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Rural employees who care for elderly family members are less likely than urban employees to receive helpful workplace benefits like flex time, paid leave or the option of telecommuting.

While rural caregivers receive fewer workplace benefits that could help them accommodate their caregiving role, rural caregivers are also likely to face special geographic challenges, says one of the authors of a study on workplace benefits for elder care.

“All of the issues around caregiving are heightened in rural areas,” said Carrie Henning-Smith, an assistant professor in the Division of Health Policy and Management at the University of Minnesota’s School of Public Health.

Approximately 44 million Americans are providing unpaid care for elderly loved ones or family members. These volunteers provide up to 90% of all the long-term care elders receive in the U.S.

Rural caregivers face special hurdles. Rural populations tend to be older. With less population density, there may be fewer volunteers at the ready. Transportation can be an issue.

Henning-Smith said she and co-author Megan Lahr, also part of Minnesota’s health policy division, were curious to see whether rural employees were more likely to have workplace benefits that might help them meet these challenges. As it turns out, they aren’t.

The study of people who were working and caring for an elderly person found that urban and rural caregivers provide comparable amounts of care (about 20 hours a week vs. 16 hours, respectively. Rural and urban caregivers also said they experience similar amounts of personal strain because of their caregiving activities.

Where the differences emerged was in employee benefits. Urban workers were more likely than rural workers to have an employee assistance program (which provides referrals for medical and other services). They were more likely to be able to telecommute and be able to use paid leave to care for a loved one.

We interviewed Henning-Smith about her study, the nature of elder care in America, and her own interests in rural issues. (The conversation has been edited for clarity and length.)


Carrie Henning-Smith, Assistant Professor, Division of Health Policy and Management, University of Minnesota

Daily Yonder: How big is the issue of caregiving for elders in the United States? Is it different in rural areas?

Henning-Smith: I think it’s an enormous issue. Estimates are that about $500 billion [a year] in unpaid care is provided by caregivers. That dwarfs the amount that we pay for nursing-home care and formal home-health services. We have tens of millions of caregivers out there providing care. I think it’s a much bigger issue than we realize. I think there are a lot of people who are providing care and don’t even realize they’re a caregiver. They would never use that term themselves. I think it’s only going to get more and more prevalent as our country ages.

In rural areas, we know that the population is older, on average, than in urban areas. So the need for care is greater. All of the issues around caregiving are heightened in rural areas.

Daily Yonder: What are some examples of the type of elder care that you’re talking about?

Henning-Smith: There are all sorts of things. The survey [the study used data from the Caregiving in the US 2015 survey] asked people if they were helping someone take care of themselves, including help with personal needs like showering, bathing, getting dressed, or running errands, accessing health care, anything like that, anything that’s sort of more than the normal.

There are sometimes fuzzy areas there too, right? And I think that’s part of why caregivers have a hard time always recognizing that they’re caregivers. If it’s a relationship where you and your mom occasionally help each other out, that’s probably not a caregiving relationship. If it’s one where she depends on you to help refill her meds, or schedule an appointment with a doctor, or shop for groceries, all of those things would be caregiving.

Daily Yonder: You found that urban and rural caregivers spend similar amounts of time on caregiving and experienced similar amounts of strain as a result. What are the differences you found between rural and urban?

Henning-Smith: Where we found a difference was in the supportive services that were available to caregivers through their workplaces. … Across the board, rural caregivers who were employed had fewer of those workplace supports than urban caregivers who were employed.

Workplaces are one avenue that can help relieve some of that burden and some of that strain. There are all sorts of ways that could happen. It could happen through providing paid leave, paid sick time, flexible work hours, being able to work remotely. Then there are all sorts of support programs that some workplaces have in place like employee assistance programs or information or referrals.

Daily Yonder: Do you have any ideas about why there’s that difference?

Henning-Smith: I think there are a bunch of reasons why there could be that difference. With the data that we had for this study, we aren’t able to say exactly what’s causing this, but we know from other evidence all sorts of differences in the occupational landscapes for rural and urban caregivers. So that’s one thing. People may just be working in different types of jobs.

Rural areas have higher unemployment rates and lower median incomes. Caregivers in rural areas may have fewer jobs available to them and so to the extent that anyone is able to choose a job based on the benefits the job offers, rural caregivers are less able to do so.

Then we also know that there are broader structural issues at play. One of them is access to broadband internet. It’s one thing to tell an employee they can work remotely if you have really good access to internet. If you don’t, it might be impossible for someone to work remotely.

Then there are findings around paid sick leave or flexible work hours, unpaid leave. Some of those policies are individual to the employer. Some of those policies are at the state level and some of those policies are at the federal level. But where we’ve seen a lot of movement recently has been at the city and municipal level to extend paid sick time or to raise the minimum wage. All those sorts of efforts might really help caregivers who are employed, but those are [more likely to be] happening in some of our large metropolitan cities. They’re not happening in individual rural communities where there are just more economic pressures on people.

I’m in Minnesota, and Minneapolis has raised the minimum wage and is working on expanding paid sick time. Washington, D.C., has passed paid sick time. Duluth, Minnesota, [passed] paid sick time, and then there are individuals states that are mandating this, like California, New Jersey, and Rhode Island. Those are the states that allow for paid family leave or require paid family leave. California, and Massachusetts, and Oregon, and Connecticut require paid sick leave, but those are states that are not as heavily rural. So we’re seeing some of the rural communities and the rural states be left behind.

I don’t want to vilify individual employers. I think employers in rural communities are really under a lot of strain too. And so I think for someone to come in and say, “This community has to provide paid sick leave,” that’s going to put a burden on the employer too. It’s just a really delicate and difficult balance.

But some of the policy solutions that people suggest are using state subsidized funds to help support paid sick leave so that burden doesn’t fall to individual employers. And that may help.

And then another important difference between rural and urban areas and why we might see some of this happening is just the availability of the healthcare workforce and health services, and availability of transportation for that matter.

So in rural areas, you might be providing care not because of the most logical option, but because there’s no formal healthcare service available to you or there are fewer options in place for you. So I think that’s another really important one about why people end up as caregivers in the first place.

Daily Yonder: What about the issue of transportation?

Transportation and distance is something that came up over and over and over again as a rural specific challenge for caregiving. And it’s a challenge in a number of ways.

For one, if someone needs to drive someone to appointments or if someone who doesn’t live with the person they’re providing care to, just the time it takes to drive to that person and back, and if you live in a wintery climate where there’s inclement weather, all of that just gets compounded when you’re out on rural roads.

And then there are also issues where the distance intersects with the healthcare workforce availability. We have heard of home health care agencies that, in rural areas, require a minimum of four hours to be able to come out to someone’s house because of the distance. It’s not worth it for them to go for less than that, but that ends up being prohibitively expensive for some people to hire out that kind of help when they can only afford an hour or they might only need an hour.

Daily Yonder: What’s your interest in rural healthcare? How did you get in the field? What motivates you to do that?

Henning-Smith: Good questions. I think most people who are interested in rural stuff have some rural roots, and I definitely do. I grew up in a rural area of southeastern Wisconsin and have kind of farm roots in Illinois and Iowa and Nebraska going back to my grandparents and great grandparents. And so it’s, in some ways, been part of my lived experience. But then all of the research I do, much of which is related to rural health, is focused on equity issues and where equity and policy intersect.

So rural health is kind of the perfect place where you see a lot of that happening and where there are policies that can help people and be useful. And I’m also just really interested in how context and place influences health. So how does where we live influence our quality of life and our health outcome? So most of the work that I do is in rural and right now I’m in the caregiving study. I’m doing some work in rural social isolation and a lot around access to care for rural residents.

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