title: Comparing the experiences of rural and urban family caregivers of the terminally ill.
abstract: BACKGROUND
  There are many challenges in delivering rural health services; this is particularly true for the delivery of palliative care. Previous work has identified consistent themes around end-of-life care, including caregiver burden in providing care, the importance of informal care networks and barriers imposed by geography. Despite these well-known barriers, few studies have explored the experience of palliative care in rural settings. The purpose of the present study was to compare the experiences of rural family caregivers actively providing end-of-life care to the experiences of their urban counterparts.
  
  
  METHODS
  Caregivers' perceived health status, the experience of burden in caregiving, assessment of social supports and the pattern of formal care used by the terminally ill were explored using a consistent and standardized measurement approach. A cross-sectional survey study was conducted with 100 informal caregivers (44 rural, 56 urban) actively providing care to a terminally ill patient recruited from a publicly funded community agency located in northeastern Ontario, Canada. The telephone-based survey included questions assessing: (i) caregiver perceived burden (14-item instrument based on the Caregiver's Burden Scale in End-of-Life Care [CBS-EOLC]); (ii) perceived social support (modified version of the Multidimensional Scale of Perceived Social Support [MSPSS] consisting of 12 items); and (iii) functional status of the care recipient (assessed using the Eastern Collaborative Oncology Group performance scale).
  
  
  RESULTS
  Rural and urban caregivers were providing care to recipients with similar functional status; the majority of care recipients were either capable of all self-care or experiencing some limitation in self-care. No group differences were observed for caregiver perceived burden: both rural and urban caregivers reported low levels of burden (CBS-EOLC score of 26.5 [SD=8.1] and 25.0 [SD=9.2], respectively; <em>p</em>=0.41). Urban and rural caregivers also reported similarly high levels of social support (mean MSPSS total score of 4.3 [SD=0.7] and 4.1 [SD=0.8], respectively; <em>p</em>=0.40). Although caregivers across both settings reported using a comparable number of services (rural 4.8 [SD=1.9] vs urban 4.5 [SD=1.8]; <em>p</em>=0.39), the types of services used differed. Rural caregivers reported greater use of family physicians (65.1% vs 40.7%; <em>p</em>=0.02), emergency room visits (31.8% vs 13.0%; <em>p</em>=0.02) and pharmacy services (95.3% vs 70.4%; <em>p</em>=0.002), while urban caregivers reported greater use of caregiver respite services (29.6% vs 11.6%; <em>p</em>=0.03).
  
  
  CONCLUSIONS
  Through the use of standardized tools, this study explored the experiences of rural informal family caregivers providing palliative care in contrast to the experiences of their urban counterparts. The results of the present study suggest that while there are commonalities to the caregiving experience regardless of setting, key differences also exist. Thus, location is a factor to be considered when implementing palliative care programs and services.
authors.affiliation: Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada. brazilk@mcmaster.ca
authors.forename: Kevin
authors.initials: K
authors.lastname: Brazil
authors.forename: Sharon
authors.initials: S
authors.lastname: Kaasalainen
authors.forename: Allison
authors.initials: A
authors.lastname: Williams
authors.forename: Christine
authors.initials: C
authors.lastname: Rodriguez
mesh_terms: D000328:Adult; D000368:Aged; D017028:Caregivers / Q000523:psychology* / Q000706:statistics & numerical data; D017281:Cost of Illness; D003430:Cross-Sectional Studies; D005192:Family Health / Q000706:statistics & numerical data*; D005195:Family Relations; D005260:Female; D006297:Health Services Accessibility / Q000706:statistics & numerical data; D006304:Health Status; D006801:Humans; D008297:Male; D008875:Middle Aged; D009369:Neoplasms / Q000453:epidemiology; D009864:Ontario; D019035:Rural Health Services / Q000706:statistics & numerical data; D012923:Social Class; D012944:Social Support; D019452:Terminally Ill; D019037:Urban Health Services / Q000706:statistics & numerical data