530046 research-article2014
WJNXXX10.1177/0193945914530046Western Journal of Nursing ResearchGoris et al.
Research Report
Community Leader Perceptions of the Health Needs of Older Adults
Western Journal of Nursing Research 2015, Vol. 37(5) 599–618 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0193945914530046 wjn.sagepub.com
Emilie Dykstra Goris1, Debra L. Schutte2, Jamie L. Rivard3, and Brian C. Schutte3
Abstract The purpose of this needs assessment was to determine community leader perceptions of health-related needs and resources available to rural-dwelling older adults as part of a community–academic partnership in the rural Midwest. A community advisory board, in accordance with community-based participatory research principles, was influential in study design and implementation. Key informant interviews (N = 30) were conducted with community leaders including professionals from schools, businesses, churches, and health care as well as government officials. Thematic analysis revealed “Family Is Central,” “Heritage,” “Strength,” and “Longevity” as important themes related to older adults and their health care needs within the community. “Close-knit” and “Church Is Central” were also identified as important aspects of elder care. Community leaders perceived the “Rural Economy,” “Distance to Resources,” and “Seasonal Resources” as significant barriers for older adults. This work contributes important insights into community leaders’ perceptions of health needs and challenges faced by older adults in rural settings. Keywords community-based participatory research, community needs assessment, geriatric 1Hope
College, Holland, MI, USA State University, Detroit, MI, USA 3Michigan State University, East Lansing, MI, USA 2Wayne
Corresponding Author: Emilie Dykstra Goris, Assistant Professor, A. Paul Schaap Science Center, Department of Nursing, Hope College, Holland, MI 49422-9000, USA. Email: [email protected]
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The number of older adults, many with complex health care needs, dwelling in rural communities is rapidly increasing. U.S. Census data demonstrate that individuals 65 and older make up about 13.1% of the population, and approximately 20% of these elderly Americans dwell in non-metropolitan designated areas (U.S. Department of Health and Human Services [HHS], 2013b). To that end, the United States is projected to experience continued growth of its older population at a rapid rate, with an estimated 88.5 million Americans aged 65 and older in the year 2050 (U.S. Census Bureau, 2010). The health care system and practitioners involved in community health initiatives must make appropriate adjustments to promote wellness among the growing population of rural elders. The U.S. HHS has recognized this need and included several objectives related to improving the health of older adults in the HHS, Healthy People 2020 Goals (U.S. HHS, 2013a). These objectives encompass both prevention and long-term services and supports in an effort to reduce health care barriers and increase quality of life among older adults. Specific initiatives include efforts to coordinate care, assist older adults in organizing care management, establish quality measures, and provide appropriate training for caregivers and health care providers in relationship to the unique health care needs of older adults (U.S. HHS, 2013a).
Health Needs of Rural Elders Barriers to health and health care commonly faced by older adults may be compounded in a rural setting, where distance from larger cities or metropolitan areas further limits access to health care products or services. Approximately 20% of Americans, or 59 million individuals, live in rural communities with fewer than 2,500 residents (U.S. Census Bureau, 2013). Among persons dwelling outside metropolitan or micropolitan statistical areas, about 17% are persons aged 65 years and older, and 2.2% are persons aged 85 and older (Werner, 2011). Health care provision may be particularly difficult in rural settings, due to limited access to medical specialists and primary health care providers, often practicing as generalists, with relatively higher workloads than their urban counterparts due to a relative shortage of health care providers in rural settings (Fordyce, Chen, Doescher, & Hart, 2007; Thornlow, 2008; Weeks & Wallace, 2008). Rural older adults have higher rates of overweight/obesity and physical inactivity, as well as fewer healthy food choices than older adults living in suburban areas, putting them at risk of heart disease, diabetes, and falls (Durazo et al., 2011). In addition, rural-dwelling older adults frequently experience greater limitations in daily activities secondary to chronic illness (Thornlow, 2008). Accessing care for chronic disease may be difficult for rural elders due to limited transportation,
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necessity of private vehicles, and geographic distance to services (Wilcox, Castro, King, Housemann, & Brownson, 2000). Rural-dwelling older adults currently working in agriculture or retired from agricultural work, which is common in rural areas, may suffer consequences of accumulated occupational exposures from toxic substances commonly used in the agricultural industry. For example, a number of studies have demonstrated increased risk of several cancers among agricultural populations (Blair & Freeman, 2009). Weeks, Wallace, Wang, Lee, and Kazis (2006) found that veterans dwelling in rural areas experience higher disease prevalence and lower physical and mental quality of life scores than an urban veteran population, when comparing 30 physical health disease categories based on International Classification of Disease (ICD)–9-CM codes (Weeks et al., 2006). Similarly, Kovac, Mikuls, Mudano, and Saag (2006) examined health disparities among persons with self-reported arthritis and verified that health disparities exist between rural- and urban-dwelling participants. Kovac further noted that these health disparities were unequally distributed along racial lines, with rural Caucasians exhibiting the lowest health-related quality of life in that study (Kovac et al., 2006). In a study of self-rated health among older adults in rural Appalachia (N = 236), only 26.1% of the participants rated their health as excellent or good, while 40.1% and 33.8% of the participants rated their health as fair or poor, respectively (Steele, Patrick, Goins, & Brown, 2005). Rural/non-rural disparities in health-related quality of life may be partially explained by differences in income, obesity, and joint disease in rural areas (Miles, Proescholdbell, & Puffer, 2011). Health disparities can also be attributed to environmental and other risk factors that may be more prevalent in rural settings (Durazo et al., 2011). For example, rural elders may face unique barriers to physical activity including lack of sidewalks, street lights, and exercise facilities (Wilcox et al., 2000). They may also be more reliant on family members for care provision or transportation to health care services (Borowiak & Kostka, 2013; Magilvy, Congdon, Martinez, Davis, & Averill, 2000) or suffer from social isolation and loneliness (Averill, 2002). Given these characteristics, rural-dwelling older adults are important targets for health research and community health initiatives. However, physiologic changes accompanying aging, prevalence of chronic illness and medication use, distrust, or transportation issues may make it more difficult to recruit rural-dwelling older adults for research participation (Dibartolo & McCrone, 2003). A high-quality health needs assessment can play an important role in identifying the needs of older adults, prioritizing these needs into communitybased research and practice initiatives, and conducting research and practice initiatives in a manner that honors community values and builds on present
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strengths. Community leaders can provide a unique perspective related to the health of older adults from within the community. For example, key informants from various community sectors provided important perspectives related to elders at the U.S.–Mexico border (Guo & Phillips, 2006). Guo and Phillips (2006) used community leader perspectives to develop a conceptual framework for educational programs and research endeavors to be utilized by health professionals caring for elders at the border. Overall, however, there is limited current information available related to the specific health needs of older adults from a within-community perspective, particularly in the rural Midwest. This article describes a community health needs assessment related to older adults from the perspective of community leaders and was completed as part of a larger community–academic health research partnership in a rural Midwestern community, using the principles of community-based participatory research. The long-term goals of the parent study are to develop innovative community- and individual-level interventions to promote community health and well-being, positively affecting both older adults and broader members of the partner community. This analysis was conducted within a broad community needs assessment of the partner communities (Schutte, Goris, Rivard, & Schutte, 2014). Results of this work and the broader needs assessment will be used to develop, prioritize, and implement a communitydriven research agenda.
Purpose The purpose of this study was to determine community leader perceptions of health-related needs and resources available to older adults using a qualitative approach. Research questions addressed in this analysis include the following: Research Question 1: How do community leaders describe older adults and their health care needs within the community? Research Question 2: What health resources are targeted toward older adults within the community? Research Question 3: What barriers do older adults face in accessing health care? Research Question 4: What resources would promote independent living for older adults?
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Method Design A qualitative approach, using thematic analysis methods (Braun & Clarke, 2006), was utilized to evaluate qualitative data generated through individual face-to-face interviews. The Institutional Review Board of the academic partner approved the study, and methods to secure protection of human subjects were followed throughout. Participants were volunteers and were aware of their right to terminate the interviews at any time. A particularly vital aspect of well-conducted community-based participatory research is the inclusion of and partnership with a community advisory board (Minkler & Wallerstein, 2008). These boards are composed of community members sharing a common identity, history, and culture (Strauss et al., 2001). Because this group is made up of individuals from the same community as participants, the community advisory board serves as a liaison between participants and researchers, facilitating research by advising about the informed consent process, study implementation, and design (Strauss et al., 2001). This is particularly important if researchers aim to build trust to conduct research within a community where members perceive a lack of community control or influence on the research process (Kingsley, Phillips, Townsend, & Henderson-Wilson, 2010). A community advisory board, namely, the Research Advisory Committee (RAC), made up of 16 community members, reviewed all aspects of this study design, including implementation procedures.
Sample and Setting The partner community is made up of three rural villages, spanning a 90 square mile area in the upper Midwest. The populations of the three villages range from 470 to 1,209 residents and exist in largely non-metropolitan areas characterized by open countryside, rural areas, and surrounding urban area populations ranging from 2,100 to 49,999 people (U.S. Department of Agriculture, 2013). The sample consisted of community leaders recruited from the three villages, representing the school, business, church, health care, and government sectors. Purposive and network sampling were used to identify leaders from each sector from all three villages and to achieve balance by gender and across age groups. Members of the RAC were asked to provide a list of people whom researchers should contact, while other informants were
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identified by word-of-mouth from previous community leaders. Face-to-face semi-structured interviews were completed with a total of 30 community leaders to determine perceptions of the health-related needs and resources available to older adults.
Instruments Demographics. Brief demographic data, including sex and age, were collected as part of the semi-structured interview guide to describe the sample. To assure representation across the three villages, participants were asked from which community sector they belonged, as well as to which of the three villages they most identified. Semi-structured interview guide. A semi-structured interview guide was developed to solicit community leader perceptions of community characteristics and strengths, and health resources and needs as related to older adults. The interview guide utilized open-ended questions and was developed in cooperation with the community RAC, in accordance with community-based participatory research principles (Minkler & Wallerstein, 2008; Wallerstein & Duran, 2006, 2010). Several questions specific to the health of older adults in the community provided the data for these analyses. Examples include, “What health care resources are targeted toward older adults in your community?” “What barriers do older adults face in accessing health care?” “What are the greatest health needs of older adults in your community,” and “What would make it easier for older adults to remain living independently?” Participants were not provided with an explicit definition of “older adults” before beginning the interviews.
Procedures Recruitment. An introductory letter was mailed to each of the 40 potential participants, after potential participants were identified in consultation with the RAC. The letter indicated that a follow-up phone call would take place to invite participation in a face-to-face interview with research team members. Follow-up contact also occurred by email communication with some potential participants. The final sample consisted of 30 community leaders. Seven potential participants were unable to be reached, two expressed interest but were unable to schedule an interview, and one community leader did not present at the agreed-upon interview location at the scheduled time and was unable to reschedule.
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Data collection. Interviews were conducted in a location most convenient for community leaders, often in a church or other community building, or at the participant’s place of business. Each interview was conducted by one of three research team members trained by the principal investigator. Data were recorded using a note-taking technique, consistent with key informant interview methods (The Access Project, 1999; UCLA Center for Health Policy Research, n.d.; University of Illinois Extension Service–Office of Program Planning and Assessment, n.d.). Notes were taken during the interview as completely as possible, using the actual words of the informant. This datarecording strategy was selected over audiotaping, given the “outsider” status of the researchers in conjunction with concerns that audiotaping may diminish the ability to gain access to key informants and would diminish their willingness to speak freely. In addition, this approach was recommended by RAC members who felt that audiotaping would negatively influence an accurate assessment of the community. Interviews were conducted over a range of 30 to 90 minutes and took place over 12 months. Data analysis. Data from the semi-structured interviews were entered from the field notes taken by the interviewer into a campus-based secure database. Data were then downloaded into an Excel spreadsheet for further analysis. First, second, and third authors used the thematic analysis methods of Braun and Clarke (2006) to evaluate qualitative data by coding transcripts. The analysis was conducted across the entire data set, and descriptive categories of data were identified and coded individually. Common themes were then identified within and across these coding categories (Knafl, 1988). Interview data were reviewed in their entirety, independently by three authors, and possible codes were denoted in the transcript margins. The three coders then searched for and reviewed themes and subthemes until there was agreement on the data code labels and corresponding definitions. Each author then separately re-coded interview data, using the agreed-upon coding schema. All discrepancies were discussed and resolved, and final code application was reviewed for accuracy by two team members. Finally, themes were considered in the context of the research questions. Data saturation was reached from the 30 interviews. The themes and subtheme labels, definitions, and exemplar quotes were reviewed with the RAC members as a strategy to evaluate the trustworthiness of the analysis. Themes were presented orally with the use of visual aids at a monthly RAC meeting. RAC members were asked to specifically consider the following questions: (a) Do these themes seem accurate, based on your understanding of the community? (b) Is anything missing, did we leave anything out? (c) Do any of the themes listed not belong? and (d) Are the words
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we used to label the themes sensitive to the values and feelings of your community? The only significant alteration was a suggestion to broaden a theme related to the role of church in the community in order to encompass additional denominations that are less prominent in the community.
Results Sample Demographics Community leaders had a mean age of 57.5 years (SD = 12.8), with a range from 35 to 86 years of age. Seventy one percent of the participants were aged 65 or younger, qualifying a subset of the sample (29%) as older adults, themselves. A slight majority (57%, n = 17) of the respondents were female. Participants were fairly evenly distributed across the community sectors: Church (19%), Education (19%), Government (10%), Health Care Providers (13%), Business (26%), and Other (6%). All three villages within the partner community were roughly equally represented in the interviews. Some participants (20%, n = 6) worked or provided services in the partner community but lived elsewhere. Community leaders were not asked how long they had dwelled in the community, although many identified themselves as lifelong residents.
Community Leader Perceptions of Older Adults and Their Health Needs Several themes emerged as descriptors of older adults and their health needs (see Table 1). Older adults benefit from the importance of family in the community, valuing relatedness and intergenerational relationships. In general, families feel a sense of responsibility in caring for older adults. “Heritage,” “Strength,” and “Longevity” were also important themes related to community leader perceptions of older adults and their health needs. Family Is Central. “Family Is Central” represents the integral role of families in community life. Community leaders consistently stated that families play an integral role in community life, especially in the lives of older adults. Illustrative quotes include community leader descriptions of the community as “family oriented,” with a “sense of family” and “family tradition.” Two subthemes of “Family Is Central” emerged as particularly relevant to older adults in the community, including “Intergenerational Relationships” and “Family Responsibility.”
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German Heritage Farming Heritage “Strength” “Longevity” “Close-knit” Everyone Helps
What health resources are targeted toward older adults within the community?
What health resources are targeted toward older adults within the community?
What barriers do older adults face in accessing health care?
“Heritage”
“Church Is Central” Church as Community Resource “Rural Economy” “Distance to Resources” “Seasonal Resources”
“Family Is Central” Intergenerational Relationships Family Responsibility
Theme
How do community leaders describe older adults and their health care needs within the community?
Research Questions
Table 1. Research Questions by Theme.
Families play an integral role in community life Crossing generations or age groups The family provides health-related resources that are central to the community A high value placed on tradition or the moving of information and actions across generations Characteristics of the community attributed to their German ancestry Characteristics of the community attributed to their farming traditions Reflecting ability, vigor, and conviction Living long lives with vitality Members of the community are held tightly together through social and cultural ties; reflecting community cohesiveness Members of the community support and care for each other The church plays an integral role in community life The church provides health-related resources that are central to the community Nature of rural community affects the economy Reflecting relative proximity to resources Access to health resources may be limited by the time of the year
Definition
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Intergenerational Relationships. “Intergenerational Relationships” reflects data that described the crossing of generations or age groups. Community leaders perceived that community members “stay together” and benefit from “strong intergenerational relationships.” For example, community leaders indicated that older adults interact with younger community members via “public school community service,” where “each student helps out” by participating in service projects that benefit older adults (e.g., leaf-raking). In addition, “grandparents are involved with grandchildren/great grandchildren and community activities.” One example of an intergenerational activity takes place annually in the elementary schools in the community. Each year, grandparents are invited to school to celebrate Grandparents’ Day on which grandparents are honored and have the opportunity to eat lunch with their grandchildren. These intergenerational relationships emerged as an important part of the community structure in relationship to older adults. Family Responsibility. The subtheme “Family Responsibility” represents that the family provides health-related resources that are central to the community; furthermore, these family-based resources were often targeted toward the older adults and their health care needs. For example, community leaders shared that “Families take care of them [older adults]” and are often “self-reliant.” Families are self-reliant in that elders are “always taken care of by family, otherwise there are not resources.” This was confirmed with the sentiment, “Family connection is strong and they take care of the older family members.” Participants shared that community members “do it well here [take care of elders]. Children make it possible. Big families share [the] burden.” In many cases, it is the “job of family to take them [older adults] to doctors,” or to provide “transportation to health services,” which further illustrates the responsibility of family in meeting health care needs of older adults. Heritage. “Heritage” was another major theme that emerged in response to questions about the nature of the community and the health of older adults. “Heritage” represents a high value placed on tradition or the sharing of information and actions across generations. Specifically, community leaders attributed characteristics of their community to aspects, or subthemes of their heritage, including “German Heritage” and “Farming Heritage.” German Heritage. The subtheme “German Heritage” represents the characteristics of the community attributed to German ancestry. Although the founding members of the communities immigrated to the area from Germany in the mid-1800s, their German roots remain an important part of the community identity. Selected quotes illustrating this subtheme include
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the following: “[Community is] homogeneous, ethnically, with German descent,” “Very great German Catholic people with good morals and good values,” “German tradition,” and “German ancestry.” Community leaders also shared that older adults “may not always ask for help or believe something is wrong with them [older adults]” in health care situations. This characteristic was often attributed to their German heritage as illustrated by the following responses: “Stubborn old Germans don’t ask for help,” and “[because of] German heritage, they won’t admit they need help.” Farming Heritage. The subtheme “Farming Heritage” represents the community characteristics that the key informants attributed to their farming traditions. Farming traditions remain a strong aspect of community identity, and data illustrating the subtheme include “Farming history” and “Older adults talk about farming” in their interactions with each other. In addition, several community leaders related the farming heritage in the community to potential health effects by mentioning “exposures to insecticides and herbicides on farms,” “Melanoma [secondary to] farming,” and “Hearing loss primarily [among] men who worked on farms” as aspects of the community elders’ needs. Strength. Community leaders also perceived that older adults in the community are strong. The major theme, “Strength,” represents the many characteristics of the community that reflect ability, vigor, and conviction. In particular, older adults were described as “proud people” who are “not afraid to work” or “hardworking.” Community leaders recognized, however, that these strengths could also manifest as stubbornness. In fact, “stubbornness” was identified as a barrier to health care. Older adults in the community were described as “fairly stubborn about accepting assistance.” Longevity. The final major theme that emerged as a descriptor of older adults in the community was “Longevity.” Community leaders perceived that many older persons in the community are living long lives with vitality. Specifically, one participant offered, “Many women in their 90s are healthy and can handle stress.” One community leader shared, “A lot of people are living longer and age 90 and older. They are sharp and [dwelling] at home.” Another participant suggested that the longevity characteristic of older adults in the community might be attributed to the presence of “long life genes.”
Health Resources Targeted Toward Older Adults Most community health resources available to older adults were intangible and stemmed from community strengths and broader community
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characteristics like the “Close-knit” nature of the community and central nature of the church as a community resource. Close-knit. “Close-knit,” defined as being held tightly together through social and cultural ties, emerged as a major theme and frequent descriptor of the partner community in general. The community was often described as “cohesive,” “close knit,” or “tight knit” with a “sense of community.” A subtheme of “Close-knit,” labeled “Everyone Helps,” emerged in response to questions pertaining to older adults. Everyone Helps. The subtheme “Everyone Helps” represents the idea that members of the community support and care for each other. Individuals or neighbors within the community often “look out for each other” and help older adults to meet transportation and other health-related needs. The subtheme is illustrated by the following exemplars: “If not driving, then [community] arranges transportation for check-up,” “Individuals will volunteer [to help],” and “People will get them [older adults] to appointments.” Church Is Central. The major theme “Church Is Central” denotes that church plays an integral role in community life as well, acting as both a relating point and community resource. Older adults, in particular, are supported by the “Church family, everyone takes care of elders.” In fact, community leaders described the church as “at heart of the community.” Church as Community Resource. While the church is central to the community, “Church as Community Resource” emerged as a related subtheme particularly relevant to older adults in the community in that the church provides many health resources targeted toward older adults. Community leaders shared that some area churches provide tangible resources such as “senior meals” and transportation services. Select quotes to illustrate this theme include “Church has volunteers to help with transportation,” “Church volunteers to take to doctor’s appointments,” and “Church will visit them at home.” In addition, participants shared that the “church keeps seniors active. Members will take seniors to outside church activities.” As illustrated above, few specific health resources targeted to older adults outside church and family resources were described. Community leaders did identify limited physical activity and social resources. For example, physical activity resources included golf, swimming, exercise classes, and pickle ball (i.e., a paddle sport played on a badminton-size court with a paddle and small wiffle-like ball), and open gym formats in middle or high schools. More often than physical activity resources, social activity resources were identified,
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including card clubs and senior dinners, as well as church suppers and delivered senior meals.
Barriers to Health Care Access for Older Adults Three major themes emerged in response to questions regarding barriers to health care access specific to older adults and included “Rural Economy,” “Distance to Resources,” and “Seasonal Resources.” Rural Economy. Community leaders shared that the nature of their rural community affects the economy in their community, represented by the major theme, “Rural Economy.” Community leaders consistently described their community as a “rural community” based on the small size of the villages, distance from more metropolitan areas, and prominence of farming activities. The nature of the rural community and economy merged as a barrier to health care for older adults. Participants recognized that in their rural setting, “big industry pieces are lacking,” and that the “town [is] too small to support a doctor.” A general lack of local health care providers and specialist services was a recurrent need identified by key community leaders. In addition, the lack of financial resources for older adults, including lacking health insurance or increasingly high co-pays, emerged as a concern. Distance to Resources. “Distance to Resources,” a theme reflecting data regarding relative proximity to resources, also emerged in relationship to access to health care providers and services among older adults in the community. Regional health care providers are located 20 to 30 miles away from the three rural villages. Some community leaders perceived these resources as being in relatively close proximity, whereas other community leaders identified this distance and limited transportation options as a barrier to health care. For example, “travel and distance [for] those who don’t drive” and “no transportation for older people” were identified as barriers to health care. Challenges faced by older adults who require specialty services or rehabilitation services, in particular, were identified as a concern and barrier as illustrated by the following response: “[older adults who become] disabled, such as breaking a hip, have to go out of town for rehab.” Community leaders also expressed concern about the impact of out-migration on older adults in the community. For example, “families are moving away,” resulting in “too long of a drive to care for the elderly.” While family members often provide important resources for older adults in the partner community, a lack of family in the community may prove to be a substantial barrier to health care access for older adults due to the distance to resources.
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Seasonal Resources. The seasonal nature of some community resources also emerged as a barrier to health care for older adults. The theme “Seasonal Resources” represents data suggesting that access to health resources may be limited according to the time of the year. For older adults, “the post office is a social place in summer.” There are “walkers in warmer weather,” and “people visit each other during good weather”; however, equivalent resources were not necessarily available in the colder months. Community leaders noted that, consequently, older adults may suffer from “isolation, especially in the winter,” due to more limited resources outside the summer months.
Promoting Independent Living for Older Adults Community leaders were also asked to identify resources that would promote independent living for older adults. Community leaders observed that, in many cases, elders remain living at home by sharing the burden among large families and church members. Community leaders stated, “Family helps make it possible to stay in home” and “a lot stay at home; Take a turn in the family.” However, the community is changing. When asked about older adults living independently, one participant stated, “Getting more difficult; Families are moving away with too long of a drive to care for elderly.” Community leaders also emphasized the limited access to assisted living and foster homes in the partner community. One participant shared, “No assisted living in community. If they [older adults] are not cared for by family, they go to assisted living [in distant City], same with nursing homes.” One health care provider stated, “We have many elderly patients in those communities still living alone, but only with family help. Older adults do not leave home until it’s not safe [to remain at home].” Community leaders were asked to offer suggestions as to what might make it easier for older adults to remain living at home in the community. Suggestions included help meeting the basic needs of older adults, such as medical and grocery needs. In addition, a resource to provide a stronger support system involving daily contact with older adults and meal support was suggested. Other resources important to local elder care included caregiver and family support, increased opportunity for physical activity, transportation, and more living options. One of the most imminent needs expressed by community leaders included establishment of a local retirement home or independent living options. In summary, residents of the partner community are closely connected, with family responsibility and intergenerational relationships as important aspects of elder care. Older adults in the community were described as strong, and community leaders shared that many older adults in the community are
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living long lives with vitality. Several barriers to health care access for older adults were identified. Distance from health care providers was an especially significant barrier for older adults. Community leaders see the need for additional resources for older adults in the community and especially emphasized the need for a local retirement home or independent living facility.
Discussion The results of this needs assessment provide important insights into the specific health needs of older adults in the rural Midwest from a within-community perspective. First, older adults receive substantial support from family. The integral nature of family within the partner community manifested in several themes and subthemes generated from this community health needs assessment. Community leaders consistently stated that families play an integral role in community life, especially in the lives of older adults. To that end, “Intergenerational Relationships” are an important part of the lives of older adults as well as part of the larger community structure. Families provide health-related resources that are central to the community, including regular care and interaction as well as transportation to health care services. These findings are echoed in a comparative study of home care nursing services used by community-dwelling older adults in rural and urban environments (Borowiak & Kostka, 2013). Rural-dwelling older adults nominated their family members as care providers 82.8% of the time, in contrast to 51.2% of urban-dwelling older adults, and reported often having someone available for potential care services (Borowiak & Kostka, 2013). Familial resources may be positively utilized to improve health for older adults (Averill, 2005). Despite the availability of some resources, rural-dwelling older adults face particular challenges (Thornlow, 2008). Because of geographic isolation and lack of proximity to health care providers, older adults dwelling in rural areas often experience unique environmental and other risk factors (Durazo et al., 2011). Challenges such as rugged terrain, precarious road conditions, and a sparse and dispersed population may make it difficult for rural elders to obtain medical services and access areas safe for exercise (Durazo et al., 2011). Consequently, older adults may also be more reliant on family members for care provision or transportation to health care services (Borowiak & Kostka, 2013; Magilvy et al., 2000). Family members may also struggle to meet obligations in caring for rural elders, as demonstrated in ethnographic work among a rural Hispanic population (Magilvy et al., 2000). Older adults without family members within the partner community in this study experienced increased barriers to health care access, often in the form of lack of transportation or inability to remain safely caring for oneself at home.
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Struggling to meet caregiving obligations did not manifest in this health needs assessment, although key informants shared that there is a strong sense of “Family Responsibility” within the community. Averill (2002) examined the meaning of health, health care perceptions, and health care issues for rural elderly individuals residing in Southwestern New Mexico (Averill, 2002). Based on 22 interviews with rural elderly individuals, family members, and community health care providers, several significant health-related issues came to light. Some deficits in provision of quality health care for older adults were unique to the community and were related to economic hardship secondary to the demise of the mining industry (Averill, 2002). Limited access to basic primary care, home health care, specialty care, and hospice care, reportedly had negative effects on the health of rural-dwelling older adults in New Mexico (Averill, 2002). Community leaders in this health needs assessment also perceived a lack of access to similar services. One of the most imminent needs expressed by community leaders included establishment of a local retirement home or independent living facility. Both community leaders in this study and individuals interviewed by Averill (2002) reported limited transportation as a barrier to health care for rural-dwelling older adults. Rural-dwelling older adults in the Southwestern New Mexico community suffered from social isolation and loneliness. However, in this “Close-knit” partner community of the rural Midwest, social isolation and loneliness were not often reported as significant barriers to health care, although one participant reported that some older adults become withdrawn and suffer negative health consequences. In contrast, elders in the partner community were described as “Strong” and community leaders perceived that many older persons in the community are living long lives with vitality. While this study provides insights into the characteristics of rural-dwelling older adults as perceived by community leaders, it also illustrates the importance of understanding any given community prior to engaging in research. Residents of the partner community in this study are closely connected, and family responsibility and intergenerational relationships are important aspects of elder care. Other communities, like that investigated by Averill (2002) in New Mexico, demonstrate unique strengths such as regionspecific knowledge, presence of dedicated problem solvers, and communitybased action groups (Averill, 2003). The themes that emerged in this study have been incorporated into community engagement and participant recruitment efforts in subsequent phases of the broader community–academic health research partnership. Research team members regularly interact with community members during religious and community festivals held in the partner communities, and are given an
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opportunity to discuss the parent study in these venues. Interestingly, participant recruitment for a registry to support future health research studies has been most successful through word of mouth in the “Close-knit” community (Rivard, Goris, Schutte, & Schutte, 2014). Continued research implementation and translational efforts must build on and support family, intergenerational relationships, and church connections. Because community leaders see the need for additional resources for older adults in the community, further research should be conducted to investigate needs from the perspective of elders in the partner community to confirm these results. Understanding the characteristics of rural older adults and tailoring recruitment strategies to the rural community are crucial to participation in and acceptance of future research efforts in the partner community (Dibartolo & McCrone, 2003). This article describes a community health needs assessment related to older adults that was completed as part of a community–academic health research partnership. The community-level health needs assessment was successfully conducted, although several limitations are acknowledged. First, although saturation of themes was reached in the qualitative data analysis, the sample size was relatively small (N = 30) and may not reflect the health needs and resources related to older adults as perceived by the community at large. Second, older adults from the community were not specifically targeted as part of this study, which may limit the usefulness of results. However, more than 25% of community leaders in this study qualified as older adults above age 65 and offered valuable perceptions. Investigators are triangulating data gathered as part of this assessment with individual-level health data collected from older adults within the community. Investigators acknowledge, however, that less integrated community members might perceive the health needs of older adults and community characteristics differently than community leaders, which would further enrich data gathered in this study. Finally, community leader interviews were documented through notetaking in the field, rather than audiotaped. The research team, in consultation with community advisory board members, believed this was the best approach for building trust and soliciting information. Although note-taking is an established method of documenting key informant interviews, investigators recognize that relevant data units and themes may have been lost during the handwritten transcriptions and that there is a risk of bias in the note-taking process. To address this potential risk, several strategies were used to verify research findings, including coding by multiple team members and memberchecking results with community advisory board members (review of major themes, subthemes, and illustrative quotes; review of manuscripts), to establish the credibility of the results.
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This study provides important insights related to the health of older adults from a within-community perspective and expands our understanding of the unique health needs of elders in the rural Midwestern United States. In addition, the study exemplifies a successful collaboration with a community advisory board, influential in study design and implementation, in accordance with community-based participatory research principles, to design and implement a community health needs assessment. This community health needs assessment was an essential step in establishing a long-term community– academic partnership. To that end, these data will be used to identify and prioritize future research and subsequent translational efforts that are consistent with community strengths, values, and needs. Acknowledgement We gratefully acknowledge the contributions of the community members for their service on the Community Research Advisory Committee who participated in the design, implementation, and analysis of this research. We are also indebted to the Community Ethics Committee for their valuable review of this manuscript.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Strategic Partnership Grant (Michigan State University [MSU] Foundation), Innovations Grant (Families and Communities Together Coalition, MSU), Departmental Funds (Microbiology and Molecular Genetics and College of Nursing, MSU), Building Academic Geriatric Nursing Capacity Predoctoral Scholarship Funds.
References The Access Project. (1999). Getting the lay of the land on health: A guide for using interviews to gather information. Boston, MA: Author. Retrieved from http:// www.accessproject.org/downloads/final%20document.pdf Averill, J. B. (2002). Voices from the Gila: Health care issues for rural elders in South-Western New Mexico. Journal of Advanced Nursing, 40, 654-662. Averill, J. B. (2003). Keys to the puzzle: Recognizing strengths in a rural community. Public Health Nursing, 20, 449-455. Averill, J. B. (2005). Studies of rural elderly individuals: Merging critical ethnography with community-based action research. Journal of Gerontological Nursing, 31(12), 11-18.
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Blair, A., & Freeman, L. B. (2009). Epidemiologic studies of cancer in agricultural populations: Observations and future directions. Journal of Agromedicine, 14, 125-131. Borowiak, E., & Kostka, T. (2013). Comparative characteristics of the home care nursing services used by community-dwelling older people from urban and rural environments. Journal of Advanced Nursing, 69, 1259-1268. Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3, 77-101. Dibartolo, M. C., & McCrone, S. (2003). Recruitment of rural community-dwelling older adults: Barriers, challenges, and strategies. Aging & Mental Health, 7, 75-82. Durazo, E. M., Jones, M. R., Wallace, S. P., Van Arsdale, J., Aydin, M., & Steward, C. (2011). The health status and unique health challenges of rural older adults in California (Health Policy Brief). Los Angeles: University of California. Fordyce, M. A., Chen, F. M., Doescher, M. P., & Hart, G. L. (2007). 2005 physician supply and distribution in rural areas of the United States (Final Report No. 116). Seattle: WWAMI Rural Health Research Center, University of Washington. Guo, G., & Phillips, L. (2006). Key informants’ perceptions of health care for elders at the U.S.-Mexico border. Public Health Nursing, 23, 224-233. Kingsley, J. Y., Phillips, R., Townsend, M., & Henderson-Wilson, C. (2010). Using a qualitative approach to research to build trust between a non-aboriginal researcher and aboriginal participants (Australia). Qualitative Research Journal, 10(1), 2-12. Knafl, K. A. (1988). Consider the possibilities of qualitative research. Western Journal of Nursing Research, 10, 125-127. Kovac, S. H., Mikuls, T. R., Mudano, A., & Saag, K. G. (2006). Health-related quality of life among self-reported arthritis sufferers: Effects of race/ethnicity and residence. Quality of Life Research, 15, 451-460. Magilvy, J. K., Congdon, J. G., Martinez, R. J., Davis, R., & Averill, J. B. (2000). Caring for our own: Health care experiences of rural Hispanic elders. Journal of Aging Studies, 14, 171-190. Miles, A., Proescholdbell, R. J., & Puffer, E. (2011). Explaining rural/non-rural disparities in physical health-related quality of life: A study of United Methodist clergy in North Carolina. Quality of Life Research, 20, 807-815. Minkler, M., & Wallerstein, N. (2008). Community-based participatory research for health: From process to outcomes. San Francisco, CA: Jossey-Bass. Rivard, J. L., Goris, E. D., Schutte, B. C., & Schutte, D. L. (2014). Engagement and recruitment strategies in a community-based translational genomics project. Manuscript in preparation Schutte, D. L., Goris, E. D., Rivard, J. L., & Schutte, B. C. (2014). Community health needs assessment in a rural setting: Foundation for a community-academic partnership. Manuscript in preparation Steele, J. C., Patrick, J. H., Goins, R. T., & Brown, D. K. (2005). Self-rated health among vulnerable older adults in rural Appalachia. The Journal of Rural Health, 21, 182-186.
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Strauss, R. P., Sengupta, S., Quinn, S. C., Geoppinger, J., Spaulding, C., Kegeles, S. M., & Millett, G. (2001). The role of community advisory boards: Involving communities in the informed consent process. American Journal of Public Health, 91, 1938-1943. Thornlow, D. K. (2008). Nursing patient safety research in rural health care settings. Annual Review of Nursing Research, 26, 195-218. UCLA Center for Health Policy Research. (n.d.). Section 4: Key informant interviews. Retrieved from http://healthpolicy.ucla.edu/programs/health-data/trainings/Documents/tw_cba23.pdf University of Illinois Extension Service–Office of Program Planning and Assessment. (n.d.). Needs assessment techniques: Conducting a key informant interview. Retrieved from http://ppa.aces.uiuc.edu/pdf_files/Conducting1.PDF U.S. Census Bureau. (2010). The next four decades, the older population in the United States: 2010 to 2050 population estimates and projections. Retrieved from https://www.census.gov/prod/2010pubs/p25-1138.pdf U.S. Census Bureau. (2013). Geography: 2010 census urban area facts. Retrieved from http://www.census.gov/geo/reference/ua/uafacts.html U.S. Department of Agriculture. (2013). Rural classifications. Retrieved from http:// www.ers.usda.gov/topics/rural-economy-population/rural-classifications.aspx U.S. Department of Health and Human Services. (2013a). Older adults. Retrieved from http://www.healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=31 U.S. Department of Health and Human Services. (2013b). A profile of older Americans: 2011. Retrieved from http://www.aoa.gov/AoARoot/Aging_ Statistics/Profile/2011/8.aspx Wallerstein, N., & Duran, B. (2006). Using community-based participatory research to address health disparities. Health Promotion Practice, 7, 312-323. Wallerstein, N., & Duran, B. (2010). Community-based participatory research contributions to intervention research: The intersection of science and practice to improve health equity. American Journal of Public Health, 100(S1), S40-S46. Weeks, W. B., & Wallace, A. E. (2008). Rural–urban differences in primary care physicians’ practice patterns, characteristics, and incomes. The Journal of Rural Health, 24, 161-170. Weeks, W. B., Wallace, A. E., Wang, S., Lee, A., & Kazis, L. E. (2006). Rural–urban disparities in health-related quality of life within disease categories of veterans. The Journal of Rural Health, 22, 204-211. Werner, C. A. (2011). The older population: 2010. Retrieved from http://www.census.gov/prod/cen2010/briefs/c2010br-09.pdf Wilcox, S., Castro, C., King, A., Housemann, R., & Brownson, R. (2000). Determinants of leisure time physical activity in rural compared with urban older and ethnically diverse women in the United States. Journal of Epidemiology & Community Health, 94, 1682-1686.
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WJNXXX10.1177/0193945914530046Western Journal of Nursing ResearchGoris et al.
Research Report
Community Leader Perceptions of the Health Needs of Older Adults
Western Journal of Nursing Research 2015, Vol. 37(5) 599–618 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0193945914530046 wjn.sagepub.com
Emilie Dykstra Goris1, Debra L. Schutte2, Jamie L. Rivard3, and Brian C. Schutte3
Abstract The purpose of this needs assessment was to determine community leader perceptions of health-related needs and resources available to rural-dwelling older adults as part of a community–academic partnership in the rural Midwest. A community advisory board, in accordance with community-based participatory research principles, was influential in study design and implementation. Key informant interviews (N = 30) were conducted with community leaders including professionals from schools, businesses, churches, and health care as well as government officials. Thematic analysis revealed “Family Is Central,” “Heritage,” “Strength,” and “Longevity” as important themes related to older adults and their health care needs within the community. “Close-knit” and “Church Is Central” were also identified as important aspects of elder care. Community leaders perceived the “Rural Economy,” “Distance to Resources,” and “Seasonal Resources” as significant barriers for older adults. This work contributes important insights into community leaders’ perceptions of health needs and challenges faced by older adults in rural settings. Keywords community-based participatory research, community needs assessment, geriatric 1Hope
College, Holland, MI, USA State University, Detroit, MI, USA 3Michigan State University, East Lansing, MI, USA 2Wayne
Corresponding Author: Emilie Dykstra Goris, Assistant Professor, A. Paul Schaap Science Center, Department of Nursing, Hope College, Holland, MI 49422-9000, USA. Email: [email protected]
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The number of older adults, many with complex health care needs, dwelling in rural communities is rapidly increasing. U.S. Census data demonstrate that individuals 65 and older make up about 13.1% of the population, and approximately 20% of these elderly Americans dwell in non-metropolitan designated areas (U.S. Department of Health and Human Services [HHS], 2013b). To that end, the United States is projected to experience continued growth of its older population at a rapid rate, with an estimated 88.5 million Americans aged 65 and older in the year 2050 (U.S. Census Bureau, 2010). The health care system and practitioners involved in community health initiatives must make appropriate adjustments to promote wellness among the growing population of rural elders. The U.S. HHS has recognized this need and included several objectives related to improving the health of older adults in the HHS, Healthy People 2020 Goals (U.S. HHS, 2013a). These objectives encompass both prevention and long-term services and supports in an effort to reduce health care barriers and increase quality of life among older adults. Specific initiatives include efforts to coordinate care, assist older adults in organizing care management, establish quality measures, and provide appropriate training for caregivers and health care providers in relationship to the unique health care needs of older adults (U.S. HHS, 2013a).
Health Needs of Rural Elders Barriers to health and health care commonly faced by older adults may be compounded in a rural setting, where distance from larger cities or metropolitan areas further limits access to health care products or services. Approximately 20% of Americans, or 59 million individuals, live in rural communities with fewer than 2,500 residents (U.S. Census Bureau, 2013). Among persons dwelling outside metropolitan or micropolitan statistical areas, about 17% are persons aged 65 years and older, and 2.2% are persons aged 85 and older (Werner, 2011). Health care provision may be particularly difficult in rural settings, due to limited access to medical specialists and primary health care providers, often practicing as generalists, with relatively higher workloads than their urban counterparts due to a relative shortage of health care providers in rural settings (Fordyce, Chen, Doescher, & Hart, 2007; Thornlow, 2008; Weeks & Wallace, 2008). Rural older adults have higher rates of overweight/obesity and physical inactivity, as well as fewer healthy food choices than older adults living in suburban areas, putting them at risk of heart disease, diabetes, and falls (Durazo et al., 2011). In addition, rural-dwelling older adults frequently experience greater limitations in daily activities secondary to chronic illness (Thornlow, 2008). Accessing care for chronic disease may be difficult for rural elders due to limited transportation,
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necessity of private vehicles, and geographic distance to services (Wilcox, Castro, King, Housemann, & Brownson, 2000). Rural-dwelling older adults currently working in agriculture or retired from agricultural work, which is common in rural areas, may suffer consequences of accumulated occupational exposures from toxic substances commonly used in the agricultural industry. For example, a number of studies have demonstrated increased risk of several cancers among agricultural populations (Blair & Freeman, 2009). Weeks, Wallace, Wang, Lee, and Kazis (2006) found that veterans dwelling in rural areas experience higher disease prevalence and lower physical and mental quality of life scores than an urban veteran population, when comparing 30 physical health disease categories based on International Classification of Disease (ICD)–9-CM codes (Weeks et al., 2006). Similarly, Kovac, Mikuls, Mudano, and Saag (2006) examined health disparities among persons with self-reported arthritis and verified that health disparities exist between rural- and urban-dwelling participants. Kovac further noted that these health disparities were unequally distributed along racial lines, with rural Caucasians exhibiting the lowest health-related quality of life in that study (Kovac et al., 2006). In a study of self-rated health among older adults in rural Appalachia (N = 236), only 26.1% of the participants rated their health as excellent or good, while 40.1% and 33.8% of the participants rated their health as fair or poor, respectively (Steele, Patrick, Goins, & Brown, 2005). Rural/non-rural disparities in health-related quality of life may be partially explained by differences in income, obesity, and joint disease in rural areas (Miles, Proescholdbell, & Puffer, 2011). Health disparities can also be attributed to environmental and other risk factors that may be more prevalent in rural settings (Durazo et al., 2011). For example, rural elders may face unique barriers to physical activity including lack of sidewalks, street lights, and exercise facilities (Wilcox et al., 2000). They may also be more reliant on family members for care provision or transportation to health care services (Borowiak & Kostka, 2013; Magilvy, Congdon, Martinez, Davis, & Averill, 2000) or suffer from social isolation and loneliness (Averill, 2002). Given these characteristics, rural-dwelling older adults are important targets for health research and community health initiatives. However, physiologic changes accompanying aging, prevalence of chronic illness and medication use, distrust, or transportation issues may make it more difficult to recruit rural-dwelling older adults for research participation (Dibartolo & McCrone, 2003). A high-quality health needs assessment can play an important role in identifying the needs of older adults, prioritizing these needs into communitybased research and practice initiatives, and conducting research and practice initiatives in a manner that honors community values and builds on present
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strengths. Community leaders can provide a unique perspective related to the health of older adults from within the community. For example, key informants from various community sectors provided important perspectives related to elders at the U.S.–Mexico border (Guo & Phillips, 2006). Guo and Phillips (2006) used community leader perspectives to develop a conceptual framework for educational programs and research endeavors to be utilized by health professionals caring for elders at the border. Overall, however, there is limited current information available related to the specific health needs of older adults from a within-community perspective, particularly in the rural Midwest. This article describes a community health needs assessment related to older adults from the perspective of community leaders and was completed as part of a larger community–academic health research partnership in a rural Midwestern community, using the principles of community-based participatory research. The long-term goals of the parent study are to develop innovative community- and individual-level interventions to promote community health and well-being, positively affecting both older adults and broader members of the partner community. This analysis was conducted within a broad community needs assessment of the partner communities (Schutte, Goris, Rivard, & Schutte, 2014). Results of this work and the broader needs assessment will be used to develop, prioritize, and implement a communitydriven research agenda.
Purpose The purpose of this study was to determine community leader perceptions of health-related needs and resources available to older adults using a qualitative approach. Research questions addressed in this analysis include the following: Research Question 1: How do community leaders describe older adults and their health care needs within the community? Research Question 2: What health resources are targeted toward older adults within the community? Research Question 3: What barriers do older adults face in accessing health care? Research Question 4: What resources would promote independent living for older adults?
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Method Design A qualitative approach, using thematic analysis methods (Braun & Clarke, 2006), was utilized to evaluate qualitative data generated through individual face-to-face interviews. The Institutional Review Board of the academic partner approved the study, and methods to secure protection of human subjects were followed throughout. Participants were volunteers and were aware of their right to terminate the interviews at any time. A particularly vital aspect of well-conducted community-based participatory research is the inclusion of and partnership with a community advisory board (Minkler & Wallerstein, 2008). These boards are composed of community members sharing a common identity, history, and culture (Strauss et al., 2001). Because this group is made up of individuals from the same community as participants, the community advisory board serves as a liaison between participants and researchers, facilitating research by advising about the informed consent process, study implementation, and design (Strauss et al., 2001). This is particularly important if researchers aim to build trust to conduct research within a community where members perceive a lack of community control or influence on the research process (Kingsley, Phillips, Townsend, & Henderson-Wilson, 2010). A community advisory board, namely, the Research Advisory Committee (RAC), made up of 16 community members, reviewed all aspects of this study design, including implementation procedures.
Sample and Setting The partner community is made up of three rural villages, spanning a 90 square mile area in the upper Midwest. The populations of the three villages range from 470 to 1,209 residents and exist in largely non-metropolitan areas characterized by open countryside, rural areas, and surrounding urban area populations ranging from 2,100 to 49,999 people (U.S. Department of Agriculture, 2013). The sample consisted of community leaders recruited from the three villages, representing the school, business, church, health care, and government sectors. Purposive and network sampling were used to identify leaders from each sector from all three villages and to achieve balance by gender and across age groups. Members of the RAC were asked to provide a list of people whom researchers should contact, while other informants were
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identified by word-of-mouth from previous community leaders. Face-to-face semi-structured interviews were completed with a total of 30 community leaders to determine perceptions of the health-related needs and resources available to older adults.
Instruments Demographics. Brief demographic data, including sex and age, were collected as part of the semi-structured interview guide to describe the sample. To assure representation across the three villages, participants were asked from which community sector they belonged, as well as to which of the three villages they most identified. Semi-structured interview guide. A semi-structured interview guide was developed to solicit community leader perceptions of community characteristics and strengths, and health resources and needs as related to older adults. The interview guide utilized open-ended questions and was developed in cooperation with the community RAC, in accordance with community-based participatory research principles (Minkler & Wallerstein, 2008; Wallerstein & Duran, 2006, 2010). Several questions specific to the health of older adults in the community provided the data for these analyses. Examples include, “What health care resources are targeted toward older adults in your community?” “What barriers do older adults face in accessing health care?” “What are the greatest health needs of older adults in your community,” and “What would make it easier for older adults to remain living independently?” Participants were not provided with an explicit definition of “older adults” before beginning the interviews.
Procedures Recruitment. An introductory letter was mailed to each of the 40 potential participants, after potential participants were identified in consultation with the RAC. The letter indicated that a follow-up phone call would take place to invite participation in a face-to-face interview with research team members. Follow-up contact also occurred by email communication with some potential participants. The final sample consisted of 30 community leaders. Seven potential participants were unable to be reached, two expressed interest but were unable to schedule an interview, and one community leader did not present at the agreed-upon interview location at the scheduled time and was unable to reschedule.
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Data collection. Interviews were conducted in a location most convenient for community leaders, often in a church or other community building, or at the participant’s place of business. Each interview was conducted by one of three research team members trained by the principal investigator. Data were recorded using a note-taking technique, consistent with key informant interview methods (The Access Project, 1999; UCLA Center for Health Policy Research, n.d.; University of Illinois Extension Service–Office of Program Planning and Assessment, n.d.). Notes were taken during the interview as completely as possible, using the actual words of the informant. This datarecording strategy was selected over audiotaping, given the “outsider” status of the researchers in conjunction with concerns that audiotaping may diminish the ability to gain access to key informants and would diminish their willingness to speak freely. In addition, this approach was recommended by RAC members who felt that audiotaping would negatively influence an accurate assessment of the community. Interviews were conducted over a range of 30 to 90 minutes and took place over 12 months. Data analysis. Data from the semi-structured interviews were entered from the field notes taken by the interviewer into a campus-based secure database. Data were then downloaded into an Excel spreadsheet for further analysis. First, second, and third authors used the thematic analysis methods of Braun and Clarke (2006) to evaluate qualitative data by coding transcripts. The analysis was conducted across the entire data set, and descriptive categories of data were identified and coded individually. Common themes were then identified within and across these coding categories (Knafl, 1988). Interview data were reviewed in their entirety, independently by three authors, and possible codes were denoted in the transcript margins. The three coders then searched for and reviewed themes and subthemes until there was agreement on the data code labels and corresponding definitions. Each author then separately re-coded interview data, using the agreed-upon coding schema. All discrepancies were discussed and resolved, and final code application was reviewed for accuracy by two team members. Finally, themes were considered in the context of the research questions. Data saturation was reached from the 30 interviews. The themes and subtheme labels, definitions, and exemplar quotes were reviewed with the RAC members as a strategy to evaluate the trustworthiness of the analysis. Themes were presented orally with the use of visual aids at a monthly RAC meeting. RAC members were asked to specifically consider the following questions: (a) Do these themes seem accurate, based on your understanding of the community? (b) Is anything missing, did we leave anything out? (c) Do any of the themes listed not belong? and (d) Are the words
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we used to label the themes sensitive to the values and feelings of your community? The only significant alteration was a suggestion to broaden a theme related to the role of church in the community in order to encompass additional denominations that are less prominent in the community.
Results Sample Demographics Community leaders had a mean age of 57.5 years (SD = 12.8), with a range from 35 to 86 years of age. Seventy one percent of the participants were aged 65 or younger, qualifying a subset of the sample (29%) as older adults, themselves. A slight majority (57%, n = 17) of the respondents were female. Participants were fairly evenly distributed across the community sectors: Church (19%), Education (19%), Government (10%), Health Care Providers (13%), Business (26%), and Other (6%). All three villages within the partner community were roughly equally represented in the interviews. Some participants (20%, n = 6) worked or provided services in the partner community but lived elsewhere. Community leaders were not asked how long they had dwelled in the community, although many identified themselves as lifelong residents.
Community Leader Perceptions of Older Adults and Their Health Needs Several themes emerged as descriptors of older adults and their health needs (see Table 1). Older adults benefit from the importance of family in the community, valuing relatedness and intergenerational relationships. In general, families feel a sense of responsibility in caring for older adults. “Heritage,” “Strength,” and “Longevity” were also important themes related to community leader perceptions of older adults and their health needs. Family Is Central. “Family Is Central” represents the integral role of families in community life. Community leaders consistently stated that families play an integral role in community life, especially in the lives of older adults. Illustrative quotes include community leader descriptions of the community as “family oriented,” with a “sense of family” and “family tradition.” Two subthemes of “Family Is Central” emerged as particularly relevant to older adults in the community, including “Intergenerational Relationships” and “Family Responsibility.”
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German Heritage Farming Heritage “Strength” “Longevity” “Close-knit” Everyone Helps
What health resources are targeted toward older adults within the community?
What health resources are targeted toward older adults within the community?
What barriers do older adults face in accessing health care?
“Heritage”
“Church Is Central” Church as Community Resource “Rural Economy” “Distance to Resources” “Seasonal Resources”
“Family Is Central” Intergenerational Relationships Family Responsibility
Theme
How do community leaders describe older adults and their health care needs within the community?
Research Questions
Table 1. Research Questions by Theme.
Families play an integral role in community life Crossing generations or age groups The family provides health-related resources that are central to the community A high value placed on tradition or the moving of information and actions across generations Characteristics of the community attributed to their German ancestry Characteristics of the community attributed to their farming traditions Reflecting ability, vigor, and conviction Living long lives with vitality Members of the community are held tightly together through social and cultural ties; reflecting community cohesiveness Members of the community support and care for each other The church plays an integral role in community life The church provides health-related resources that are central to the community Nature of rural community affects the economy Reflecting relative proximity to resources Access to health resources may be limited by the time of the year
Definition
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Intergenerational Relationships. “Intergenerational Relationships” reflects data that described the crossing of generations or age groups. Community leaders perceived that community members “stay together” and benefit from “strong intergenerational relationships.” For example, community leaders indicated that older adults interact with younger community members via “public school community service,” where “each student helps out” by participating in service projects that benefit older adults (e.g., leaf-raking). In addition, “grandparents are involved with grandchildren/great grandchildren and community activities.” One example of an intergenerational activity takes place annually in the elementary schools in the community. Each year, grandparents are invited to school to celebrate Grandparents’ Day on which grandparents are honored and have the opportunity to eat lunch with their grandchildren. These intergenerational relationships emerged as an important part of the community structure in relationship to older adults. Family Responsibility. The subtheme “Family Responsibility” represents that the family provides health-related resources that are central to the community; furthermore, these family-based resources were often targeted toward the older adults and their health care needs. For example, community leaders shared that “Families take care of them [older adults]” and are often “self-reliant.” Families are self-reliant in that elders are “always taken care of by family, otherwise there are not resources.” This was confirmed with the sentiment, “Family connection is strong and they take care of the older family members.” Participants shared that community members “do it well here [take care of elders]. Children make it possible. Big families share [the] burden.” In many cases, it is the “job of family to take them [older adults] to doctors,” or to provide “transportation to health services,” which further illustrates the responsibility of family in meeting health care needs of older adults. Heritage. “Heritage” was another major theme that emerged in response to questions about the nature of the community and the health of older adults. “Heritage” represents a high value placed on tradition or the sharing of information and actions across generations. Specifically, community leaders attributed characteristics of their community to aspects, or subthemes of their heritage, including “German Heritage” and “Farming Heritage.” German Heritage. The subtheme “German Heritage” represents the characteristics of the community attributed to German ancestry. Although the founding members of the communities immigrated to the area from Germany in the mid-1800s, their German roots remain an important part of the community identity. Selected quotes illustrating this subtheme include
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the following: “[Community is] homogeneous, ethnically, with German descent,” “Very great German Catholic people with good morals and good values,” “German tradition,” and “German ancestry.” Community leaders also shared that older adults “may not always ask for help or believe something is wrong with them [older adults]” in health care situations. This characteristic was often attributed to their German heritage as illustrated by the following responses: “Stubborn old Germans don’t ask for help,” and “[because of] German heritage, they won’t admit they need help.” Farming Heritage. The subtheme “Farming Heritage” represents the community characteristics that the key informants attributed to their farming traditions. Farming traditions remain a strong aspect of community identity, and data illustrating the subtheme include “Farming history” and “Older adults talk about farming” in their interactions with each other. In addition, several community leaders related the farming heritage in the community to potential health effects by mentioning “exposures to insecticides and herbicides on farms,” “Melanoma [secondary to] farming,” and “Hearing loss primarily [among] men who worked on farms” as aspects of the community elders’ needs. Strength. Community leaders also perceived that older adults in the community are strong. The major theme, “Strength,” represents the many characteristics of the community that reflect ability, vigor, and conviction. In particular, older adults were described as “proud people” who are “not afraid to work” or “hardworking.” Community leaders recognized, however, that these strengths could also manifest as stubbornness. In fact, “stubbornness” was identified as a barrier to health care. Older adults in the community were described as “fairly stubborn about accepting assistance.” Longevity. The final major theme that emerged as a descriptor of older adults in the community was “Longevity.” Community leaders perceived that many older persons in the community are living long lives with vitality. Specifically, one participant offered, “Many women in their 90s are healthy and can handle stress.” One community leader shared, “A lot of people are living longer and age 90 and older. They are sharp and [dwelling] at home.” Another participant suggested that the longevity characteristic of older adults in the community might be attributed to the presence of “long life genes.”
Health Resources Targeted Toward Older Adults Most community health resources available to older adults were intangible and stemmed from community strengths and broader community
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characteristics like the “Close-knit” nature of the community and central nature of the church as a community resource. Close-knit. “Close-knit,” defined as being held tightly together through social and cultural ties, emerged as a major theme and frequent descriptor of the partner community in general. The community was often described as “cohesive,” “close knit,” or “tight knit” with a “sense of community.” A subtheme of “Close-knit,” labeled “Everyone Helps,” emerged in response to questions pertaining to older adults. Everyone Helps. The subtheme “Everyone Helps” represents the idea that members of the community support and care for each other. Individuals or neighbors within the community often “look out for each other” and help older adults to meet transportation and other health-related needs. The subtheme is illustrated by the following exemplars: “If not driving, then [community] arranges transportation for check-up,” “Individuals will volunteer [to help],” and “People will get them [older adults] to appointments.” Church Is Central. The major theme “Church Is Central” denotes that church plays an integral role in community life as well, acting as both a relating point and community resource. Older adults, in particular, are supported by the “Church family, everyone takes care of elders.” In fact, community leaders described the church as “at heart of the community.” Church as Community Resource. While the church is central to the community, “Church as Community Resource” emerged as a related subtheme particularly relevant to older adults in the community in that the church provides many health resources targeted toward older adults. Community leaders shared that some area churches provide tangible resources such as “senior meals” and transportation services. Select quotes to illustrate this theme include “Church has volunteers to help with transportation,” “Church volunteers to take to doctor’s appointments,” and “Church will visit them at home.” In addition, participants shared that the “church keeps seniors active. Members will take seniors to outside church activities.” As illustrated above, few specific health resources targeted to older adults outside church and family resources were described. Community leaders did identify limited physical activity and social resources. For example, physical activity resources included golf, swimming, exercise classes, and pickle ball (i.e., a paddle sport played on a badminton-size court with a paddle and small wiffle-like ball), and open gym formats in middle or high schools. More often than physical activity resources, social activity resources were identified,
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including card clubs and senior dinners, as well as church suppers and delivered senior meals.
Barriers to Health Care Access for Older Adults Three major themes emerged in response to questions regarding barriers to health care access specific to older adults and included “Rural Economy,” “Distance to Resources,” and “Seasonal Resources.” Rural Economy. Community leaders shared that the nature of their rural community affects the economy in their community, represented by the major theme, “Rural Economy.” Community leaders consistently described their community as a “rural community” based on the small size of the villages, distance from more metropolitan areas, and prominence of farming activities. The nature of the rural community and economy merged as a barrier to health care for older adults. Participants recognized that in their rural setting, “big industry pieces are lacking,” and that the “town [is] too small to support a doctor.” A general lack of local health care providers and specialist services was a recurrent need identified by key community leaders. In addition, the lack of financial resources for older adults, including lacking health insurance or increasingly high co-pays, emerged as a concern. Distance to Resources. “Distance to Resources,” a theme reflecting data regarding relative proximity to resources, also emerged in relationship to access to health care providers and services among older adults in the community. Regional health care providers are located 20 to 30 miles away from the three rural villages. Some community leaders perceived these resources as being in relatively close proximity, whereas other community leaders identified this distance and limited transportation options as a barrier to health care. For example, “travel and distance [for] those who don’t drive” and “no transportation for older people” were identified as barriers to health care. Challenges faced by older adults who require specialty services or rehabilitation services, in particular, were identified as a concern and barrier as illustrated by the following response: “[older adults who become] disabled, such as breaking a hip, have to go out of town for rehab.” Community leaders also expressed concern about the impact of out-migration on older adults in the community. For example, “families are moving away,” resulting in “too long of a drive to care for the elderly.” While family members often provide important resources for older adults in the partner community, a lack of family in the community may prove to be a substantial barrier to health care access for older adults due to the distance to resources.
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Seasonal Resources. The seasonal nature of some community resources also emerged as a barrier to health care for older adults. The theme “Seasonal Resources” represents data suggesting that access to health resources may be limited according to the time of the year. For older adults, “the post office is a social place in summer.” There are “walkers in warmer weather,” and “people visit each other during good weather”; however, equivalent resources were not necessarily available in the colder months. Community leaders noted that, consequently, older adults may suffer from “isolation, especially in the winter,” due to more limited resources outside the summer months.
Promoting Independent Living for Older Adults Community leaders were also asked to identify resources that would promote independent living for older adults. Community leaders observed that, in many cases, elders remain living at home by sharing the burden among large families and church members. Community leaders stated, “Family helps make it possible to stay in home” and “a lot stay at home; Take a turn in the family.” However, the community is changing. When asked about older adults living independently, one participant stated, “Getting more difficult; Families are moving away with too long of a drive to care for elderly.” Community leaders also emphasized the limited access to assisted living and foster homes in the partner community. One participant shared, “No assisted living in community. If they [older adults] are not cared for by family, they go to assisted living [in distant City], same with nursing homes.” One health care provider stated, “We have many elderly patients in those communities still living alone, but only with family help. Older adults do not leave home until it’s not safe [to remain at home].” Community leaders were asked to offer suggestions as to what might make it easier for older adults to remain living at home in the community. Suggestions included help meeting the basic needs of older adults, such as medical and grocery needs. In addition, a resource to provide a stronger support system involving daily contact with older adults and meal support was suggested. Other resources important to local elder care included caregiver and family support, increased opportunity for physical activity, transportation, and more living options. One of the most imminent needs expressed by community leaders included establishment of a local retirement home or independent living options. In summary, residents of the partner community are closely connected, with family responsibility and intergenerational relationships as important aspects of elder care. Older adults in the community were described as strong, and community leaders shared that many older adults in the community are
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living long lives with vitality. Several barriers to health care access for older adults were identified. Distance from health care providers was an especially significant barrier for older adults. Community leaders see the need for additional resources for older adults in the community and especially emphasized the need for a local retirement home or independent living facility.
Discussion The results of this needs assessment provide important insights into the specific health needs of older adults in the rural Midwest from a within-community perspective. First, older adults receive substantial support from family. The integral nature of family within the partner community manifested in several themes and subthemes generated from this community health needs assessment. Community leaders consistently stated that families play an integral role in community life, especially in the lives of older adults. To that end, “Intergenerational Relationships” are an important part of the lives of older adults as well as part of the larger community structure. Families provide health-related resources that are central to the community, including regular care and interaction as well as transportation to health care services. These findings are echoed in a comparative study of home care nursing services used by community-dwelling older adults in rural and urban environments (Borowiak & Kostka, 2013). Rural-dwelling older adults nominated their family members as care providers 82.8% of the time, in contrast to 51.2% of urban-dwelling older adults, and reported often having someone available for potential care services (Borowiak & Kostka, 2013). Familial resources may be positively utilized to improve health for older adults (Averill, 2005). Despite the availability of some resources, rural-dwelling older adults face particular challenges (Thornlow, 2008). Because of geographic isolation and lack of proximity to health care providers, older adults dwelling in rural areas often experience unique environmental and other risk factors (Durazo et al., 2011). Challenges such as rugged terrain, precarious road conditions, and a sparse and dispersed population may make it difficult for rural elders to obtain medical services and access areas safe for exercise (Durazo et al., 2011). Consequently, older adults may also be more reliant on family members for care provision or transportation to health care services (Borowiak & Kostka, 2013; Magilvy et al., 2000). Family members may also struggle to meet obligations in caring for rural elders, as demonstrated in ethnographic work among a rural Hispanic population (Magilvy et al., 2000). Older adults without family members within the partner community in this study experienced increased barriers to health care access, often in the form of lack of transportation or inability to remain safely caring for oneself at home.
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Struggling to meet caregiving obligations did not manifest in this health needs assessment, although key informants shared that there is a strong sense of “Family Responsibility” within the community. Averill (2002) examined the meaning of health, health care perceptions, and health care issues for rural elderly individuals residing in Southwestern New Mexico (Averill, 2002). Based on 22 interviews with rural elderly individuals, family members, and community health care providers, several significant health-related issues came to light. Some deficits in provision of quality health care for older adults were unique to the community and were related to economic hardship secondary to the demise of the mining industry (Averill, 2002). Limited access to basic primary care, home health care, specialty care, and hospice care, reportedly had negative effects on the health of rural-dwelling older adults in New Mexico (Averill, 2002). Community leaders in this health needs assessment also perceived a lack of access to similar services. One of the most imminent needs expressed by community leaders included establishment of a local retirement home or independent living facility. Both community leaders in this study and individuals interviewed by Averill (2002) reported limited transportation as a barrier to health care for rural-dwelling older adults. Rural-dwelling older adults in the Southwestern New Mexico community suffered from social isolation and loneliness. However, in this “Close-knit” partner community of the rural Midwest, social isolation and loneliness were not often reported as significant barriers to health care, although one participant reported that some older adults become withdrawn and suffer negative health consequences. In contrast, elders in the partner community were described as “Strong” and community leaders perceived that many older persons in the community are living long lives with vitality. While this study provides insights into the characteristics of rural-dwelling older adults as perceived by community leaders, it also illustrates the importance of understanding any given community prior to engaging in research. Residents of the partner community in this study are closely connected, and family responsibility and intergenerational relationships are important aspects of elder care. Other communities, like that investigated by Averill (2002) in New Mexico, demonstrate unique strengths such as regionspecific knowledge, presence of dedicated problem solvers, and communitybased action groups (Averill, 2003). The themes that emerged in this study have been incorporated into community engagement and participant recruitment efforts in subsequent phases of the broader community–academic health research partnership. Research team members regularly interact with community members during religious and community festivals held in the partner communities, and are given an
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opportunity to discuss the parent study in these venues. Interestingly, participant recruitment for a registry to support future health research studies has been most successful through word of mouth in the “Close-knit” community (Rivard, Goris, Schutte, & Schutte, 2014). Continued research implementation and translational efforts must build on and support family, intergenerational relationships, and church connections. Because community leaders see the need for additional resources for older adults in the community, further research should be conducted to investigate needs from the perspective of elders in the partner community to confirm these results. Understanding the characteristics of rural older adults and tailoring recruitment strategies to the rural community are crucial to participation in and acceptance of future research efforts in the partner community (Dibartolo & McCrone, 2003). This article describes a community health needs assessment related to older adults that was completed as part of a community–academic health research partnership. The community-level health needs assessment was successfully conducted, although several limitations are acknowledged. First, although saturation of themes was reached in the qualitative data analysis, the sample size was relatively small (N = 30) and may not reflect the health needs and resources related to older adults as perceived by the community at large. Second, older adults from the community were not specifically targeted as part of this study, which may limit the usefulness of results. However, more than 25% of community leaders in this study qualified as older adults above age 65 and offered valuable perceptions. Investigators are triangulating data gathered as part of this assessment with individual-level health data collected from older adults within the community. Investigators acknowledge, however, that less integrated community members might perceive the health needs of older adults and community characteristics differently than community leaders, which would further enrich data gathered in this study. Finally, community leader interviews were documented through notetaking in the field, rather than audiotaped. The research team, in consultation with community advisory board members, believed this was the best approach for building trust and soliciting information. Although note-taking is an established method of documenting key informant interviews, investigators recognize that relevant data units and themes may have been lost during the handwritten transcriptions and that there is a risk of bias in the note-taking process. To address this potential risk, several strategies were used to verify research findings, including coding by multiple team members and memberchecking results with community advisory board members (review of major themes, subthemes, and illustrative quotes; review of manuscripts), to establish the credibility of the results.
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This study provides important insights related to the health of older adults from a within-community perspective and expands our understanding of the unique health needs of elders in the rural Midwestern United States. In addition, the study exemplifies a successful collaboration with a community advisory board, influential in study design and implementation, in accordance with community-based participatory research principles, to design and implement a community health needs assessment. This community health needs assessment was an essential step in establishing a long-term community– academic partnership. To that end, these data will be used to identify and prioritize future research and subsequent translational efforts that are consistent with community strengths, values, and needs. Acknowledgement We gratefully acknowledge the contributions of the community members for their service on the Community Research Advisory Committee who participated in the design, implementation, and analysis of this research. We are also indebted to the Community Ethics Committee for their valuable review of this manuscript.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Strategic Partnership Grant (Michigan State University [MSU] Foundation), Innovations Grant (Families and Communities Together Coalition, MSU), Departmental Funds (Microbiology and Molecular Genetics and College of Nursing, MSU), Building Academic Geriatric Nursing Capacity Predoctoral Scholarship Funds.
References The Access Project. (1999). Getting the lay of the land on health: A guide for using interviews to gather information. Boston, MA: Author. Retrieved from http:// www.accessproject.org/downloads/final%20document.pdf Averill, J. B. (2002). Voices from the Gila: Health care issues for rural elders in South-Western New Mexico. Journal of Advanced Nursing, 40, 654-662. Averill, J. B. (2003). Keys to the puzzle: Recognizing strengths in a rural community. Public Health Nursing, 20, 449-455. Averill, J. B. (2005). Studies of rural elderly individuals: Merging critical ethnography with community-based action research. Journal of Gerontological Nursing, 31(12), 11-18.
Goris et al.
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Blair, A., & Freeman, L. B. (2009). Epidemiologic studies of cancer in agricultural populations: Observations and future directions. Journal of Agromedicine, 14, 125-131. Borowiak, E., & Kostka, T. (2013). Comparative characteristics of the home care nursing services used by community-dwelling older people from urban and rural environments. Journal of Advanced Nursing, 69, 1259-1268. Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3, 77-101. Dibartolo, M. C., & McCrone, S. (2003). Recruitment of rural community-dwelling older adults: Barriers, challenges, and strategies. Aging & Mental Health, 7, 75-82. Durazo, E. M., Jones, M. R., Wallace, S. P., Van Arsdale, J., Aydin, M., & Steward, C. (2011). The health status and unique health challenges of rural older adults in California (Health Policy Brief). Los Angeles: University of California. Fordyce, M. A., Chen, F. M., Doescher, M. P., & Hart, G. L. (2007). 2005 physician supply and distribution in rural areas of the United States (Final Report No. 116). Seattle: WWAMI Rural Health Research Center, University of Washington. Guo, G., & Phillips, L. (2006). Key informants’ perceptions of health care for elders at the U.S.-Mexico border. Public Health Nursing, 23, 224-233. Kingsley, J. Y., Phillips, R., Townsend, M., & Henderson-Wilson, C. (2010). Using a qualitative approach to research to build trust between a non-aboriginal researcher and aboriginal participants (Australia). Qualitative Research Journal, 10(1), 2-12. Knafl, K. A. (1988). Consider the possibilities of qualitative research. Western Journal of Nursing Research, 10, 125-127. Kovac, S. H., Mikuls, T. R., Mudano, A., & Saag, K. G. (2006). Health-related quality of life among self-reported arthritis sufferers: Effects of race/ethnicity and residence. Quality of Life Research, 15, 451-460. Magilvy, J. K., Congdon, J. G., Martinez, R. J., Davis, R., & Averill, J. B. (2000). Caring for our own: Health care experiences of rural Hispanic elders. Journal of Aging Studies, 14, 171-190. Miles, A., Proescholdbell, R. J., & Puffer, E. (2011). Explaining rural/non-rural disparities in physical health-related quality of life: A study of United Methodist clergy in North Carolina. Quality of Life Research, 20, 807-815. Minkler, M., & Wallerstein, N. (2008). Community-based participatory research for health: From process to outcomes. San Francisco, CA: Jossey-Bass. Rivard, J. L., Goris, E. D., Schutte, B. C., & Schutte, D. L. (2014). Engagement and recruitment strategies in a community-based translational genomics project. Manuscript in preparation Schutte, D. L., Goris, E. D., Rivard, J. L., & Schutte, B. C. (2014). Community health needs assessment in a rural setting: Foundation for a community-academic partnership. Manuscript in preparation Steele, J. C., Patrick, J. H., Goins, R. T., & Brown, D. K. (2005). Self-rated health among vulnerable older adults in rural Appalachia. The Journal of Rural Health, 21, 182-186.
618
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Strauss, R. P., Sengupta, S., Quinn, S. C., Geoppinger, J., Spaulding, C., Kegeles, S. M., & Millett, G. (2001). The role of community advisory boards: Involving communities in the informed consent process. American Journal of Public Health, 91, 1938-1943. Thornlow, D. K. (2008). Nursing patient safety research in rural health care settings. Annual Review of Nursing Research, 26, 195-218. UCLA Center for Health Policy Research. (n.d.). Section 4: Key informant interviews. Retrieved from http://healthpolicy.ucla.edu/programs/health-data/trainings/Documents/tw_cba23.pdf University of Illinois Extension Service–Office of Program Planning and Assessment. (n.d.). Needs assessment techniques: Conducting a key informant interview. Retrieved from http://ppa.aces.uiuc.edu/pdf_files/Conducting1.PDF U.S. Census Bureau. (2010). The next four decades, the older population in the United States: 2010 to 2050 population estimates and projections. Retrieved from https://www.census.gov/prod/2010pubs/p25-1138.pdf U.S. Census Bureau. (2013). Geography: 2010 census urban area facts. Retrieved from http://www.census.gov/geo/reference/ua/uafacts.html U.S. Department of Agriculture. (2013). Rural classifications. Retrieved from http:// www.ers.usda.gov/topics/rural-economy-population/rural-classifications.aspx U.S. Department of Health and Human Services. (2013a). Older adults. Retrieved from http://www.healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=31 U.S. Department of Health and Human Services. (2013b). A profile of older Americans: 2011. Retrieved from http://www.aoa.gov/AoARoot/Aging_ Statistics/Profile/2011/8.aspx Wallerstein, N., & Duran, B. (2006). Using community-based participatory research to address health disparities. Health Promotion Practice, 7, 312-323. Wallerstein, N., & Duran, B. (2010). Community-based participatory research contributions to intervention research: The intersection of science and practice to improve health equity. American Journal of Public Health, 100(S1), S40-S46. Weeks, W. B., & Wallace, A. E. (2008). Rural–urban differences in primary care physicians’ practice patterns, characteristics, and incomes. The Journal of Rural Health, 24, 161-170. Weeks, W. B., Wallace, A. E., Wang, S., Lee, A., & Kazis, L. E. (2006). Rural–urban disparities in health-related quality of life within disease categories of veterans. The Journal of Rural Health, 22, 204-211. Werner, C. A. (2011). The older population: 2010. Retrieved from http://www.census.gov/prod/cen2010/briefs/c2010br-09.pdf Wilcox, S., Castro, C., King, A., Housemann, R., & Brownson, R. (2000). Determinants of leisure time physical activity in rural compared with urban older and ethnically diverse women in the United States. Journal of Epidemiology & Community Health, 94, 1682-1686.
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