Authors' Research

Introduction/ literature review

The American population is aging. As reported by Crist (1999, p. 102) from the US Census, “In 1997 the 65-74 age group was eight times larger than in 1900 (18.5 million), … the 75-85 age group was 16 times larger (11.7 million) and the 85+ group was 31 times larger (3.9 million).” There were 35.5 million people age 65 and older in 2000, and there will be 69.4 million in 2030 (Kotlikoff & Burns,2000), accounting for 20% of the population (Crist, 1999). As cited by Kotlikoff and Burns, “in the year 2080, the number of seniors (96.5 million) will exceed the number of young people (95.8 million)” (p.8 ). According to Bayer and Harper’s (2000) Fixing to Stay, 83% of individuals surveyed 45 years of age and older reported that they want to stay in their current residence as long as possible. Eighty nine percent of those 55 and over would like to stay in their current residence as long as possible. Clearly indicated by these studies, the desire to age in place is a prominent and deeply held desire. As the population ages and even more citizens are concerned with staying in their homes, the issues surrounding aging in place will unavoidably rise to the forefront of concern for all.

One explanation for the desire to age in place uses the person-environment theoretical model.

The person-environment model describes an interactive relationship between the person and the environment. The environment may be defined as the totality of circumstances surrounding an individual and includes a combination of the external physical and complex social and cultural conditions affecting one’s behavior, (Messecar, 2000, p. 32).

As reported by Crist (1999, p. 102), from McAuley & Bleiszner, the number of aging individuals in nursing facilities continues to rise, yet, a survey of persons over the age of 60 reflects the nationally held desire of most older individuals to have paid care givers or relatives assist them to remain in their homes. “Many people who qualify for a nursing home fully paid for by Medicaid would rather remain on waiting lists for Medicaid’s home and community programs, even doing without the care they need. … People would rather be number 30,000 on a list for community care than go into a nursing home” (Basler, 2004, ¶6). The person-environment model explains how these discrepancies result in the aforementioned behaviors and choices. As reported by Crist (1999), from Cox et al, studies reveal that residents of long term care facilities lack individual control over their daily activities and lack opportunities for personal decision making and creative expression. These limitations make evident the discrepancy between the desires of older Americans and the current institutional environments in which to age.

The prospect of aging at home decreases the probability that a person-environment mismatch would occur. As reported by Crist (1999, p. 105) from Thomas, Smits, Kee and Gould, “living in one’s home or personal dwelling should provide the highest degree of personal autonomy and access to resources of all types. Research indicates that independent living promotes life satisfaction, health and self esteem.” This indicates the home as the ideal setting for person-environment match.

Evidence supports this idea by an examination of differences in quality of life between the following living environments: personal dwelling, specialized housing and nursing homes. Crist’s (1999) pilot study of individuals 65 or older (N= 87) used the Flannagan Quality of life scale and two general health items to compare various types of housing and the impact on quality of life. Crist found that “Personal dwelling subjects reported that living conditions resulted in the best quality of life among the three groups”(p. 111).

The aforementioned person-environment mismatches result when disability or other barriers occur, preventing independent living of the aging. William D. Novelli (2001, ¶5) states, “More than anything, Americans with disabilities want independence in their daily lives and nearly all want to remain in their own homes and receive care there, but they and the families that care for them are often frustrated by the absence of a coherent, easily accessible and affordable ‘system’ to help them.” Specific barriers that prohibit independent living may include but are not limited to: falls resulting in severe disability and functional impairment, lack of information regarding accessible home modifications, lack of funding for needed changes and a hesitance to make changes that one cannot make on their own.

Unintentional falls are the leading cause of nonfatal injury in the United States for all people ages 25 and over (National Center for Injury Prevention Control, 2003). According to the AARP public policy institute (n.d.), the majority (55%) of fall injuries of older adults occurred inside their home, and 43% of these falls occurred at the floor or ground level. As reported by the CDC’s National Center for Injury Prevention and Control ( n.d., ¶5) from Sterling, “Of those who fall, 20%-30% suffer moderate to severe injuries such as hip fractures or head traumas that reduce mobility and independence, and increase the risk of premature death.” Although falls are one of the greatest barriers to aging in place, fall risk and severity can be decreased with the proper implementation of home modifications. According to Bayer and Harper’s (2000) Fixing to Stay survey, when respondents were asked why they had not modified their homes or had not modified them as much as they desired, they cited not having the ability do to the modifications themselves or not being able to afford the needed changes. “Even though most people prefer to stay in their homes, Medicaid still spends 70% of its long term care dollars on nursing homes and only 30% on alternative programs” (Basler, 2004, ¶3 ). Other frequently cited reasons for not making modifications to their homes included not trusting contractors, not knowing how to make the necessary changes, not having anyone to make the changes for them and not knowing how to find a good contractor to modify their home. (Bayer & Harper, 2000, p.6 ).

One key method for overcoming these barriers to independent living and aging in the home is the concept of Universal Design.

Universal Design is a concept that extends beyond the issues of accessibility for people with disabilities and offers a powerful rationale for responding to the broad diversity of users who have to interact with the built environment…. Above all, it highlights a major paradigm shift—from treating people as a part of the medical model, as dependant, passive recipients of care—to a model where everyone is treated as an equal citizen and disability is seen merely as a social construct, (Sandhu, 2000, p. 81).

Most research surrounding Universal Design examines the impact of environmental modifications within the home to facilitate independence and prevent injury. The following studies empirically demonstrate these findings.

Long (1994) presented a study to obtain the relationship between housing modifications and limitations in routine daily activities among persons with various types and degrees of physical disability. Four hundred eighty six individuals from the National Centers Design Advisory Network returned a mailed national survey assessing difficulty and dependence in areas such as bathing, cooking and home care. “Chi square analyses of the presence of home modification and task dependency and difficulty reveal that home modifications are important in reducing dependence and difficulty” (p. 427). Researchers plan to continue investigating person-environment fit in evaluation of housing and in development of devices used to aid in ADLs.

Casteel et al. (2004) conducted a randomized control study to test the effectiveness of the “No More Falls!” (NMF) program. The NMF program consisted of a multifaceted intervention including the removal of environmental hazards, management of medications, development of strength and balance and treating vision and hearing impairments. Reported falls of the test group were not significantly lower during the test period, however among the NMF participants, the odds of falling decreased significantly during the year following participation in the program and the risk of falling of non participants did not decrease during the year following the study.

Nikolaus and Bach (2003) conducted a randomized controlled trial to evaluate the effect of a multi-disciplinary intervention team to reduce falls in community dwelling older people. Three hundred sixty subjects admitted to the hospital showing signs of functional decline were randomly assigned to test or control groups. The baseline number of falls was collected for all participants. Intervention applied to the test group included home assessment, home modification, education on fall prevention and adaptive equipment use and mobility aids. The control group received normal physician care post release from hospitalization. After one year, follow up interviews were conducted and revealed that among those participants who were not labeled as “frequent fallers,” there was a 37% lower fall rate. It was found that the home intervention based on evaluating home environmental hazards, providing necessary modifications and training on use of adaptive equipment significantly reduced the number of falls in community dwelling frail elderly and resulted in a 75.7% compliance rate among study participants after a 12 month follow up interview. Over all, the intervention reduced the number of reported falls by 31%.

There are still other areas within Universal Design that are suggested but not empirically researched/supported. The Centers for Disease control suggests the removal of tripping hazards such as clutter and rugs, use of non-slip mats in the bathtub or shower, use of grab bars near the toilet and tub, additional handrails for staircases and improved lighting throughout the home (CDC, 2005). AARP suggests replacing door knobs with lever door handles, widening doorways and even moving to safer and more accessible neighborhoods (AARP, n.d., ¶3). Still other suggestions have been made by organizations such as the Adaptive Environments Human Centered Design to create more holistic and comprehensive lifestyle modifications, made beyond home modifications (Mace, 1998). For example, Boyce (2003, p. 178) addresses the psychological and physiological impacts of increased lighting on the aging. He suggests that increased lighting may “alleviate some of the symptoms of Alzheimer’s Disease, reduce seasonal depression, and help with some forms of sleep disturbance.” The implications of the Universal Design paradigm have broad applications for the aging and disabled populations so that they may live as equal citizens and disability is seen merely as a social construct. The limited nature of supportive research on the aforementioned modifications and their specific benefits reveals a lack of research in the area of Universal Design and provides new avenues for future research.

The aging and disabled populations of America show a significant interest in aging in their current residences as long as possible. Dissatisfaction with the prospect of institutionalized aging facilities may result from the lack of person-environment congruence. Many barriers to independent living exist, but under the paradigm of Universal Design, most of the problems and limitations to independence can be eliminated with a holistic perspective. According to Messecar (2005), the majority of caregivers were dissatisfied with the most common methods of receiving information regarding home modifications: catalogs, television and the Internet. Taking a client centered perspective, Crist (1999) suggests that occupational therapists can modify contexts to better meet client and caregivers needs by eliminating person-environment discrepancies. One of these discrepancies is the dissemination of information and resources regarding Universal Design’s implications and applications. Bayers and Harper (2000) report that surveyed Americans expressed interest in receiving information about: how to stay in their homes as they aged, avoiding home repair and home modification fraud, and information about varying types of home modifications.

Messecar’s (2002, ¶3) study of caregiver criteria for useful home modification information concluded that “the source of information that caregivers found most useful was provided by experts such as occupational therapists… however, many caregivers reported that this source of information was not available to them… and [therefore] not meeting caregivers’ needs.” Messecar clearly shows that there is a need for educational materials designed to assist professionals. Professionals mush be equipped to address the needs and desires for this information to effectively reach the public. The solution could be for occupational therapists to provide this knowledge and expertise in order to fill the gap.

An extensive review of literature shows a need for intervention regarding aging in place and Universal Design. The purpose of our study was to assess the knowledge, actions and desires of Greater Kansas City area residents regarding aging in place and Universal Design. In addition, our survey determined barriers to aging in place and their respective causes. Results were used in the creation of a comprehensive occupational therapy reference manual designed for the purpose of enabling occupational therapists to assist disabled or aging clients to remain in their homes longer.

Methods

Subjects:

The sample of participants was obtained using a convenience sampling technique. Researchers set up a surveying table at a house on the Kansas City’s 2005 Spring Homes Tour. The Homes Tour gathered community members interested in new home ideas and design styles. Tour participants were from around Kansas City and the surrounding areas. Researchers were present to request participation of Homes Tour participants on three consecutive weekends, and surveys were present for tour participants who toured the home during the week. Completed surveys were returned to the table at the time of completion. A total of 127 participants completed and returned surveys. See Table 1 for a summary of demographic information regarding participants. Participants were also able to enter a drawing for a $50 gift certificate to a local shopping venue as an added incentive. All information obtained from the survey and the drawing were kept separate as to maintain participant anonymity.

Instrumentation:

The instrument utilized in this research project is a 4 page question and answer survey. The survey gathered information regarding respondent demographics, household status, knowledge, desires and attitudes regarding aging in place, Universal Design, related barriers and respective causes. Demographic information was defined as information regarding age, ethnicity and other individual variation among survey respondents, similar to census data. Household information included housing status, number of persons within each household and characteristics of residents therein. Knowledge, desires and attitudes regarding occupational therapy, Universal Design, home modifications, aging in place and perceived barriers to aging in place were assessed using Likert scale response options. An additional section was also included allowing participants to comment on any additional issues regarding the survey.

Researchers designed the instrument according to a series of predetermined study questions. A copy of the instrument is available upon request of the authors. The survey was pilot tested with over 30 individuals of varying ages and backgrounds, as well as edited by three University Faculty for soundness and validity.

The instrument allowed for general quantitative data to be collected on Kansas City area residents. It also allowed for general correlations to be drawn between specific demographic characteristics, attitudes and knowledge regarding aging in place and home modification, and specific barriers to making such changes.

Procedures:

All survey participants were given a survey packet containing a clipboard, an ink pen, a cover letter, and a survey to complete. Each cover letter contained a statement of consent informing participants of their rights and the purpose of the study. All methods and procedures were approved by the Rockhurst University Human Subjects Committee prior to conduction of research. All participant information was kept confidential and no identifying data was kept or associated with the surveys. Surveys will be retained for 3 years in a locked office and destroyed at the end of that time.

Data Analysis:

Descriptive data and correlational comparisons were conducted on the data. Original research questions utilized in the origination of the instrument were further refined to create the following more specific hypotheses for analysis:

Is there a gap in knowledge regarding Universal Design and aging in place and a need for Occupational Therapists to act as educators and resources on these topics?
Is there a relationship between respondents’ ages and their desire to age in place?
Is there a relationship between respondents’ perceived level of preparations for aging in place and actual reported preparations?
Is there a relationship between respondents’ level of preparation and their reported desire to stay in their home as they age?

Some related questions on the survey were combined to create more comprehensive definitions of knowledge, level of preparation, and cumulative desire to stay in the home as a person ages. All analysis was conducted using the SPSS statistical program. Pearson correlation coefficients were calculated to determine the relationship between specific factors in our hypotheses. All data presented from this survey is reported as percentages and does not identify any specific participants.

Results:

Is there a gap in knowledge regarding Universal Design and aging in place and a need for Occupational Therapists to act as educators and resources on these topics?

One hundred and twenty seven surveys were completed and returned to researchers. Descriptive calculations revealed that 91% of respondents reported that they had heard of Occupational Therapy. When asked how much knowledge respondents had regarding the concept of Universal Design, 65.4% of respondents reported knowing little to nothing. When asked to report how important it was for the respondent to remain in their home regardless of age, illness or disability, 70.9% of respondents stated that it was important to very important for them to stay in their home as they age. When asked their feelings about moving to a nursing home, 72.4% of respondents reported feeling negatively to very negatively. Also, 91.3% of respondents reported that they would use at least one resource (website, brochure, and/or a consultant) to aid them in modifying their home in order to age in place.

Is there a relationship between respondents’ ages and their desire to age in place?

Respondents were asked to report their age in a series of demographic questions and asked to report how important it was to them to remain in their homes as they aged. Pearson correlations revealed no significant relationship between respondents’ age and reported desire to age in place (R= -.191). This results in approximately 1.4% of responses significantly correlating to one another.

Is there a relationship between respondents’ perceived level of preparations for aging in place and actual reported preparations?

Analysis also revealed only a mild significant relationship between respondents’ perceived level of preparation to age in place and their actual reported preparations (saving money, securing future funding, modifying or moving from their current home, arranging for caregivers, and/or purchasing additional insurance). The Pearson correlation revealed a significant relationship between these variables of approximately 13.5% (R= .367).

Is there a relationship between respondents’ level of preparation and their reported desire to stay in their home as they age?

Pearson correlation between respondent’s reported desire to age in their home and the number of preparations that they have made in order to age in place revealed no significant relationship (R= .049). This means that approximately .2% of respondents’ actions and desires were directly related.

Discussion:

A reportedly high number of respondents (91%) stated that they had heard of Occupational therapy. This means that the profession is at least widely heard about among Kansas City area residents and could therefore be utilized as a well known resource for information dissemination regarding Universal Design and aging in place. This high level of recognition may also make Occupational Therapists trusted consultants for these issues and thus a more utilized resource.

There is an apparent lack of knowledge regarding Universal Design, with greater than 2/3 of respondents stating that they knew little to nothing about Universal Design. Combined with the high level of desire to age in place (70.9%), which is consistent with Bayer and Harper’s (2000) Fixing to Stay survey, this reveals a significant gap between desire and knowledge among the surveyed populous. This demonstrates a need for education and justifies the creation of educational materials regarding Universal Design. Such a resource could include materials addressing the issues discovered by Bayer and Harper’s (2000) Fixing to Stay survey, such as how to find funding, how to find reliable contractors, and how to make the necessary changes. The high response rate regarding the respondents’ willingness to utilize a resource (91.3%) to assist them in aging in place also reinforces this endeavor. With both comprehensive educational materials and an easily accessible consultant, knowledgeable on Universal Design, its concepts, and its implementation, individuals may be able to turn theirs desires to age in place into a more possible reality.

The apparent lack of relationship between age and the desire to remain in one’s home means that regardless of age, individuals do not want to have to leave their home when they are older. With this knowledge, educators and advocates of the concept of Universal Design can work to reach individuals of any age. Desire to age in place is not an age specific concern and therefore education on the topic can be designed and disseminated to the population at large, not just a selected subset.

Another correlation that immerged from the survey showed a weak correlation between surveyed participants’ perceived level of preparation for aging in place and their actual actions (R= .367). With only a 13.7% correlation between these variables, there is a definite disconnect between perceptions and reality. As educators, Occupational Therapists should utilize this finding by making sure concrete actions are addressed with their consumers, and they must work to orient the consumer to the direct actions necessary to age in place (i.e. saving money, securing future funding, modifying or moving from their current home, arranging for caregivers, and/or purchasing additional insurance, etc.). The creation of educational materials must also present action oriented information with easy to understand guidance for the implementation of Universal Design concepts in order for one to age in place.

In addition, this survey revealed virtually no relationship between respondents’ desire to age in place as related to their level of preparation to do so. When asked how important it was for them to stay in their homes as they aged, 70.9% stated that it was important to very important for them to stay in their home. These findings are similar to those reported by Bayer and Harper (2000). With such a strong response, one would think that these same individuals would have made more preparations to allow this desire to be a reality. When their reported actions were compared to their reported desires, there was virtually no connection between the two variables (R=.049). This sheds some light on the type of population Occupational Therapists may be serving. Individuals may have a strong desire to age in place but may not be making the necessary changes to do so. This may also be related to their perceived level of preparation. If one feels that they are prepared to age in place, then they are not looking for or making changes. When equipped with this knowledge and the appropriate tools related to Universal Design, an Occupational Therapist may, through therapeutic use of self and education, reveal to clients and consumers the discrepancy between their desire to age in place and their actual level of preparation to do so. This can then open the door to change and allow the client’s desires to be a more probable reality.

Limitations:

Several variables impact the overall integrity of this study. Although participants on the tour of homes were not specifically on tour to see a Universally Designed house, their interest in purchasing a new home may mean they are more motivated consumers and may have a heightened knowledge of home modifications, sensitivity to Universal Design, and bias attitudes regarding home modifications and aging in place. This would limit the ability to apply the research findings to the greater Kansas City area and to the general populous residing in their own homes. The survey was administered in a Universally Designed house. Participants were requested to complete the survey based upon their knowledge prior to their tour of the home, but the location of the survey and the participant’s exposure to the home may have impacted their levels of knowledge and their desires to age in place.

Another limitation is the general use of a convenience sample. The location of the home utilized for surveying was located in an area of the city traditionally seen as more affluent. This may have impacted the make up of the population touring the home, such as higher levels of income, generally higher levels of education, ethnic composition and perceptions of barriers to aging in place. If the study were to be repeated in the future, conducting a mailing survey with random selection of participants from the entire city, or conducting several separate convenience samples at different locations across the city would be recommended in order to gather a more representative sample.

Conclusion:

This study took a preliminary examination of the knowledge, actions and desires of Greater Kansas City area residents regarding aging in place and Universal Design. From its results, occupational therapists gain unique perspective into the specific perceptions of a surveyed population as compared to their desires and actions. Therapists gain the knowledge that the vast majority of persons, regardless of age, desire to age in their homes. Therapists also learn that clients may have an inaccurate perception of their level of preparation to age in place, may not know how to utilize Universal Design, or where to access the necessary information to make home modifications. Since this study also revealed that desire may not correlate to action, occupational therapists are in a unique position to act as agents of change for their clients through education, personal intervention and therapeutic use of self. With a focus on holistic care, striving to achieve the person-environment fit as provided through the concepts of Universal Design, therapists have yet another forum for action regarding the overall wellbeing of their clients and themselves.
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