Document Type

Dissertation

Date of Degree

Fall 9-1-2021

Primary Advisor

Philippus Van der Wees

Keywords

Aging in Place, participation in society, functional ability, age-friendly cities and communities, person-centered planning, community action plans, theory of change

Abstract

Background: Baby boomers are steadily aging in America and represent an increased population in nearly every sector. In suburban communities today, older adults make up 51% of the population. Ninety-five percent of all older adults live in community settings and have expressed a desire to avoid costly institutionalization and to remain in their homes and communities, also called aging in place. Older adults in moderate income suburban communities are increasingly at a higher risk for institutionalization should their health or finances decline as the access to their wealth is within the home in which they dwell. This process forces many suburban-dwelling older adults to liquidate their assets in order to access funding. This demeaning process negates the vision of aging in place. Aging in place services are not only preferred by older adults, but they also are shown to be a more cost-effective solution to institutionalization. Older adult participation in community life is shown to enhance aging in place and enrich communities. Communities have recognized the need for action planning to support the needs of older adults to age in place; however, plans often lack empirical evidence, they leave out older adults, particularly those with disabilities, and the planning process takes a top-down approach often from the perspective of planners and policy makers.

Objective: The purpose of this study was three pronged at a micro, meso, and macro level. At the micro level the goal was to assess the relationship of participation in society (satisfaction) with a) individual characteristics of community-dwelling older adults and b) environmental characteristics in select suburban South Jersey communities. At the meso level the goal was to a) garner a deep understanding of participant perceived barriers and facilitators and b) elicit suggestions for addressing them in order to c) inform a focused situation analysis and theory of change. Lastly, at the macro level, the goal was to understand fidelitous empowerment procedures of older adult participation in society through person-centered community action planning. In order to develop community action plans that shape policy and facilitate meaningful participation, local communities must first begin to develop an evidence-based understanding of strategies for engaging older adults in the plan development processes. Through the development of a theory of change for community action plans in select suburban Southern NJ communities, older adults of varied ability levels are able to meaningfully participate in society and effectuate further participation.

Methods: This study utilizes the Consolidated Framework for Implementation Research to map aging in place literature and uncover opportunities to propel aging research through engagement of older adults in the theory of change process. Drawing from multiple theories, this explanatory sequential mixed methods study telephonically surveyed (n=64) and interviewed (n=14) older adults from three suburban communities in southern NJ. In the first, quantitative phase of the study, cross-sectional telephone survey data using interactive voice response (IVR) and Qualtrics survey software was collected from a purposeful sample to examine how satisfaction with participation in society (dependent variable) was related to community features and individual characteristics (e.g. functional ability level). Data was analyzed using IBM SPSS. The second, qualitative phase was conducted as a follow-up to the quantitative results. Maximum variation sampling of survey participants who agreed to follow up resulted in the selection of 14 telephone interviews. Participants explained barriers and facilitators to participation in society and suggested objectives to overcome barriers and leverage facilitators to participation in society. NVivo software was utilized for analysis using templated and axial coding. Appreciative Inquiry Theory was utilized to inform the qualitative process and development of a theory of change.

Results: A multiple linear regression analysis was conducted to determine how much of a variation in the dependent variable, satisfaction with participation (USER-P), can be explained by the independent variables measuring individual characteristics and community characteristics. Three variables, functional mobility (WHODAS score; B= -0.266), availability of healthcare services (B= 8.20), and availability of information to events, services, and programs (B= 8.905) added statistically significantly to the prediction (p < .05) of the dependent variable. The multiple regression model statistically significantly predicted USER-P satisfaction, (adj. R2 = .456, p < .001). A secondary analysis using binomial logistic regression models was performed for the variables that are considered specific to community participation. WHODAS score statistically significantly predicted satisfaction in outdoor mobility (OR=.952, 95% CI [.908, .997]), exercise (OR .948, 95% CI [.902, .997]), and daytrips (OR= .961, 95% CI [.924, .999]). The findings from the quantitative analysis, guided by Appreciative Inquiry, were used to inform the qualitative strand of the study. Three overarching domains emerged from the qualitative findings: Basic, Social, and Growth. These findings as well as the co-developed outcomes chain were used to create the theory of change. The theory of change articulates a set of needs that are desired and suggested objectives to address these needs. The theory of change coupled with the translational stakeholder meeting bridges further engagement with older adults in planning. Stakeholders identified four fidelitous empowerment procedures required to induce person-centered community action planning: leveled engagement, communication, enfranchisement and champions, and social/cultural capital.

Conclusion: Within the context of the Consolidated Framework for Implementation Research (CFIR), basic, social, and growth domains must first be understood as needs, suggested objectives to meet needs, and desired outcomes within the individuals involved, the inner setting, and the outer setting so that interventions (theory of action) can be designed with the explicit theory of change process. The theory of change developed in this study explains that older adults are empowered to participate in one’s community when there is support for basic and home living needs (basic), when options for participation match one’s level of ability, interest, and values (social), and when one is invited and knows where to find information about programs, services, or events (growth). The theory of change is a demonstration of a process that utilizes person centered planning toward consumer leadership in system development and recognizes that aging in place is impacted by health factors as well as social determinants of health. Planning teams now have the translational tools to create customizable, theory-driven, and evidence-based approaches for strategies to engage older adults with varied ability levels to feel empowered to participate not only socially in community activities, but also civically in the development of community action plans.

Comments

©2021 by Emily Balog. All rights reserved.

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