Written by Jessica Cantrall, Edited by Nicole M. Summers-Gabr
This piece was originally published in The Community Psychologist (TCP) Summer 2023 Volume 56, Number 4. Past TCP columns are available online, at https://www.scra27.org/publications/tcp/
Living in a rural area can come with various challenges, and the disparities in health outcomes that affect those living in these areas have been documented throughout existing literature. Some of these disparities include a higher risk of preventable diseases such as diabetes, a higher risk of suicide, unintentional injury, and opioid overdose (Eberhardt & Pamuk, 2004; Hartley, 2004, Case & Deaton, 2015; Stein et al., 2017). Two groups that may have a greater struggle in rural areas are children and older people. Around 20% of U.S. children live in rural areas and face unique health and healthcare challenges such as geographic and socioeconomic determinants (Bettenhausen et al., 2021). Older adults face similar challenges with geographic isolation and socioeconomic health determinants. For example, rural elderly were more likely to not seek medical care due to cost than those living in urban areas (Carter & Dean, 2021). One of the greatest needs for children and older people in rural areas is access to essential services such as long-term care facilities and daycares.
Workforce Shortages in Eldercare and Childcare
As rural populations tend to be older than urban populations, rural places increasingly need eldercare services. In 2021, adults over 65 years old accounted for more than 20% of the rural population (Davis, et al., 2022). However, rural areas have fewer nursing homes than urban or suburban areas (Sharma et al., 2022). Additionally, 43% of those living without skilled nursing facility services are in rural counties. Not only do residents in rural areas struggle with access to a nearby nursing facility, but the open nursing facilities are also facing debilitating staff shortages. One recent survey found that 86% of nursing homes experienced at least moderate staffing shortages (O’Connell-Domenech, 2023). As residents of rural communities age, they are often forced to make difficult decisions between moving away from family, trying to age at home without much assistance, or choosing a nursing home where the quality of care may be lacking due to limited staff.
Another service that may be limited in rural areas is daycares. Daycares benefit communities greatly; however, there are often significant barriers to accessing care, such as long waitlists due to limited facilities and higher costs (Workman & Ullrich, 2017). Overall, 31.7% of families with children under six do not have access to formal childcare facilities. Families in rural areas may face an even greater need for childcare services. For example, rural parents live an average of 10 miles from their daycare provider, while those in urban areas are only around 3.5 miles away. Lack of available childcare was also cited as the reason that 80% of rural households had one parent per household not working (Guevara, 2021).
Consequently, unless families have a network they can rely on for support, families in rural areas face difficult decisions to drive long distances or only have one working parent in the household. Table 1 demonstrates rural and urban disparities in elder and childcare services.
Benefits of Intergenerational Care Centers
As the lack of eldercare and childcare centers persists in rural communities, one solution could be to have intergenerational care centers. Intergenerational care centers combine child daycare and senior care services (either senior daycare programs or nursing homes). This is not a new concept; several communities have implemented this kind of program. There are around 105 intergenerational shared spaces in the U.S., and while they may differ in the form of programming, they share the same goal of uniting young children with older adults (Abate, 2018). For instance, a facility in California brought elderly adults into the daycare for special programming each day, where they did activities such as cooking and playing together (Abate, 2018). In another example in Washington state, the daycare and the nursing facility are situated in the same building (Jansen, 2016). Six days a week, a daycare classroom of young children would visit with the residents. While these are urban examples, rural communities may be able to create something similar where a daycare is housed inside of a nursing home or combined with a senior services center. The daycare and activity staff for older people could facilitate specific times during the day for shared activities such as craft or story time. This type of program could be incredibly beneficial, especially for staff working at the facility, who could enroll their children in these programs and lessen the transportation burden.
Another benefit to combing daycares and eldercare facilities in rural areas would be the combination of resources. For example, while many daycares do not have a nurse on staff, children could benefit from having a trained nurse who could better tend to emergencies. Another way that combined resources may benefit intergenerational care centers is that they may require fewer employees. Some staff may have roles that serve two purposes, such as an activity assistant could serve both older adults and young children. In the past, a lack of staffing meant that nursing homes and daycares were at risk of reducing their capacity or shutting down entirely (Leonhardt, 2022; Leys, 2023). Combining these services may help lessen the staffing burden, as there would only be a need for one set of administrative staff.
Finally, formulating intergenerational care facilities in rural communities may ameliorate the social isolation and loneliness that many older adults face. Older adults have a higher risk of loneliness due to retirement or living alone, and rural residents have an even greater risk due to barriers such as transportation or lack of broadband access (Henning-Smith, 2020). Older adults in intergenerational care programs or facilities may thrive with opportunities to provide mentorship for young children, such as by reading, demonstrating how to write their letters, or scaffolding activities.
Concerns of Intergenerational Care Centers
Of course, with the benefits of intergenerational facilities, it is also important to recognize potential risks. First, there is the increased risk of the spread of disease where you have populations interacting that are already vulnerable. Second, there is the challenge of safety, where background checks would likely be necessary for adult residents for the protection of the children. Third, there could be a challenge around coverage. While both eldercare and childcare centers often have out-of-pocket costs, Medicaid can provide coverage for some instances of long-term care; however, it is unclear if creating combined centers could impact coverage eligibility. Finally, creating an intergenerational care center or program does not automatically solve the dilemma of transportation or distance for those who live farther away.
Closing Remarks
As rural communities consider innovative ways to meet their aging population and encourage the retention of young families, intergenerational care facilities may need to be an option. The intergeneration care model has been piloted in several communities and benefited both groups participating in the programs. While there are still some challenges to consider, creating more centers utilizing this model may fill a gap in services in rural communities while also providing further incentives to the financial and social benefits still being discovered.
References
Abate, C. (2018, June 15). Here’s what happens when you combine a day care and a nursing home. Healthline. https://www.healthline.com/health-news/what-happens-when-you-combine-day-care-and-nursing-home
Bettenhausen, J.L., Winterer, C.M., & Colvin, J.D. (2021). Health and poverty of rural children: An under-researched and under-resourced vulnerable population. Academic Pediatrics, 21(8S), S126–S133. https://doi.org/10.1016/j.acap.2021.08.001
Carter, E, and Dean, O. (2021, October 26). Rural-urban health disparities among US adults ages 50 and older. AARP Public Policy Institute. https://doi.org/10.26419/ppi.00151.001
Case, A., & Deaton, A. (2015). Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century. Proceedings of the National Academy of Sciences of the United States of America, 112(49), 15078–15083. https://doi.org/10.1073/pnas.1518393112
Davis, J.C., Rupasingha, A., Cromartie, J., & Sanders, A. (2022). Rural America at a glance: 2022 edition. United States Department of Agriculture Economic Information Bulletin, 246. https://www.ers.usda.gov/publications/pub-details/?pubid=105154
Eberhardt, M. S., & Pamuk, E. R. (2004). The importance of place of residence: examining health in rural and nonrural areas. American Journal of Public Health, 94(10), 1682–1686. https://doi.org/10.2105/ajph.94.10.1682
Guevara, H. (2021, October 13). Families in rural communities face acute child care challenges. First Five Years Fund. https://www.ffyf.org/families-in-rural-communities-face-acute-child-care-challenges/
Hartley D. (2004). Rural health disparities, population health, and rural culture. American Journal of Public Health, 94(10), 1675–1678. https://doi.org/10.2105/ajph.94.10.1675
Henning-Smith, C. (2020). Meeting the social needs of older adults in rural areas. JAMA Health Forum, 1(11), e201411-e201411. https://doi.org/10.1001/JAMAHEALTHFORUM.2020.1411
Jansen, T.R. (2016, January 20). The preschool inside a nursing home. The Atlantic. https://www.theatlantic.com/education/archive/2016/01/the-preschool-inside-a-nursing-home/424827/
Jessen-Howard, S., Malik ,R., & Workman, S. (2018, October 31). Understanding infant and toddler child care deserts. Center for American Progress. https://www.americanprogress.org/article/understanding-infant-toddler-child-care-deserts/
Leonhardt, M. (2022, November 15). Staff shortages are crippling childcare centers across the U.S., and that’s only the beginning of the problem. Fortune. https://fortune.com/2022/11/15/staff-shortages-are-crippling-childcare-centers/
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Leys, T. (2023, January 22). Small-town nursing homes closing amid staffing crunch. NBC News. https://www.nbcnews.com/health/aging/nursing-homes-small-towns-closing-staff-shortages-rcna66779
O’Connell-Domenech, A. (2023, January 9). More than 8 in 10 nursing homes face staffing shortages: Survey. Changing America. https://thehill.com/changing-america/well-being/longevity/3809450-more-than-8-in-10-nursing-homes-face-staffing-shortages-survey/
Parker, C.B. (2016). Older people offer resources that children need, Stanford report says. Stanford News. https://news.stanford.edu/2016/09/08/older-people-offer-resource-children-need-stanford-report-says/
Rush, C. (2022, October 12). ‘Desperation’: Child care struggle worsens in rural U.S. Associated Press. https://apnews.com/article/inflation-health-education-covid-child-care-837040ecd097d67aa00c2d178ea0e659
Sharma, H., Xu, L., Ullrich, F., MacKinney, C., Mueller, K. (2022). Nursing homes in rural America: A chartbook. Rural Policy Research Institute. https://rupri.org/2022/07/21/rupri-releases-nursing-homes-in-rural-america-a-chartbook-july-2022/
Stein, E.M., Gennuso, K.P., Ugboaja, D.C., & Remington, P.L. (2017). The epidemic of despair among white Americans: Trends in the leading causes of premature death, 1999-2015. American Journal of Public Health, 107(10), 1541–1547. https://doi.org/10.2105/AJPH.2017.303941
Symens-Smith, A & Trevelyan, E. 2019. The older population in rural America: 2012-2016. United States Census Bureau. https://www.census.gov/library/publications/2019/acs/acs-41.html
United States Census Bureau. (2016, December 8). Measuring America: Our changing landscape. https://www.census.gov/library/visualizations/2016/comm/acs-rural-urban.html
Workman, S. V., & Ullrich, R. (2022, October 19). Quality 101: Identifying the core components of a high-quality early childhood program. Center for American Progress. https://www.americanprogress.org/article/quality-101-identifying-the-core-components-of-a-high-quality-early-childhood-program/
