Homebound Seniors in Rural Communities:

Recruitment Challenges & Emerging Themes

Jyotsna M. Kalavar, Ph. D. & John Rapano

Penn State University

ABSTRACT

Homebound seniors are an “invisible” segment of the gerontological population in rural communities. This study was based on interviews conducted with 196 homebound seniors in Fayette, Greene, and Schuylkill counties of Pennsylvania. First, this paper focuses on varying approaches employed to recruit this “hard to reach” population. Next, challenges faced by the research team with actual conduct of the interviews are mentioned. Last, this paper examines the qualitative data from the structured interview conducted in-home. These open-ended questions sought to understand the experience of being homebound, as well as issues of formal service provision.Findings suggest that homebound seniors perceive their situation negatively. Nearly half of all seniors suggested an improvement in advertising of services that are offered. Nearly one-third of all respondents did not indicate a need or desire for services.Yet, when probed about a desired program, nearly half of the participants suggested a visitation or socio-recreational program.

One of the more important social trends over the last several decades has been the demographic change that reflects the "graying of America." It has been estimated that one-quarter of those aged 65 and older live in areas defined as rural, and that 20% of Americans over age 65 are homebound (Smicklas-Wright, Lago, Bernardo, and Beard, 1990).While homebound rural seniors represent a significant subgroup of rural older adults, they are repeatedly ignored in the gerontological literature.

Homebound rural elderly are difficult to identify, live in geographically dispersed communities (often with a limited tax base) with limited access to services, and face many formidable challenges compared to their urban counterparts. Homebound rural elderly have been described with terms such as "unknown", "unsought", "unreached" (Brickner, 1993). It is not surprising then that rural homebound elderly have been rarely included in gerontological research.

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.'

This project aimed to increase our understanding of the "culture of homebound rural elderly" by examining the experiences of homebound rural seniors in three selected counties of Pennsylvania. The first part of this paper will describe the recruitment challenges as well as approaches employed to access this "invisible" gerontological population. The second part of this paper will focus on the seniors’ narrative regarding their homebound experience.

Recruitment Challenges

Area Agencies on Aging

We began with initial contact established with the respective Area Agencies on Aging (AAA) that administer home care services to the three counties. These AAA may be limited to a single county or may extend their boundaries to a multi-county service area. They may offer a complete range of services to homebound seniors directly, or may subcontract part or all of the services offered to this population.

Initial meetings were held with agency personnel to describe the purpose, and significance of the project. Their input regarding optimal recruitment strategy with this population was considered. A subsequent meeting was held with the home care service staff that had direct contact with the homebound senior. It was decided that the staff that came in direct contact with homebound seniors would informally introduce the project, and describe the salience of participation. By staff introducing the proposed study, the project gained legitimacy in the eyes of the seniors. These homebound seniors interacted regularly with the home care staff enough to know them beyond acquaintanceship.

Following the informal introduction to this proposed project, home care staff distributed papers describing the project, and inviting the senior to participate in this. Two handouts were developed in conjunction with project personnel and AAA staff. One, a fact sheet (large font size) that provided answers to questions that we anticipated these homebound seniors may have. For instance, " How do I know that you are not trying to sell me something or that you are real?", "What are the questions about?" "What is the catch? Where is the $20 payment coming from?."This fact sheet addressed the above questions by providing legitimate contact names and telephone numbers of project personnel and relevant AAA personnel. Assurances regarding confidentiality of responses, voluntary nature of participation, and presentation of group results was provided. Two, a second sheet offered seniors an opportunity to participate in this described project. Seniors were requested to choose one of two options: decline to participate or agree to be contacted by project personnel. Those who chose the latter option were further requested to provide their name and contact telephone number. Home care service staff then arranged for the entire package of sheets to be forwarded periodically to the research project coordinator. This was an ongoing process that spanned over a five-month period.

Only those seniors who confirmed interest in being contacted were considered for possible inclusion in this study. The Research Coordinator then followed-up with a telephone call to the senior who expressed interest in project participation. This provided an opportunity to further explain the proposed project, answer questions, as well as make arrangements to schedule an in-home interview. Of nearly 450 sheets that were circulated, a positive response rate of 33% was initially received for this rural homebound population. It was clear that alternate strategies had to be employed to get close to a sample of 200 homebound seniors.

Media

Through press releases from the university campus, publicity for this project was sought in the local community. Three different newspapers featured an article regarding the funded project, the salience of participation in this endeavor, and to ensure that "voices were heard." The published articles also included contact names and telephone numbers of project personnel. Around this period, the Principal Investigator also participated in a television interview as part of a campus promotion program on the local television channel. This interview was replayed on several occasions. Many homebound seniors spend several hours watching television. It was learnt later that many of their television viewing choices are limited to a few channels, and many participants had made a name-face connection with the Principal Investigator.

Community

Local churches in these communities were contacted to provide referral names of homebound seniors known to their congregation. This was also done to ensure that we could get a sample of homebound seniors who may or may not be serviced by formal services within the county. On occasion, homebound seniors would provide names and telephone numbers of other ‘homebound seniors’ that they knew. The next step was to contact managers of senior housing within the community. They were briefed about the research project, and permission was sought to post flyers in high-traffic areas as well as clear visibility within the housing complex. Further, a letter describing the project was sent to the local sheriff or chief of police in each county explaining the general purpose of the study, its' importance, the organization sponsoring the study, the time frame, and names of project personnel. Such an update was necessary so they could legitimize the project as well as allay any fears that potential participants may express to them.

With these multi-approaches employed, the project team was able to enlist 196 homebound seniors to participate in this study. However, there were further challenges with conducting the in-home interviews. Since they were homebound seniors, we expected that they would have great flexibility and large blocks of time available in their daily schedule. Instead, it turned out that many of them took long afternoon naps or were very late risers. Also, a significant portion of their daily schedule featured formal or informal home health care services that they received. Many of these seniors live in remote, isolated rural neighborhoods. Several streets had no names posted, and directions provided were based on unique neighborhood features such as “a particular tree at the junction”, etc. Consequently, more time was spent in figuring out the location than had been originally anticipated.

Participants in this study received either a $20 gift certificate redeemable at a local store or a check for $20 that was subsequently mailed to them. While this incentive sparked the interest of some participants, many of them were appreciative of the plain opportunity to have human contact as well as express their concerns. Many seniors were so grateful to have a “new visitor” that project personnel often spent additional time socializing after the research interview.

Emerging Themes of the Homebound Experience

Sample

The sample comprised a total of 196 homebound rural seniors from Fayette, Greene and Schuylkill counties of Pennsylvania. Of the 196 participants in this study, 76% were female respondents. A majority of the homebound seniors were widowed (54.6%), while those who reported being married were 24.5% of the population. Nearly 83% of this population reported an education level of 12 years or below. Participants were most likely to be living alone (63.1%), followed by living with spouse (24.1%). Majority of respondents (85.6%) reported an annual income below $15,000.

The project interview included four open-ended questions designed to learn more about how senior respondents felt about being homebound and their views on formal services. The discussion below focuses on the main themes that emerged when these responses were analyzed. This was defined as themes when mentioned by at least five respondents. Minor themes, which were mentioned by fewer than five respondents, are not discussed.

Open-Ended Questions

1.What is your experience of being homebound?

2.There are many services out there for homebound seniors like you. How could such services be made available so more people can use them?

3.Are there services out there that you do NOT use? And, why not? What would it take for you to use these services?

4.If you could create one program for homebound seniors, what would that be?

The first open-ended question was, “What is your experience of being homebound?” A total of 190 respondents had some type of response to this question. The fourteen main themes emerging from their responses are shown below. Some respondents mentioned multiple themes in their responses, while others mentioned just a single theme.

Many respondents had very negative views about being homebound. Over one-fourth of the respondents (28%) said in ways varying from one person to another that they missed getting out and doing things. Respondents mentioned missing the outdoors, traveling, driving, and going to church. One-eighth of the respondents (12%) indicated they were depressed. Some respondents mentioned feeling “miserable,” “terrible,” or wanting to die. More than one-tenth of the respondents (11%) said they were lonely. Respondents mentioned feeling cut off and missing their spouse and friends. One-tenth of respondents (11%) indicated feeling frustrated or angry about their situation. Seven percent of respondents said that they missed being independent, while four percent said that being homebound was a boring existence. One-tenth of respondents (11%) said simply that they did not like being homebound.

Table 1

Themes in response to the question, “What is your experience of being homebound?”

 Main Themes

Number of Respondents Mentioning Theme

Percent of Respondents Mentioning Theme

I miss getting out and doing things

53

28%

I accept it and I’ve adjusted to it

35

18%

I’m depressed

23

12%

I’m lonely

21

11%

It’s part of life¾what can you do?

21

11%

I don’t like it

20

11%

I’m frustrated and angry

20

11%

I miss being independent

13

7%

Family members help out

12

6%

I still get out and do things

10

5%

It’s boring

7

4%

I’m happy

5

3%

I’m thankful it’s not worse

5

3%

I don’t feel homebound

5

3%

On the other hand, more than one-sixth of the respondents (18%) said that they accepted being homebound and that they have adjusted to it. About one-tenth of respondents (11%) said that being homebound is part of life, and that nothing can be done about it. Six percent of respondents indicated that children and other family members help out by running errands, doing household chores, or providing emotional support. Five percent of respondents mentioned that they still get out and do things. Three percent of respondents reported that they were happy. Another three percent said they were thankful that their situation was not worse. Three percent also said that they did not really feel homebound.

 The second open-ended question was, “There are many services out there for homebound seniors like you. How could such services be made available so more people can use them?” A total of 175 respondents had some type of response to this question. The seven main themes emerging from their responses are shown below. Again, some respondents mentioned multiple themes in their responses, while others mentioned just a single theme.

Nearly one-half of the respondents (46%) said that the services should be advertised and that service providers should get the word out. These respondents appeared to interpret the question as one pertaining to awareness of services rather than to availability or access. Respondents mentioned advertising through TV, radio, newspapers, the mail, bulletin boards, and flyers. They also mentioned getting the word out through senior centers, community centers, the meals-on-wheels program, doctor’s offices, churches, and word of mouth. In a related theme, ten percent of respondents said that they or other seniors are not aware of all the services that exist.

Table 2

Themes in response to the question, “There are many services out there for homebound seniors like you.How could such services be made available so more people can use them?”

 Main Themes

Number of Respondents Mentioning Theme

Percent of Respondents Mentioning Theme

Advertise, get the word out

81

46%

Not sure

34

19%

People aren’t aware of the services that exist

17

10%

Better transportation

13

7%

People should call or write to find out more       about available services

8

5%

I’m dissatisfied with the services I’ve used

7

4%

I’m satisfied with the services I’ve used

6

3%

Seven percent of respondents said that transportation should be improved. Some indicated that transportation is not available to them, while others said that public transportation schedules are limited.

Some respondents used this question as an opportunity to provide their views on the quality of services they had used. Four percent said they were dissatisfied with the services they had used, while three percent said they were satisfied. About one-fifth of the respondents (19%) were not sure about an answer to this question.

The third open-ended question was, “Are there services out there that you do NOT use? And, why not? What would it take for you to use these services?” A total of 180 respondents had some type of response to this question. The nine main themes emerging from their responses are shown below. As before, some respondents mentioned multiple themes in their responses, while others mentioned just a single theme.

Table 3

Themes in response to the question, “Are there services out there that you do NOT use? 

And, why not? What would it take for you to use these services?”

 Main Themes

Number of Respondents Mentioning Theme

Percent of Respondents Mentioning Theme

I have no need or desire for services

59

33%

People aren’t aware of the services that exist

31

17%

Services are inconvenient and waiting lists are      too long

18

10%

I don’t know of any services I don’t already      use

16

9%

Need transportation

15

8%

I’m not physically able to use services

15

8%

I can’t afford services

6

3%

I use services already

6

3%

Not sure

6

3%

One-third of the respondents (33%) said that they do not have a need or desire for services. Some respondents indicated that family members take care of their needs. Others said that they dislike large crowds, do not like to socialize, or feel that senior centers are dominated by “cliques” and gossiping.

About one-sixth of the respondents (17%) said that they or other seniors are not aware of all the services that exist. One-tenth of the respondents (10%) indicated that services are inconvenient or that waiting lists are too long. With respect to convenience, respondents complained about inconvenient and inconsistent pick-up times, having to call a day in advance for transportation, and that using services is too much trouble.

About one-tenth of respondents indicated that they did not know of any services out there that they did not use already. Eight percent of respondents said they needed transportation in order to make greater use of services.

The fourth open-ended question was, “If you could create one program for homebound seniors, what would that be?”A total of 176 respondents had some type of response to this question. The seven main themes emerging from their responses are shown below. Although the question asked respondents to name just one program, some respondents mentioned more than one type of program in their responses, while others mentioned just a single program.

Table 4

Themes in response to the question, “If you could create 

one program for homebound seniors, what would that be?”

 Main Themes

Number of Respondents Mentioning Theme

Percent of Respondents Mentioning Theme

Visitation program

38

22%

Social and recreational activities

37

21%

Don’t know

32

18%

Help with housekeeping and errands

28

16%

Better transportation

23

13%

Religious activities

11

6%

There’s no need for any new program

5

3%

More than one-fifth of the respondents (22%) said they would create some type of visitation program. Respondents said that such a program would alleviate loneliness and boredom, as well as help seniors to keep their minds active. It would also permit someone to check up on the homebound periodically to see how they were doing. More than one-fifth of respondents (21%) also said they would create social or recreational activities programs. Activities mentioned by respondents included get-togethers, knitting, music, arts and crafts, games, and trips to the mall. About one-sixth of respondents (18%) did not know what type of program they would create.

About one-sixth of respondents (16%) said they would create a program to provide help with housekeeping and errands. Respondents mentioned that they could use help with cooking, cleaning, repairs, and snow removal. About one-eighth of respondents (13%) indicated that they would improve transportation services. Respondents felt that public transportation should be more convenient and more frequent.

Six percent of respondents said they would create some type of religious activities program. Three percent said that existing programs were sufficient and that there was no need for any new program.

DISCUSSION

Homebound seniors in rural communities are a difficult group to identify. It is not surprising then that very sparse information is available on this group. The issue of services for the homebound rural elderly is greatly hampered by the lack of data regarding their needs. In order to be successful in reaching their goals, programs and services in rural communities should target the needs of this gerontological population.

Numerous homebound elderly perceive their situation negatively. This is not surprising since many studies have shown that rural elders experienced more symptoms of depression and loneliness (Nyman, Sen, Chan & Commins,1991),higher suicide rates (U. S.Congress, 1990) and cognitive impairment (Blazer, George, Landerman, Pennybacker, Melville, Woodbury, Manton, Jordan & Locke,1985)than their urban counterparts. This may not only reflect isolation experienced in rural communities but also the continuing emphasis on service recipients as “needy people. ” Many respondents stressed loneliness, depression, and lack of mobility as result of being homebound.

Many of the homebound seniors believe that they are not aware of services that are available to them. According to Neese & Abraham (1997), even though the need for services is high among rural seniors, their service utilization rates tend to be low. The multitude of service providers, with separate organizations providing care management, home-health services, in-home services, home delivered meals, and volunteer services appear to foster this perception. It remained unclear whether respondents were unwilling to comment freely on current services for fear of losing them or whether they did perceive many of their needs being met.

If we are to maintain elderly adults in the community, the challenge from a service delivery perspective is to provide appropriate services that directly address their needs. That is, differentially sensitive models of rural service programs must be developed.As this project suggests, the development of social visitation programs could improve the quality of life for homebound elderly in rural isolated communities.As suggested by Eller (1992), it may behoove us to consider with each rural community the development of a “civic” infrastructure - a sense of communal social responsibility with intergenerational overtones.Such a partnership should not only serve the care recipient but also utilize the assets of the rural homebound individual as a contributing member of the community.

REFERENCES

Blazer, D., George, L. K., Landerman, R., Pennybacker, M., Melville, M. L., Woodbury, M., Manton, K. G., Jordan, K., & Locke, B. Z.(1985).Psychiatric disorders: A rural/urban comparison. Archives of General Psychiatry, 42, 653-656.

Brickner, P. W.(1993). Finding the unreached patient. JAMA, 225:1645.

Eller, R. D.(1986, October). Appalachia: Still waiting for spring. Seeds, pp12-15.

Neese, J. B., & Abraham, I. L.(1997). Cluster analysis of psychogeriatric characteristics and service use among rural elders.Issues in Mental Health Nursing, 18, 1-18.

Nyman, J. A, Sen, A., Chan, B. Y., & Commins, P. P.(1991). Urban/rural differences in home health patients and services.The Gerontologist, 31, 457-466.

Smiciklas-Wright, H., Lago, D. J., Bernardo, V., & Beard, J.(1989).Nutritional assessment of Homebound Rural Elderly. Paper presented at the American Institute of Nutrition Conference in Charleston, SC.

Author Note: This project was made possible by a grant from the Center for Rural Pennsylvania, a legislative agency of the Pennsylvania General Assembly.An earlier version of this paper was presented at the annual meeting of the Gerontological Society of America in San Francisco, November 1999.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. J. Kalavar, Penn State University (New Kensington) , 3550 7th Street , Upper Burrell 15068 Email: jmk18@psu. edu