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December 2018, Volume XXXII, No 9

special focus: rural Health

Supporting unpaid caregivers in rural Minnesota

What physicians should know

ccording to the AARP, the vast majority of all long-term care is provided by unpaid friends and family members, who provide an estimated nearly $500 billion worth of care annually. At the last count, more than 40 million Americans are providing unpaid care to a loved one.

While this is a labor of love for many, it can come with health consequences for caregivers who experience stress and burden as a result of their caregiving role. For caregivers who are also working outside of the home, either full- or part-time, the demands of juggling employment and caregiving—often on top of other responsibilities—can be overwhelming. For caregivers living in rural areas, where employment opportunities and access to health care are both more limited, accessing the support they need to successfully balance their multiple roles can be especially challenging.

Juggling employment with unpaid caregiving

For unpaid caregivers who hold outside jobs—in retail, offices, farming, or other settings—employers could play an important role in helping to navigate the balance of employment and caregiving roles; however, not all workplaces are created equally.

In a University of Minnesota Rural Health Research Center study entitled “Rural-Urban Difference in Workplace Supports and Impacts for Employed Caregivers,” published in the Journal of Rural Health (2018), we presented findings from the 2015 Caregiving in the U.S. survey. This survey collected data from unpaid caregivers across the country, conducted by the AARP and the National Alliance for Family Caregiving. We used these data to examine differences in workplace supports for unpaid caregivers by rural and urban location.

The nationally representative sample included 635 employed caregivers from across the country, 12.5 percent of whom lived in rural areas. Across rural and urban locations, volunteer caregivers holding outside jobs were, on average, more likely to be female, in their 40s, with a household income between $30,000 and $74,999. Employed caregivers in rural areas were significantly less likely to have a college degree (26 percent vs. 42 percent) and were also more likely to be non-Hispanic White (76 percent vs. 59 percent), compared with employed caregivers in urban areas. Employed caregivers in urban areas were providing 20.5 hours per week of unpaid care and employed caregivers in rural areas were providing 15.6 hours per week of unpaid care, on average.

"More than 40 million Americans are providing unpaid care to a loved one."

At the same time, employed caregivers in both urban and rural locations were working approximately 35 hours per week outside of the home for an employer.

We found that employed caregivers in urban locations had significantly more supportive services available to them through their workplace than employed caregivers in rural locations. Specifically, volunteer rural caregivers holding separate jobs were less likely than employed urban caregivers to be able to telecommute or work remotely (9.7 percent vs. 24.9 percent); less likely to have supportive programs, such as employee assistance programs (EAP), information, and referrals available to them through their workplace (15.2 percent vs. 25.8 percent); and less likely to have paid leave available to them (17.7 percent vs. 34.1 percent). Fewer than half of all employed rural caregivers had paid sick leave (45.6 percent vs. 52.7 percent of employed urban caregivers) and flexible work hours (49.3 percent vs. 54.7 percent of employed urban caregivers), although the rural-urban differences in those two measures were not statistically different. These differences are shown in Figure 1.

We also examined the number of negative workplace impacts among rural and urban employed caregivers and found that nearly half of all volunteer caregivers with outside jobs, regardless of location, had taken time off, gone into work late, and/or left early from work, despite the relatively low rate of paid leave and paid sick time available to caregivers. For caregivers without access to paid leave or flexible hours, taking this time off or missing hours of work may mean foregoing wages. The only significant rural-urban difference that we identified in negative workplace impacts was in the rate of turning down promotions: 6.5 percent of employed caregivers in urban locations reported that they had turned down a promotion, compared with 1.5 percent of employed caregivers in rural locations. However, the lower rate of turning down promotions among volunteer rural caregivers holding outside jobs may be indicative of the fact that fewer promotion opportunities were available to them in the first place.

In multivariate regression models, we found that having more negative workplace impacts from one’s caregiving role was associated with increased caregiver burden, even after adjusting for the hours one works, demographic and socioeconomic characteristics, and the amount of care one provides. Prior research has found a strong link between increased caregiver burden and strain and poorer health outcomes for unpaid caregivers, making it urgently important to find ways to reduce strain and burden for caregivers. For employed caregivers who are juggling multiple demanding roles with their responsibilities for loved ones and their employers, focusing on supports within the workplace is one logical starting place to alleviate strain.

What employers could do

Overall, our findings indicate significant room for improvement in workplace supports for employed caregivers generally, with much greater need in rural areas. Because of the difference in economic and occupational landscapes between rural and urban settings, including the fact that rural areas have recovered more slowly from the Great Recession, rural caregivers have fewer job options available to them than do urban caregivers, and may be less likely to choose a job based on the benefits it provides. This leaves rural caregivers in a precarious position, coupled with more limited access to health care and increased barriers related to transportation and accessing supportive services in general.

"Being at the front lines of treating both caregivers and their care recipients puts physicians in a unique position."

There are a variety of policy and programmatic interventions that could be used to address poor access to workplace supports for rural caregivers employed in outside jobs.

At the employer level, this might include expanding access to employee assistance programs and ensuring that employees are aware of existing benefits and programs; providing a quiet space for employees to make phone calls (i.e., scheduling medical appointments for their loved ones); allowing time and space for volunteer caregivers across the organization to meet with one another to commiserate and offer ideas and support; and offering flexible break times, working hours, and work locations, to the extent that doing so is possible.

At the local, state, and federal policy level, solutions might include expanding access to broadband internet to make it possible to work remotely; providing caregiver stipends and/or tax credits so that caregivers can work less if they choose to; expanding requirements around paid leave and paid sick time to include caregiver responsibilities; increasing the minimum wage; and expanding community supportive services for caregivers, as well as increasing public awareness around those programs that already exist, such as the Senior LinkAge Line in Minnesota.

What physicians could do

Physicians should be aware of this issue and have an important role to play in addressing it. They may find themselves treating the health consequences of stress and strain related to juggling work and unpaid caregiving. Being at the front lines of treating both caregivers and their care recipients puts physicians in a unique position to be able to speak to the importance of supporting caregivers for the sake of population health.

At a minimum, physicians should make it a standard practice to ask patients about the many, and various, roles that they juggle and whether, and how, those are impacting their well-being. They should then be prepared to connect patients with resources, ideally by partnering with a social worker or other expert in available resources. Physicians are also in a unique role to advocate for the importance of addressing the well-being of caregivers, especially those in rural areas who provide an irreplaceable service that too often goes unnoticed.

Carrie Henning-Smith, PhD, MPH, MSW, is an assistant professor of health policy and management at the University of Minnesota School of Public Health, and the deputy director of the University of Minnesota Rural Health Research Center.

Megan Lahr, MPH, is a research fellow and project manager at the University of Minnesota Rural Health Research Center. 

Figure 1. Workplace benefits for employed caregivers by rural-urban location. Source: “Rural-Urban Difference in Workplace Supports and Impacts for Employed Caregivers,” Journal of Rural Health, June 28, 2018.

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Megan Lahr, MPH, is a research fellow and project manager at the University of Minnesota Rural Health Research Center.