hubs of connection and social interaction.

Place-based, intersectional variation in caregiving patterns and health outcomes among informal caregivers in the United States

Introduction

Informal caregiving is a critical component of the healthcare system despite numerous impacts on informal caregivers' health and well-being. Racial and gender disparities in caregiving duties and health outcomes are well documented. Place-based factors, such as neighborhood conditions and rural-urban status, are increasingly being recognized as promoting and moderating health disparities. However, the potential for place-based factors to interact with racial and gender disparities as they relate to caregiving attributes jointly and differentially is not well established. Therefore, the primary objective of this study was to jointly assess the variability in caregiver health and aspects of the caregiving experience by race/ethnicity, sex, and rural-urban status.

Methods

The study is a secondary analysis of data from the 2021 and 2022 Behavioral Risk Factor Surveillance System (BRFSS) from the Centers for Disease Control and Prevention. Multivariable logistic regression or Poisson regression models assessed differences in caregiver attributes and health measures by demographic group categorized by race/ethnicity, sex, and rural-urban status.

Results

Respondents from rural counties were significantly more likely to report poor or fair health (23.2% vs. 18.5%), have obesity (41.5% vs. 37.1%), and have a higher average number of comorbidities than urban caregivers. Overall, rural Black male caregivers were 43% more likely to report poor or fair health than White male caregivers (OR 1.43, 95% CI 1.21, 1.69). Urban female caregivers across all racial groups had a significantly higher likelihood of providing care to someone with Alzheimer's disease than rural White males (p < 0.001). Additionally, there were nuanced patterns of caregiving attributes across race/ethnicity*sex*rural-urban status subgroups, particularly concerning caregiving intensity and length of caregiving.

Discussion

Study findings emphasize the need to develop and implement tailored approaches to mitigate caregiver burden and address the nuanced needs of a diverse population of caregivers.

Cultural Values Influence on Rural Family Caregivers' Decision-Making for Ill Older Adult Loved Ones

CONTEXT

Rural older adult Americans receive more intense treatment at end of life. Studies indicate that those who participate in goals of care conversations receive care more concordant with their values. Yet, rates of documented goals of care discussions are lower in rural and Black communities. Although multi-factorial, the role that rural family caregivers (FCGs) play in decision-making for ill loved ones is understudied.

OBJECTIVE

This study aimed to explore rural FCGs cultural values, beliefs, and attitudes about serious illness and treatment decision-making and to understand how these factors influence their decision-making around goals of care for their family members.

METHODS

This is an embedded qualitative study within a tele-palliative care consult randomized trial that the PEN-3 theoretical model guided. Semi-structured interviews were conducted with FCGs who had completed study participation. Thematic analysis was used to analyze the data.

RESULTS

Twelve rural FCGs center their decisions around core values, and the decision-making experience was supported by faith. A model of how the key themes and subthemes interact around the central space of supporting the seriously ill loved to demonstrate the complexity of caregiving when race and rurality intersect is presented.

CONCLUSION

This study is a foundational step in understanding how rural FCGs beliefs and values influence decision-making. We recommend incorporating those constructs into the development of culturally responsive decision-support interventions.

An online intervention to improve the health and well-being of informal caregivers of individuals with Alzheimer's disease: A pilot study

Objective

Describe an intervention to improve the health and well-being of informal caregivers of individuals with Alzheimer's disease (AD) and present pilot program findings.

Methods

Participants (N = 31, mean age = 45.7) were randomly assigned to one of two conditions: an online synchronous didactic lesson and peer support session series or an asynchronous didactic only session series. Outcome variables included physical health, nutrition intake, and stress. One-way ANOVA was conducted to examine the effects of the intervention. The least significant difference (LSD) post hoc test was used to analyze the difference pattern between means.

Results

Participants in both conditions reported healthier dietary behavior and lower level of stress from pre-intervention to the post-intervention. These effects were not maintained at one-month follow up.

Conclusion

An online educational intervention may improve the health and well-being of informal caregivers of people with AD. Further research is necessary to determine which specific intervention components to include and what strategies may help participants maintain improved health behaviors.

Innovation

This program focused on the health and well-being of informal caregivers of individuals with AD rather than on emphasizing how caregivers can perform their caregiving duties better. The intervention was provided in an underserved lower-income, rural area.