Factors Affecting Family Caregiver Stress: The Effect of State Commitment to Home and Community Based Service

Background and Purpose: Because Home and Community Based Services (HCBS) are designed to provide assistance for disabled older adults in the community, access to and use of HCBS may have significant impact on family caregivers' stress. Because states are given freedom to design their HCBS under the HCBS waiver program, states greatly differ in their expenditure and eligibility criteria for HCBS. Ecological theory informs that caregiver stress is a result of dynamic interactions between individual and contextual factors (Compton & Galaway, 1994). However, contextual factors of the state level have been largely neglected in caregiving research. The purpose of this study is to examine how state commitment to HCBS and individual factors are associated with caregiver stress. Methods: The data were extracted from the Caregiver Survey of the 2004 National Long-Term Care Survey. 1,799 family caregivers from 44 states were included in this study after excluding 124 caregivers from six states: five states (Alaska, District of Columbia, New Mexico, Vermont, and Nevada) because of small within group variability and Arizona because of its operation of a unique state program instead of HCBS waivers. The vast majority of the sample were married (72%), female (79.4 %), and White (90.9%). The percentage of states' long term care expenditure spent on HCBS waivers was used as a proxy measure for state commitment to HCBS. The multilevel modeling analysis was conducted using SPSS 14. Eight individual-level variables (gender, education, ethnicity, Activities of Daily Living [ADL] and Instrumental Activities of Daily Living [IADL] limitations of an older adults, physical strain, financial strain, and service utilization), one state-level variable (state commitment to HCBS), and a cross-level interaction term between state commitment to HCBS and service utilization were examined. Because of the negatively skewed distribution, the variable of stress was log-transformed. Result: The random intercept was not significant (B=.003, p= .417) and the intra-class correlation coefficient was .005, indicating 0.5% of the variability in caregiving stress was related to differences between states. Findings suggested that caregivers who are female, have a higher education, perceive more physical strain and economic hardships, and take care of the older adult with more IADL limitations are more likely to experience a higher level of stress. The cross level interaction between service utilization and state commitments to HCBS was significant, suggesting that as state commitment to HCBS increases, the relationship between service utilization and the caregiver stress increases by 14.1%. Service utilization was related to lower levels of caregiver stress regardless of in which state caregivers live; however, there are smaller differences of caregiver stress between service users and non-users living in a state with higher state commitments to HCBS. Conclusion and Implications: The findings suggest an important role of state commitment to HBCS in creating caregviging context. As the demands for informal caregiving is increasing, further efforts by states are needed in expanding supportive long-term care policy for family caregivers of older adults in the community.