Abstract
Introduction
Like many communities throughout the US, the small New England city that is the site of our study has begun to plan for their burgeoning aging population. According to the Federal Interagency Forum on Aging-Related Statistics, there were 52 million people age 65 and over living in the United States in 2018, which accounted for 16% of the total population. By 2030 the number and proportion of older Americans is expected to more than double, growing from 35 million in 2000 to 73 million, representing 21% of the U.S. population (Federal Interagency Forum on Aging-Related Statistics, 2020). While one in five US residents is projected to be 65 or older by 2030, it is estimated that one in four Rhode Islanders will be 65 or older (Rhode Island Office of Healthy Aging., 2021).
As a first step in determining areas in which to improve livability for its residents, the nonprofit organization, The city Partnership for Families (NPFF), administered the 2019 AARP Community Survey (Binnette, 2017). The online and print survey, offered in English and Spanish, asked respondents to assess the World Health Organization’s eight areas that influence health and quality of life: housing, outdoor spaces and buildings, transportation, community support and health services, social participation, respect and social inclusion, civic participation and employment, and communication and information. Over 93% of respondents felt that being able to live independently in their own home was very important or extremely important. This finding is consistent with AARP research nationwide that most people ages 50 and older want to stay in their homes and communities for as long as possible.
In an overview of the results of the AARP Age-Friendly Community Surveys in 77 communities, Jeste et al. (2016) found the major areas of improvement cited by survey participants included safe, accessible and affordable housing; pleasant and clean environments with access to outdoor spaces, affordable and reliable transportation; inclusion of older adults in community-related decision-making; work and volunteer opportunities available, and access to a wide range of health services including preventive physical and mental health care.
Choi (2020) analyzed 3,650 mail-in 2015 AARP Surveys based on a random sample of 5,000 people from 14 US communities. In examining the two measures of health, self-rated health and functional limitations, Choi found that satisfaction with outdoor spaces and buildings, transportation, and social participation and inclusion were consistently associated with positive health, perceived age-friendliness of a community, and with the intention to age in place.
The scholarly research focusing on older adults has pointed to the many understandings of aging in place, aging well, and the barriers facing older adults as they try to maintain a quality of life that is congruent with their own concepts of aging. For example, in qualitative research from New Zealand, when asked about aging in place, most of the research participants did not know the meaning of the term aging in place (Wiles et al., 2012). The overarching message from the elders was that they wanted choices about their living arrangements and they wanted access to services. The research participants pointed to the importance feeling a sense of belonging and familiarity with the wider community.
Is aging in place good social policy? In a commentary in the Journal of Aging & Social Policy, Golant (2008) called the movement for aging in place “irrational exuberance.” Golant argued that aging in place policies are not in the best interests of low-income and frail older homeowners in the United States who don’t have the money or resources to take care of their housing. Golant urges the policy advocates in the field of aging to include planning for vulnerable homeowners to move to smaller owned units, rentals, or planned affordable older adult housing complexes. In a national overview of the difficulty of paying for the rising costs associated with home ownership for older adults, Molinsky and Herbert (2020) found that when older adults are cost-burdened with housing (i.e., paying over 30% of their income on housing) that food and healthcare may be sacrificed. Only one-third of the renters who are eligible for housing assistance who are aged 62 and over receive the assistance (Watson et al., 2017).
Is aging in place possible? A study of county commissioners of the aging in the 54 rural US counties with the highest proportion of residents aged 85 and over (Henning-Smith et al., 2022) discovered the challenges faced by the oldest of the old aging in place in rural US were the lack of services, the large geographical distances to cover, the resistance of some older adults to accept help, the challenge of recruiting and retaining health care workers, and the challenges of promoting social connectedness.
What is aging well? It is clear that aging well is culturally dependent. For example, in a focus group and key informant interview study in three neighborhoods in Singapore with an aging population (Bhuyan et al., 2020), the authors found that age-friendly meant inclusiveness, positive social and physical environments, and a sense of place and safety. The older adults in the study also made clear that they look forward to meeting and interacting with younger people as well.
Anthropologist Sarah Lamb suggests that embedded within the North American ideal of successful aging are the values of independence, productivity, and self-maintenance (Lamb, 2014). In contrast, drawing on observations from her fieldwork among older people in West Bengal India, Lamb found a different view of aging. Many of Lamb’s older adult interlocutors felt well cared for by their children, in-laws and grandchildren with whom they lived. They appeared to be content to sit all day and not be concerned with being “productive.” Lamb was impressed with how prevalent and expected it is for people to talk about death.
Another model of aging that appears to incorporate meaningful decline is found in the work of Anna Corwin in her study of aging Catholic nuns (Corwin, 2020). In her research, Corwin found that the nuns continued to meaningfully interact with each other beyond the point of the person being “productive.” According to Corwin, the convent community incorporated an ideology of aging in which personhood was valued and becoming dependent was not viewed negatively.
Positive aspects of aging were uncovered in a focus group study from Israel (Ayalon & Lir, 2022) in which women 54 years and older were asked about the positive gains they observed as they aged. Among the positive elements of aging expressed was living long enough to see the breakdown of gender stereotypes and gaining control over their personal appearance as they decided for themselves how they could be attractive.
The objective of the study described below was to enable older adults to talk about the challenges of aging in place as well as to talk about those aspects of the community that facilitate aging in place. The study exposed a nuanced understanding of aging in place that extended the findings of the AARP Community Survey.
Method
Focus groups are a type of group interview generally conducted with a small group of participants (6 –12 group members), all of whom share a culture or subculture. The focus group enables the participants, who are experts about their own culture or subculture, to talk in a comfortable setting. A focus group elicits the language and worldview of the participants. The discussions are audiotaped, transcribed and then carefully analyzed for content. Participants should be more or less similar to each other in the sense of sharing the culture or subculture that is the object of the study (Bernard, 1995).
Focus groups have been used in diverse populations in order to explore the “insider” or emic point of view within a culture. For example, focus group studies have been utilized in order to discover barriers to care among an urban population of people with Chronic Obstructive Lung Disease (COPD) (Glasser et al., 2016), to discover areas for program improvement for a Housing First program with individuals experiencing homelessness (Glasser & Hirsch, 2019), and to discover the barriers to returning to the university for US veterans (Glasser et al., 2009).
The purpose of this Focus Group Study was to understand the needs of the residents of a small city aged 65 and over in terms of what it would take for them to “age in place.”
We asked the following open-ended questions in each Focus Group:
What are the best things about living here?
What are the worst things or challenges about living here, especially as we age?
What are your suggestions for improving your ability to age in place?
How has the pandemic affected your life?
In addition to conducting the focus groups, we administered a Brief Demographic Survey that asked the participants their gender, age, marital status, household composition, general health status, disability status, respondent being a care giver, educational level, ethnicity, race, and annual income. No names were recorded in the Survey. The Brief Demographic Survey enabled us to compare the focus group participant characteristics with US Census data on the city residents aged 65.
The 32 participants were 65 years and older. One focus group had an additional characteristic in that everyone in the group was a caregiver to another person. We had one person in the Spanish-speaking group.
Individuals were invited to participate in the focus groups through outreach to a random sample of the local Senior Center and to the City voter registration list of residents 65 years and older. The Senior Center is a membership organization with an annual fee of $30 per year. We also reached out to the housing authority, the community action project older adult services, and the elder services of a social service organization.
Thus participants included those living alone or with a partner in a house, condo or non-subsidized apartment, and those living in congregate housing including low income and moderate income housing.
All of the focus groups occurred between November 2020 and mid-January of 2021. One of the authors (Glasser), who also speaks Spanish, conducted the focus groups and one of the authors (Smith) provided technological assistance, helping individuals access the Zoom meeting and troubleshooting any technical difficulties during the sessions.
Because the Focus Group Study was conducted during the pandemic, we used Zoom, which also allowed us to receive a written transcript of the meetings. The participants accessed the Zoom meeting either via the Internet or via their own phones. There was no charge to the person’s phone, and no password was required. The one group in Spanish was translated into English for the analysis. Each Focus Group lasted approximately 1 hr.
The written transcriptions were then analyzed using the program NVivo, in order to discover the themes that emerged from the Focus Group responses. All names were removed from the written transcription.
Each participant received a $20 Ocean State Job Lot gift card as a thank you for his or her participation.
Results
Below we compare the demographic characteristics of the participants of the Focus Group Study with the 2020 Rhode Island Healthy Aging Community Profile for the city (Dugan, Sliverstein & Lee, et al. 2020).
As can be seen in Table 1., the group participants were somewhat younger than the 2020 Rhode Island Healthy Aging Community Profile. The race and ethnicity distribution indicates less percentage White and a greater percentage of African American within the Focus Group participants.
A Comparison of the Focus Group Participants with Older Adults in a Community Profile.
Analysis of the Major Themes of the Focus Groups
The major challenges that the focus group participants described were: knowing where to get complete and reliable information about vital services, the lack of affordable housing, the expense of living in the city, needing assistance in adapting one’s house to becoming more age-friendly, the barriers to walkability, and the challenge of transportation when one can no longer safely drive. The focus group participants also described some of the advantages of living in this small city that made aging in place possible.
The Challenge of Knowing the Available Services
A theme running through the focus groups was the participants’ lack of access to knowledge about important services for the older population. The city does not have a Human Services or Social Services department nor a Senior Services Department, in contrast to many other Rhode Island communities. Within the City government, there is no one whose responsibility is human services.
Comments that are reflective of the lack of knowledge are:
Just sitting here today. I’m hearing different snippets of things that are going on with people on this call, who are involved in different organizations, but I don’t know any of them.
In terms of my planning for the next ten years, what kind of housing would be available to me if I need help? I do not know about the home care services or even nursing services.
In terms of personal home health care, not just in here, but throughout the state, everybody’s on their own.
On the other hand, for those individuals who lived in congregate housing or were connected to the local Senior Center, a nonprofit membership organization, some of the participants felt that they indeed knew where to turn.
I live at an independent living for older adults. We have a social worker on staff, who is here once a week. It means that I can have surgery or whatever I need and people come in here to help.
The Senior Center has a wealth of information available and activities. We’re so fortunate to have it as a tremendous resource.
The Senior Center is the place I would call if I had a question about something regarding aging.
The Challenge of Affordable Housing
For the focus group participants who lived in affordable and/or congregate housing, there was a recognition that living in affordable housing was a major advantage to aging in place in the city. Affordable housing in the US is understood to be housing wherein one pays 30% of their income for rent.
There’s so much to see and I appreciate where I live. The affordable housing gives me the opportunity to stay here.
It’s very freeing for me personally (living in affordable housing), so I like it. And, also, the location is fabulous, because I can walk to my bank and to the super market. I have a little cart so I can walk home with my groceries.
On the other hand, there was a recognition that housing is in the city is very expensive as is maintaining one’s housing.
When I was growing up here there were apartments everywhere. Nowadays it’s hard to find apartments, because so many of them are Airbnb. And it took me four years looking to find my place.
We have historic districts and that’s great in terms of maintenance and respect for the past, but it’s also another barrier in terms of modifying things that I may need as I get older.
People say that about their children. Oh, my kids couldn’t afford to live here, you know, taking ordinary jobs.
Living Here is Expensive
There were many expressions of concern about the current and future expenses of aging in place regarding the price of housing.
I didn’t have a sense of the city when I first moved here to work. Very few people that I worked with lived here, because it’s expensive. People would leave right after work and go home.
Some of the services we may need, such as cleaning or gardening, may be available around here, but are pretty expensive.
We have a lot of nonprofits here, which pay no taxes.
I have no tax relief. I’m 78 years old, and I don’t know how many more years I’ve got left. I shouldn’t have to pay taxes. I’ve done my duty.
In this big building (affordable housing for older adults), we should have Internet connection for everyone. Right now, Wi Fi is a big part of my total budget.
Many of the focus group participants expressed an appreciation of the economic, age, race and ethnic diversity of the city, and were aware of the implications of the increasing expense of living in the city.
With the city being so expensive, we’re going to get a population of people that is one
demographic (wealthy) and lose all diversity.
Walkability
One of the most treasured aspects of the city, according to the focus group participants, was its walkability.
My favorite part is walking every day. I went for a nice walk this morning along the beach road.
You can see people the minute you walk out the door that you recognize.
I’m widowed and I live alone. But I go out walking and people are friendly in the stores.
However, there are threats to walkability, often having to do with the physical disrepair of some of the streets.
In some of the areas where tourists come, they have really done a wonderful job in making the sidewalks very nice to walk on. But in the areas where other people live here, the sidewalks are horrendous, and it’s easy for someone to trip, fall and get hurt.
I love the trees, but sometimes the trees grow through the sidewalks, making it hard to walk and cracking the pavement. And it’s also not just for us. It is for our families with strollers. It crosses a lot of boundaries.
As a New England state, there are periods of snow and ice that makes walking hazardous.
There used to be a requirement for people to clear their walkways within an hour after the snow stops, but that does not seem to be honored now.
Educational and Cultural Opportunities
Focus group participants expressed an appreciation of the community, if they took advantage of some of the educational and cultural opportunities.
We take advantage of all of the events here. You don’t have to move because the special events come here. We go to the music festivals, and we’ve been to the all the sailing events.
It is nice that the historic houses have programs in the wintertime, and if you or your spouse is over 65, it is free.
Transportation
Some of the focus group participants were concerned about how they would be getting around as they aged.
You know, I think sometimes it is hard getting around. There are a lot of areas where buses do not go and to take a cab can be quite expensive.
There’s going to be a time when I’m not driving. I think our public transportation, is pretty limited. For those of us who don’t walk, I think that needs to be addressed in some way.
Where are the free bus passes for older adults?
We should have transportation services from the local hospital available in the wee hours of the morning. For example, people may be discharged from the emergency room, which happened to me about a year ago. My wife and I found ourselves sitting in the lobby without any way to get home.
Health Care
The health care in the community was discussed in positive terms throughout the focus groups. Among the comments were:
After I stay in the hospital, my doctors call me. They are very concerned.
I see people in this building with a lot of health problems, and the visiting nurses come to check up on the people.
I go to the doctor, a Spanish-speaking doctor, who takes care of me (Spanish speaking participant)
The Importance of Zoom
Several people remarked on how glad they were to be connected to others via Zoom. Our focus groups took place at the height of the Pandemic, when Zoom technology was new to many. The Senior Center had sessions teaching Zoom so that older adults could connect with family and friends during this time of extreme isolation.
I hope that after this (Pandemic) is over, we will still have the option of doing things like this (i.e., our Focus Group) on Zoom. For example, for our group today, who would have wanted to go out and get together? It is good to not have to leave our homes in bad weather.
It would be good to have a dual kind of system of in-person and on Zoom when the pandemic is over.
Discussion
The Focus Group Study elicited the thoughts of the 32 participants by asking open-ended questions, which gave people the opportunity to say whatever mattered to them. As can be seen by the results, many of the things that made participants appreciate the city, such as its walkability, were a source of concern if they could not continue to do it, due to snow, ice, or cracked sidewalks.
We thought that in the Focus Group Study the participants were also able to project themselves into the near future, when they might be in need of services. For example, participants voiced concern about when they were no longer driving or needed home health care after an injury or operation.
A theme throughout the conversations was the challenge of knowing how one learns about essential services. The city does not have a department of social services, human services or senior services. The many nonprofits are competing with each other for funding to provide the services.
It became evident that those people living in the low and moderate income congregate housing knew where to turn if they needed help with such things as home health care since there were service providers in the housing. People who were connected to the Senior Center also said that they could turn there for help and referrals. The strength of the support that people living in congregate housing surprised us and made us consider the advantages of congregate living and thinking about ways to increase access to help. One avenue of increased support would be to have the Senior Center move from its nonprofit status to a city-administered service open to all older adults.
On the other hand, several people said that they never heard of the services that some of the participants were mentioning as sources of help. Those living alone or with their partner and not connected with the Senior Center appeared to be at a loss in terms of sources of help. As one participant said regarding home health care: “Everybody’s on their own.”
The concern about walkability and mobility is a theme that corroborates other recent research regarding the barriers to aging in place. For example, Brim et al. (2021) found that even the word “fall” was fraught with negative associations of frailty and weakness. Some of the older adults used euphemisms such as stumble, trip, or become unsteady instead of fall.
In focus group research from Senior Centers in Los Angeles, Gallo et al. (2022) found older adults said that the crosswalk signals were not long enough for them to safely cross the street. Some of the focus group participants expressed distrust of the ride-hailing companies such as Uber/Lyft which further limited their mobility.
How Did the Focus Group Study Results Compare With the Results of the AARP Community Survey?
We were able to compare our results with the AARP Community Survey done in the same community a year earlier. The major areas of congruence in terms of concerns of both the AARP Community Survey and the Focus Group study were: the expense of housing and housing maintenance; the poor state of the sidewalks and the difficulties of pedestrian crossings; the difficulty of finding out about services for older adults; the challenge of affordable home health care providers; and the challenge of relying on public transportation.
There were also areas of concern in the AARP Community Survey not expressed in the Focus Group Study. The AARP Community Survey introduced topics for the respondents to rate, unlike the Focus Group Study, which was designed to be open-ended and allow participants to introduce their own concerns. Some of the areas of concern of the AARP Community Survey not expressed by the focus group participants were a lack of jobs and job training for older adults, a lack of affordable parking and a lack of driver education or refresher courses
Finally, there were areas of concern and suggestions in the Focus Group Study not expressed in the AARP Community Survey including: the development of buildings along the waterfront that now block views of the water; The city a closed community to non-city-born residents; the suggestion to provide case management for older adults within primary care; and the recommendation to provide tax relief for older adults.
Study Limitations
The majority of the Focus Group Study participants were referred to the study through their connections with professionals and services within the community. Aside from the three participants who answered our letter of invitation through the voter registration list, we were talking with older adults who were connected to at least one service in the community. This means that our results may not be generalizable to the larger community, which includes more isolated older adults.
The focus group participants also had access to a computer, iPad or smart phone, or knew how to dial into the Zoom number. We offered help to connect to Zoom, but most of the participants were technologically proficient, again challenging the generalizability of the study.
Conclusion
Focus group studies allow investigators to hear directly from community members. This becomes vital when we think of community planning as the global population grows older and we strive for age-friendly communities that will enable older adults to age in place.
The many communities in the United States that have participated in the AARP Age-Friendly Community Surveys could consider a focus group study in order to discover more about the challenges faced by their community’s older adults. Hearing the voices of older adults in their own community can be a powerful source of advocacy as communities weigh how to devote resources to their growing aging population.
Footnotes
Acknowledgements
We thank the 32 Focus Group participants who gave their time to ponder the question of how to improve the age-friendliness and enable people to age in place. We thank the community leaders Kathleen Burke, Carmela Geer, Pauline Perkins Moye, Meaghan Sloane, Rebekah Gomez, Kim Wetherald, Heather Hole Strout and Lynn Ceglie for introducing us to the city’s older adults who so generously shared their thoughts with us.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Funding for this study came from the van Beuren Charitable Foundation to the Newport Partnership for Families
Institutional Review Board Approval Number
The Age Friendly Newport Focus Group Study: Toward an Age-Friendly Newport received approval from the Brown University IRB (Institutional Research Board) on October 11, 2020 (HRPP Approval memo, Protocol #2009002796 | “Focus Group Study: Toward an Age-Friendly Newport”)
Ethical Considerations
The Focus Group Study: Toward an Age-Friendly City received approval from the Brown University IRB (Institutional Research Board) on October 11, 2020 (HRPP Approval memo, Protocol #2009002796 | “Focus Group Study: Toward an Age-Friendly City”).
Because the study took place during the pandemic, before the advent of the vaccines, we asked for and received permission from the IRB committee to undertake an oral consent process in order to minimize how much the older adult would need to leave their house. The principal investigator called each person who had volunteered for the focus group before the focus groups began and explained the focus group to them. The principal investigator also asked them the questions on the Brief Demographic Survey. We explained that the participant could skip any questions in the Brief Demographic Survey and could participate to the extent that felt comfortable to them in the focus group. All of the participants consented to be in the study and this was noted in a study file.
