Stroke is the leading cause of serious long-term disability affecting more than four million people in the United States [1-3]. An estimated 500,000 strokes occur each year in the United States and between 11,000 and 15,000 of those strokes are seen among veterans receiving services through the Department of Veterans Affairs (VA) health system. Approximately 80,000 veterans in the VA system are stroke survivors [4-6]. Research indicates that racial/ethnic variations exist in the incidence and mortality of stroke. African Americans and Latinos have a higher incidence of stroke and greater stroke mortality, especially at younger ages and in the lower socioeconomic tiers [1,7-10]. Latino and African-American stroke patients are twice as likely as Caucasian patients to experience a recurrent stroke within 2 years of their first stroke and have greater residual physical impairment after stroke [11-12]. Within Latino subgroups variations also exist, with higher levels of stroke mortality among Puerto Ricans than Cuban or Mexican Americans . Most stroke survivors are released home, often to informal caregivers, for a period of recovery.
African Americans, Latinos, and other minority groups in the United States often face barriers that restrict their use of health services . After stroke, a variety of health services may be used by survivors, including hospital admissions; speech, occupational, and physical therapy; outpatient clinic visits, and various formal care services in the home. Given that African-American and Latino groups face greater stroke burden and greater poststroke disability, examining patterns of health services use of these groups is important. Using Andersen's Behavioral Model of Health Services Use to guide our research questions, we first investigate the racial and ethnic variation in health service use among stroke survivors in our sample. Second, we examine the degree to which caregiver context is an enabling factor in the use of health services for the veterans in our sample of veterans.
According to Andersen's Behavioral Model of Health Services Use, barriers and facilitators to health service use can be used to explain patterns of utilization . Under this model, three types of factors affect the use of health services: predisposing, enabling, and need. Predisposing factors such as race, age, sex, and education affect whether a particular individual will use health services. Enabling factors can be those that enable or impede health service use, including living arrangements, access to healthcare, income, and social and family support. Need factors are specific to health status and physical/ mental functioning. Individuals with greater impairment need more care and thus may have greater use based on this alone. To our knowledge, no work has explored the role of caregivers as it relates to patterns of health service use. Postacute stroke recovery in the home is often a long-term process, and an important aspect of recovery is the presence of an informal caregiver. A majority of stroke survivors return home for rehabilitation, usually to an informal caregiver who is a spouse, child, or friend. Little is known about the specific role caregivers play in the recovery process for stroke survivors, but some evidence suggests that some of the racial and ethnic variation in poststroke recovery may be mediated, at least in part, by the presence of a caregiver .
Racial/ethnic differences among caregivers for a number of conditions such as Alzheimer disease, dementia, and cancer have been researched in the literature. African-American and Latino caregivers have different attributes when compared with Caucasian caregivers. Latino caregivers are less likely to institutionalize those in their care, or delay institutionalization the longest compared with other racial/ethnic groups . Latino caregivers are also more likely to be family members, and culturally they report a greater sense of duty toward the elderly in their care compared to other racial/ethnic groups [18-19]. …