ABSTRACT
Purpose
Increasing population longevity has led to greater demand for home and community‐based services (HCBS) to assist older adults as an alternative to institutional care. Despite the recognized benefits of HCBS, there are significant differences in their availability and utilization between rural and urban communities. This study aimed to (1) compare rural and urban caregivers of older veterans in terms of searching for and receiving services and (2) examine differences in expressed interest in various service types.
Methods
Five hundred and eleven older veterans’ caregivers completed an online survey on various HCBS. Rural‐Urban Commuting Area codes (RUCA) were utilized to determine rurality, and data were analyzed using chi‐squares, t‐tests, and logistic regressions.
Findings
There were no differences in service interest between urban and rural caregivers. However, there were differences between the services searched for and those received. Urban caregivers were less likely than rural caregivers to seek respite. Urban caregivers also reported receiving more services than rural caregivers.
Conclusion
This study indicates that rural and urban caregivers’ interest in services is similar; however, rural veterans receive fewer HCBS than their urban counterparts. This study highlights potential gaps in the service pathway for rural caregivers. It provides insights into which specific services might benefit from targeted interventions to improve access and utilization for veterans in rural areas. The findings directly inform evidence‐based resource allocation, targeted program development, and policy interventions designed to mitigate rural−urban disparities in caregiver support.
Keywords: family caregivers, home and community‐based services (HCBS), informal caregiving, veterans
1. Introduction
Rural areas face unique challenges in healthcare delivery, including provider shortages, greater distances to services, limited transportation options, and fewer specialized services [1]. The number of Americans aged 65 and older is projected to increase from 58 to 82 million by 2050, with rural areas expected to experience a disproportionately high growth in their older adult populations [2]. This demographic shift presents substantial challenges for healthcare systems, particularly in meeting the complex medical needs of older adults with functional and cognitive limitations [2−5].
Not only do older adults living in rural areas typically have less formal education and fewer financial resources than their urban counterparts, but they also often rely more heavily on informal caregivers and support networks (e.g., family, friends) that may themselves face resource constraints [6]. However, of the estimated 48 million informal caregivers of adults in the United States, only a fraction utilized available support services [7]. Underutilization is often due to a lack of knowledge about available services, cultural preferences in caregiving, stigma about using or asking for services, dearth of services (i.e., none in the surrounding areas or not enough staff to meet demand), financial constraints, transportation barriers, and competing responsibilities (e.g., taking care of children or another adult, work, school) [8].
Despite policy advancements in home and community‐based services (HCBS), significant knowledge gaps remain in our understanding of rural−urban differences in caregiver service utilization. Previous research has primarily documented general rural−urban disparities in healthcare access or examined broader categories of caregiver burden [9]. However, we lack a comprehensive understanding of the specific aspects by which rural−urban disparities affect caregiver service utilization. Prior studies have rarely distinguished between caregivers’ awareness of available services, their interest in accessing them, their efforts to seek them out, and their actual use of them. These components of service utilization represent key stages along a continuum from recognition of need to active participation and utilization of support services [10]. These three critical dimensions of service engagement may be differentially affected by rural−urban contexts [11]. This distinction is crucial because different factors may influence these three dimensions: searching for services may be affected by awareness and perceived need; receiving services may be constrained by availability, accessibility, and eligibility; while interest in services may reflect underlying preferences, cultural factors, or assumptions about availability. Understanding these distinctions could help to identify specific intervention opportunities to enhance service delivery to caregivers in rural areas.
Additionally, methodological limitations in prior research have constrained the understanding of rural−urban differences in caregiver experiences. Most studies have relied on secondary data analysis (e.g., the primary focus of the study was not on caregivers), local samples, or subjective self‐classifications of rurality rather than objective measures [12]. Few studies have achieved an intended balanced representation of rural and urban caregivers, introducing potential sample bias and limiting the statistical power to detect meaningful differences.
The present study addresses critical methodological limitations in prior research by employing balanced rural−urban sampling, objective rurality classification using Rural‐Urban Commuting Area (RUCA) codes, and a novel examination of service utilization factors.
This study aims to (1) compare rural and urban caregivers in terms of services they search for and eventually receive, identifying potential gaps in the service pathway, and (2) examine differences in expressed interest in various service types, which may indicate unmet needs or preferences among rural and urban caregivers. By examining these patterns across multiple service categories, this study provides insights into which specific services might benefit from targeted interventions to improve access and utilization in rural areas. The findings directly inform evidence‐based resource allocation, targeted program development, and policy interventions designed to mitigate rural−urban disparities in caregiver support.
2. Methods
2.1. Study Population and Data Collection
A survey examining the experience and impact of coordinating care for older veterans with complex care needs was administered using the Qualtrics federal platform between August and November 2022. A national sample of informal caregivers of U.S. military veterans 65 years or older was identified via a Qualtrics panel, which is a large pool of respondents who agree in advance to participate in survey studies. These panels are often used by online platforms to ensure demographic diversity in recruitment while keeping costs low. Study staff coordinated with a project coordinator from Qualtrics, who used their panel aggregator system, an internal Qualtrics system where over 20 web‐based panel providers have been identified, screened, and utilized by Qualtrics recruiters to supply diverse, quality respondents depending on survey inclusion/exclusion criteria. Research has supported the Qualtrics panel recruitment methodology as an effective strategy. Unlike non‐panel‐recruited, anonymous online samples, studies have shown that Qualtrics panels can yield higher quality samples through internal quality control and prescreened respondents [13]. This data collection method has become increasingly popular, with evidence showing that data quality from the Qualtrics panel is on par with data from conventional data collection methods [14].
Potential panel participants were provided with a link to a study description and an eligibility survey on the Qualtrics platform. Informed consent was obtained prior to accessing the eligibility survey. Initial eligibility was based on whether the potential caregiver participant (1) assisted an older (65 years old or more) U.S. military veteran who lived independently in the community, (2) had provided assistance for more than a month, (3) brought the veteran to at least one in‐person medical appointment in the previous 12 months, and (4) was not a professional caregiver (e.g., visiting nurse). A 50/50 split between rural and urban respondents was implemented using U.S. Department of Veterans Affairs’ RUCA codes to ensure adequate comparisons for veterans living in rural versus urban areas. RUCA codes were determined by the veterans’ zip codes. RUCA codes classify U.S. census tracts using population density and work commuting patterns. RUCA codes in the metropolitan and micropolitan groups were classified as urban (RUCA codes 1−3), and those classified as small town and rural were classified as rural (RUCA codes 4−10). An 80/20 racial split of self‐designated White/other than White was implemented to provide a sample reflective of the general U.S. population.
Out of the 6876 people who initiated the survey, 5104 (74.23%) were found to be ineligible. Of the 1772 eligible individuals, 236 (13.32%) chose not to participate. The remaining 1536 individuals consented and completed the survey. After Qualtrics conducted its automatic validity checks (e.g., bot checks, birth year), 437 (28.45%) surveys were excluded. The remaining 1099 were manually validated by a study team member. This survey included several validity checks (i.e., repeating questions or pairing questions whose answers depended on each other) to assess data validity. Respondents’ reporting service era that did not match their reported age (e.g., born in 1960, but the service era was Korean War), their length of service not matching their service era (e.g., only reported Korean War [1950−1955] for service, but also reported they had served 20 years), and their period of service indicating that they were younger than 65 (e.g., only chose period of service as 2001 or later) were the three top validity checks. An additional 588 (53.50%) were eliminated using these validity checks, resulting in a final sample of 511 participants. This final sample met the locale and racial parameters described earlier.
The survey took approximately 30 min to complete, and participants were monetarily compensated through Qualtrics’ panel incentive system for their participation. Participants remained anonymous to the study staff. This cross‐sectional data collection was completed in accordance with a protocol approved by the Veterans Affairs Bedford Healthcare System Insititutional Review Board.
2.2. Measures
2.2.1. Demographics
Participants reported on the age, gender, race (American Indian or Alaska Native, Asian, Black/African American, Native Hawaiian or other Pacific Islander, White/Caucasian), ethnicity (of Hispanic, Latino, or Spanish origin [yes/no]), education (some HS or less, HS degree/GED, some college, Associate’s/Vocational/Technical degree, Bachelor’s degree, some graduate school, Graduate degree), and income (under $20,000, $20,000−$39,999, $40,000−$59,999, $60,000−$79,999, $80,000−$99,999, $100,000−$119,000, $120,000−$139,999, $140,000, or more) for themselves and the veteran they cared for. Participants also reported their relationship with the veteran (family, friend, other), whether they cohabitate with the veteran (yes/no), and if not cohabitating, how far apart the caregiver and veteran live (in minutes/in hours) (Table 1).
TABLE 1.
Caregivers’ and veterans’ demographic information by area.
Rural (N = 258; 50.5%)
Urban (N = 253; 49.5%)
n (%)/M (SD)
n (%)/M (SD)
χ
2
/t
p
V/d
Age (years)
Veteran
75.0 (7.42)
74.8 (7.20)
0.35
0.7240
0.03
Caregiver
44.9 (13.76)
43.3 (13.70)
1.30
0.1949
0.12
Gender
Veteran (% male)
241 (93.8%)
237 (94.1%)
0.90
0.8974
0.01
Caregiver (% female)
175 (67.8%)
160 (63.2%)
1.33
0.2485
0.05
Race (White/Caucasian)
Veteran
233 (90.3%)
182 (71.9%)
28.26
<0.0001
0.24
Caregiver
234 (90.7%)
184 (72.7%)
27.71
<0.0001
0.23
Ethnicity (Hispanic/Latino)
Veteran
26 (10.4%)
9 (3.5%)
9.39
0.0022
0.14
Caregiver
14 (5.5%)
25 (9.9%)
3.55
0.0596
0.08
Education (% college degree)
Veteran
32 (12.6%)
65 (25.6%)
13.62
0.0002
0.17
Caregiver
48 (18.7%)
100 (39.5%)
26.90
<0.0001
0.23
Income (≥60,000)
Veteran
60 (23.4%)
88 (34.8%)
6.62
0.0101
0.13
Caregiver
(living separately)
61 (33.7%)
74 (41.8%)
2.50
0.1136
0.08
Relationship
Family
170 (67.2%)
173 (67.1%)
0.18
0.9123
0.02
Spouse
19 (11.2%)
20 (11.6%)
Wife
19 (100%)
19 (95.0%)
Husband
0
1 (5.0%)
Child
86 (50.6%)
83 (48.0%)
Daughter
64 (74.4%)
57 (68.7%)
Son
23 (26.7%)
26 (31.3%)
Other family
65 (38.2%)
70 (40.5%)
Friend
81 (32.0%)
82 (31.8%)
Other
2 (1.0%)
3 (1.2%)
Cohabitation (% No)
183 (70.9%)
179 (70.8%)
0.00
0.9644
0.00
Distance apart (minutes)a
17.7 (26.31)
26.3 (35.12)
2.60
0.0098
0.28
b
2.2.2. Veteran Medical Complexity
Discerning the veteran’s health was important to fully understand the caregiver’s experience. Information on the frequency of overnight hospital stays and emergency room visits in the past 12 months was reported. The number of healthcare clinicians and medications was also asked. Veterans’ level of independence was measured by the activities of daily living (ADLs) (e.g., dressing, bathing) [15] and the instrumental activities of daily living (iADLs) (e.g., navigating the healthcare system, attending medical visits) [16], validated measures (Table 2).
TABLE 2.
Veterans’ medical complexity by area.
Rural (N = 258)
Urban (N = 253)
n (%)
n (%)
χ2
p
V
Nights in hospitala
None
107 (41.5%)
83 (32.8%)
4.11
0.0427
0.09
≥1
151 (58.5%)
170 (67.2%)
Emergency room visitsa
None
94(36.4%)
92 (36.4%)
0.00
0.9868
0.00
≥1
164 (63.6%)
161 (63.6%)
Number of healthcare clinicians
1−2
98 (38.0%)
88 (34.8%)
2.86
0.2395
0.07
3−4
147 (57.0%)
143 (56.2%)
≥5
13 (5.0%)
22 (8.7%)
Number of medications
0−4
104 (40.3%)
107 (42.3%)
0.59
0.7459
0.03
5−10
137 (53.1%)
133 (52.6%)
≥11
17 (6.6%)
13 (5.1%)
M (SD)
M (SD)
t
p
d
ADLb
1.7 (2.03)
2.1 (2.05)
−1.86
0.0628
0.20
IADLc
3.9 (2.01)
3.8 (1.91)
0.86
0.3912
0.05
2.2.3. Services to Assist the Veteran
Participants were asked, “Have you searched for services to help you care for the Veteran (for example, on websites, in‐person, by phone)” (no/yes). Participants who responded yes indicated “What services you have searched for or received” (searched for/received/not searched for or received) (Tables 3 and 4). Finally, participants indicated “What services they would be interested in” (no/yes). The service categories and examples were chosen from a synthesis of the literature on HCBS and the experience of the study team. For each of these questions, the following service categories were asked: (1) caregiver support services (e.g., support groups, self‐care tips, tips for helping veteran); (2) community services (e.g., elder services, council on aging); (3) exploitation, abuse, neglect services; (4) financial services (e.g., debt relief, budgeting, benefits); (5) helping services (e.g., food delivery, nursing); (6) home safety/equipment (e.g., ramps, grab bars); (7) legal services (e.g., wills, healthcare proxy, power of Attorney, guardianship); (8) respite services (e.g., home aides, day programs for veteran); and (9) transportation services (e.g., paratransit, VA transportation).
TABLE 3.
Caregivers’ service interest by area (N = 511).
Rural
Urban
Service type
n (% yes)
n (% yes)
Estimate
SE
p
OR (95% CI)
Helping
136 (52.7%)
147 (58.3%)
−0.11
0.09
0.2019
0.80 (0.56−1.13)
Caregiver support
125 (48.6%)
132 (52.4%)
−0.07
0.09
0.3988
0.86 (0.61−1.22)
Home safety/equipment
121 (46.7%)
132 (52.4%)
−0.11
0.09
0.1995
0.80 (0.56−1.13)
Community
113 (43.8%)
125 (49.4%)
−0.11
0.09
0.2053
0.80 (0.56−1.13)
Financial
107 (41.3%)
113 (44.7%)
−0.07
0.09
0.4356
0.87 (0.61−1.24)
Transportation
99 (38.4%)
111 (44.1%)
−0.12
0.09
0.1932
0.79 (0.56−1.13)
Respite
94 (36.6%)
105 (41.8%)
−0.11
0.09
0.2252
0.80 (0.56−1.15)
Legal
73 (28.4%)
90 (35.7%)
−0.17
0.10
0.0777
0.71 (0.49−1.04)
Exploitation, abuse, neglect
31 (12.1%)
38 (15.0%)
−0.12
0.13
0.3384
0.78 (0.47−1.30)
TABLE 4.
Caregivers’ services searched or received by area (N = 226).
Rural
Urban
Service type
n (% yes)
n (% yes)
Estimate
SE
p
OR (95% CI)
Searched
Caregiver support
69 (64.5%)
64 (53.8%)
0.02
0.16
0.8875
1.05 (0.54−2.02)
Community
60 (56.1%)
62 (52.1%)
0.12
0.17
0.4699
1.27 (0.66−2.43)
Financial
48 (44.9%)
46 (38.7%)
−0.03
0.15
0.8251
0.94 (0.53−1.67)
Helping
46 (43.0%)
55 (46.2%)
0.35
0.18
0.0531
2.01 (0.99−4.09)
Respite
41 (38.3%)
31 (26.1%)
−0.32
0.15
0.0362
0.53 (0.29−0.96)
Home safety/equipment
37 (34.6%)
46 (38.7%)
0.24
0.18
0.1725
1.62 (0.81−3.25)
Transportation
36 (33.6%)
47 (39.0%)
0.24
0.15
0.1253
1.60 (0.88−2.93)
Legal
31 (29.3%)
32 (26.9%)
−0.02
0.16
0.9210
0.97 (0.53−1.78)
Exploitation, abuse, neglect
11 (10.3%)
18 (15.1%)
0.22
0.20
0.2721
1.57 (0.70−3.50)
Received
Caregiver support
12 (11.2%)
32 (26.9%)
0.55
0.22
0.0128
3.01 (1.26−7.19)
Community
17 (15.9%)
33 (27.7%)
0.43
0.20
0.0360
2.35 (1.06−5.20)
Financials
13 (12.2%)
26 (21.9%)
0.32
0.20
0.1032
1.91 (0.88−4.18)
Helping
32 (29.9%)
46 (38.7%)
0.42
0.19
0.0264
2.32 (1.10−4.86)
Respite
19 (17.8%)
22 (18.5%)
−0.08
0.19
0.6659
0.85 (0.41−1.76)
Home safety/equipment
39 (36.5%)
50 (42.0%)
0.27
0.18
0.1237
1.72 (0.86−3.41)
Transportation
21 (19.6%)
31 (26.3%)
0.32
0.18
0.0736
1.89 (0.94−3.80)
Legal
15 (13.2%)
21 (17.7%)
0.16
0.19
0.4246
1.36 (0.64−2.92)
Exploitation, abuse, neglect
3 (2.8%)
5 (4.2%)
0.44
0.42
0.3036
2.40 (0.45−12.66)
2.3. Data Analysis
We used chi‐square tests and independent‐samples t‐tests to examine differences in demographic and medical‐complexity measures between veterans living in rural and urban areas. We used Satterthwaite’s method to compare the distance apart when equal variances between the rural and urban caregiver groups could not be assumed. We conducted a series of logistic regression models to predict differences in the probability of searching for or receiving specific services between rural and urban caregivers, using a subsample of caregivers who reported having searched for services more broadly. We conducted another series of logistic regression models using the full caregiver sample to determine which services caregivers were most interested in and identify any statistically significant differences between urban and rural caregivers. We report each model’s estimate, standard error (SE), p‐value, and odds ratio (OR). All analyses were conducted using SAS Enterprise Guide 8.3.
3. Results
3.1. Demographics
There was no significant difference between rural and urban veterans’ age (p = 0.72) and gender (p = 0.90) (Table 1). However, there were significant differences in race (χ2 = [1, N = 511] = 28.26, p <0.0001), ethnicity (χ2 = [1, N = 355] = 9.39, p <0.01), education (χ2 = [1, N = 493] = 13.62, p <0.01), and income between rural and urban veterans (χ2 = [1, N = 415] = 6.62, p = 0.01) (Table 1). Rural veterans were more likely to be White or Hispanic/Latino, less educated, and to have a lower income than those in urban settings.
There were no significant differences in age (p = 0.19), gender (p = 0.25), ethnicity (p = 0.06), or income (p = 0.11) between rural and urban caregivers (Table 1). There were statistically significant differences between race (χ2 = [1, N = 511] = 27.71, p <0.0001) and level of education (χ2 = [1, N = 511] = 26.90, p <0.001) (Table 1). Rural caregivers were more likely to be White and have less formal education than their urban counterparts.
There was no difference in the type of relationship between the caregiver and the veteran (p = 0.91), nor in whether the caregiver lived with the veteran (p = 0.96) (Table 1). However, for caregivers who lived separately from the veteran, there was a statistically significant difference between the time it took rural (M = 17.70 min, SD = 26.31) and urban (M = 26.30 min, SD = 35.12) caregivers to travel to the veteran’s home (t(1) = 2.60, p = 0.01). It took urban caregivers longer to get to the veteran’s home than rural caregivers.
3.2. Veteran Health and Independence
The number of healthcare clinicians the veteran currently had (p = 0.24) and the number of daily medications (p = 0.75) did not differ between rural and urban veterans (Table 2). However, while visits to the emergency room (ER) were not different, overnight hospital stays were significantly different, such that urban veterans spent more nights in the hospital than rural veterans (χ2 = [1, N = 511] = 4.11, p <0.05) (Table 2). There were no differences in ADLs (p = 0.06) or IADLs (p = 0.39) between rural and urban veterans (Table 2).
3.3. Service Type Interest
All participants (N = 511) were asked which services they would be interested in to help provide care for the veteran (Table 3). Helping services (e.g., food delivery, nursing) (52.7% rural; 58.3% urban), caregiver support services (e.g., support groups, self‐care tips, tips for helping veteran) (48.6% rural; 52.4% urban), and home safety/equipment (e.g., ramps, grab bars) (46.7% rural; 52.4% urban) were the top areas that caregivers expressed interest in, while exploitation, abuse, and neglect services (12.1% rural; 15.0% urban) was last (Table 3). There were no statistically significant differences between rural and urban caregivers’ interest in various services (Table 3).
3.4. Services Searched and Received
Participants were asked if they had searched for any services. Two hundred twenty‐six (44.2%) responded yes. There was no significant difference between rural (41.5%, n = 107) and urban (47.0%, n = 119) caregivers (Estimate = −0.11, p = 0.21, OR = 0.80) regarding the proportion who had searched for services.
Of the 226 participants who had searched for any service (Table 4), the top two services searched for were caregiver support services (64.5% rural; 53.8% urban) and community services (e.g., elder services, council on aging) (56.1% rural; 52.1% urban). Financial services (e.g., debt relief, budgeting, benefits) (44.9%) were the third most searched for service among rural caregivers, while helping services (46.2%) were the third most searched for service among urban caregivers (Table 4). Searching for respite (e.g., home aides, day programs for veterans) and helping services significantly differed between rural and urban participants. Urban participants were twice as likely to search for helping services (p = 0.05, OR = 2.01), while searches for respite services were approximately half as likely for those residing in urban communities (p = 0.04, OR = 0.53) (Table 4).
For services received, caregivers living in an urban area were approximately three times as likely to have received caregiver support (p = 0.01, OR = 3.01) and over twice as likely to have received community and helping services compared to rural caregivers (p = 0.04, OR = 2.35 and p = 0.03, OR = 2.32, respectively) (Table 4).
Home safety/equipment services (36.5% rural; 42.0% urban) and helping services (29.9% rural; 38.7% urban) were the most received services for all caregivers (Table 4). There was a statistically significant difference between rural and urban caregivers in receiving caregiver support services, community services, and helping services, with urban caregivers receiving all three more often than rural caregivers.
4. Discussion
In this study of a balanced sample of informal caregivers assisting U.S. military veterans age 65 or older, we found that while the caregivers and veterans were demographically similar between urban and rural respondents, there were differences in the HCBS they searched for and received. Both veterans and their caregivers were similar in age and gender, regardless of their rural or urban location. Rural veterans were more likely to be White, less educated, and poorer than urban veterans, with rural caregivers also more likely to be White with fewer years of education. Most veterans were male, with caregivers being female, most notably daughters. These findings are consistent with prior research showing that caregiving is disproportionately provided by women, particularly daughters and spouses, across both veteran and nonveteran populations [8, 17, 18].
Rural and urban veterans were reported to be similar in terms of medical complexity and functioning. All veterans had high numbers of healthcare appointments, clinicians, and medications, as well as high functional impairment. While not statistically significant, there was a trend of rural veterans being more impaired than urban veterans in relation to basic ADLs. Prior studies on older rural populations have found health disparities between rural and urban locations, with those in rural areas having worse health and needing more caregiving than urban adults [9, 19]. Visits to the ER did not differ between rural and urban veterans. However, urban veterans were found to spend more overnight stays in the hospital than rural veterans. This finding may be because more hospitals are available in urban areas, so it may reflect differences in access rather than in health when using services. Rural healthcare may involve more clinics, where inpatient services are not available. For caregivers who did not live with the veteran, it took significantly longer for urban caregivers to travel to veterans’ homes to pick up veterans for healthcare appointments. This may be due to traffic and other urban transportation challenges (e.g., public transportation, parking), suggesting that time to reach a location can be a greater barrier than physical distance. Those living in urban areas, where services may be physically closer, may need to allocate more total time to caregiving, which can be a serious burden.
While rural and urban caregivers were interested in the same types of services to help them assist veterans, fewer than half reported searching for them. The small number of caregivers who actively sought services may reflect the fact that they were already receiving them. It could also be that caregivers may not have known about available services, did not have the time to search for them, or, in the case of older caregivers, may not have the technological knowledge or equipment to find them.
For all caregivers, caregiver support and community services were the most searched for services. Significant differences in the types of services searched for by area existed for helping and respite services. More urban caregivers sought helping services than rural caregivers. Helping services, as defined in this study, include food services and at‐home nursing care. These services typically need to be provided daily rather than occasionally, thus requiring the service provider to be available within a reasonable distance of the client. Because of the greater distances in rural areas, these services may not be feasible for rural caregivers. Brick‐and‐mortar businesses that provide these services are difficult to establish and staff in remote areas of the country [1]. Rural caregivers, however, searched for respite services more often than urban caregivers. Respite services were defined as having an aide or a day program for the veteran. Having a health aide come to the home or dropping off the veteran in a day program could encounter the same limitations as those highlighted in helping services for rural caregivers. The lack of a physical business, as well as the travel distance, not only for the caregiver but also for a home health aide to reach a person’s home, are significant obstacles to obtaining respite.
Interestingly, the most well‐received services for all caregivers were not the ones reported as being the most searched for. Home safety, helping, and transportation were ranked the top three services received by rural and urban caregivers. For every service type, urban caregivers were the majority beneficiaries. The percentage of urban caregivers who received requested services was higher than that of rural caregivers, who received less than a quarter of the requested services. Moreover, urban caregivers received significantly more caregiver support, community services, and helping services than rural caregivers. The lack of rural caregivers receiving desired services may be due to availability, distance, and accessibility factors. A silver lining is that all but a few caregivers who were interested and searched for services reported receiving a service in at least one category to assist them with the veteran.
5. Limitations
This study has some limitations. A longitudinal study would have allowed us to examine whether the services sought were ultimately received. To address this issue, we asked about prior interest and action (i.e., searching), current situation (i.e., received), and possible future action (i.e., interest), but it does not provide temporal sensitivity, which would allow us to understand how long it took to receive services. A second limitation is the use of a Qualtrics panel to recruit participants. Although this approach has significant strengths, it may limit the participant pool to those who are technologically literate and have a readily available computer and internet connection to complete the survey, which may explain why the caregivers in our sample are younger than those reported elsewhere [20]. However, outside the VA, a higher percentage of caregivers are adult children, so this study may be a more representative sample of the general population than just the VA. Lastly, questions about services did not include any time constraints (e.g., in the last year) nor a connection to whether they received the specific services they searched for. However, it did provide an overview of the services caregivers are interested in and search for, as well as what they are currently receiving. Future studies should be more specific.
6. Conclusion
In this well‐balanced survey designed to explore rural−urban differences, the health and independence of rural versus urban veterans were the same. Caregivers were interested in the same sorts of services. Yet, the services caregivers searched for and received varied by area.
Many of these differences are likely driven by limited availability or prohibitive travel distances for certain categories of services in rural areas, especially those requiring daily in‐person visits (e.g., home‐delivered meals, in‐home nursing care). But even among services that do not require daily contact, such as respite, we still observe a gap. This should be the focus of future research. This study was cross‐sectional, so it would be important to leverage a longitudinal design to follow caregivers as they identify a need, search for services, and determine whether they receive the desired services, and the barriers encountered.
Given that providing HCBS supports caregivers and reduces caregiver burden/burnout [21, 22], healthcare systems and policies should focus on expanding services such as respite, which could feasibly be delivered to rural communities.
Funding
Funding for this project was supported by the VA Office of Rural Health #009682.
Conflicts of Interest
The authors declare no conflicts of interest.
Disclosures
The views expressed in this manuscript are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government. This study was reviewed and approved by the Institutional Review Board at the Bedford Healthcare System VA.
Data Availability Statement
Research data are not shared.
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Associated Data
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Data Availability Statement
Research data are not shared.
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