Copyright 1992 by The Cerontological Society of America The Cerontologist Vol. 32, No. 2, 227-233
This study, using a large, nationally representative sample of noninstitutionalized disabled older persons, found that urban residents were much more likely than rural residents to receive formal assistance in every ADL and IADL considered. Rural residents were more likely to receive informal assistance and to receive two-thirds more person days of informal assistance per week. No residence differences in unmet need for care were identified. Key Words: Rural elderly, Urban elderly, Disability
Residence Differences in Formal and Informal Long-Term Care Daniel O. Clark, PhD1
1 Case Western Reserve University, Department of Sociology, Cleveland, OH 44106-7124.
Vol. 32, No. 2,1992
227
allow one to test this hypothesis are limited. Using 1976 data gathered through self-administered questionnaires from Area Agencies on Aging (AAAs), Nelson (1980) showed that AAAs identifying their service area as rural were less likely to have services for the severely disabled than were those identifying their service area as urban or as a mix of urban and rural. This evidence, coupled with the proposition that formal caregivers are best suited for tasks involving a specific interval of time and requiring specific technical skills (Litwak, 1985), suggests that rural/ urban differences in caregiving are likely to be greatest in specialized services for the severely disabled. Two studies have examined area of residence differences in caregiving by both type of task and source of care (i.e., formal/informal), but they provided little support for the above expectation. Blieszner and colleagues (1987) showed that in nursing care, a form of care that would seem to be most amenable to formal assistance and targeted for the severely disabled, 32.1% of rural respondents reported the use of formal assistance, while 22.5% of the small city and 40.5% of the urban respondents reported the use of formal assistance. The same study showed that a lower percentage of total assistance with home management services, meal preparation, personal care, and continuous supervision came from formal caregivers in rural than in small city and urban areas. Stoller and Earl (1983), in contrast, failed to find significant MSA and non-MSA county differences in the type (formal or informal) of care received. However, much variation in the sociodemographic characteristics and health of older populations exists within MSA and non-MSA counties and more detailed areal categorizations are generally necessary to capture areal differences (Coward & Cutler, 1988). Factors other than service availability are likely to be involved in urban/rural differences in caregiving. A life-span framework suggests that certain characteristics of physical and social contexts (e.g., housing conditions, service accessibility, informal support networks) experienced over the life course, in con-
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As the size and age of the older population continue to increase, the proportion of the population requiring physical assistance increases as well, leading to greater levels of social, psychological, and financial burden for both families and societies. Thus, both personal and contextual determinants of caregiving need study. Area of residence is an often-used proxy for social and physical context. This study examines residence differences in formal and informal care for specific activity of daily living (ADL) and instrumental activity of daily living (IADL) tasks using a nationally representative sample of noninstitutionalized, disabled older persons. It also considers whether the intensity of formal or informal care and the proportion of elders with an unmet need for care vary by rural versus urban residence. In contrast to prior studies, this research controls for the influences of sociodemographic characteristics and disability levels, both of which covary with caregiving and residence. Several recent studies have examined the formal and informal structure of caregiving networks across areas of residence. Using a 1984 national sample of older persons, Coward, Cutler, and Mullens (1990) found that 73% of severely disabled nonmetropolitan (non-MSA) county residents and 55% of severely disabled metropolitan (MSA) county residents living in central cities reported receiving informal assistance only. This study also showed that central city respondents were nearly twice as likely as non-MSA respondents to report receiving formal and informal assistance simultaneously, 35.4% and 18.4%, respectively. Similarly, a 1979 sample of older Virginians has provided evidence that older urban as compared with older rural persons are twice as likely to report the use of formal assistance only or a mix of iniformal and formal assistance (Blieszner et al., 1987). Availability of formal services may explain some of these differences; however, high-quality data that
Method
Data The data used in this study are drawn from the longitudinal National Long-Term Care Survey (NLTCS). The NLTCS, conducted by the U.S. Bureau of the Census and cosponsored by the Health Care Financing Administration and the Office of the Assistant Secretary for Planning Evaluation, was a longitudinal study with a 1982 baseline survey and followups in 1984 and 1989. This analysis utilizes the 1982 cross-sectional data (the 1989 data were not available at the time of this study). The initial screening consisted of 36,000 Medicare recipients who were 65 years of age or over. These persons were contacted by telephone and screened for indications of functional disability that had lasted, or was expected to last, 3 months or longer. Once identified as disabled, the individual was included in the sample. The sample was stratified by census geographic region, age, race, and reason for Medicare entitlement (Macken, 1986). The result is a sample of 6,393 persons, of whom 6,088 participated, yielding a response rate of 95%. Of these persons, 23 were missing information on area of residence and another 903 were not disabled on the ADL or IADL items included in this study. Household interviews were conducted with the sample person or a proxy respondent, the latter making up 26% of the sample. Extensive analyses have been conducted on the data and measures of the 1982 NLTCS (e.g., Manton, 1988; Macken, 1986) and will not be repeated here. All have shown the data to be reliable and represent-
ative of the older disabled population of the United States. Sociodemographic Characteristics The sociodemographic measures were age, race, gender, education, income, and marital status. Age was coded in years, race as 1 = white and 0 = other, gender as 1 = male and 0 = female, and education in years of completed schooling. Income was recoded to the midpoint of the household's income category and reported in approximate 1982 dollars. Marital status was 1 = married and 0 = other. Disability Disability is defined as the reporting of a met or unmet need for assistance to perform an ADL or, in the case of lADLs, a met or unmet need that is due to a health or disability problem. The use of special equipment to perform a particular ADL or IADL also was considered an indication of disability. Level of disability was measured as the total number of ADLs and the total number of lADLs for which assistance or special equipment were needed. In-home Care Several measures of formal and informal in-home care were employed in this analysis. Formal care is that received for pay or from persons representing professional social or health care organizations. Informal assistance is that received without pay and from a provider who does not represent a professional social or health care organization. The variables employed here measured whether the respondent reported that formal or informal help was received over the week prior to the interview. With the exception of formal ADL assistance, which is not available by specific task, these results are presented for each ADL and IADL. The final measures of long-term care refer to the intensity of care and the absence of needed care. The number of person days that help was received with ADLs and lADLs and the number of informal caregivers were used as measures of intensity of care. The person days measure is the sum of the number of days per week that each caregiver provided assistance. While person days per week is presented separately for formal and informal care, number of caregivers is reported for informal caregivers only. Absence of care is simply the reporting of an unmet need for assistance. This was examined by severity of disability, which was measured using Kempen and Suurmeijer's (1990) hierarchical order of ADLs and IADLS, and by residence. /Areas of Residence An assumption that underlies the area of residence categories presented below is that community size and population density are important distinguishing characteristics of areas of residence with regard to issues of health care. As mentioned, areas with dispersed populations are believed to have fewer health care resources available and the residents of these 228
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cert with individual health and economic statuses, may influence utilization preferences and expectations in later life. Present individual and contextual factors, on the other hand, may represent current opportunities and constraints on caregiving. The effect of any one of these factors on caregiving may vary depending on the task at hand, which suggests that it is important to examine residence differences in formal and informal care by type of task. In short, the types of services needed to support the frail, disabled elderly and their caregivers may vary across communities (e.g., Scott & Roberto, 1988), but what types of assistance are needed in which types of communities remains unclear. The following study addresses three issues with regard to the relationship between caregiving and area of residence. Do associations between area of residence and formal and informal care vary by type of caregiving task? With level of disability and sociodemographic characteristics controlled, are urban/rural differences in the receipt of formal and informal care evident and do these differences vary by caregiving task? And are the observed differences important to those in need of assistance? Specifically, does the intensity of care and the proportion of elders with an unmet need for care vary by urban/rural residence?
Results
Table 1 presents the 1982 disabled population of the United States (based on estimates from the NLTCS), sample sizes, and sociodemographic characteristics for each of the areas of residence. Note that approximately 83% of the disabled population resides in urban areas (i.e., cities, suburbs, and towns) and that large variation across the areas of residence is evident. Also note that overall the disabled residents of rural areas are younger, more likely to be white, married, have less income and education, and are more likely to be male. If one contrasts non-MSA and MSA counties in a similar manner, the same differences are evident, although the magnitudes of the differences are not as great. The percentage of those who are disabled on an
Analytic Procedure The amount of formal and informal assistance being received in each ADL and IADL is presented for
Table 1 . Estimated Disabled U.S. Population (in Thousands of Persons), Sample Sizes, and Sociodemographic Characteristics, by Area of Residence, 1982, for Study of Residence Differences in Long-term Care
Metropolitan
Disabled population Mean age Percentage white Percentage male Mean education Mean household income Percentage married Sample size
Nonmetropolitan
City
Suburb
Open
Total
Town
Nonfarm
Farm
Total
Total
804 77.6 79 32 9.0 11,565 36 782
2,406 77.8 86 35 9.1 12,758 43 2,331
344 77.2 92 41 S.4 10,456 48 331
3,554 77.7 85 35 9.0 12,131 42 3,444
928 77.8 91 34 8.8 10,052 43 1,121
329 75.9 86 45 8.1 9,862 55 382
189 77.5 91 50 8.3 10,012 59 218
1,501 77.4 90 38 8.6 10,004 48 1,721
5,055 77.6 86 36 8.9 11,495 44 5,165
Note. Sample sizes reported refer to those associated with age. Eighteen percent and five percent of the cases were missing for income and education, respectively. These cases were excluded from the income and education means reported in this table and from the multivariate analyses reported in the following tables. Analyses of nonresponse did not indicate the existence of a pattern across age,
race, or gender categories.
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each area of residence as the percentage of those persons disabled on that specific ADL or IADL who are receiving active or stand-by assistance. Then, using multiple logistic regression, the likelihood of receiving formal and informal assistance net of health and sociodemographic influences was computed for ADLs and lADLs by rural/urban residence. Ordinary least squares regression equations were used to assess rural/urban differences in person days of assistance and number of caregivers. Finally, multiple logistic regression was used to assess urban/ rural variations in the proportion of respondents with an unmet need for care. For each of the above procedures, rural was coded 1 and consisted of open areas of MSA counties and farm and nonfarm areas of non-MSA counties. City, suburban, and town areas were urban and coded 0. As has been done in a study of residence differences in health (Cutler & Coward, 1988), this study held age, race, gender, and education constant while comparing caregiving arrangements across areas of residence. In addition, because marital status and income vary with both place of residence (Clifford et al., 1985) and caregiving (Dwyer & Miller, 1990b), as does level of disability (Coward, Cutler, & Mullens, 1990), these factors also were held constant in the regression equations.
rural areas experience substantial difficulties in accessing social and health services (Clarke & Miller, 1990). Following the work of Fuguitt, Brown, and Beale (1989), this study distinguishes between areas in terms of both a metropolitan/nonmetropolitan county dimension and an urban/rural area dimension. This distinction is important because large variations are found within non-MSA and MSA counties (see, e.g., Coward, Cutler, & Schmidt, 1989). The categories within MSA counties are: 1) cities greater than 250,000 in size; 2) suburbs, including areas within 30 miles of a large city or any incorporated area within a metropolitan county; and 3) unincorporated open country or farm areas more than 30 miles from a large city (this category is labeled "open" in the tables that follow). The categories within non-MSA counties are: 1) towns or cities of fewer than 50,000 inhabitants; 2) unincorporated open country nonfarm areas (open country areas identified by the interviewer as primarily nonagricultural); and 3) unincorporated farm areas (open country areas that were identified as primarily agricultural). The distinction between the latter two categories (i.e., farm and nonfarm) is important because of the large differences in the health and demographic characteristics of the older populations of these areas (Coward & Cutler, 1988). The distinction made in the NLTCS is based on the interviewer's coding of an open country area as either mainly agricultural or not. This distinction is not, therefore, based on the occupation of the respondent. No means for assessing the reliability of the interviewer's assessment of an open country area was available. The rural categories presented above vary slightly from the U.S. Bureau of the Census definition of rural in that only unincorporated areas have been defined as rural. In addition to unincorporated areas outside of MSAs, the Bureau of the Census defines incorporated areas of fewer than 2,500 persons as rural.
Table 2. Percentages of Those with Specific Disability Receiving Informal Assistance with ADL or lADL Tasks, by Area of Residence, in Study of Residence Differences in Long-term Care Metropolitan
ADL Eating Using toilet In/out of bed Walk inside Dressing Bathing lADL Grocery shop Prepare meal Housework Walk outside Traveling Manage money
City
Suburb
31.8 27.6 38.4 20.3 59.0 44.3 90.8 88.7 86.2 44.5 93.5 98.6
Nonmetropolitan
Open
Total
Town
Nonfarm
37.3 28.3 33.9 21.6 64.3 43.6
23.9 24.9 33.4 20.6 58.8 39.3
35.1 27.7 35.1 21.2 62.2 43.3
30.0 24.5 28.8 21.5 68.6 38.7
92.9 87.3 87.0 36.7 94.6 97.7
97.3 94.6 95.9 34.7 96.8 100.0
92.5 88.2 87.4 38.4 94.5 98.1
93.9 90.7 88.7 32.1 95.0 97.3
Farm
Total
35.5 21.8 26.2 22.3 63.5 36.9
48.6 28.1 32.8 17.0 60.0 39.7
32.7 24.2 28.9 20.5 65.3 38.3
94.1 89.1 91.6 31.5 95.0 94.3
96.6 95.6 96.7 20.8 98.8 100.0
94.9 90.7 90.4 30.3 95.5 97.0
Table 3. Percentages of Those with Specific Disability Receiving Formal Assistance with ADL or lADL Tasks, by Area of Residence, in Study of Residence Differences in Long-term Care
Nonmetropolitan
Metropolitan
ADL Formal ADL assistance lADL Grocery shop Prepare meal Housework Walk outside Traveling Manage money
City
Suburb
Open
Total
Town
8.5
10.1
5.2
9.4
8.6
21.7 23.5 22.9 19.7 16.3 17.8
15.2 20.3 21.9 15.8 14.4 15.2
7.1 5.7 8.4 9.3 6.7 8.7
16.3 19.8 21.1 16.4 14.3 12.5
19.8 25.9 24.5 16.6 17.8 15.6
230
Farm
Total
8.7
4.8
7.9
11.9 19.1 19.5 11.3 10.1 11.2
11.1 20.4 19.7 10.3 11.6 8.4
16.6 22.9 22.0 14.1 15.0 14.5
Non Farm
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There does appear to be a rural/urban pattern evident in informal lADL assistance, however. Residents of the three rural areas were more likely than the urban residents to receive informal assistance with grocery shopping, meal preparation, housework, and traveling. Note that more variation is evident within MSA and non-MSA areas and between rural and urban areas than is evident between MSA and non-MSA counties. The same is true with regard to formal care. Table 3 shows that a relatively low percentage of disabled persons received formal assistance with their disabilities. The specific ADL task in which formal assistance was received was not available, but it is clear that a much lower percentage of residents of open and farm areas received formal ADL assistance than did residents of the other areas. This finding is supported by Dwyer and Miller (1990a), who showed that the number of formal ADL helpers was lower for rural residents than for small city and urban residents. Table 3 also shows that for each of the lADLs considered a lower percentage of disabled persons of rural areas received formal assistance than did disabled persons of urban areas. The residence differences in caregiving reported to this point have not taken into account the sociodemographic characteristics of the respondents or level of disability (shown in Table 4). Tables 5 and 6 present the likelihood of formal and informal assis-
ADL or lADL and receiving informal assistance is presented in Table 2. Assistance may be either active or stand-by. Stand-by assistance indicates that another person is present as the ADL or lADL is performed by the respondent. It is important to note that the reporting of a disability is not conditional upon having assistance. For example, one may use special equipment or have an unmet need. The importance of examining each task individually is evident from the different percentages receiving assistance by task. The proportion receiving assistance with dressing and the IADLS, with the exception of walking outside, for example, is over two-thirds, whereas the proportion receiving ADL assistance (excluding dressing) and assistance with walking outside is generally less than one-third. The fact that no particular area of residence has the highest or lowest percentage receiving care for every task shown demonstrates the importance of examining area of residence variation by specific task as well. For example, residents of farm areas who need eating assistance were more likely to get informal eating assistance than residents of the other areas but were the least likely to receive informal assistance with walking inside. Similarly, city residents were the most likely to receive informal assistance with bathing and getting in or out of bed but were the least likely to receive assistance with grocery shopping, housework, or traveling out of walking distance.
Table 4. Estimated Disabled U.S. Urban and Rural Population and Means and Percentages for Sociodemographic Characteristics, 1982, in Study of Residence Differences in Long-term Care
Disabled population (thousands) Mean number of ADLs Mean number of lADLs Mean age Percentage white Percentage male Mean education Mean household income Percentage married Sample size
Urban
Rural
4,138 2.27 2.76 77.8 86.0 34.2 9.0 11,647 41.7 4,234
862 2.36 2.89 76.7 90.1 45.3 8.3 10,110 56.4 931
Note. Sample sizes reported refer to those associated with age. Eighteen percent and five percent of the cases were missing Tor income and education, respectively. These cases were excluded from the income and education means reported in this table and from the multivariate analyses reported in the following tables. Analyses of nonresponse did not indicate the existence of a pattern across age, race, or gender categories.
SE
Chi square
Model chi square
.821 1.16 1.06 1.21 .935 .835
.18 .15 .14 .13 .15 .11
1.2 1.0 0.2 2.2 0.2 2.6
420.8 1,142.9 1,428.7 951.4 2,648.0 1,915.6
1.35** 1.65*** 1.34** .825 1.32* .942
.10 .10 .09 .10 .13 .11
8.3 25.3 9.8 3.7 4.3 0.3
2,373.6 2,492.8 740.2 971.4 3,943.1 2,960.6
Odds ADL Eating Using toilet In/out of bed Walking inside Dressing Bathing IADL Grocery shop Prepare meal Housework Walk outside Traveling Managing money
Note. The multiple logistic regression coefficients for the intercept, epi, demographic uemugrapiiiL characteristics, »_iidicn.it:iibiu-b, cand disability are suppressed.
*p < .05; **p < .01; ***p < .001.
Table 6. Odds of a Rural Resident Receiving Formal Assistance Relative to an Urban Resident Net of the Effects of Sociodemographic Characteristics and Level of Disability in Study of Residence Differences in Long-term Care
Odds ADL ADL assistance IADL Grocery shop Prepare meal Housework Walk outside Traveling Managing money
SE
Chi square
Table 7. Ordinary Least Squares Regression Models for Sociodemographic Characteristics, Disability, and Area of Residence (Urban = 0, Rural = 1), Regressed on Amount of Assistance, in Study of Residence Differences in Long-term Care
Model chi square
.704*
.17
4.3
450.1
.717** .628** .637*** .706** .713** .704**
.13 .13 .12 .13 .12 .13
7.0 13.5 14.1 7.2 7.4 7.1
269.3 260.6 318.9 247.1 224.4 211.3
Dependent variable Person days of formal assistance Person days of informal assistance Number of informal caregivers
Model R2
.07
.07
.68***
.17
.29
.09*
.04
.14
-.19*
Note. The coefficients for the intercept, sociodemographic characteristics, and number of disabilities are suppressed. The coefficients indicate the average difference in days of care per week and number of informal caregivers for rural residents relative to urban residents.
Note. The multiple logistic regression coefficients for the intercept, characteristics, cand disability are suppressed. Cpi, demographic UeillUgldpillL t-MdldLltMIMICb,
*p < .05; **p < .01; ***p < .001.
*p
This study, using a large, nationally representative sample of noninstitutionalized disabled older persons, found that urban residents were much more likely than rural residents to receive formal assistance in every ADL and IADL considered. Rural residents were more likely to receive informal assistance and to receive two-thirds more person days of informal assistance per week. No residence differences in unmet need for care were identified. Key Words: Rural elderly, Urban elderly, Disability
Residence Differences in Formal and Informal Long-Term Care Daniel O. Clark, PhD1
1 Case Western Reserve University, Department of Sociology, Cleveland, OH 44106-7124.
Vol. 32, No. 2,1992
227
allow one to test this hypothesis are limited. Using 1976 data gathered through self-administered questionnaires from Area Agencies on Aging (AAAs), Nelson (1980) showed that AAAs identifying their service area as rural were less likely to have services for the severely disabled than were those identifying their service area as urban or as a mix of urban and rural. This evidence, coupled with the proposition that formal caregivers are best suited for tasks involving a specific interval of time and requiring specific technical skills (Litwak, 1985), suggests that rural/ urban differences in caregiving are likely to be greatest in specialized services for the severely disabled. Two studies have examined area of residence differences in caregiving by both type of task and source of care (i.e., formal/informal), but they provided little support for the above expectation. Blieszner and colleagues (1987) showed that in nursing care, a form of care that would seem to be most amenable to formal assistance and targeted for the severely disabled, 32.1% of rural respondents reported the use of formal assistance, while 22.5% of the small city and 40.5% of the urban respondents reported the use of formal assistance. The same study showed that a lower percentage of total assistance with home management services, meal preparation, personal care, and continuous supervision came from formal caregivers in rural than in small city and urban areas. Stoller and Earl (1983), in contrast, failed to find significant MSA and non-MSA county differences in the type (formal or informal) of care received. However, much variation in the sociodemographic characteristics and health of older populations exists within MSA and non-MSA counties and more detailed areal categorizations are generally necessary to capture areal differences (Coward & Cutler, 1988). Factors other than service availability are likely to be involved in urban/rural differences in caregiving. A life-span framework suggests that certain characteristics of physical and social contexts (e.g., housing conditions, service accessibility, informal support networks) experienced over the life course, in con-
Downloaded from http://gerontologist.oxfordjournals.org/ at Yale University on July 2, 2015
As the size and age of the older population continue to increase, the proportion of the population requiring physical assistance increases as well, leading to greater levels of social, psychological, and financial burden for both families and societies. Thus, both personal and contextual determinants of caregiving need study. Area of residence is an often-used proxy for social and physical context. This study examines residence differences in formal and informal care for specific activity of daily living (ADL) and instrumental activity of daily living (IADL) tasks using a nationally representative sample of noninstitutionalized, disabled older persons. It also considers whether the intensity of formal or informal care and the proportion of elders with an unmet need for care vary by rural versus urban residence. In contrast to prior studies, this research controls for the influences of sociodemographic characteristics and disability levels, both of which covary with caregiving and residence. Several recent studies have examined the formal and informal structure of caregiving networks across areas of residence. Using a 1984 national sample of older persons, Coward, Cutler, and Mullens (1990) found that 73% of severely disabled nonmetropolitan (non-MSA) county residents and 55% of severely disabled metropolitan (MSA) county residents living in central cities reported receiving informal assistance only. This study also showed that central city respondents were nearly twice as likely as non-MSA respondents to report receiving formal and informal assistance simultaneously, 35.4% and 18.4%, respectively. Similarly, a 1979 sample of older Virginians has provided evidence that older urban as compared with older rural persons are twice as likely to report the use of formal assistance only or a mix of iniformal and formal assistance (Blieszner et al., 1987). Availability of formal services may explain some of these differences; however, high-quality data that
Method
Data The data used in this study are drawn from the longitudinal National Long-Term Care Survey (NLTCS). The NLTCS, conducted by the U.S. Bureau of the Census and cosponsored by the Health Care Financing Administration and the Office of the Assistant Secretary for Planning Evaluation, was a longitudinal study with a 1982 baseline survey and followups in 1984 and 1989. This analysis utilizes the 1982 cross-sectional data (the 1989 data were not available at the time of this study). The initial screening consisted of 36,000 Medicare recipients who were 65 years of age or over. These persons were contacted by telephone and screened for indications of functional disability that had lasted, or was expected to last, 3 months or longer. Once identified as disabled, the individual was included in the sample. The sample was stratified by census geographic region, age, race, and reason for Medicare entitlement (Macken, 1986). The result is a sample of 6,393 persons, of whom 6,088 participated, yielding a response rate of 95%. Of these persons, 23 were missing information on area of residence and another 903 were not disabled on the ADL or IADL items included in this study. Household interviews were conducted with the sample person or a proxy respondent, the latter making up 26% of the sample. Extensive analyses have been conducted on the data and measures of the 1982 NLTCS (e.g., Manton, 1988; Macken, 1986) and will not be repeated here. All have shown the data to be reliable and represent-
ative of the older disabled population of the United States. Sociodemographic Characteristics The sociodemographic measures were age, race, gender, education, income, and marital status. Age was coded in years, race as 1 = white and 0 = other, gender as 1 = male and 0 = female, and education in years of completed schooling. Income was recoded to the midpoint of the household's income category and reported in approximate 1982 dollars. Marital status was 1 = married and 0 = other. Disability Disability is defined as the reporting of a met or unmet need for assistance to perform an ADL or, in the case of lADLs, a met or unmet need that is due to a health or disability problem. The use of special equipment to perform a particular ADL or IADL also was considered an indication of disability. Level of disability was measured as the total number of ADLs and the total number of lADLs for which assistance or special equipment were needed. In-home Care Several measures of formal and informal in-home care were employed in this analysis. Formal care is that received for pay or from persons representing professional social or health care organizations. Informal assistance is that received without pay and from a provider who does not represent a professional social or health care organization. The variables employed here measured whether the respondent reported that formal or informal help was received over the week prior to the interview. With the exception of formal ADL assistance, which is not available by specific task, these results are presented for each ADL and IADL. The final measures of long-term care refer to the intensity of care and the absence of needed care. The number of person days that help was received with ADLs and lADLs and the number of informal caregivers were used as measures of intensity of care. The person days measure is the sum of the number of days per week that each caregiver provided assistance. While person days per week is presented separately for formal and informal care, number of caregivers is reported for informal caregivers only. Absence of care is simply the reporting of an unmet need for assistance. This was examined by severity of disability, which was measured using Kempen and Suurmeijer's (1990) hierarchical order of ADLs and IADLS, and by residence. /Areas of Residence An assumption that underlies the area of residence categories presented below is that community size and population density are important distinguishing characteristics of areas of residence with regard to issues of health care. As mentioned, areas with dispersed populations are believed to have fewer health care resources available and the residents of these 228
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cert with individual health and economic statuses, may influence utilization preferences and expectations in later life. Present individual and contextual factors, on the other hand, may represent current opportunities and constraints on caregiving. The effect of any one of these factors on caregiving may vary depending on the task at hand, which suggests that it is important to examine residence differences in formal and informal care by type of task. In short, the types of services needed to support the frail, disabled elderly and their caregivers may vary across communities (e.g., Scott & Roberto, 1988), but what types of assistance are needed in which types of communities remains unclear. The following study addresses three issues with regard to the relationship between caregiving and area of residence. Do associations between area of residence and formal and informal care vary by type of caregiving task? With level of disability and sociodemographic characteristics controlled, are urban/rural differences in the receipt of formal and informal care evident and do these differences vary by caregiving task? And are the observed differences important to those in need of assistance? Specifically, does the intensity of care and the proportion of elders with an unmet need for care vary by urban/rural residence?
Results
Table 1 presents the 1982 disabled population of the United States (based on estimates from the NLTCS), sample sizes, and sociodemographic characteristics for each of the areas of residence. Note that approximately 83% of the disabled population resides in urban areas (i.e., cities, suburbs, and towns) and that large variation across the areas of residence is evident. Also note that overall the disabled residents of rural areas are younger, more likely to be white, married, have less income and education, and are more likely to be male. If one contrasts non-MSA and MSA counties in a similar manner, the same differences are evident, although the magnitudes of the differences are not as great. The percentage of those who are disabled on an
Analytic Procedure The amount of formal and informal assistance being received in each ADL and IADL is presented for
Table 1 . Estimated Disabled U.S. Population (in Thousands of Persons), Sample Sizes, and Sociodemographic Characteristics, by Area of Residence, 1982, for Study of Residence Differences in Long-term Care
Metropolitan
Disabled population Mean age Percentage white Percentage male Mean education Mean household income Percentage married Sample size
Nonmetropolitan
City
Suburb
Open
Total
Town
Nonfarm
Farm
Total
Total
804 77.6 79 32 9.0 11,565 36 782
2,406 77.8 86 35 9.1 12,758 43 2,331
344 77.2 92 41 S.4 10,456 48 331
3,554 77.7 85 35 9.0 12,131 42 3,444
928 77.8 91 34 8.8 10,052 43 1,121
329 75.9 86 45 8.1 9,862 55 382
189 77.5 91 50 8.3 10,012 59 218
1,501 77.4 90 38 8.6 10,004 48 1,721
5,055 77.6 86 36 8.9 11,495 44 5,165
Note. Sample sizes reported refer to those associated with age. Eighteen percent and five percent of the cases were missing for income and education, respectively. These cases were excluded from the income and education means reported in this table and from the multivariate analyses reported in the following tables. Analyses of nonresponse did not indicate the existence of a pattern across age,
race, or gender categories.
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each area of residence as the percentage of those persons disabled on that specific ADL or IADL who are receiving active or stand-by assistance. Then, using multiple logistic regression, the likelihood of receiving formal and informal assistance net of health and sociodemographic influences was computed for ADLs and lADLs by rural/urban residence. Ordinary least squares regression equations were used to assess rural/urban differences in person days of assistance and number of caregivers. Finally, multiple logistic regression was used to assess urban/ rural variations in the proportion of respondents with an unmet need for care. For each of the above procedures, rural was coded 1 and consisted of open areas of MSA counties and farm and nonfarm areas of non-MSA counties. City, suburban, and town areas were urban and coded 0. As has been done in a study of residence differences in health (Cutler & Coward, 1988), this study held age, race, gender, and education constant while comparing caregiving arrangements across areas of residence. In addition, because marital status and income vary with both place of residence (Clifford et al., 1985) and caregiving (Dwyer & Miller, 1990b), as does level of disability (Coward, Cutler, & Mullens, 1990), these factors also were held constant in the regression equations.
rural areas experience substantial difficulties in accessing social and health services (Clarke & Miller, 1990). Following the work of Fuguitt, Brown, and Beale (1989), this study distinguishes between areas in terms of both a metropolitan/nonmetropolitan county dimension and an urban/rural area dimension. This distinction is important because large variations are found within non-MSA and MSA counties (see, e.g., Coward, Cutler, & Schmidt, 1989). The categories within MSA counties are: 1) cities greater than 250,000 in size; 2) suburbs, including areas within 30 miles of a large city or any incorporated area within a metropolitan county; and 3) unincorporated open country or farm areas more than 30 miles from a large city (this category is labeled "open" in the tables that follow). The categories within non-MSA counties are: 1) towns or cities of fewer than 50,000 inhabitants; 2) unincorporated open country nonfarm areas (open country areas identified by the interviewer as primarily nonagricultural); and 3) unincorporated farm areas (open country areas that were identified as primarily agricultural). The distinction between the latter two categories (i.e., farm and nonfarm) is important because of the large differences in the health and demographic characteristics of the older populations of these areas (Coward & Cutler, 1988). The distinction made in the NLTCS is based on the interviewer's coding of an open country area as either mainly agricultural or not. This distinction is not, therefore, based on the occupation of the respondent. No means for assessing the reliability of the interviewer's assessment of an open country area was available. The rural categories presented above vary slightly from the U.S. Bureau of the Census definition of rural in that only unincorporated areas have been defined as rural. In addition to unincorporated areas outside of MSAs, the Bureau of the Census defines incorporated areas of fewer than 2,500 persons as rural.
Table 2. Percentages of Those with Specific Disability Receiving Informal Assistance with ADL or lADL Tasks, by Area of Residence, in Study of Residence Differences in Long-term Care Metropolitan
ADL Eating Using toilet In/out of bed Walk inside Dressing Bathing lADL Grocery shop Prepare meal Housework Walk outside Traveling Manage money
City
Suburb
31.8 27.6 38.4 20.3 59.0 44.3 90.8 88.7 86.2 44.5 93.5 98.6
Nonmetropolitan
Open
Total
Town
Nonfarm
37.3 28.3 33.9 21.6 64.3 43.6
23.9 24.9 33.4 20.6 58.8 39.3
35.1 27.7 35.1 21.2 62.2 43.3
30.0 24.5 28.8 21.5 68.6 38.7
92.9 87.3 87.0 36.7 94.6 97.7
97.3 94.6 95.9 34.7 96.8 100.0
92.5 88.2 87.4 38.4 94.5 98.1
93.9 90.7 88.7 32.1 95.0 97.3
Farm
Total
35.5 21.8 26.2 22.3 63.5 36.9
48.6 28.1 32.8 17.0 60.0 39.7
32.7 24.2 28.9 20.5 65.3 38.3
94.1 89.1 91.6 31.5 95.0 94.3
96.6 95.6 96.7 20.8 98.8 100.0
94.9 90.7 90.4 30.3 95.5 97.0
Table 3. Percentages of Those with Specific Disability Receiving Formal Assistance with ADL or lADL Tasks, by Area of Residence, in Study of Residence Differences in Long-term Care
Nonmetropolitan
Metropolitan
ADL Formal ADL assistance lADL Grocery shop Prepare meal Housework Walk outside Traveling Manage money
City
Suburb
Open
Total
Town
8.5
10.1
5.2
9.4
8.6
21.7 23.5 22.9 19.7 16.3 17.8
15.2 20.3 21.9 15.8 14.4 15.2
7.1 5.7 8.4 9.3 6.7 8.7
16.3 19.8 21.1 16.4 14.3 12.5
19.8 25.9 24.5 16.6 17.8 15.6
230
Farm
Total
8.7
4.8
7.9
11.9 19.1 19.5 11.3 10.1 11.2
11.1 20.4 19.7 10.3 11.6 8.4
16.6 22.9 22.0 14.1 15.0 14.5
Non Farm
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There does appear to be a rural/urban pattern evident in informal lADL assistance, however. Residents of the three rural areas were more likely than the urban residents to receive informal assistance with grocery shopping, meal preparation, housework, and traveling. Note that more variation is evident within MSA and non-MSA areas and between rural and urban areas than is evident between MSA and non-MSA counties. The same is true with regard to formal care. Table 3 shows that a relatively low percentage of disabled persons received formal assistance with their disabilities. The specific ADL task in which formal assistance was received was not available, but it is clear that a much lower percentage of residents of open and farm areas received formal ADL assistance than did residents of the other areas. This finding is supported by Dwyer and Miller (1990a), who showed that the number of formal ADL helpers was lower for rural residents than for small city and urban residents. Table 3 also shows that for each of the lADLs considered a lower percentage of disabled persons of rural areas received formal assistance than did disabled persons of urban areas. The residence differences in caregiving reported to this point have not taken into account the sociodemographic characteristics of the respondents or level of disability (shown in Table 4). Tables 5 and 6 present the likelihood of formal and informal assis-
ADL or lADL and receiving informal assistance is presented in Table 2. Assistance may be either active or stand-by. Stand-by assistance indicates that another person is present as the ADL or lADL is performed by the respondent. It is important to note that the reporting of a disability is not conditional upon having assistance. For example, one may use special equipment or have an unmet need. The importance of examining each task individually is evident from the different percentages receiving assistance by task. The proportion receiving assistance with dressing and the IADLS, with the exception of walking outside, for example, is over two-thirds, whereas the proportion receiving ADL assistance (excluding dressing) and assistance with walking outside is generally less than one-third. The fact that no particular area of residence has the highest or lowest percentage receiving care for every task shown demonstrates the importance of examining area of residence variation by specific task as well. For example, residents of farm areas who need eating assistance were more likely to get informal eating assistance than residents of the other areas but were the least likely to receive informal assistance with walking inside. Similarly, city residents were the most likely to receive informal assistance with bathing and getting in or out of bed but were the least likely to receive assistance with grocery shopping, housework, or traveling out of walking distance.
Table 4. Estimated Disabled U.S. Urban and Rural Population and Means and Percentages for Sociodemographic Characteristics, 1982, in Study of Residence Differences in Long-term Care
Disabled population (thousands) Mean number of ADLs Mean number of lADLs Mean age Percentage white Percentage male Mean education Mean household income Percentage married Sample size
Urban
Rural
4,138 2.27 2.76 77.8 86.0 34.2 9.0 11,647 41.7 4,234
862 2.36 2.89 76.7 90.1 45.3 8.3 10,110 56.4 931
Note. Sample sizes reported refer to those associated with age. Eighteen percent and five percent of the cases were missing Tor income and education, respectively. These cases were excluded from the income and education means reported in this table and from the multivariate analyses reported in the following tables. Analyses of nonresponse did not indicate the existence of a pattern across age, race, or gender categories.
SE
Chi square
Model chi square
.821 1.16 1.06 1.21 .935 .835
.18 .15 .14 .13 .15 .11
1.2 1.0 0.2 2.2 0.2 2.6
420.8 1,142.9 1,428.7 951.4 2,648.0 1,915.6
1.35** 1.65*** 1.34** .825 1.32* .942
.10 .10 .09 .10 .13 .11
8.3 25.3 9.8 3.7 4.3 0.3
2,373.6 2,492.8 740.2 971.4 3,943.1 2,960.6
Odds ADL Eating Using toilet In/out of bed Walking inside Dressing Bathing IADL Grocery shop Prepare meal Housework Walk outside Traveling Managing money
Note. The multiple logistic regression coefficients for the intercept, epi, demographic uemugrapiiiL characteristics, »_iidicn.it:iibiu-b, cand disability are suppressed.
*p < .05; **p < .01; ***p < .001.
Table 6. Odds of a Rural Resident Receiving Formal Assistance Relative to an Urban Resident Net of the Effects of Sociodemographic Characteristics and Level of Disability in Study of Residence Differences in Long-term Care
Odds ADL ADL assistance IADL Grocery shop Prepare meal Housework Walk outside Traveling Managing money
SE
Chi square
Table 7. Ordinary Least Squares Regression Models for Sociodemographic Characteristics, Disability, and Area of Residence (Urban = 0, Rural = 1), Regressed on Amount of Assistance, in Study of Residence Differences in Long-term Care
Model chi square
.704*
.17
4.3
450.1
.717** .628** .637*** .706** .713** .704**
.13 .13 .12 .13 .12 .13
7.0 13.5 14.1 7.2 7.4 7.1
269.3 260.6 318.9 247.1 224.4 211.3
Dependent variable Person days of formal assistance Person days of informal assistance Number of informal caregivers
Model R2
.07
.07
.68***
.17
.29
.09*
.04
.14
-.19*
Note. The coefficients for the intercept, sociodemographic characteristics, and number of disabilities are suppressed. The coefficients indicate the average difference in days of care per week and number of informal caregivers for rural residents relative to urban residents.
Note. The multiple logistic regression coefficients for the intercept, characteristics, cand disability are suppressed. Cpi, demographic UeillUgldpillL t-MdldLltMIMICb,
*p < .05; **p < .01; ***p < .001.
*p
