Rural Health Policy

The Impact of Informal Care Giving on Labor Force Participation

by Rural Farming and Nonfarming Families

M a y E . Horwitz, M A , and Thomas C. Rosenthal, M D

ABSTRACT Using data from the National Survey of Families and Households, 1987, this study contrasts urban versus rural, and farm versus rural nonfarm informal care givers of the elderly and disabled to illustrate the conflicts that each group experiences when combining work and care giving. Women are the prima y care givers in both rural and urban areas. Rural care givers spent more time providing care than urban care givers, whether the dependent resided in the care giver‘s home or elsewhere in the community. A moderate difference existed in the number of hours care givers spent at work, although the rural care giver’s spouses worked significantly more hours than urban spouses. Rural nonfarm care givers spent more hours caring for individuals residing in their communities, while farm care givers spent the most time in household-related activities when caring for someone in their homes. In-home activity decreased the number of hours spent a t work, while community care giving did not.

nformal care givers, i.e. family, friends or neighbors, provide 80 percent of America’s long-term health care to the elderly or disabled outside of institutions such as hospitals or I nursing homes (Brody 1985; Stone, Cafferata, &

Sangl, 1987). The elderly (persons older than 65 years) are the fastest growing segment of the population, growing 185 percent from 1950 to 1989 (Bureau of the Census, 1991; Stone, et al., 1987). Persons older than age 85 are increasing even faster and are more suscep- tible to multiple chronic conditions, placing an even greater burden on informal care givers. Of the 31 million Americans aged 65 years and older, 25 percent live in rural areas according to Bureau of the Census 1991 definitions.

Rural informal care givers are likely to encounter

problems of isolation, transportation, decreased access to health care, and decreased support from the formal health care system more intensely than urban care givers. Fewer than 50 percent of the rural elderly own cars, yet public transportation is almost nonexistent in rural communities (Barber, Jelinek, Barbe, & Libo, 1985). Rural residents average 30 minutes travel time to health care facilities (Lucas & Rosenthal, 1992), and often must travel to urban areas for specialist care. Formal long-term care agencies are more plentiful in urban areas. Care givers often shoulder the burden of transporting those needing care to medical facilities, meal programs, day care, and grocery stores, compro- mising time for personal, family, or work responsibili- ties. All these factors affect care givers’ ability to maintain dependents’ households and their own.

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Farming families, a subset of rural care givers, are further influenced by the more entangled relationship of family and farm (Dwyer, Lee, & Coward 1990; Lee, Dwyer, & Coward, 1990; Matthews, 1988). Underinsured farm families with limited cash flow, but assets too great to qualify for public assistance are often forced to assume more of the care giving burden. Also, many farming families work in the paid labor market to supplement household income and secure health insurance. Not only does this take away from farm duties, but for care givers, it creates an added burden of trying to coordinate the farm work, a second job, and care giving.

giving on work for farm and rural nonfarm informal care givers. Sampling methodologies used to date have involved samples of care givers drawn from state health agencies that are already assisting the recipient, corporations that support employee assistance pro- grams, or hospitals (Anastas, Gibeau, & Larson, 1990; Barusch & Spaid, 1989; Scharlach, 1989; Young & Kahana, 1989). These samples are likely to miss the informal care giver not enrolled in the formal home health care system. Informal care giving studies have measured the effect of care giver "burden" or "strain" on care givers' abilities to fulfill their care giving roles (Cantor, 1983; Poulshock & Deimling, 19841, but few studies have examined how "work should be fac- tored as care giver burden. The degree of work conflict created by care giving can be measured by the number of times the respondent was late for work, used the work phone to fulfill care giving responsibilities, changed work schedules, took time off without pay, or missed career opportunities (Gibeau & Anastas, 1989; Neal, Chappman, Ingersoll-Dayton, Emlen, & Biose, 1990; Scharlach & Boyd, 1989).

versus rural nonfarm informal care givers of the elderly and disabled to illustrate the conflicts that each group experiences when combining work and care giving. It further explores the hypothesis that rural farm and nonfarm informal care givers experience a stronger negative effect on occupational work time than urban care givers and that farm families face the strongest negative effect.

There have been few studies of the impact of care

This study contrasts urban versus rural, and farm

Methodology

A secondary analysis of the National Survey of Families and Households (NSFH, 1987) was con- ducted to compare rural versus urban, and farming

versus rural nonfarming informal care giving popula- tions. The survey consists of a national probability sample of 13,017 respondents from the noninstitutional United States population age 19 and older. One adult per household was randomly selected to be the primary respondent. A shorter self- administered questionnaire was given to the spouse or cohabiting partner of the primary respondent. The sample design was cross-sectional.

The 2,145 informal care givers in the survey were defined as those respondents who indicated that they had someone in the home who needed special care, or that they provided help to someone outside the household. The relationship of the care recipient to the respondent was determined along with hours spent performing care giving tasks and working in the labor market.

Urban residence was defined as a metropolitan area 50,000 or greater population, or a county adja- cent to a metropolitan area with 2,500 or greater population. Rural residence is defined as a county not adjacent to a metropolitan area or a county adjacent to a metropolitan area with fewer than 2,500 popula- tion. It is estimated that 15 percent of the U.S. popula- tion resides in rural areas meeting this strict defini- tion of rural (NSFH, 1987).

Farming and nonfarming status was determined by the respondent's or the spouse's primary occupa- tion. Farming status may be acquired if either the respondent's and /or spouse's primary occupation was farming. Primary occupation was defined as the occupation at which the individual spends the majority of his or her working day, thus eliminating "hobby" farmers from the sample.

Functional status of the care giving recipient (hereafter known as dependent) was calculated through a series of questions measuring level of assistance required for activities of daily living (bathing, feeding, etc.) and instrumental activities of daily living (household work, running errands, etc.) Care giving hours and household chore time were determined by "the number of hours spent doing those tasks last week.'' Occupational hours were determined by the number of hours the care giver worked the previous week.

ences between group means and chi square to test for differences between group proportions. Ordinary

Student t tests were calculated to test for differ-

For more information contact Mary E. Horwitz, M A , Associate Director of Research, Department of Family Medicine, Family Medicine Modular Complex, 462 Grider St.-ECMC, Buffalo, NY 14215.

Horwitz and Rosenthal 267 Fall 1994

Table 1. Characteristics of the Care Givers: Means, Standard Deviations, and Percentages.

Care Givers Non-Care Givers

Sex Male Female

Age Mean Standard deviation

Education Mean Standard deviation

Metropolitan Status Rural Urban

Employment Status Not employed Part time Full time

Number of Children None One Two or more

Marital Status Married Not married

Time Spent in Household- related Tasks

Mean hours per week Standard deviation

Time Spent in Occupational Work

Mean hours per week Standard deviation

Time Spent in Care Giving- related Tasks

Mean hours per week Standard deviation

33.7% 66.3%

46.4 17.6

11.9 3.0

15% 85%

13.2% 20.8% 65.9%

60.7% 16.8% 22.5%

53.8% 46.2%

33.2 28.7

34.7 19.3

20.3 26.6

44.4%* 58.6%

42.2* 17.3

12.3* 3.0

15% 85 %

9.5%* 17.6% 72.9%

55.4%' 17.2% 27.4%

52.8% 47.2%

30.1' 27.1

37.1' 17.4

- -

Total Respondents 2,145 10,872

' Significance level is P<O.OOl

least squares multivariate analysis was used to determine the impact of the independent variables (age, sex, education, care giving hours outside the household, and time spent in household-related tasks) on the dependent variable (occupation hours) for a subsample of employed care givers.

Results

Two thirds of the care givers were women, and 4.24 years older than noncare givers (P<O.OOI) (Table 1). Eighty-five percent of the 2,145 care givers lived in urban areas and 15 percent lived in rural areas as defined above, a ratio equivalent to the general population ratio (chi square 1.24, df=l). Informal care givers worked outside the home 2.35 fewer hours per week (P<O.OOl) and were less likely to work full-time jobs than noncare givers. Care givers were also more likely not to be employed (P<O.OOl). Thirty-nine percent of the care givers had children younger than age 18 in the household.

Care givers reported spending 33.2 hours per week in household-related activities (cooking, cleaning, laundry, outdoor maintenance, etc). This was 3.1 more hours per week worked than families with children or those without care-giving responsi- bilities. An average of 20 hours per week were spent in care-giving duties.

As Table 2 illustrates, rural care givers spent more time providing care than urban care givers, whether the dependent resided in the care giver's home or elsewhere in the community. While only a moderate difference existed in the number of hours each group of care givers spent at work (student t= -1.5, P<O.lO), rural care givers' spouses worked 3.S more hours per week than urban spouses (student t= -2.4, P<O.Ol).

Table 3 presents results specific to employed care givers. The total number of respondents reported decreased because some failed to identify a primary occupation in the survey. Rural nonfarmers were more involved in care giving outside the household than farmers, differing by 8.7 hours per week (P<O.lO). Farm care givers spent more hours in household-related activities (including care giving tasks) than urban care givers W0.05). Additionally, farm care givers committed 5.5 more weeks per year to care giving. Farm care givers worked 6.2 more occupational hours per week than rural nonfarm care givers and 7.2 more hours than urban care givers (P<0.05). Finally, dependents of employed farm care

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cal in sex, age, and education (P<O.OOl, equation no. 1). Table 2. Urban and Rural Comparison of Time

Spent in Care Giving, Household Work, and Occupatioal Work Per Week.

Urban Rural

Hours spent in care giving outside household per week 19.6 2 3 . P

(25.9) (30.2)

Hours spent in household tasks per week (including related care-giver tasks) 32.5 37.2**

(28.2) (32.1)

Weeks per year spent caring for dependent family member 21.1 21.5

(20.0) (20.6)

Hours spent in child care per week 0.52 0.45 (2.2) (2.0)

Respondent occupational hours per week 34.4 36.P

(19.2) (19.7)

Spouse occupational hours per week 40.7 44.2*** (12.8) (10.9)

Dependency level of care recipient: 0 (low) to 7 (high) 3.5 3.6

(1.9) (2.0)

Total number of respondents 1,820 325

Student t test measures differences between group means significance levels are as follows: * P<O.lO ** P4.05 *** P<0.01

Note: Standard deviation appears in parentheses

givers were functionally more dependent than urban dependents (P<0.05).

ling for residence (urban versus rural), occupation (employed urban, employed rural, employed rural farmer), sex, age, education, community care giving hours per week, and care giving household hours per week (Table 4). Findings indicate that rural residents worked approximately five more occupational hours than their urban counterparts even if they are identi-

Occupational work time was estimated control-

Farm care givers (equation no. 2, D1, D2) d o not work significantly more occupational hours as compared to urban employed care givers. Rural nonfarm care givers, on the other hand, worked outside the home approximately five more hours per week than their employed urban counterparts. Women care givers worked approximately six fewer hours per week than male care givers (P<0.05). As a care giver’s age in- creased, hours at work significantly decreased (P<O.Ol). As the care giver’s education level increased, occupational hours per week increased. Care giving for a family member residing in the community, but not in the care giver’s own household, had no signifi- cant effect on the care giver’s hours at work. However, in-home responsibilities of household tasks and care giving tasks significantly decreased the number of hours a care giver spent at his or her job.

Discussion

The primary focus of the National Survey of Families and Households was to gather a broad spectrum of information ranging from marriage to child-rearing to work history. Therefore, only a portion of the survey addressed care-giving activities. The survey used broad categories to identify the primary care giver, the number of hours spent in care giving, the particular tasks performed, and details about occupation type. In spite of these limitations, the survey represents current information of informal care givers across a broad population base.

Certain characteristics of America’s care-giving population stand out as different from the noncare- giving population. Older women provide most of the care with little reliance on family or public resources (Crawford, 1991). Women have lower educational levels than male care givers, spend fewer hours in the occupational work force, and may, therefore, be more available for care giving (Crawford, 1991). Care givers spend 25 percent more time in household tasks, care giving, and work tasks combined than noncare givers (Table 1). The increased work load probably affects lifestyle, health, and leisure time in ways not explored by the survey.

rural and urban populations. Despite similar func- tional status scores of care recipients, the rural care giver works more hours at work, in the home and in providing care. The fewer hours spent in provision of care by urban residents suggests increased use of

There is a similar ratio of informal care givers in

Homitz and Rosenthal 269 Fall 2994

Table 3. Comparison of Employed Urban, Rural Nonfarm, and Rural Farm Care Giver Time Spent in Providing Care, Household Work, and Occupational Hours; Means and (Standard Deviations).

Urban Rural Nonfarmer Rural Farmer “4) (B) (C)

Care giving hours outside household per week 17.3 (24.0) 23.1 (29.1) 14.4 (20.0) (B>C)*

Household-related tasks per week (including care giving) 26.8 (22.3) 29.4 (23.8) 36.6 (26.9) (C>A)**

Weeks of each year spent caring for dependent family member 18.3 (19.1) 20.6 (20.3) 23.8 (22.8) ( G A Y

Hours spent in child care per week 0.57 (0.9) 0.27 (0.51) 0.18 (.023)

Occupational hours per week (respondent) 37.5 (17.3) 38.5 (18.4) 44.7 (23.5) ( G A Y

Occupational hours per week (spouse) 40.6 (11.9) 43.1 (9.2) 43.9 (15.3)

Dependency level of care recipient (O=low; 7=high) 3.0 (2.3) 3.2 (2.2) 4.8 (2.1) (C>A)**

Number of respondents 415 70 38

Student t test measures differences between group means-significance levels: ‘P<O.lO, **P<0.05.

formal home health care services by urban people. Rural household demands are further stretched because the rural care giver’s spouse spends more time at work than do urban spouses. These findings illustrate how a recipient’s functional level cannot be used as the sole judge of care-giving demand, and that many factors contribute to a greater demand on rural care givers. If fewer formal resources are used, rural care givers must perform a greater range of tasks themselves.

level. They provide care more hours per week and more weeks per year than either rural nonfarm or urban care givers. Farm families are more likely to care for people in their own homes than are urban or rural nonfarm families. This could be because they are more anchored to the farm by farm work de- mands. Farm care givers also care for individuals with the highest dependency level, yet they spend the highest number of hours at occupational work. Whether these findings relate to a tradition for closely knit extended families, less insurance coverage, or lack of formal services cannot be determined by this data set.

Compared to men, women’s occupational hours decrease more as care giving hours increase, probably

Farm care givers experience the highest demand

because they shoulder the greatest care-giving burden. Because women are more likely to be care givers, an aging society needs to seek a greater understanding of how tomorrow’s women will handle the burden of care giving and maintaining their own families, households, and careers. The survey demonstrates that as in-home responsibilities increase, (measured as “household-related tasks”), occupational hours decrease for the general care- giving population.

Household-related tasks time increases propor- tional to care-giving load. This double burden phenomena may be explained by other studies that show an overlap of care-giving time with household tasks (Poulshock & Deimling, 1984). For example, a woman who cares for her husband might not per- ceive increased demands for cooking, cleaning or washing as care-giving tasks because she did those activities previous to her husband’s disability. Grocery shopping for neighbors might not be per- ceived as a care-giving task if care givers shop for themselves at the same time. Care givers merge activities to lessen the effect of both household tasks and care-giving tasks on family, work, and leisure. This tendency results in underestimation of the contribution made by informal care givers.

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Table 4. Regression Coefficients and (Standard Error) for Work Time by Residence, Sex, Age, Education, Community Care-giving Hours, and Household Tasks.

All Em p 1 o y e d Care Givers Care Givers

Equation 1 Equation 2

Urban/rurala 5.38 (2.15)*** Dlb 12.87 (10.13) Residence indicator D2 5.24 (2.06)**“

Sex -6.17 (1.59)** -5.53 (1.54)***

Age -0.16 (0.06)*** -0.15 (O.O6P*

Education 0.67 (0.30)** 0.49 (0.29)*

Caregiving hours -0.02 (0.03) -0.03 (0.03) outside household

Household task hours -0.15 (0.03)t -0.13 (0.03)t including care giving

Work time 35.96 (19.4) 37.85 (17.82)

R2 0.11

Number of respondents 614

0.09

599

a. Urban=O; rural=l. b. Dl (rural farmer)=l; urban care giver=O.

D2 (rural nonfarmer)=l; urban care giver=O.

Levels of signficance: *P<O.lO; **P<0.05; “**P<O.Ol; tP<0.001.

Conclusion

Rural residents already use 17 percent fewer home health services than do urban residents (Kenney & Dubay, 1992). Families continue to be an important health care resource for disabled and growing elderly populations, and rural care givers commit even more time to the needs of dependent family members with fewer resources than do their urban counterparts. Isolation, transportation, and decreased support from the formal health care system further strain their resources. The potential contribution of family net- works and rural care-giver assistance programs, not explored here, needs further description.

The movement of women into the labor force decreases their availability to maintain the level of care now provided (Boaz & Muller, 1992). With the growing elderly population, the importance of understanding the whole home health care system, formal and informal, becomes urgent. Resource allocation must be based on extended family support, access to home health care, and financial status when the alternative is expensive skilled nursing home care (Kemper, 1992).

A synthesis of federal, state, community, em- ployer, and family resources is needed to support the informal network as a part of the health care system of the future, i.e. employee assistance programs, federal family leave legislation, and increased state funding of local agencies for community education and care-giver support programs.

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