Journal of Rural Community Psychology               Volume E6   Number 1   Spring 2003

 

Homebound Rural Elderly in Pennsylvania: Health perspectives

 

Jyotsna M. Kalavar  & John Rapano

 

ABSTRACT

 

Homebound seniors in rural communities have been rarely included in gerontological studies. Using personal interviews with 196 homebound seniors in Pennsylvania, this study examined health, depression, and mobility limitations. Results suggested that homebound rural elderly face an array of multifaceted problems that are fairly intricately linked. Besides physical health limitations, the average CES-D score was 17.30 (SD=11.20). The modal profile indicates that homebound rural seniors are likely to be female, middle-old (75-84 years), widowed, with high school education or less, living alone, and with income less than $10,000/year.

Homebound Rural Elderly in Pennsylvania: Health perspectives.

 

In recent years, the explosive growth in the gerontological population of America is unmistakably evident. Rural elderly comprise 24.6% of the nation’s population of people over age 65 (United States Bureau of the Census, 1992). In Pennsylvania, 31.1% of the elderly population resided in rural areas (Pennsylvania State Data Center, 2001). Many rural communities have experienced economic downturns that have left limited resources available for elders. Due to rural depopulation, the proportion of seniors has risen largely due to out-migration of youth and aging-in-place of adults (Krout & Coward, 1998). Despite their growing numbers, very little is known about the rural elderly. Much of the gerontological literature carries an “urban bias”, in that studies have largely focused on non-rural elderly or have focused on an “urban/rural” comparison (Miller, May & Miller, 1998).

 

Some researchers have used the term “rural disadvantagement” when highlighting rural/urban differences on health dimensions (Kivett and Scott, 1979; Nelson, 1980). Rural elderly are among the most at-risk populations for mental health problems Wagenfield, 1990; Buckwalter, Abraham, Smith, & Smullen, 1993), and report more physical illnesses, physical impairments, and disabilities than their urban counterparts (Wagenfield, 1990; Wakefield, 1990). Repeatedly ignored in the rural gerontological literature are those elderly who are homebound seniors. Brickner (1993) has described homebound seniors with terms such as “unknown”, “unreached”, “unsought”, etc. It is not surprising then that homebound adults in rural communities have been rarely included in research studies.

 

Homebound rural senior citizens represent a small but significant subgroup of rural older adults. Living in geographically widespread communities with limited resources, these seniors often experience difficulty with service access and service utilization. Rural environments often offer considerable social supports (Scott & Roberto, 1985; Rowles & Johansson, 1993), but these seniors also endure frequent disparities in the level of quality of these support systems when compared to their urban counterparts. Older adults may rely increasingly not only on kinship and non-kinship networks for informal support but also on formal support systems.

As disability increases, there may be a corresponding change in social, financial, and cognitive forces that may lead to despair, depression, and hopelessness. The degree of success that various systems have in addressing the multifaceted needs of homebound seniors becomes a salient issue in maintaining quality of life. In light of these issues, it is imperative to develop a profile of homebound rural seniors so informed decision-making could occur.

 

Two specific goals guided this project. They included:

To further our understanding of the experience of homebound rural elderly, and

To explore similarities/differences in the experience of being a homebound senior in rural Pennsylvania

Driven by socio-demographics, Fayette, Greene and Schuylkill counties of Pennsylvania were chosen for this study. According to the U.S. Census Bureau (1996), compared to the state average of 15.9% of senior citizens over age 65 in the population, Schuylkill county (20.6%), Fayette county (18.7%) and Greene county (16.7%) rank higher and represent varying proportions of seniors relative to the general population. While Schuylkill and Fayette counties represent different geographical regions for comparative purposes, Fayette and Greene county are located within southwestern Pennsylvania.

 

Formal Services for Homebound Seniors

 

Formal services for homebound seniors in rural communities is a complex enterprise. Often, they have different funding sources, have different levels of coordination or involvement, and even different definitions of who is considered homebound. Adapted from the Pennsylvania Department of Aging definition, recruitment of homebound seniors (age 60 and over) for this project was based on meeting one of the following two criteria:

a) Self-definition of being homebound based on inability to leave the house without the assistance of another individual.

b) A recipient of services delivered at home that may include home delivered meals or home health services based on assessment of 'need.'

It was apparent at the start of this project that the three counties differed with regard to their structure, types of services offered, as well as mode of service delivery (direct services/subcontracted services). To promote a better understanding of such differences, the following section highlights formal service provision in the aforementioned counties.

 

Schuylkill county.  The Schuylkill County Office of Senior Services is a public social service agency designated by the Pennsylvania Department of Aging as a Planning and Service Area (PSA) which involves itself with all issues concerning persons aged 60 and older who are residents of Schuylkill county. This agency promotes a continuum of care designed to assist older persons in leading independent, meaningful and dignified lives in their own homes and communities as long as possible. Further, homebound clients may be eligible for the following assistance: volunteer services, transportation, aide services, nutrition services, skilled services such as R.N. and L.P.N., chore services, and assistance to caregivers.

 

Fayette and Greene counties.  Fayette and Greene counties are part of a multi-county Planning and Service Area (PSA) served by a non-profit social service agency, the Southwestern Pennsylvania Area Agency on Aging, Inc. This agency is responsible for planning and coordinating services for adults age 60 and older in Fayette and Greene counties. Besides several direct services offered by AAA, additional services are offered through 15 subcontracting agencies as well. Examples of direct services include Intake/Referral, Options Assessment, Legal services, Family Caregiver support program, Protective services, Nursing Home Diversion program, PDA waiver program, and Apprise (assistance to Medicare beneficiaries). Other services provided through subcontractors include Home Delivered meals, Personal Assistance service, Personal care, Home support, Care Management, Prime Time Health, Home Health, and Options Intensive In-Home services. With the exception of Home Delivered Meals and Home Health, these Pennsylvania Department of Aging (PDA) services are available to persons who are homebound and meet the services eligibility requirement as determined through the assessment and care management process. In addition to home health services provided through the PDA, home health services are also available through a number of health based organizations throughout this service area.

 

Methodology

 

Sample

 

Formal service providers largely provided access to homebound seniors in all three counties. As formal service providers they are in frequent contact with these seniors, and were judged to be in the best position to invite seniors to participate in this study, offer legitimacy to the project, and seek permission for project personnel (other than service providers) to contact them subsequently. Additional resources for sample recruitment included publicity in county newspapers, referrals from clergy, senior centers, as well as senior housing. Research team members conducted all interviews in the home of the senior.

The sample comprised of 196 homebound rural seniors residing in Fayette (n=100), Schuylkill (n=60), and Greene (n=36) counties of Pennsylvania. Table 1 highlights the profile of this sample, that includes several socio-demographic differences evident between participants of the three counties.

 

As shown in Table 1, the sample was predominantly female (76%). The age distribution for this sample showed variation between counties. For instance, 41.70 % of the respondents in Greene County reported being over 85 years of age, compared to 26.30% in Fayette county and 16.90% of the residents in Schuylkill county. With regard to marital status, fewer married people (16.70%) and more widowed respondents (58.30%) in Schuylkill county than the other two counties. Nearly half the sample had less than 12 years of educational. On average, respondents were most likely to live alone (63.10%), and this figure was higher in Schuylkill county (71.70%) than the other two counties. Most respondents (62.60%) had incomes less than $10,000 per year. Incomes greater than $21,000 was reported highest in Greene county, lowest in Schuylkill county.

 

Of the entire sample, majority of participants were Protestants (57.30%). This figure was highest in Greene county (81.80%). Nearly 55% of the respondents in Schuylkill County reported being Catholic.

 

Interview

 

Trained project personnel conducted the 196 structured interviews at the home of the participant. Besides socio-demographic data, the interview comprised of questions that addressed self-reported health, , depressive symptomatology, and mobility limitations. Health was assessed by the Self-Rate Health Index (Lawton, Moss, Fulcomer, & Kleban, 1982) and the Health Conditions Checklist (Lawton et al, 1982). Mobility limitations was addressed by several questions concerning activities respondents performed within the home. The global question used to assess extent of mobility limitations (“How would you describe your ability to get around within the house?”) was rated on a 3-point scale ranging from ‘hardly restricted’ to ‘severely restricted.’

 

Depressive symptomatology was measured by the Center for Epidemiological Studies- Depression (CES-D) scale developed by Radloff (1977) for use with community populations. This is a 20-item rating scale with scores that may range from 0-60. Higher scores reflect greater depressive symptomatology. A score of 16 or more is considered depressed. Acceptable reliability and validity have been established for the general population by several authors (Radloff, 1977; Weissman, Sholomskas, Pottenger et al, 1977; Ross and Mirowsky, 1984; Snyder, 1987; Hann, Winter, & Jacobsen, 1999).

 

Results

 

Health

 

Overall health ratings for each of the three counties are listed below. These self-reported health ratings of overall health ranged from 1=Poor to 5=Excellent. In Fayette county, the mean rating was 2.15 (SD=.69), compared to the mean rating of 2.34 (SD=.69) in Schuylkill county and the mean rating of 1.92 (SD=.84) in Greene county. Such differences in health rating were found to be significant (F= 3.295)at the p<.05 level.

 

Table 2.  Bivariate associations of health conditions with county of residence

Health Conditions	Fayette county	Schuylkill county	Greene county	X2
	n=100	n=60	n=36	df
	No. (%)	No. (%)	No. (%)	P
Diabetes
Yes	29 (52.7%)	14 (25.5%)	12 (21.8%)	X2=1.20
No	71 (50.4%)	46 (32.6%)	24 (17.0%)	df=2
Hypertension
Yes	52 (48.6%)	32 (29.9%)	23 (21.5%)	X2=1.56
No	48 (53.9%)	28 (31.5%)	13 (14.6%)	df=2
Heart trouble
Yes	52 (58.4%)	17 (19.1%)	20 (22.5%)	X2=11.56*
No	47 (44.3%)	43 (40.6%)	16 (15.1%)	df=2
Paralysis
Yes	14  (51.9%)	5 (18.5%)	8 (29.6%)	X2=3.66
No	86 (50.9%)	55 (32.5%)	28 (16.6%)	df=2
Effects of stroke
Yes	22 (66.7%)	5 (15.2%)	6 (18.2%)	X2=5.003
No	78 (47.9%)	55 (33.7%)	30 (18.4%)	df=2
Arthritis/Rheumatism
Yes	77 (50%)	48 (31.2%)	29 (18.8%)	X2=.304
No	23 (54.8%)	12 (28.6%)	7 (16.7%)	df=2
Stomach ulcer
Yes	15 (46.9%)	7 (21.9%)	10 (31.3%)	X2=4.49
No	84 (51.5%)	53 (32.5%)	26 (16.0%	df=2
Emphysema/Asthma
Yes	27 (64.3%)	9 (21.4%)	6 (14.3%)	X2=3.80
No	73 (47.4%)	51 (33.1%)	30 (19.5%)	df=2
Glaucoma
Yes	10 (55.6%)	4 (22.2%)	4 (22.2%)	X2=2.92
No	90 (50.8%)	55 (31.1%)	32 (18.1%)	df=2
Cataract
Yes	53 (58.9%)	21 (23.3%)	16 (17.8%)	X2=4.93
No	47 (44.3%)	39 (36.8%)	20 (18.9%)	df=2
Tumor/Cancer
Yes	17 (63.0%)	4 (14.8%)	6 (22.2%)	X2=3.68
No	83 (49.1%)	56 (33.1%)	30 (17.8%)	df=2
Liver trouble/Jaundice
Yes	5 (55.6%)	0 (0%)	4 (44.4%)	X2=6.41*
No	95 (50.8%)	60 (32.1%)	32 (17.1%)	df=2
Health Conditions	Fayette county	Schuylkill county	Greene county	X2
	n=100	n=60	n=36	df
	No. (%)	No. (%)	No. (%)	P
Gall bladder trouble
Yes	9 (50%)	2 (11.1%)	7 (38.9%)	X2=6.975*
No	90 (50.8%)	58 (32.8%)	29 (16.4%)	df=2
Kidney trouble
Yes	19 (65.5%)	5 (17.2%)	5 (17.2%)	X2=3.41
No	81 (48.5%)	55 (32.9%)	31 (18.6%)	df=2
Circulation/Hardening arteries
Yes	49 (48%)	32 (31.4%)	21 (20.6%)	X2=.982
No	51 (54.3%)	28 (29.8%)	15 (16%)	df=2
Broken hip
Yes	3 (50%)	0 (0%)	3 (50%)	X2=5.26
No	97 (51.1%)	60 (31.6%)	33 (17.4%)	df=2
Broken bones
Yes	10 (45.4%)	7 (31.8%)	5 (22.7%)	X2=.419
No	90 (51.7%)	53 (30.5%)	31 (17.8%)	df=2
Anemia
Yes	19 (55.9%)	8 (23.5%)	7 (20.6%)	X2=.975
No	81 (50%)	52 (32.1%)	29 (17.9%)	df=2
Parkinson's disease
Yes	3 (100%)	0 (0%)	0 (0%)	X2=2.955
No	96 (50%)	60 (31.3%)	36 (18.8%)	df=2
Insomnia
Yes	54 (53.5%)	27 (26.7%)	20 (19.8%)	X2=1.50
No	46 (48.4%)	33 (34.7%)	16 (16.8%)	df=2
Nervousness
Yes	52 (55.9%)	20 (21.5%)	21 (22.6%)	X2=7.33
No	48 (46.6%)	40 (38.8%)	15 (14.6%)	df=2
Note: Because of missing data, sums do not always equal totals
*p<.05

 

As noted in Table 2, self-reported health conditions are listed by county of residence. For instance, heart trouble was more likely to be reported by participants in Fayette than Greene or Schuylkill counties. Statistically significant results from Chi-square tests (p<.05) for differences in health status was found between counties. Such differences were noted with health conditions such as heart trouble, liver trouble, gall bladder and nervousness or tension.

 

Center for Epidemiology-Depression (CES-D) Scale

 

As noted in Table 3, a mean score of 17.30 (SD=11.20) was noted for the entire sample on the CES-D scale. CES-D scores varied significantly between counties. The mean score in Fayette county was 15.77 (SD+11.71), 16.35 in Schuylkill county (SD=9.10), and 23.13 (SD=11.33) in Greene county, F=6.370, p<.001. Correlations between CES-D total score and age (r= -.208, p<.01) as well as with overall health rating (-.422, p<.001) were both statistically significant and negative.

 

Table 3.  Mean scores and Standard deviation of CES-D scores by county

	MEAN	SD
Fayette county	15.77	11.71
Schuylkill county	16.35	9.10
Greene county	23.13	11.33
TOTAL	17.30	11.20

 

 

Table 4.  Analysis of Variance for CES-D scores by county of residence

Source of variation	SS	df	MS	F
Between groups	1515.74	2	757.78	6.370*
Within groups	22959.67	193	118.96
Total	24475.240	195

*p<.01

 

Nearly half of the participants (45.1%) reported having a score higher than 16 on the CES-D. A score of 16 is considered to be suggestive of depression in community populations. This included 69.7% of participants in Greene county, 43.6% of respondents in Schuylkill county, and 43% of the sample in Fayette county.

 

Analyses of Extent of Mobility Limitations

 

For the entire sample, the extent of mobility limitations was significantly correlated with total CES-D score (.248, p<.05), age (.180, p<.01), and overall health rating (-.22, p<.002). Female respondents expressed more limitations than male respondents (-.158, p<.02) and those who lived with others had more mobility limitations (.212, p<.05) than those who lived alone.

 

Discussion

 

Results show that in all three counties studied, there is considerable overlap in the experience of being a homebound rural senior. Specifically, the modal profile indicates that members of this group are likely to be female, middle-old, widowed, with high school education, at-risk for depression, report one or more health limitation, and with incomes less than $10,000/year.

 

We cannot treat homebound rural elderly as a homogenous population. Rural elders are diverse in their health care needs and service utilization. Despite the above listed modal profile, this study demonstrated that there are differences between counties on socio-demographic indicators, health indicators, as well as self-reported health ratings. This may reflect not only health status differences in the population under study but also differences in service resources and mode of service provision between counties. For instance, Fayette county has several aging service providers, compared to one lead agency in each of the other two counties. In Schuylkill county, the singular Office of Senior Services involves itself with all issues concerning persons 60 and over.

 

It is generally agreed that depression is the most common nonorganic mental disorder among persons aged 65 and older (United States Congress, 1990; Willis, 1993). The CES-D scale (Radloff, 1977) was intended for use in community studies to screen for clinically significant depressive symptomatology. Depressive symptomatology meeting the CES-D threshold are very prevalent in this sample of homebound rural seniors. The finding that depressive symptoms were associated with functional or mobility limitations is consistent with previous research (Hybeles, Blazer, and Pieper, 2001; Beekman, Deeg, Braam, Smit & Van Tilberg, 1997). Does depression lead to mobility limitations or is this vice versa? Given the cross-sectional nature of this research data such questions remain unanswered. While there is no evidence that rural populations have less mental illness than urban counterparts (Conger, 1993), stigma about mental health and seeking treatment may be greater in rural areas (Rohland & Rohrer, (1998). While such an examination was beyond the scope of this study, this highlights the need for increased research in rural mental health.

 

To determine the best match between available resources and the needs of the individual, it is necessary to listen to the individuals in this target population. Information should not be gathered by representatives of the organizations who serve them, and who will ultimately be involved in decisions that may be involved in the transition from independence to more restrictive long term care living situations. In reaching the target population in the three counties, it was necessary to rely largely on service providers to provide access to subjects. It is not clear how much this contributed to a ‘selection bias’ in our sample.

 

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Author Note

 

This project was made possible by a grant from the Center for Rural Pennsylvania, a legislative agency of the Pennsylvania General Assembly.

 

A preliminary version of this paper was presented at the 1st International Conference on Rural Aging, Charleston, WV (June 2000).

We would like to express our sincere appreciation to Kerry Grimm, Noreen Hobbs, Tesha Honse, Cynthia Olavsky, and Valarie Washington for their assistance with the research project.

 

Address correspondence to Dr. Kalavar at: Penn State University (New Kensington campus), 3550 7th Street, Upper Burrell PA 15068 Email: jmk18@psu.edu