[global hr forum 2013] a happy third age for whom? : examining accessibility of publicly funded,...

A Happy Third Age for Whom?:

Examining Accessibility of Publicly Funded, Health Education Programs for Low-Income

Seniors in the United States

Ian Baptiste (St. George’s University)

Arlette Wildman (St. George’s University)

Lisa Merriweather (UNC, Charlotte)

About the Authors

Baptiste & Merriweather are adult educators

Wildman is a clinical psychologist

11/13/2013 Happy Third Age for Whom? 4

Outline

Part 1 introduces the study

Part 2 describes constraints LIS encounter in participating in publicly funded health education programs

Part 3 describes and assesses an exemplary publicly funded, health education program, A Matter of Balance,

Part 4 raises questions for further investigation

11/13/2013 5 Happy Third Age for Whom?

Part 1: Introduction


Purpose of our study

To interrogate the notion of unrestricted choice that is assumed in the rhetoric of “Happy Third Age.”

We do so via: …an examination of publicly funded, health education

programs for low income seniors (LIS) in the United States.

A low income senior is 60+ and earns below the US official poverty threshold.


Third Age Defined

“…. that time in our lives when our children no longer live in our homes and when we begin to plan for the next, and probably greatly modified, phase of our work life…” (Third Age Portfolio.Com: http://thirdageportfolio.com/).


http://thirdageportfolio.com/

Rhetoric of Unrestricted Choice

Advocates a Happy Third Age argue that… “…The Third Age is another opportunity to

decide what we want to be when we grow up” (Third Age Portfolio.Com: http://thirdageportfolio.com/).


http://thirdageportfolio.com/

Research Method

An embedded, exploratory case study using:

Content analysis of archival data: a) USA census data, and

b) Websites of agencies serving seniors

Telephone interviews with providers of publicly funded, health education programs


Our Embedded Cases Are…

USA

Ohio Two counties within Ohio (Hamilton, urban, and Noble,

rural), and

One publicly funded, health education program in Hamilton county: A Matter of Balance


County map of Ohio

• (Source: http://en.wikipedia.org/wiki/File:Ohio_counties_map.png).


http://en.wikipedia.org/wiki/File:Ohio_counties_map.png

Why LIS?

They are one of the most challenged groups of seniors – financially, educationally, and health wise.

And therefore are good test of the notion of unrestricted choice.


Why USA?

Because of the ready availability of data on low income seniors

And because of the United State’s global influence


Why Publicly Funded, Health Education Programs?

• Wildman and Baptiste both teach Health Education

• Health is a primary concern of all seniors

• We chose publicly funded programs to examine the social contract that society has made with our study population (LIS).

• Society’s social obligations, we believe, are manifested in the public programs sponsored by its civil societies (e.g., NGOs, CBO and faith-based organizations); and its public and private sectors.


Research Questions

1. What constrains the participation of low income senior (LIS) in the United States in publicly funded, health education programs?

2. How are programs tailored to address these constraints?

3. What challenges do program providers encounter and how do they address them?


Part 2: Constraints to LIS’s Participation in

Education


The Typical LIS in the US…

… lives with a spouse

• Over half (57%) the older noninstitutionalized persons lived with their spouse in 2012 (US dept HHS, A profile of Older Americans, 2012).



… lives with at least one dependent grandchild for whom s/he is a primary caregiver.


0

500,000

1,000,000

1,500,000

2,000,000

2,500,000

3,000,000

3,500,000

4,000,000

4,500,000

5,000,000

USA

Households withgrandparents living withgrandchildren

Households withgrandparents responsiblefor own grandchildrenunder 18 (42%)

Householder or spouse withno parent of grandchildrenpresent (34%)

No Empty Nest 11/13/2013 20 Happy Third Age for Whom?

0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

160,000

Ohio





0

2,000

4,000

6,000

8,000

10,000

12,000

Hamilton





0

50

100

150

200

250

300

Noble






… has no retirement income and must therefore continue to work for wages and receive public assistance.


Households with & without Retirement Income

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

USA(82.5)

Ohio(79.6)

Hamilton(82.7)

Noble(68.4)

with retirement income

without retirementincome



…probably did not graduate from high school and therefore has less than high school diploma


Persons 25 and over with less than HS Diploma

USA Ohio Hamilton Noble

29,518,935 (14,6%)

939,133 (12.1%)

63,990 (12.1%)

2,200 (21.0%)


15%

28% 57%

Educational Distribution of Persons 25+

USA

Less than HS Diploma

With Bachelor's Degree

Remaining (between HS &BA)


12%

25%

63%

25+ Educational Distribution (Ohio)





12%

33% 55%

25+ Educational Distribution (Hamilton)





21%

8%

71%

25+ Educational Distribution (Noble)





0

2

4

6

8

10

12

Adult literacy (% 16+ lacking basic prose literacy skills) (2003)

Ohio, 9.1

Hamilton, 7.3

Noble, 11.3

% o

f 1

6+

po

pu

lati

on

Adult Literacy 16+



Is NOTlikely to own a computer or know how to use one.

And if s/he possesses a computer and knows how to use it, there is a high chance that she does not subscribe to broadband internet access.


0

10

20

30

40

50

60

70

80

90

Computer ownership Broadband subscription

% o

f p

op

ula

tio

n

Computer Ownership & Broadband Access in Ohio’s Urban & Rural Areas (2010)

Ohio (65+)

Urban

Rural


The Typical LIS in the US …

… likely suffers from at least one of the following 5 chronic illness:

– diseases of the heart,

– cancer,

– arthritis,

– diabetes,

– Alzheimer’s


Eight Leading Causes of Death

Rank

Cause USA Ohio Hamilton Noble

1. Diseases of the heart 1 1 1 1

2. Cancer 2 2 2 1

3. Stroke 3 3 3 3

4. Chronic Lower Respiratory Diseases 4 4 4 4

5. Unintentional Injury 5 5 5 5

6. Diabetes Mellitus 6 6 7 7

7. Alzheimer’s 7 7 6 6

8. Influenza & Pneumonia 8 8 8 8 11/13/2013 37 Happy Third Age for Whom?

Selected Health Indicators - Persons 25+

Ohio Hamilton Noble

Smokers 23.4% 23.0% 30.0%

Overweight 36.2% 32.4% 30.3%

Obese 26.5% 24.5% 32.6%

Diabetes 7.9%

7.8% 8.6%

Arthritis 31.1% 30.7% 29.6% 11/13/2013 38 Happy Third Age for Whom?

The Typical LIS in the US …

… has no employer-assisted health insurance and must therefore rely on public assistance (e.g., Medicare & Medicaid)


0

2

4

6

8

10

12

14

16

Low income 65+ Without healthinsurance (18+)

Without healthinsurance (17-)

% o

f p

op

ula

tio

n

Age group

Health Insurance Coverage

Ohio

Hamilton

Noble



…is severely cost burdened; spending 50% or more of her/his household income on rent and utilities


0

5

10

15

20

25

30

35

Severely Cost Burdened Cost Burdened

% o

f lo

w in

com

e 6

0+

ren

ter

ho

use

ho

lds

Housing cost burden

% Low Income 60+ Renter Households with Housing Cost Burden

Ohio

Hamilton

Noble


Ohio

Low income60+ renterhousehold(est)

Severely costburdened60+ renterhouseholds

Hamilton

Low income60+ renterhouseholds(est)

Severely costburdened60+ renterhouseholdsNoble

Low income 60+renter households(est)

Severely costburdened 60+renter households

Cost burden of extremely low income (0-30% of AMI) 60+ renter households



…is food insecure

According to the USDA, a food insecure person is one for whom “consistent access to adequate food is limited by a lack of money and other resources….”

Finding herself in such unenviable situation, the food insecure person engages in “a financial juggling act, where sometimes the food ball gets dropped.”

• Source: USDA: Economic Research Service: http://www.ers.usda.gov/topics/food-nutrition-assistance/food-security-in-the-us/definitions-of-food-security.aspx#.UmGHodjomF8


http://www.ers.usda.gov/topics/food-nutrition-assistance/food-security-in-the-us/definitions-of-food-security.aspx



















Persons 65+ below

poverty line (2010), 131,383

Food insecure persons

65+ (2013)[15.9%], 257,900

Ohio

Some middle income families are also food insecure


Persons 65+ below poverty

line (2010), 14,106 Food insecure

persons 65+ (2013)[15.9%],

16,991

Hamilton



Persons 65+ below poverty

line (2010), 388 Food insecure persons 65+

(2013)[15.9%], 484

Noble



Part 3: Examining Accessibility to Health

Education Programs for LIS:


Health Education Programs Targeted to LIS

Several are offered across Ohio and the US, including:

Nutrition Education (a component of the Senior Farmer’s Market Nutrition Program): http://aging.ohio.gov/services/seniorfarmersmarketnutritionprogram/

Community Putting Prevention to Work: http://www.cdc.gov/CommunitiesPuttingPreventiontoWork/communities/profiles/obesity-oh_hamilton-county.htm.

Healthy U & Healthy U: Diabetes: http://aging.ohio.gov/services/evidencebasedhealthyagingprograms/


http://aging.ohio.gov/services/seniorfarmersmarketnutritionprogram/

http://aging.ohio.gov/services/seniorfarmersmarketnutritionprogram/

http://www.cdc.gov/CommunitiesPuttingPreventiontoWork/communities/profiles/obesity-oh_hamilton-county.htm






http://aging.ohio.gov/services/evidencebasedhealthyagingprograms/

http://aging.ohio.gov/services/evidencebasedhealthyagingprograms/

Fall Prevention is the program we chose to examine more closely


Falling is Serious Business

In the US, 30 percent of adults age 65 and older living in the community fall each year.

An older Ohioan falls every two minutes and sustains a fall-related injury every five minutes, resulting in two hospitalizations each hour, an emergency room visit every eight minutes and three deaths each day.


Preventing Falls: “A Matter of Balance”

A Matter of Balance, is an evidence-based, award-winning nationwide program designed to help individuals manage falls risks and increase activity levels.

Developed by researchers at Boston University in collaboration with Maine Health Partnership for Aging

In Ohio, the program is coordinated by Steady U, a division of Ohio Department of Aging.

In Hamilton County, Ohio, it is administered by the Hamilton Fall Prevention Taskforce (HFPTF), with funding from Hamilton County Public Health department


http://www.aging.ohio.gov/steadyu/resources/matterofbalance.aspx

Research Questions

1. How is the “A Matter of Balance” program tailored to address the constraint of LIS?

2. What challenges do program providers encounter and how do they address them?


Data Sources

Websites of Providers, e.g.,

• Steady U, Ohio: http://www.aging.ohio.gov/steadyu/

• Hamilton County Fall Prevention Task Force (FPTF): Hamilton County Public Health: http://www.fallpreventiontaskforce.org/ No phone contact info on web

Phone interviews with program coordinators & coaches


http://www.aging.ohio.gov/steadyu/

http://www.fallpreventiontaskforce.org/

Interview Guide

1. How are LIS made aware of the program? What is your marketing strategy? What marketing challenges do you encounter and how are they addressed?

2. How do LIS get to the program? What support do they need to physically access the program (e.g., free transportation, child support)? What challenges to attending the program do LIS encounter and how does the program assist in alleviating them?

3. Describe the main learning activities (video, lecture, lecture/discussion, one-on-one demonstration, etc., etc.)

4. What forms of interaction (learner/facilitator; learner/learner) are incorporated into the learning activities?

5. How would you assess the pacing of the learning activities (ideal, oaky, too fast, too slow)

6. At what level(s) of education (literacy, numeracy, etc., etc.) are the learning activities pitched?

7. What form of learner support is provided (one-on-one tutorials; group demonstrations; peer tutoring, etc.)?


Findings – Program Description (I)

Program typically runs for 8 weeks, one hour per week

Two trained coaches facilitate each session – one is usually a peer tutor

Marketing is conducted via posters, flyers and presentations at/to/by agencies and organizations frequently visited by LIS, such as such as senior centers, community centers, retirement communities, libraries, hospitals and churches).

A few providers rely on social media, newspaper articles, local TV


Findings – Program Description (II)

Programs seldom supply transportation so providers try to deliver training at locations close to residents’ homes, such as senior centers, community centers, retirement communities, libraries, hospitals and churches.

Some programs are delivered on-site, at apartment complexes in which seniors reside.

Location and duration of sessions are adapted to audience: e.g., 45-60 min presentations for small groups that just want information; the full program for groups that are more interested; or adjusting the program to 4 weeks (2 sessions per week


Findings – Program Description (III)

First 2 sessions are devoted to the nature, fear and experiences of falling; tools: videos and coach-led discussions; in-home assessments—upon invitation, coaches walk through the home with the resident

Sessions 3 – 8 are physical exercises: tools: coach led demonstrations, sometimes with aid of physical or occupational therapist, EMT/fire depts

The seniors use this time to socialize so the use of games such as Fall Prevention Bingo makes the presentation interactive.


Findings - Strengths

Providers are well aware of the constraints LIS face and consider them in program design and implementation

Marketing strategies are often adequate

Learning objectives are reasonable

Learning activities are appropriately pitched, interactive, adequately paced and adaptable to learner’s situation

Adequate learner support is provided—in the form of adjusting the pacing; demonstrations; instant feedback; in-home assessments; and one-on-one, out of class assistance.

Due to long-term community involvement, providers have built trust with target audience thereby ensuring receptivity to program


Findings - Weaknesses

Overworked and underpaid staff

Heavy staff turnovers, typical of social service programs

Program does not cater to the MORE physically challenged (but still mobile) seniors

The group format may exclude shy individuals

Younger seniors don’t wish to be grouped with older seniors, so segmenting of the senior pop is suggested,

Classes are currently offered only on evenings; adding other times might increase attendance

Currently no data on proportion of eligible LIS that attend but anecdotal evidence suggests it’s less that 10%


Findings - Opportunities

Huge potential for numeric growth

Can build on initial success and nationwide reputation

Not much technical difficulties in adapting or tailoring program to new groups of seniors


Findings – Threats

• Not enough training venues across Hamilton

• Insufficient and unreliable funding: “still a challenge to get adequate, reliable funding for preventive (non-medical) measures”


Part 4: Conclusions & Recommendations


Conclusions (I)

Program boasts relatively well trained, dedicated staff

Program is technically sound. Service providers are doing the best they can with the little they have.

The authors of this paper were pleasantly surprised that the life circumstances of LIS are not the major threat to program’s success.


Conclusions (II)

The major threat to the program’s success is insufficient and unreliable funding.

• It is the State and not civil society (such as educational providers) that is reneging on its social contract.


Responding to the Issue: Contributions from CHAT

• CHAT = Cultural Historical Activity Theory

• Resolving contradictions is one of the greatest sources of change.

• The challenge is therefore to accurately identify contradictions and their sources and find ways to resolve them.


The Contradiction?

Health prevention programs are costly; and demonstrable positive outcomes tend to be long term and less dramatic than treatment programs.

Politicians and law makers are rewarded for short-term, dramatic outcomes.

Just like the rest of us, elected officials (whose responsibility it is to allocate public funds) are likely to put their own job security over long term preventive care for LIS: one of the most vulnerable and least politically powerful groups in their constituencies.


Addressing the Contradiction: Contribution from Organization Theory

• Do not demonize individual politicians and law makers.

• Treat the issue as organizational behavior, not individual behavior.

• In this case the organization is the state and its subsidiaries.


A Matter of Legitimation

• Institutional Theory of Organization argues that there are 3 sets of mechanisms by which organizations institutionalize and legitimate their practices.

1. Mimicry: Doing what other organizations do because no other option seems available. “That’s the way things are/are done.”

2. Moral suasion (Normative/Internal Motiivation):. Doing what seems best. Assessing the various options and doing what seems ethically right even though it might be politically costly.

3. Coercion (External Motivation): Taking the path of least resistance—a cost benefit analysis in which the benefits of underfunding preventive care for LIS outweigh the negative consequences.


Closing Question

• In the case of underfunding of health education for LIS, which form(s) of legitimation currently operate and what can be done to change the practice?


Thank You


[global hr forum 2013] a happy third age for whom? : examining accessibility of publicly funded,...

Education

age portfolio

funded programs

health educationhealth

health wise

rhetoric of happy

low income seniors lis

public programs

low income seniorsand