In this study, we set out to identify community resources that older adults with OA report using in their daily self-management of OA. Using qualitative methodology, we found that participants easily identified community resources while also giving the context in which environmental characteristics made it easier or harder to engage in self-management activities throughout the community.
Our findings reveal that participants relied upon religious organizations, medical providers, and social networks for medical care and medical information, and this supported their ability to medically manage their OA. They listed community aquatics centers, senior centers, shopping centers and recreational facilities as resources they used for physical activity and walking - a commonly recommended form of exercise for behaviorally managing OA. In addition, participants discussed using services offered by local pharmacies, shopping centers, and religious organizations, as well as depending on their social network (e.g., family, friends and neighbors) for services such as transportation and assistance with housework. These community resources appear to allow these participants to reduce, modify or adapt the way they conduct everyday activities so as to maintain independence despite OA symptoms and pain. Finally, the social network emerged as an important resource that assisted in the emotional management of OA. Participants discussed the positive benefits of conversation and receiving emotional support from their social network.
A contextual description of the community environment, as relating to the community resources used for OA management, also emerged from the focus group discussions. Participants cited sidewalks, walking surfaces, and lighting as built environment features that acted as facilitators and/or barriers to activities conducted in the community. They also discussed proximity to community resources, especially recreational facilities and costs associated with community programs as barriers and/or facilitators to resources typically necessary for medical or behavioral OA management. Finally, participants highlighted the function of built environment features such as lack of handicap parking, access ramps, curb cuts, and automatic doors as barriers to maintaining independence, accessing identified community resources, and engaging in activities necessary for role management.
Many of the resources identified in this study (e.g., recreational facilities, social network members) are similar to resources that older individuals have previously identified as important for maintaining health (Feldman & Oberlink, 2003
; Weierbach & Glick, 2009
). Our findings are also consistent with past research suggesting that community-built environment factors (e.g., access to facilities, availability of options, cost, sidewalk condition/availability) play a role in physical activity levels in older adults, either with and without arthritis (Humpel et al., 2002
; Martin et al., 2007
; Shih et al., 2006
; Wilcox et al., 2006
). In addition, recent research examining the association between specific built environment features (e.g., sidewalks, parks, curbs with curb cuts) and disability, indicates that neighborhood proximity to parks, adequate handicap parking and presence of public transportation are supportive of older adults’ continued social, leisure and work role activities (White et al., 2010
Previous studies examining transportation access and availability (both perceived and actual) in elderly populations suggest that transportation (public and private) is an integral component in maintaining social relationships, personal independence, participation in activities, physical functioning, and chronic disease management efforts as it facilitates easier access to services and medical resources, especially in rural communities (Balfour & Kaplan, 2002
; Johnson, 2002
; La Gory & Fitpatrick, 1992
; Rosenbloom, 1993
; Goins et al., 2006
; Wilkie et al., 2007
; Keysor et al., 2010
). Our findings also indicate that transportation is important and necessary for older adults’ continued engagement in self-management tasks. Private or personal transportation was cited more often as a community resource than was public transportation. Many participants discussed being self-reliant (e.g., driving themselves) or relying upon social network (e.g., being driven by family or friends). We hypothesize that older residents may be more familiar and comfortable with private transportation because Johnston County has historically been without a comprehensive public transportation system. Alternatively, participants may be unaware of the availability or eligibility guidelines of county-wide paratransit services.
In addition, our findings suggest that social support networks may have a beneficial effect on physical and mental health outcomes by supporting the individual with OA in all three forms of self-management tasks: medical/behavioral, role, and emotional. The importance of social support on older adults and in chronic disease management (particularly arthritis), is well documented in the literature. Social support can be complex in its effect on the physical health and psychological well-being of the recipient, as giving and receiving social support, either actual or received, has been shown to yield both beneficial and harmful outcomes (Affleck et al., 2005
; Lanza & Revenson, 1993
). Previous research indicates that older adults with arthritis are in receipt of greater instrumental support from their social support network than older adults with other chronic diseases (Penninx et al., 1999
). It also indicates that relatives, friends and neighbors form the social environment that can provide direct support, as well as act as a resource to reduce stress and depressive symptoms (La Gory & Fitpatrick, 1992
) and improve health-related quality of life in older adults with OA (Ethgen et al., 2004
Our findings extend existing literature by suggesting that building structures and amenities found at frequently visited community locations (e.g., churches, grocery stores, recreational facilities) can easily act as either a facilitator or a barrier to an individual’s ability to use community resources when engaging in OA self-management tasks, particularly in the context of medical/behavioral and role self-management tasks. In order to make accommodations for these physical OA symptoms, participants told us they make use of ramps, curb-cuts and handicap parking. Participants also reported choosing to visit shops with automatic doors and frequenting community areas with accessible and available handicap parking so as to avoid hand, knee or hip pain associated with OA. While community resources that offer services, like home delivery, can help an older adult avoid navigation of inaccessible community locations by bringing needed goods and services directly to the individual, it is important to consider ways in which to increase community accessibility for all individuals.
Many of the environmental barriers that participants in this study identified as influencing the accessibility of resources located in the community (e.g., ramps, curb-cuts, ground/floor surfaces, handicap parking, and manual doors) are, in theory, guided by the Americans with Disabilities Act (ADA) Accessibility Guidelines for Buildings and Facilities (ADAAG) (United States Access Board, 2010
). These guidelines serve as the minimum basis for ADA standards aimed at reducing discrimination and inaccessibility of public areas for individuals with disabilities. These guidelines and standards are relevant to older adults (especially those with OA) as they might have difficulty navigating the community environment due to functional limitations or pain caused by chronic conditions. Physical environment barriers might keep older adults from accessing community resources for good health management. We hypothesize that many community-areas described by participants as inaccessible may be in areas of Johnston County that are either more rural or of older construction age and would benefit from site improvements that take ADAAG guidelines into consideration. Modifications to the physical environment may help to buffer mobility impairments and disability in older adults due to chronic illness, as well as promote sustained engagement in life-activities that take place in a community setting.
Finally, previous research examining the role of environment and neighborhood characteristics on older adults’ quality of life, health, disability, and physical functioning, has found that living in a worse environment typically results in worse health outcomes (Balfour & Kaplan, 2002
; La Gory & Fitpatrick, 1992
; Wilkie et al., 2007
; Keysor et al., 2010
). Clarke and George’s research examining the role of the built environment in the Disablement Process suggests that “structural barriers operate as ‘exacerbators’ that increase the gap between an individual’s functional capacity and their ability to carry out desired activities, calling attention to the importance of the ‘person-environment fit’” (Lawton, 1983
; Clarke & George, 2005
). Findings from our study support this conclusion, as well as encourage us to consider that the availability and accessibility of community resources for older adults is supportive of positive chronic disease self-management activities (medical/behavioral, role, and emotional management tasks). These activities may in turn play a role in reducing or preventing further functional decline and disability in older adults with chronic conditions like OA.
This formative, qualitative study has several strengths. First, the nature of a qualitative research approach allowed us to probe and understand the context of how individuals with arthritis use community resources to manage their OA in more depth than would a telephone or mailed survey. In addition, by recruiting community-dwelling individuals from several areas of Johnston County, including areas considered rural and urban/suburban by North Carolina standards, we heard about participants’ varied experiences in these different areas. It should be noted that this study is limited by its inability to scientifically generalize findings to other populations due to convenience sampling techniques, eligibility criteria, and the average age (71 years) of the participants. While our sample size was small (N=37), previous research has indicated this number is sufficient for this type of formative examination (Griffin & Hauser, 1993
; DePaulo, 2000
). Finally, we acknowledge that our findings might be subject to social desirability bias. Participants might be more likely to identify and discuss community resources related to OA management they believe are appropriate (e.g., physical activity recreational facilities) rather than resources used, but considered socially inappropriate (e.g., local bar).
Future research might expand upon this study by examining how older adults, particularly those with OA, engage in daily activities or make accommodations given their OA management strategies. More specifically, research might consider OA management strategies in terms of continued participation in valued life activities such as appointments, shopping, hobbies, and social activities (e.g., visiting) that more often take place in out-of-home environments. Because there are differences in how individuals with and without mobility limitations experience the community environment, more research should be conducted with participants ranging from having ‘no limitations’ to ‘severe limitations’. Finally, future research might consider built-environment interventions at the community-level to improve accessibility of community spaces for older adults with functional limitations, particularly in areas with community amenities and facilities of older age.
In summary, as the aging baby-boomer generation ‘grays’ America, the number of older Americans living with multiple chronic diseases and disease-related activity limitation is projected to increase, as are associated levels of disability (National Center for Chronic Disease Prevention and Health Promotion, 2009
). Application of the Corbin and Strauss self-management tasks to organize the community resources identified by our focus group participants allowed for a richer contextual understanding of which community resources older adults with arthritis use to engage in tasks related to OA self-management (e.g., manage pain and functional limitations). This knowledge can assist health care providers in identifying gaps in resource and service provision, as well as discussing and developing OA management plans with their patients. This study also adds support for multi-level, context appropriate interventions to better the use of community resources to improve the health of older community-dwelling adults, regardless of OA status. Finally, city and regional planners might work with local businesses and builders to incorporate senior-friendly design into new construction or in public and private community spaces renovations to increase accessibility for all residents, especially older adults. Findings from this formative study both support and illustrate that community resources and the community environment are important factors in daily OA management.