Rural-dwelling older adults have been identified as a population at risk for health disparities due to low socioeconomic status, health literacy challenges, and obstacles to health care access (National Rural Health Association, 2017; Oregon Office of Rural Health, 2017). Health care providers and community stakeholders who are invested in reducing health disparities for older adults in rural settings require information about physical, psychosocial, economic, and environmental factors that influence health status. Existing research provides quantifiable data about information such as service use and health outcomes (Goris, Schutte, Rivard, & Schutte, 2015; Rural Health Information Hub, 2017a). However, few studies describe perceptions of health and health care of rural-dwelling older adults (Skinner & Winterton, 2018; Song & Kong, 2015). Any efforts to impact existing health disparities may be misguided without knowing what health and health care mean to older adults. The purpose of the current study was to describe the meaning of health and health care from the perspective of rural-dwelling adults age 75 and older in the Northwestern United States.
Disparities in health care access are cited as the number one problem for rural residents (Gamm, Hutchison, Bellamy, & Dabney, 2010). Access to physicians is limited when only 10% of physicians practice in rural areas and approximately 20% of the population is rural dwelling (Rural Health Information Hub, 2017a). Rural hospital mergers and closures have been numerous, and hospitals that remain operational lack specialty health care services (Kaufman et al., 2016). A survey exposed a consequence of health care access disparity for rural-dwelling Medicare recipients (Alfero et al., 2013). Patients treated for myocardial infarction (MI) in rural hospitals had a significantly higher 30-day post MI death rate than patients treated in urban hospitals. This death rate was attributed to not only the impact of lack in cardiac specialists but also lack of follow-up care after serious health events (Alfero et al., 2013).
Health is negatively impacted for individuals who are geographically isolated, socially disconnected, and lonely (Pantell et al., 2013). The average population per square mile of land is an indicator of geographic isolation; less than one person per square mile lived in the two counties where the current study took place (U.S. Census Bureau, 2016). With geographic isolation comes the travel distance to health care facilities that negatively impacts health, especially when weather, road conditions, and lack of transportation are barriers for individuals seeking care (Rural Health Information Hub, 2017a). For chronically ill older adults with mobility issues or losses in social network, health may also be impacted by diminished contact with people. The resulting feelings of loneliness impact emotional health (Marcille, Cudney, & Weinert, 2012; Theeke & Mallow, 2013). In sum, geographical isolation as well as social isolation are risk factors impacting the health of older adults living in rural communities.
Social isolation and poverty often coexist for rural-dwelling older adults (Anderson & Thayer, 2018; Bolin et al., 2015). In Oregon, where the current study took place, 16.6% of the population lived in poverty. However, in the two counties included in the study, 19.3% and 21.3% of the population, respectively, lived in poverty. Statewide, adults age 75 and older constituted 6.5% of the population in 2016. By comparison, the same two counties reported a population of adults age 75 and older as constituting 9% of the population and growing (U.S. Census Bureau, 2016). These statistics support the likelihood of rural-dwelling adults age 75 and older living in poverty in Oregon. Coupled with geographic isolation, health disparities exist due to inability to afford follow-up care and treatment of chronic conditions and transportation expenses to distant health care providers (Bolin et al., 2015; Rural Health Information Hub, 2017a).
It is estimated that nine of 10 adults struggle with the everyday health information available in health care facilities, the media, and communities, and adults age 65 and older living in poverty are more likely to have limited health literacy skills (Office of Disease Prevention and Health Promotion, 2010; Zahnd, Scaife, & Francis, 2009). In general, poor health literacy in rural areas has been identified as a barrier to healthy outcomes, impacting physical and mental health (James, 2014). Specifically, rural areas have fewer individuals who receive health information from the internet than individuals in urban areas. Rural-dwelling older adults are therefore at risk for health literacy challenges that impact healthy self-care practices and contribute to health disparities (Office of Disease Prevention and Health Promotion, 2010).
Rural America is heterogeneous, and determinants of health can be embedded in distinct cultural contexts that vary by region, state, or county (Farmer, Munoz, & Threlkeld, 2012). For example, nurses providing care in four different rural hospitals in the southeastern region of the United States concluded that knowledge about the uniqueness of each rural setting was beneficial to the delivery of quality care (Averill, 2015). Despite the differences in rural culture, older adults are often considered a homogenized group of individuals. An assumption that all adults age 75 and older experience loss and despair represents an ageist narrative prevalent in society (Sweetland, Volmert, & O'Neil, 2017). Yet, research about older adults indicates that individuals in their later years tend to be more variable in nature than their younger counterparts, possibly related to the breadth of experiences lived through many years (Hayman, Kerse, & Consedine, 2017; Twigg & Martin, 2015). The heterogeneity of older adults living in unique rural communities requires consideration when policies and practices related to health resources are developed. Their perspectives about the meaning of health and health care could be a critical component to the planning process for development of health care services. Information about health care disparity for rural-dwelling older adults is easily accessible from the perspective of policy makers (Goris et al., 2015; Rural Health Information Hub, 2017a). However, information about health care disparity from the perspective of rural-dwelling older adults is difficult to find.
The current project used an exploratory qualitative descriptive approach to gather interview data directly from rural-dwelling older adults who were potential recipients of health care. Qualitative description includes an attempt to understand complex situations in the context of where the experience takes place and to describe the experience in the everyday language of participants (Sandelowski, 2000, 2010; Sullivan-Bolyai, Bova, & Harper, 2005). The objective was to develop a descriptive summary of the meaning of personal health and health care from the perspective of rural-dwelling older adults age 75 and older, staying true to the language of participants. The study was granted Institutional Review Board approval from the investigators' university.
Two counties in a single state in the Northwestern United States were chosen for this study because of their frontier designation (i.e., six or fewer residents per square mile) (Oregon Office of Rural Health, 2017). The population for both counties had a higher proportion of adults age 75 and older and a higher number of persons in poverty compared to the rest of the region (U.S. Census Bureau, 2016).
Participants and Sampling Strategy
Older adults were interviewed using a semi-structured guide. A purposive sample of 18 individuals age 75 and older participated. This age group was selected because of growing evidence that heterogeneity of very old adults intensifies with more life experience and would contribute to rich descriptive data. In addition, a rural context for gerontological research is underutilized (Skinner & Winterton, 2018).
Local community members known to the investigators recruited participants: directors of two senior centers, a home delivery meals driver, and colleagues who knew residents of the rural communities where interviewing occurred. Older adults living in either an assisted living residence or nursing home were excluded, assuming some type of health care support was readily available. Recruiters used verbal and written explanations about the intended study. Investigators relied on recruiters to screen for age and the ability to converse in English without undue fatigue during a potentially 1-hour session. If interest was expressed, potential participants called an investigator for further explanation and arranged a time to be interviewed. Eighteen rural-dwelling older adults were recruited by this process (Table 1). The exact age of one participant was not elicited; therefore, mean age is derived from 17 participants.
Participant Demographics (N = 18)
A semi-structured interview guide was developed to capture the meaning of health and health care for rural-dwelling adults age 75 and older (Table 2). Written consent was obtained from each participant before beginning a digital recording of the interview. The average recorded time for interviews was 33.8 minutes (range = 12.3 to 60.3 minutes). Additional data came from field notes taken during and after each interview, including factors that impacted the quality of the interview, as well as the physical and social environment. Interviews took place in 12 homes, five private rooms in community senior centers, and one private long-term care room where a spouse was recovering from illness. Interview sessions occurred between June 14, 2017 and July 7, 2017.
Digital recordings of interviews were transcribed by the principal investigator (PI; D.M.) as well as two Bachelor of Science nursing students. The students underwent a training session conducted by the PI and each finished transcript was verified for accuracy with the audio recording. Transcripts were uploaded into NVivo version 11 computer software. The PI began coding transcripts into the software. Midway through the interview process, the PI and co-investigator (T.R.) came together and reviewed emerging codes from hard copies of coding summaries generated by the software. At this point, 10 codes and seven sub-codes had been organized. Data analysis continued with both investigators recursively moving among hard copies of transcripts for manual coding, re-listening to interview recordings, and reviewing updated computer-generated summaries, staying true to the language of participants.
Participant confidentiality and data security measures were taken. Transcripts, audio recordings, and computer software reports used coded identities for participants. Data were stored in a locked desk in a locked office during the data collection and analysis process. Investigators destroyed audio recordings, transcripts, and computer software reports once the iterative process of data analysis was completed.
After 18 interviews, no new meaning units emerged, and data collection ended with a total of 18 codes, 13 sub-codes, and interview field notes. Three subsequent investigator sessions for reflection and discussion resulted in condensing meaning units into themes and sub-themes (Kvale & Brinkmann, 2015). Table 3 represents the meaning condensation process for the theme “health,” subtheme “what it is,” and defining characteristic “ability to function.”
Condensation Process: Health—What it is: Ability to Function
The interview guide incorporated a “member check” (Powers & Knapp, 2011, p. 106) that offered participants an opportunity to clarify any meaning throughout the interview. The recursive process of content analysis between computer software coding and manual coding from hard copy transcripts reflected an effort to stay true to the everyday descriptive language of participants. Although participant interviews took place in two different counties, they were distributed across three distinct geographic population clusters. The varied reporting from these areas helped create a more complete narrative of the meaning of health and health care for rural-dwelling older adults.
Results are reported in three descriptive formats. Table 4 is a linear presentation of themes, sub-themes, and defining characteristics. Table 5 offers exemplars taken directly from interview transcripts. The meaning of health and health care is elaborated on and supported by relevant literature to situate these results in current information about health and health care for rural-dwelling older adults.
Themes, Sub-Themes, and Defining Characteristics
Participant Response Exemplars
Meaning of Health
When asked the question, “Can you describe what health means to you personally?”, participant responses fell into dichotomous subthemes: what health is and what health is not. The meaning of health was described in terms of maintaining functional ability, maintaining an active mind, and adhering to healthy habits, such as walking, eating wisely, and getting adequate sleep. Keeping busy was also integral to health and contributed to meaningful living. For example, 10 of 18 participants reported volunteering on a regular basis more than once per week, often focusing their services on individuals younger than themselves.
Some participants responded to the question about the meaning of health by immediately referring to personal health challenges or describing what health is not. For them, it was a description of injuries, illnesses, and surgeries. Interestingly, the descriptors about what health is not were less densely described compared to the expressions of what health is. When asked, “Do you consider yourself healthy?”, most participants offered affirmative answers despite only reporting health challenges.
The meaning of health from an everyday rural perspective takes into consideration determinants of health that may not be readily identified as contributing factors. One participant contextualized the meaning of health from the perspective of his rural community while talking pointedly about a fuel assistance program that had been eliminated:
When you're talking about health, we are not just talking about providers, we are talking about a whole bunch of stuff that affects your health and let me tell you, if it is −21° you need to have your wood, your gas, or your oil delivered, it is going to have a determinant effect on your health. They [public officials making the decisions] have no clue, absolutely no clue…
Family support varied among participants: some lived with family, some lived great distances from family, and some had outlived most family members. However, participants did not indicate a feeling of social isolation. The study sampling process drew from groups of individuals already socially connected through churches and community centers. A cohesive social network, with or without family connectedness, seemed to be connected to their definition of health.
For eight participants, the interview question about health brought forth memories of spouses and close family members who experienced health trajectories with poor outcomes. By sharing these heartfelt stories of loved ones, participants contributed rich retrospective accounts of health and health care in a rural context. As the stories about death of a child, months in rehabilitation for a spouse, or surviving cancer unfolded, the ability to bounce back from loss and adversity also unfolded. For these participants living well into old age, the ability to bounce back from adversity became part of their description of health.
Meaning of Health Care
The meaning of health care was again expressed in a dichotomous fashion: you want it, or you want to avoid it. Many participants appreciated the fact that a rural hospital was accessible for care and praised their existing resources. Conversely, other participants identified the local hospital as inadequate and blameworthy for poor health outcomes. Few participants were clear about their conviction to avoid health care altogether unless a situation was a dire emergency.
When asked the question, “Can you think of some obstacles or barriers to receiving health care?”, some participants had to pause at length before answering. Obstacles such as lack of specialty health care providers or the absence of a nearby pharmacy were normalized. These circumstances were placed on par with traveling long distances for household staples and did not fit their definition of an obstacle. Other participants quickly identified obstacles to health care and correlated their lower use of services with long distances to care. Participants associated their lower use of services with long distances to care only found in major cities.
Winter weather conditions, hours of travel, and safety issues while passing through remote areas were verbalized frequently. Disruption in ongoing treatments, such as cancer chemotherapy or renal dialysis, was a concern. Participants recognized that distance to care could translate into a need for more extensive health care in the future or an unfortunate outcome of delayed treatment regimes. Yet, moving closer to treatment centers was personally and financially not feasible.
Health consequences of missed appointments for some participants were either poorly understood, minimized, or acknowledged as a tradeoff for traveling in poor weather or road conditions. One participant with chronic heart disease experienced worsening symptoms over a period of days. Failing to address the symptoms promptly resulted in a 4-day hospitalization. For a few participants in this study, the importance of health care services was rejected altogether. An exception might be a dire emergency, but a come-what-may attitude prevailed.
Discussion and Implications
Assessing strengths and challenges within population groups is an important undertaking for nurses who are committed to closing the gap between health disparity and health equity. The meanings of health and health care for this sample of rural-dwelling older adults were elucidated through the processes of interview and analysis. Participants were living long, active lives and did not subscribe to a narrative that getting old meant decline, loss, and despair. Their self-perception of personal health was positive. A determination to maintain a meaningful lifestyle, despite reporting multiple chronic health problems, was evident. Similar findings have been reported in studies with older, more diverse populations from varied regions of the United States, including urban-living African American individuals in a mid-Atlantic state (Loeb, 2006), women in a Southeastern state (Roberto & McCann, 2011), and a meta-synthesis of three Southeastern rural studies (Averill, 2015).
Rural living for participants meant being a member of a cohesive social network that supported a meaningful existence. Friends and neighbors coming together in mutual support was integral to everyday life. Churches and community centers were well-situated to promote socialization and activities for older adults (O'Rourke & Sidani, 2017; Plunkett, Leipert, Ray, & Olson, 2016). Evidence implies that being involved in community contributes to positive mental health and quality of life (James, 2014; Twigg & Martin, 2015). On the other hand, being physically isolated due to remote living, as well as socially isolated, contributes to poor health among older adults (Anderson & Thayer, 2018; Theekes & Mallow, 2013). While talking about friends and neighbors, participants described a cohesive social network in a way that suggested something more powerful than the “neighborhood” or “social connectivity” taken alone. Participant descriptions of health included multiple references to their social network, possibly mitigating the impact of disparate conditions on overall health.
Resilience has been defined as “rein-tegrating and flourishing despite adversity” (Bolton, Praetorius, & Smith-Osborne, 2016, p. 171). Recounting negative life events allows older adults to focus on positive outcomes from an experience (Browne-Yung, Walker, & Luszcz, 2017). For some participants, family sagas about loss of a loved one to illness or injury shed further light on the dimensions of rural health care access issues. However, in retelling their stories, the evidence of bouncing back from adversity was remarkable. A “redemptive capacity” (Brown-Yung et al., 2017, p. 288) described in these narratives seemed to be a key to well-being for rural-dwelling older adults.
Ultimately, additional years of exercising a redemptive capacity accounts for strengthening resilience for some older adults and may contribute to longevity (Hayman et al., 2017; Zeng & Shen, 2010). Strength and resilience of adults age 75 and older who have defined rural living and are vested in community wellness may be an untapped resource for closing the gap between health disparity and health equity. Participants in the current study had voice, agency, and motivation along with resilience. As nurses address the problems compounded by social determinants of health, including older adults in health care planning for their own community is essential.
The meaning of health care for rural-dwelling older adults in the current study suggested that preventive health-seeking behavior was not a priority. For example, only one participant commented on the need for a dentist, a potential preventive care provider. Preventive health care– seeking behaviors in rural regions occur less often when compared to urban regions according to Florence, Southerland, Pack, and Wykoff (2012). Noteworthy is the fact that dental services are not included in Medicare coverage, and fixed incomes for older adults prevent the purchase of private dental insurance (Gerontological Society of America, 2017). Lack of providers prevents routine oral health care. Furthermore, low health literacy regarding care of teeth and gums has been documented (Zahnd et al., 2009). While exploring reasons for health disparities and looking for answers, self-care patterns and health literacy challenges require consideration in addition to health insurance and provider availability. Nurses can target not only health literacy needs, but are well-positioned to advocate locally, regionally, and nationally for insurance and provider equity.
Policies and practices to remedy rural health disparities must consider social determinants of health or social conditions impacting where one lives (Rural Health Hub, 2017b). One participant in the current study decried the elimination of a winter fuel assistance program. To stave off health-threatening cold, food and medicine was rationed to purchase an alternative fuel source. This example underscores the need to consider social determinants of health as well as contextual uniqueness for place of residence (James, 2014). In this instance, contextual uniqueness included bitter, cold winters and the prevalence of older adults living with a challenging economic status and compromised health status.
Gerontological research is shifting focus from understanding the limitations of illness to understanding wellness for individuals in late life (Twigg & Martin, 2015). When asked, “What is the meaning of health and health care?”, participants offered more descriptors of wellness than illness, highlighting an important finding in the current study. Nurses and other health professionals would be well-served to lessen the biomedical narrative entrenched in education and workplace settings. Biomedical narratives tend to foster negative views of aging with more focus on decline and disease and less focus on health promotion and prevention (Phelan, 2011; Twigg & Martin, 2015).
The current findings support the need to imagine wellness possibilities for older adults and work toward improving health outcomes where aging in place is occurring. Gerontological nurses must acknowledge the strength of rural-dwelling older adults, listening closely to their priorities, and engage them as partners-in-action to improve the health of their communities.
Investigators relied on local resources for recruitment of participants, including the aid of directors of two senior centers, a home delivery meals driver, and colleagues who knew residents of the rural communities. Therefore, the meaning of health and health care for socially isolated, rural-dwelling older adults was largely limited to those with at least some social connections. All participants were English-speaking and Caucasian, representing the predominant demographic of the region. The findings are specific to this region and cannot be generalized to a wider population of rural-dwelling adults age 75 and older.
The research team did not pilot the interview guide. This oversight may have limited the richness of responses due to the inclusion of several close-ended questions.
The responses of rural-dwelling adults age 75 and older were couched in a deep reverence for everyday rural life and the peace that characterized their place of residence. Their positive self-perception of health defied the stereotypical narrative that old age means inevitable decline, loss, and despair. Participants agreed that the advantages of rural living outweighed the disadvantages, and obstacles that routinely challenged health care access were normalized. While acknowledging strengths and challenges, nurses can engage older adults as partners in community research, planning, and action to mitigate health disparities as they age in place.
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Participant Demographics (N = 18)
|Mean age (years) (range)||79.9 (75 to 97)|
|Gender (n, %)|
| Female||14 (78)|
| Male||4 (22)|
|Marital status (n, %)|
| Widowed||11 (61)|
| Married||5 (28)|
| Divorced||2 (11)|
|Household status (n, %)|
| Lives alone||9 (50)|
| Lives with spouse||5 (28)|
| Lives with daughter||2 (11)|
| Lives with sister||2 (11)|
|The Meaning of Health and Health Care for Older Adults in Rural Oregon|
|Date:________ Time ________|
|Interviewer||(Recorder on) I am interested in understanding what it is like to live in rural Oregon. I am most curious about the viewpoint of older individuals. Specifically, I would like to understand the meaning of personal health and the meaning of health care for you. This is from your perspective, so no response is right or wrong.|
|I am hoping this information may help nurses and health care workers gain insight into better care practices in your community. The interview will be recorded, and I might take a few notes, as well. You may refuse to answer any question, and you can ask me to stop at any time.|
|Also, you will not be personally identified in any report of this study.|
|Question 1||How long have you lived in your current residence?|
| • Do you live with someone?|
| • Do you have family or neighbors who stop by?|
| • Do you feel safe living here?|
|Question 2||Can you describe what “health” means to you personally?|
| • Do you consider yourself healthy?|
| • Do you have certain habits that keep you healthy?|
| • What else contributes to your health?|
|Question 3||Can you describe what “health care” means to you?|
| • Do you think you need health care?|
| • Does a health care provider visit you?|
| • Do you go see a health care provider?|
| • Can you think of some barriers to receiving health care?|
|Interviewer||Summarize aloud the main points articulated during the interview.|
|Question 4||Are these main points that I have summarized appropriate conclusions from what you have shared with me? (Member check)|
| • If I have misrepresented your words, please feel free to clarify this for me.|
|Question 5||I have concluded my questions for you. Do you have anything more you would like to share?|
|Interviewer||Thank you very much for your time and for sharing your story (recorder off).|
|End Time:_________ Total:____________|
Condensation Process: Health—What it is: Ability to Function
|Meaning Unit||Condensed Meaning Unit||Defining Characteristic|
|“Reasonably able to do the things I used to do and make adjustments”||Able to do things||Health is the ability to function|
|“To be able to do all the things I've been able to do these 97 years [laughs]”||Able to do all things I've been doing|
|“Being able to do what I used to do”||Do what I used to do|
|“It means I want to have good health so I can get around, you know, and stuff like that”||Can get around|
|“Well, health, good health, means you can function physically”||Function physically|
|“I hope to be 87 and be able to function. I don't want to [get older] if I am not”||Being able to function is important|
Themes, Sub-Themes, and Defining Characteristics
|Meaning of Health||Meaning of Health Care|
|What it is||You want it|
| Ability to function|| Important if you need it|
| Active mind|| Trusted provider|
| Healthy habits||You want to avoid it|
| Keeping busy|| Lack of privacy in a small town|
|What it is not|| Emergency only|
| Illness|| People get worse (die)|
| Injury||Obstacles that add to difficulty|
| Surgery|| Lack of specialty providers|
|Rural everyday life|| Access|
| Cohesive social network|| Distance/weather|
| Bounce back|| Transportation|
Participant Response Exemplars
|Meaning of health|
| What it is||“I hope to be 87 and be able to function. I don't want to [get older] if I am not able to function.”|
| What it is not||Participant responses included descriptions of injuries, illnesses, and surgeries.|
| Rural everyday life|
| Cohesive social network||“I have rancher friends on either side of me and they keep track of me so to speak…and we've kind of worked up a network out here…that if anyone is sick, do you need food for today, do you need somebody to cook for you.”|
| Bounce back||(Recovering from knee surgery) “Making adjustments…which is very hard for things I can no longer do. The head wants to do one thing and the body just says…no more. If I should get a leak in the roof, I would know how to fix it. But because of the clock [i.e., getting older], I can't climb on a ladder or do it, you know all those type of things. I just have to find a handyman.”|
|“No, I don't worry. I guess I have a theory. There's a Bible verse, ‘If God brings ya to it, he'll see ya through it.’ That's my theory.”|
|Meaning of health care|
| You want it||Two of the geographic centers of interviews had community access hospitals, and participants seemed grateful. One participant called the hospital “a blessing.”|
| You want to avoid it||“I try to stay away from the doctor's office as much as I can. My father always said, ‘Ya don't want to go to the hospital ‘cause that's where people go to die.’ I pretty much have to be horizontal [i.e., before accessing an emergency room].”|
|“I don't go looking around for health issues.” (Response when asked if a provider is seen regularly.)|
|“I like him [provider] immensely. Unfortunately, I had him when he was a kid in class. I have difficulty getting undressed in front of him.”|
| Distance||“I go to the VA hospital 200 miles away. We have a van that goes over twice a week. It's just that it's an all-day event for a 20-minute visit.”|
| Specialty care||“If you get into anything specialized, then they [physicians] ship. We can maintain a blood pressure, but if you go into atrial fib [fibrillation], then you're shipped two and a half hours away.”|
| Access||“Just waiting 30 days or so for an appointment, that's too long. I can go to the emergency room and see a doctor anytime.”|