Barriers to service use have been defined primarily by descriptive studies of rural service providers or service users. Little qualitative information is available regarding the structural and personal processes that are involved in providing, as well as accepting, services. This study compares service providers' perceptions of need with those of the rural adults they serve.
HEAlTH AND SERVICE USE AMONG THE RURAL ELDERLY
The types of physical health problems experienced by older adults living in rural areas are similar to the general elderly population (Krout, 1986). Chronic conditions such as arthritis, hypertension, heart problems, and hearing loss predominate. However, it has been suggested that rural older adults experience symptoms of ill health at a rate significantly higher than that of their urban peers (Hendricks, 1988). These differences may arise from several intervening factors, such as income level, nutritional intake, and lack of health-care services.
Recent reviews of literature on service needs of the rural elderly suggest that availability, accessibility, and lack of awareness are common barriers preventing them from receiving adequate health and social services (Coward, 1985; Krout, 1986). Although the number and type of services available to older adults has increased dramatically during the last 2 decades, comprehensive services are often lacking in rural areas (Krout, 1987; Nelson, 1980). In addition, residents of less densely populated geographic areas also experience problems in accessing appropriate services due to their geographic remoteness and isolation (Ambrosius, 1981; Parkinson, 1981). The lack of service knowledge by older rural adults often stems from looselydefined and poorly understood communication networks of health and social service organizations (Ecosometrics, 1981; Krout, 1983).
THE RURAL ACCESS STUDY
Selected social service professionals, health-care providers, and elderly residents of two planning and service areas (PSAs) in Northeast Colorado were interviewed regarding their knowledge, attitudes, and perception of factors that facilitate and inhibit the delivery of services to older adults. Both PSAs (Weld and Northeast) are considered primarily farming and ranching areas. Weld County covers 4,004 square miles with one central city of 60,000 people. Forty percent of the population over age 60 Uves in rural areas. The Northeast area spans six counties (9,229 square miles) with only one town having a population of approximately 12,000 people. Fifty-three percent of this PSA's 60-plus population Uves in rural areas.
Semi-structured interviews were conducted with 32 provider respondents identified through County Senior Service Directories in each of the seven counties included in this study. Respondents included physicians, nurses, social workers, and staff and administrators of agencies serving older adults. Twenty-eight seniors ranging in age from 62 to 94 and living independently in the sevencounty area were also interviewed. They were identified through senior centers, ministers, and service providers. AU interviews took place between January and April 1989.
The interviews with the service providers were guided by the following four questions: What are the existing financial barriers to deHvering medical and social services to elderly residents? What are the existing organizational barriers to delivering medical and social services to elderly residents? What are potentially feasible strategies for overcoming the financial and organizational barriers that you have identified? What are the unmet medical and health needs of rural versus nonrural elderly residents of Northeastern Colorado?
Two primary questions guided the interviews with the elderly respondents: if you had any health problems in the last year, how were your health-care needs met? Do you have any service needs that are not being met? If yes, why?
QuaUtative methods in data collection and analysis were chosen for this study. Audio recordings of each interview were transcribed; data were compiled, coUated, and summarized. Analysis was composed of estabhshing the range and frequency of response categories by category of respondent using a systematic content analysis of recorded material from the interview. Two researchers independently reviewed and coded each interview. When there was disagreement as to response category, the two researchers jointly reviewed and discussed the material until they reached agreement.
Eight provider issues were identified from the analysis of the interviews. These issues are discussed and illustrated with supporting, representative quotes from respondents.
Regressive Financial Systems
The predominant issue depicted state and federal health service financial reimbursement mechanisms as regressive when they are translated into practice. Many of the providers expressed frustration explicitly about how the Medicare and Medicaid reimbursement systems produced unfair and shortsighted actions in taking care of complex and, in many cases, long-term medical and social issues of older thents. The discussions on the regressive nature of Medicare and Medicaid reimbursement systems focused on home health care and primary medical care. In particular, providers described several instances of patients who were discharged but lacked the appropriate eUgibiUty for home health coverage that would maintain them in their own homes. This forced the patients to relinquish their property to the state so that they would be eUgible for nursing home care under Medicaid. In the providers' own words:
"The No. 1 challenge I have is not having enough money to cover client needs."
"We have a lot of services available in this area, but it is a matter of whether seniors are financially eligible for them."
"We need to be very careful when referring patients to community care, that it is affordable to the patient as well as funded or supported by Medicare."
Confusion About Program Eligibility
The second major issue was best characterized as client confusion over the eligibility for specific programs. The sources of confusion were numerous, but the most prominent were the complex system of rules and regulations defining eligibility that had to be interpreted by providers and that were potentially difficult to communicate to elderly clients. Misperceptions were created on the part of clients about which programs were available and whether there were restrictions or impositions present if a person received specific types of senior services.
"Seniors often don't know who to call or what services are available, because the system of eligibility for specific programs is so complicated and confusing."
"Many physicians do not know what services are available in the community for seniors, let alone have knowledge about the financing systems that govern eligibility for these programs."
Dignity and Value of Seniors in Society
The majority of providers talked about the necessity to respond to and maintain the dignity of elderly clients. Concern was expressed about the value of seniors in our society and the problems that can develop when people retire. Closely related to the issue of dignity and value were discussions of perceived isolation of the older adults. Isolation did not appear to be tied directly to geographic isolation, but rather social isolation regardless of a person's residence.
"Many seniors will not accept services that are available to them because of pride."
"We get so involved in providing care to people that we often forget to ask what it is that people need."
"Many elderly feel very funny about letting complete strangers into their homes to help them. This can make it difficult to get services to them."
Rural Versus Nonrural Differences
More than half the providers mentioned differences between serving older adults living in populated areas versus those living on ranches or in rural locations. The predominant issue was the difficulty in reaching the rural elderly with the needed services at an affordable cost. Many providers felt frustrated by the perceived barrier of geographic remoteness in Northeastern Colorado. Yet, several providers were under the impression that elderly persons who live in these rural areas are more physically and emotionally independent compared with their "urbanized" counterparts.
"In rural areas, most seniors have the attitude of, 'if it ain't broke, don't fix it.'"
"I know one old man who is 90 years old and he feeds 50 head of cattle every morning on his ranch. When he comes into my office, he can barely walk down the hallway from one room to the next because he is so crippled. But he has a sense of purpose on his ranch, and this keeps him going."
Coordination of Services
Nearly half of the providers talked in various ways about turf battles over funding and coordination of services. This issue was described with some frustration. In one county, several respondents mentioned that the Area Agency on Aging was doing a superlative job in coordinating limited resources for the senior population in the county. Outside this county, comments were characterized by a focus on less welldefined coordination efforts and confusion over who was doing what and what services were available for older residents.
'There are too many chiefs and a lot of competition for limited resources in the delivery of senior services."
'The problem in coordinating care for seniors is a political fight among professions. Struggles over control get in the way of successful coordination of care."
Providers focused on transportation as a key barrier to access for services among older residents, especially in disperse rural areas. Inability to drive an automobile and dependence on others for transportation, private or public, was viewed as an obvious constraint on people accessing services when they needed them.
"In rural areas, many seniors may not do anything for themselves until they are in a crisis situation, then someone else has to step in. This is a function of remoteness and lack of access to easily available transportation."
'Tn situations where free transportation is available, there are many potential clients who choose not to take advantage of it; this is an attitude problem."
Knowledge About the Aging Process
Several respondents mentioned that providers need to learn more about the human aging process. There was a perception that lack of knowledge is, in general, a shortcoming of the rural provider system.
"Many physicians lack information on the total picture of the patient. If they knew more of the social issues, they may be able to help that person more effectively from a medical standpoint."
"We need to know more about the normal aging process. This may be especially true among rural practitioners who may not be as current as those practitioners who are practicing in urban areas."
Education of Dependents
Many providers were concerned about the need to better educate the children of elderly persons regarding changing needs of aging people. Concern was expressed that seniors degenerate too long before intervention occurs, precisely because family members do not recognize the signs and symptoms of degeneration.
'Teaching the kids of the old-old to know when their parents are no longer able to live at home is a Hg issue."
"A lot of the problem is that many seniors do not see themselves as old enough to need specific services to help them."
"Most seniors do not want their kids to know that they cannot do something, so they put up an act and soon there is a big crisis."
The results of the interviews with the older adults were substantively and structurally different from the providers. Five service-related issues are presented with supporting, representative statements from the older respondents.
I Am Still "Me"
Pervading all the discussions with older participants was the fact that they had active minds but bodies that were less cooperative. Several respondents expressed amazement in thinking about themselves as old people; it was their failing physical health that continuously reminded them that they were no longer 18 years old.
'The thing is, when you get older, you just get older outside, you don't get older inside. I still feel 45 inside. People just look at you as older."
"I remember waking up one morning and looking in the mirror and being shocked at the person that I saw."
"You're always young - you feel like 18. Your body just gets old."
Fear of Dependency
The second major issue was a marked expression of fear of dependency. This fear was usually expressed in conjunction with a failing physical condition, such as eyesight or immobility. Several respondents talked about the fear of dependency in tangible terms, such as not being able to drive. Other respondents expressed it in more subtle ways, such as complaining about the difficulty of finding someone to clean the house or mow the lawn. Whatever the expression, it was strongest in people who had described their lives as previously being very active.
"I don't like to be a burden. I hope I pass on with my boots on."
"Once you stop and pity yourself, you are finished."
An issue that emerged from analyzing respondents' self-descriptions of their lives during their adult years and currently is that those who were active and skilled in social relations and approached their life in a problem-solving manner as they aged also did so in their early years. Those people who were surrounded with caring people at age 80 were surrounded by caring people (by their own description) when they were 40. Similarly, people who described themselves as lonely in their current life also described their early years as being unfulfiUing. For example, one older man in his late 70s with failing eyesight and severe arthritis had already begun thinking about where he could buy a three-wheeled electric cart that would enable him to be mobile and independent once he lost his driver's license. In contrast, a woman in her 60s who appeared very depressed and isolated had always been a dependent person and cut off from many close relationships.
Three components to the issue of finances emerged in this study. The first was that among individuals covered by Medicare and private insurance, there was strong praise for the coverage provided. The second component was having to hire professional help to sort through the paperwork to process the Medicare and private insurance billing forms. Third was the complaint among several respondents who felt that it was better to be a pauper than a person of the middle class in terms of having adequate health-care coverage.
"If you are not a millionaire, you are better off being poor."
"Low-income seniors have the program advantages; the middle class are the ones who have to finance the low-income people."
Perhaps the most poignant issue that emerged from the senior participants was that of trying to maintain dignity in the face of debilitating physical conditions. This was a complex issue that involved not only the individual's changing status due to physical health, but also the changed status in society of being an older person who felt less valued by society in general.
Summary of Content AnalysisPro vider Versus Senior Perspectives
"I had a heart attack last year and now I do nothing. I just sit on the front porch and look wise."
"I have to hire people to do this and that and it is frustrating because I don't have that much money and I don't like to ask for help."
"Many of the people who come to the senior center would not come if it were federally subsidized, because they would see it as welfare."
PROVIDER VERSUS SENIOR PERSPECTIVES
The Figure summarizes the contrasts between the provider and senior issues identified by the content analysis. Similarities between the two groups surfaced with regard to finances and the issue of dignity. From the provider's perspective, the issue of finance is one of limited resources to meet unlimited need. Their challenge is twofold: to try to be clever to make services that are funded by Medicare, Medicaid, and private insurance correspond to physical and emotional needs of seniors; and to find economic resources from professional services within the constraints of turf battles among professional disciplines. Seniors, on the other hand, view the issue of finances in terms of the costs of medical care, home care, and other social services. There was a perception that unless one is well taken care of with a good pension and Social Security benefits, one is better off poor than a member of the middle class.
The issue of dignity was the most consistent between providers and seniors. Providers were cognizant of respecting the independence and dignity of the senior cUent. They realized that some cUents decline their services because they are embarrassed or do not want to reveal their personal economic situation. Seniors expressed the need to maintain dignity in close association with the need to maintain independence and to cope with degenerating physical conditions, which made them afraid of becoming dependent on others.
The other issues that emerged were functionally and structurally different. The provider perspectives appear to be shaped by perceptions of need defined by older persons who have sought health and social services either in a crisis or due to a specific problem. From this perspective, providers are constantly dealing with the reaUty of complex social and medical interventions within the constraints oí reimbursement mechanisms that are perceived to be rigid and, in some cases, inappropriate to the real needs of individuals. From the seniors' perspective, the issues are defined in terms of the daily experience of living. Although aU respondents had at least one chronic condition, they still thought of themselves as younger people. Life for them was largely focused on adapting to increasing physical limitations within a famiUar Ufe context, not in an imposed social context that labels them as senior citizens and, therefore, eligible for specific services.
SUMMARY AND CONCLUSION
The findings from this exploratory study suggest that we know very little about the perceptions of rural older adults vis-à-vis the perceptions of professionals who deliver services to them. As has been suggested by previous research, it appears that services that are offered may not actually meet the needs of these older adults (Krout, 1983). Although caution needs to be taken in generalizing these findings due to the small, nonrandom sample of individuals on which they are based, the contrasts identified between the two groups heighten the barriers of service deUvery and use.
It is important to note that several provider respondents mentioned that service providers need to learn more about the human aging process. Although gerontology content is present in nursing curricula, there is a continuing need for nurse educators to emphasize the issues and concerns of the aging person. Understanding the needs of older adults within the context of the family is particularly important for rural communities where the family is often the most important and available source of support. The providers in this study indicated that family members do not always recognize the signs and symptoms of degeneration in older people. Nurses may need to emphasize assessment skills that will ultimately assist caregivers in earlier diagnosis and intervention for healthcare problems of their elder family members.
Nurses and other health-care providers working with the rural elderly need to be sensitive to the perspective of rural older adults, which is often characterized by a lifestyle of simpUcity and frugaUty. The work ethic is strong in rural communities, as is concern about government financing of health care (Shankar, 1980). The findings of this study support previous research that suggests that nurses who work in rural areas should possess adaptabiUty and flexibility (Benson, 1982; StuartBurchardt, 1982).
Nurses and other service providers can most effectively deliver services to rural elders by listening to their perspectives and priorities for care and adapting services accordingly. For example, nurses may perceive the frail elder in a rural setting to be vulnerable and in need of assistance from others. The results from this study indicate that dependence on others is a significant fear of older rural adults. To be successful, nurses must therefore consider the personal feelings and perceptions of their elder patients when developing and implementing intervention strategies. Future research is necessary to determine the true needs of older adults in rural areas so that services can be effectively modified to meet existing and future needs.
- Ambrosius, G.R. To dream the impossible dream: Delivering coordinated services to the rural elderly. In P. Kim, C- Wilson (Eds.), Toward the mental health of the rural elderly. Washington, DC: University Press of America, 1981.
- Benson, A., Sweeney, M., Nicholls, R- A faculty learns about rural nursing. Nursing and Health Care 1982; 10(2):78-82.
- Coward, R., Rathbone-McCuan, E. Delivering health and human services to the elderly in rural society. In R. Coward, G. Lee (Eds.), The elderly in rural society. New York: Springer, 1985.
- Ecosometrics. Review of reported differences between the rural and urban elderly: Status, needs, service, and service cost. Washington, DC: Administration on Aging, 1981. Contract No. 1 05-80-6-065).
- Hendricks, J., Turner, H. Social dimensions of mental illness among rural elderly populations. M J Aging Hum Dev 1988; 26(3): 169-190.
- Krout, J. Correlates of service utilization among the rural elderly. Gerontologist 1983; 23:500504.
- Krout, J. Rural-urban differences in senior center activities and services. Gerontologist 1987; 27:92-97.
- Krout, J.A. The aged in rural America. New York: Greenwood Press, 1986.
- Lassey, W., Lassey, M. The physical status of the rural elderly. In R. Coward, G. Lee (Eds.), The elderly in rural society. New York: Springer, 1985.
- Nelson, G. Social services to the urban and rural aged: Experience of Area Agency on Aging. Gerontologist 1980; 20:200-207.
- Parkinson, L. Improving the delivery of health services to the rural elderly: A policy perspective. In P. Kim, C. Wilson (Eds.), Toward the mental health of rural elderly. Washington, DC: University Press of America, 1981.
- Shanker, D., Quiring, J. Characteristics of nursing in rural settings. Kansas Nurse 1980; 55:4-6
- Stuart-Burchardt, S. Rural nursing. Am J Nurs 1982; 27:616-618.
Summary of Content AnalysisPro vider Versus Senior Perspectives