Dementia Care in Rural Appalachia: Multilevel Analysis of Individual and County-level Factors.

BACKGROUND AND OBJECTIVES: Home- and community-based services (HCBS) are underutilized, despite offering significant health benefits to both care recipients and caregivers. Drawing upon Andersen's extended behavioral model of health services use, we examined individual and county-level factors influencing HCBS utilization for dementia care in rural Appalachia.

RESEARCH DESIGN AND METHODS: We analyzed data from telephone interviews with 123 dementia family caregivers in rural Appalachian counties (Mage = 64.7, SDage = 12.2). Multilevel analyses were conducted to examine the effects of individual-level and county-level factors on the use of home-based services (home health care and personal care services) as well as community-based services (adult day care and transportation services).

RESULTS: Results indicated that caregivers' receipt of informal support from family or friends were associated with more use of home-based services (B = 0.42, p = 0.003). Conversely, longer travel times to service providers were linked to use of fewer community-based services (B = -0.21, p < .001). Residing in counties with more home health agencies was associated with higher utilization of home-based services (B = 0.41, p = 0.046). However, higher county tax expenditures for HCBS were not linked to home-based or community-based service use.

DISCUSSION AND IMPLICATIONS: Findings suggest that informal support in caring for the person living with dementia enables HCBS use in rural Appalachia. In contrast, limited geographic accessibility and service availability can impede HCBS use in rural regions. Policymakers are urged to allocate direct public funding to service providers to expand service availability in under-resourced rural regions.