Duration: 10/01/2018 to 09/30/2023

Administrative Advisor(s):

NIFA Reps:

Non-Technical Summary

Statement of Issues and Justification

A. The need as indicated by stakeholders. That is, how the proposed activity addresses national and/or regional priorities. Authors are requested to identify the appropriate SAAESD Priority Areas to which this activity contributes.
The likelihood of experiencing a minor to a chronic disability increases significantly as one ages. Preventing health problems can allow one to age in place for a longer duration. The environment in which one lives facilitates accessibility; social networks and services can ensure that older adults stay engaged with the community; and, financial resources can be used to make changes or hire help when necessary. Needs of older adults can vary, but by examining the resources in the community in conjunction with the elder’s home environment, older adults can achieve aging in place. Older adults can benefit from individual support based on indicators of wellness that facilitate aging in place, such as the ability to perform activities of daily living. Providing adequate and affordable housing to meet the needs of an aging population is one of today’s major challenges facing rural communities, where the median age is six years higher than in urban areas (U.S. Census Bureau, 2016).

This proposal addresses Goal 5. Enhanced Economic Opportunity and Quality of Life for Americans.

B. The importance and extent of the problem. What would be the consequences if the work were not done?
By 2030, one in five people in the United States (U.S.) will be 60 years of age or older (U.S. Census Bureau, 2014), and by 2060, 98 million will be over 65 (Mather, Jacobsen, & Pollard, 2015; United Nations, 2015). In rural communities, the increasing population of older adults is a critical challenge. Older adults tend to suffer from chronic conditions and have more functional limitations and require an array of medical and health-related goods and services, thereby increasing competition for limited resources at the community and individual level. This project will address the policies and programs that have been, or need to be, developed to accommodate aging in place in rural communities. And, through completion of this project, the concept--aging in place--will be holistically addressed and will advance the body of knowledge related to the phenomena.

C. The technical feasibility of the research.
We seek to answer two basic research questions: (1) What is the opportunity to maintain, remodel, or design high-quality sustainable housing for aging in place in rural communities and (2) What policies and programs provide best practices to promote the creation and implementation of successful aging in place design and initiatives?” We will use extant and primary data to answer these questions.

D. The advantages for doing the work as a multistate effort.
This multistate effort is dedicated to addressing the needs of rural older adults who prefer to age in place. The cross disciplinary team consists of social sciences academics skilled in both qualitative and quantitative methodologies, resulting in peer-reviewed journal articles, presentations, outreach programs, and successful grant proposals. The multistate approach allows use of diverse skills of team members and their affiliated institutions. Extension team members provide an understanding of stakeholder concerns and state and local governmental interventions addressing aging-in-place.

E. Benefits or impacts of the research including impact on science.
The project will advance knowledge of state responses that allow older adults the ability to age in place in rural areas and lay the groundwork for new policies toward accommodating environmental, social and financial factors to age in place. We anticipate that identifying specific programs, policies, and practices will provide information for policy makers to improve the efficiency, effectiveness, and significance of public funding supporting aging in place initiatives in rural places. In addition to policy impacts, the project will provide a foundation for future development of Extension programs to facilitate education at the local level of aging in place.

F. Identify the stakeholders, customers, and/or consumers for which the activity is intended.
Maintaining and improving satisfaction through quality living environments is important for individuals, families, and communities. USDA provides many supports in rural communities, for example, nutrition assistance, single-family modifications, and multifamily and community investments (U. S. Department of Agriculture, 2015). Identifying the programs and policies that can work together to support older adults’ needs have a direct relationship to not only surviving, but thriving as one ages.

Related, Current and Previous Work

This proposal represents a new project. The most significant related research includes yhr following.

Literature Review and Theoretical Background

Aging in Place: Preference
A high proportion of older adults prefer to age in place (Stanford Center on Longevity, 2013) in familiar housing and communities where they have attachments (Golant, 2008; Pynoos, Nishita, Cicero, & Caraviello, 2008). The ability to remain in one’s own home is dependent upon the ability to function in later life (Stanford Center on Longevity, 2013). The demographic shift to an older population in the U.S. is unprecedented, especially in rural communities. An aging population experiences acute issues such as adequacy and affordability of healthcare and housing, and the ability to successfully age in place without risk to health, welfare, and safety. Aging in place, although preferred, may be problematic for older adults living in rural areas with limited access to goods and services in the community, such as medical facilities, emergency services, and a sufficient workforce to provide home health aid.

Aging in Place: Challenges
Age-related chronic diseases often result in physical and mental declines that may result in disablement (Verbrugge & Jette, 1994). The Disablement Process Model describes the pathways among the pathology, impairments, functional limitations (e.g., climbing stairs), and disability. Successful aging in place requires an environment that is amenable to change according to the abilities (Iwarsson, 2005; Lawton, 1989; Lawton & Nahemow, 1973). If the person-environment fit is incompatible, then aging in place will be a challenge or unattainable. Unfortunately, current housing often does not support the needs of older adults who want to age in place in their existing homes, especially those who are living in rural communities (Greiman & Ravesloot, 2016). Older adults’ behavioral competence is evident when their abilities match the environmental demands (Golant, 2003a; Schaie & Willis, 1999). Environmental barriers can lead to increased feelings of disability within one’s home (Stark, 2001) and support at home allows aging in place when one faces health changes (Iwarsson & Wilson, 2006; Oswald, Jopp, Rott, & Wahl, 2011).

There is an interaction between physical and mental health and the residential environment (Golant, 2003a, 2003b). Changes in psychological and physical abilities may be incompatible with the home environment (Iwarsson, 2005; Rothenberg & Koplan, 1990; Verbrugge & Jette, 1994). A concern among individuals, families, health practitioners, policy makers, and researchers is how to assess and modify health-related barriers to aging in place, and its financial burdens. Research has focused on home and community-based services (Tang & Lee, 2010), home modifications (Sabia, 2008), smart technology (Demiris et al., 2004), and home-equity release (Moulton, Loibl, & Haurin, 2017). Additional research has examined place attachment, that is, the psychological bond that a person experiences in relationship to a place and is related to psychological well-being. Lies, Kang, and Sample (2017) identified design features of a home and the surrounding community that supported place attachment for older adults in a rural co-housing community.

Aging in Place: Policy
Policies to assist individuals with aging in place exist, but changes are likely necessary and empirical results will be key for new policy development (Pynoos et al., 2008). Research results indicate that intervention and policy need to be established at the family and community level (Bascu et al., 2014; Bull, Krout, Rathbone-McCuan, & Shreffler, 2001). This will require stakeholder involvement in a sustained, multilevel effort (Bascu et al., 2014).

The World Health Organization (WHO) Age-Friendly Communities Initiative (AFCI) provides a framework of eight dimensions that enable aging in place: (1) outdoor space and buildings, (2) transportation, (3) housing, (4) social participation, (5) respect and social inclusion, (6) civic participation and employment, (7) communication, and (8) community support and health services (World Health Organization, 2007). This framework sets the stage for policy that reflects the complex interaction among the environments and older adults. In the U.S., AFCI is at the early stage of development. Obviously, there is a need to go “beyond” efforts at collecting purely descriptive data in order to formulate appropriate policies and programs of AFCI (Hwang & Ziebarth, 2015). The AFCI has the potential of providing new and important information on implementing current health and housing policies responding to population aging.
Theory
This research uses the Morris and Winter (1978) theory of family housing adjustment to explore how and why people age in place. Families apply six housing norms to their preferences for living conditions: space, tenure, structure type, quality, neighborhood, and expenditure. Space refers to rooms required for activities of daily living. Tenure refers to the right to property usage; the prevailing norm is ownership. Structure type refers to the type of building. Quality norms refer to materials, aesthetics, features, etc., and are generally related to household income. Neighborhood norms include residential character, infrastructure, and social variables. The sixth housing norm, with increasing importance for older adults, is housing expenditures, i.e., affordability. It refers to seniors’ ability to afford housing costs (Joint Center for Housing Studies, 2016). Households are generally considered “housing cost burdened” if they pay more than 30 percent of their monthly income toward housing expenses, and “severely housing burdened” if they pay more than 50 percent of their monthly income toward housing expenses (Stone, 2010). If housing preferences are not met, then families move or modify their residences, or adapt their formal and informal support networks (Morris & Winter, 1978).

The theory of family housing adjustment works well with older adults and aging in place, as norms are operationalized and deficiencies addressed. Each of the housing norms applies as follows. Regarding space, the rooms required for activities for daily living may change as one ages. For example, families may decide that space that was once adequate for a large family may no longer be appropriate for an individual. Space may be allocated for overnight care. And finally, extant space may be altered to facilitate aging in place, including the incorporation of universal design principles. Regarding tenure, ownership is the norm and aging in place allows adults to retain ownership, often remaining in their preferred structure type, that is, most often a single-family home. Regarding quality, owners are able to express personal preferences related to materials and features in their homes. By remaining in one’s home, one remains in the same neighborhood. But, often, when a change of dwelling is preferred, alternative and more appropriate housing options are not available in the same neighborhood or community. Finally, regarding expenditure, remaining in one’s home is usually the less expensive alternative in contrast to moving to costly assisted living facilities or nursing homes.

Objectives

1. Identify and analyze secondary data sources to identify the environmental, social, and financial factors that impact (positive/negative) successful aging in place in rural communities using secondary data
   
2. Collect primary data from key informants to identify and analyze environmental, social, and financial factors that impact (positive/negative) successful aging in place in rural communities using primary data.
   
3. Examine and draft policies and programs that promote successful aging in place in rural communities and encourage inclusive civic participation
   

Methods

The project will employ both quantitative and qualitative research methods using secondary and primary data sources. Below, the data sources and methods of analysis are described.

Secondary data sources to be used include U.S. Census data, the American Housing Survey (AHS) including the special module associated with housing modifications, and other secondary data sources as needed, such as state level data. The AHS dataset contains demographic, housing unit, and neighborhood quality indicators that may address aging in place. The set also provides variables related to housing modifications, and whether respondents experienced difficulties with activities of daily living. Individual state level efforts related to aging in place will be analyzed to understand states’ factors that relate to aging in place. The states examined will be those represented by the research team members’ place of work. The research may first examine states to determine whether some policy exists. Is a policy being implemented? This is important in of itself. Second, if a policy is implemented, what are some key features? Are there commonalities across the states examined? The research may reveal other insights about policy not explored in this proposal.

Primary data will be collected from key informants in each state, primarily Extension educators. They will be approached through a self-completed questionnaire, one-on-one interviews, or focus groups. The questions will be framed to assess factors in their states that impact successful aging in place in rural communities. The research instrument (whether the questionnaire or interview/focus group plan) will include both closed-ended and open-ended questions. Closed-ended question responses will be analyzed descriptively and using statistical analyses such as tests of association and tests of variance. Open-ended question responses will be analyzed using content analysis to identify themes. These data, coupled with the secondary data will be analyzed for opportunities for policies and programs that can improve the well-being of older adults.

Measurement of Progress and Results

Outputs

• Outputs include conducting workshops to gather primary data. Here, researchers would involve participants on the local level, engaging them to gather data that would inform aging in place curriculum. This curriculum that would consist at least of a 45-minute presentation, a 15-minute truncated lesson, a fact sheet, and an evaluation would be of use to educators nationwide. The primary recipient of this effort is the public, that is, end users, and local leaders. Blind peer-reviewed content would include at least four referred journal articles. It is expected that the articles would have national, if not international interest, adding to the body of literature about the aging population. The primary recipient of this is academics, that is, increasing the body of knowledge and policy makers and legislators.

Outcomes or Projected Impacts

• The goal of the project “Aging in Place: Home and Community in Rural America” is to address the opportunities and challenges of creating and sustaining livable rural communities for older residents, operationalized as 65 years of age and over. In our study, we use the term “aging in place” to include home and community-based services to prevent relocation to an institutional setting or to a different community. Features that enable occupants to approach and use their homes independently or with minimal assistance can improve their quality of life. Inaccessible environments in rural settings can negatively impact self-esteem, increase the onset of depression due to isolation and the risks of falls, and increase the involvement of informal and formal caregivers (Pynoos & Nishita, 2003; Satariano, 2006; Stineman, Ross, Maislin, & Gray, 2007). Inaccessible environments can also impede the delivery of home health services, lessen mental and physical health, and intensify utilization of health services (Pynoos, Steinman, & Nguyen, 2010; Stineman et al., 2007). By conducting this research, we aim to identify solutions that avoid institutionalization and improve the quality of life of older adults in rural communities. Figure 1 illustrates a logic model of the research inputs, outputs, and outcomes (impacts).

Milestones

(2018):Will focus on finalizing research questions for Objective 1 determining specific variables from the secondary data sources.

(2019):Will focus on Objective 1 to examine the data for successful aging in place. The research team will submit at least one conference presentation and one manuscript derived from first and second year secondary data analysis

(2020):Will focus on Objective 2 by collecting primary data from key informants in the states. Based on the results from Year 1 and Year 2, instruments for collecting data will be developed. Research will be at the state level in the context of rural places. The research team will submit one conference presentation and one manuscript based on primary data collection and analysis.

(2021):Will focus on Objective 3 and unify the findings from Year 1 through 3. Policy briefs and outreach publications will continue

(2022):Will include a series of workshops with stakeholders to identify and implement practical ways to implement the findings and recommendations from the research. Year 5 will include a final conference presentation and manuscripts

Projected Participation

View Appendix E: Participation

Outreach Plan

As seen in Table 1, the results will be distributed to two key audiences. First, the public includes those that benefit from programming and local leaders. Second, academics and policy makers and legislators will also receive information. Programs, curriculum, and refereed journal articles and conference presentations will provide accessibility to a variety of recipients.

Organization/Governance

All research team officers are elected for at least two-year terms to provide continuity for the project. A USDA assigned Administrative Advisor will provide administrative guidance for the project. The research team members represent states in the south central, southeast, eastern, and north central regions.

Literature Cited

 

Bascu, J., Jeffery, B., Novik, N., Abonyi, S., Oosman, S., Johnson, S., & Martz, D. (2014). Policy, community and kin: Interventions that support rural healthy aging. Activities, Adaptation, & Aging, 38(2), 138-155.

Bull, N., Krout, J., Rathbone-McCuan, E., & Shreffler, M. (2001). Access and issues of equity in remote/rural areas. The Journal of Rural Health, 17(4), 356–359.

Cavanaugh, J. C., Blanchard-Fields, F. (2015). Adult development and aging (7th ed.). Boston: Cengage Learning.

Demiris, G., Rantz, M. J., Aud, M. A., Marek, K. D., Tyrers, H. W., Skubic, M., & Hussam, A. A. (2004). Older adults’ attitudes towards and perceptions of ‘smart home’ technologies: A pilot study. Medical Informatics and the Internet in Medicine, 29(2), 87-94.

Golant, S. (2008). Commentary: Irrational exuberance for the aging in place of vulnerable low-income older homeowners. Journal of Aging and Public Policy, 20(4), 379-397.

Golant, S. M. (2003a). Conceptualizing time and behavior in environmental gerontology: A pair of old issues deserving new thought. The Gerontologist, 43(5), 638–648.

Golant, S. M. (2003b). The urban-rural distinction in gerontology: An update on research. In H. W. Wahl, R. J. Scheidt, & P. G. Windley (Eds.), Annual review of gerontology and geriatrics (Vol. 23, pp. 280–312). New York: Springer.

Greiman, L., & Ravesloot, C. (2016). Housing characteristics of households with wheeled mobility device users from the American Housing Survey: Do people live in homes that facilitate community participation? Community Development, 47(1), 63-74.

Hwang, E., & Ziebarth, A. (2015). Walkability features for seniors in two livable communities: A case study. Housing and Society, 42(3), 207-221.

Iwarsson, S. (2005). A long-term perspective on person - environment fit and ADL dependence among older Swedish adults. The Gerontologist, 45(3), 327-336.

Iwarsson, S., & Wilson, G. (2006). Environmental barriers, functional limitations, and housing satisfaction among older people in Sweden: A longitudinal perspective on housing accessibility. Technology and Disability, 18, 57-66.

Joint Center for Housing Studies. (2016). Older households 2015-2035: Projections and implications for housing a growing population. Cambridge: Harvard University.

Lawton, M. P. (1989). Environmental proactivity in older people. In V. L. Bengston & K. W. Schaie (Eds.), The course of later life: Research and reflections. New York: Springer.

Lawton, M. P., & Nahemow, L. (1973). Ecology and the aging process. In C. L. Eisdorfer, M. P. Lawton (Eds.), The psychology of adult development and aging (pp. 619–674). Washington, D.C.: American Psychological Association.

Lies, M. M., Kang, M., & Sample, R. K. (2017). Place attachment and design features in a rural senior cohousing community. Housing and Society, 44(1-2), 41-63.

Mather, M., Jacobsen, L. A., & Pollard, K. M. (2015). Aging in the United States. Population Reference Bureau, 70(2), 1-23.

Morris, E. W., & Winter, M. (1978). A theory of family housing adjustment. Journal of Marriage and the Family, 37(1), 79-88.

Moulton, S., Loibl, C., & Haurin, D. (2017). Reverse mortgage motivations and outcomes: Insights from survey data. Cityscape, 19(1), 73-98.

Oswald, F., Jopp, D., Rott, C., & Wahl, H. W. (2011). Is aging in place a resource for or risk to life satisfaction? The Gerontologist, 51(2), 238-250.

Pynoos, J., Nishita, C., Cicero, C., & Caraviello, R. (2008). Aging in place, housing and the law. The Elder Law Journal, 16, 77-105.

Pynoos, J., & Nishita, C. M. (2003). The cost and financing of modifications in the United States. Journal of Disability Policy Studies, 14(2), 68–73.

Pynoos, J., Steinman, B. A., & Nguyen, A. Q. (2010). Environmental assessment and modification as fall prevention strategies for older adults. Clinics in Geriatric Medicine, 26(4), 633–644.

Rothenberg, R. G., & Koplan, J. P. (1990). Chronic disease in the 1990s. In L. Breslow, J. E. Fielding, & L. B. Lave (Eds.), Annual Review of Public Health (Vol. 11, pp. 267-296).

Sabia, J. J. (2008). There’s no place like home: A hazard model analysis of aging in place among older homeowners in the PSID. Research on Aging, 30(1), 3-35.

Satariano, W. (2006). Epidemiology of aging: An ecological approach. Burlington, MA: Jones & Bartlett Learning.

Schaie, K. W., & Willis, S. L. (1999). Theories of everyday competence and aging. In V. L. Bengston & K. W. Schaie (Eds.), Handbook of theories of aging (pp. 174-195). New York: Springer.

Stanford Center on Longevity. (2013). Livable community indicators for sustainable aging in Place. Retrieved from https://www.metlife.com/assets/cao/mmi/publications/studies/2013/mmi-livable-communities-study.pdf

Stark, S. (2001). Creating disability in the home: The role of environmental barriers in the United States. Disability & Society, 16(1), 37-49.

Stineman, M. G., Ross, R. N., Maislin, G., & Gray, D. (2007). Population-based study of accessibility features and the activities of daily living: Clinical and policy implications. Disability & Rehabilitation, 29(15), 1165–1175.

Stone, M. (2010). Shelter poverty: New ideas on housing affordability. Philadelphia, PA: Temple University Press.

202. S. Department of Agriculture. (2015). Retrieved from https://www.usda.gov/wps/portal/usda/usdahome?contentid=2015/07/0202.xml

U.S. Census Bureau. (2014). An aging nation: The older population in the United States. Retrieved from https://www.census.gov/prod/2014pubs/p25-1140.pdf

U.S. Census Bureau. (2016). New Census data show differences between urban and rural populations. Retrieved from https://www.census.gov/newsroom/press-releases/2016/cb16-210.html

United Nations. (2015). World population ageing. Retrieved from http://www.un.org/en/development/desa/population/publications/pdf/ageing/WPA2015_Report.pdf

Verbrugge, L. M., & Jette, A. M. (1994). The disablement process. Social Science Medicine, 38(1), 1-14.

World Health Organization. (2007). Global age-friendly cities: A Guide. Retrieved from http://www.who.int/ageing/publications/Global_age_friendly_cities_Guide_English.pdf

 

Attachments

Land Grant Participating States/Institutions

FL, GA, IL, NC, OH, SD, VA, WY

Non Land Grant Participating States/Institutions

Texas - Texas State University, University of Massachusetts/Boston