In recent years a growing number of international, national, state, and local initiatives have started working to make existing communities more aging friendly. This interest in changing the physical and social environment of existing communities to improve the health and well-being of older adults and help them age in place is a reaction to a confluence of factors, including the aging of the U.S. population, a projected increase in disability and chronic disease in future cohorts of older adults, and an inadequate long-term care system. Aging-friendly communities share three characteristics: 1) individuals can continue to pursue and enjoy interests and activities, 2) supports are available so that individuals with functional disabilities can still meet their basic health and social needs, and 3) older adults can develop new sources of fulfillment and engagement (Lehning, Chun, & Scharlach, 2007). Framed by an internal determinants and diffusion model, this study uses a sequential explanatory mixed methods research design to explore 1) the extent to which 101 cities in 9 counties in a geographically and economically diverse metropolitan area have adopted aging-friendly policies, programs, and infrastructure changes in the areas of community design, housing, transportation, health care and supportive services, and opportunities for community engagement, and 2) the diffusion factors, community characteristics, and government characteristics associated with such adoption.

The researcher collected and analyzed quantitative and qualitative data from four types of respondents: city planners/community development directors, directors of county adult and aging services, county transportation authority employees, and public transit officials. In the quantitative phase, the researcher combined primary data collected via online surveys with secondary data from the 2000 U.S. Census and the 2000 California Cities Annual Report. In the qualitative phase, a subsample of 18 survey respondents participated in open-ended telephone interviews to provide a more in-depth understanding of the process of the adoption of aging-friendly innovations and expand on the quantitative findings.

For the first research question, the most common aging-friendly innovations adopted by local governments include those that target alternative forms of mobility, including incentives for mixed use neighborhoods, infrastructure changes to improve walkability, discounted public transportation fares, and changes to improve accessibility of public transit. The least common policies and programs are those that aim to help older adults continue driving and those that provide incentives to develop accessible new housing for older adults. For the second research question, bivariate analyses of city-level data provide partial support for an internal determinants and diffusion model. Cities with a larger total population, larger percent of the population with a disability, and have experienced public pressure or individual advocacy for aging-friendly innovations adopted more aging-friendly policies, programs, and infrastructure changes. Contrary to hypotheses, cities with higher population educational attainment, higher median household income, and a larger proportion of the population age 65 and older adopted fewer aging-friendly innovations. Qualitative interviews offered potential explanations for these results. First, disability groups may be more active than older adults in terms of advocating for the adoption of certain aging-friendly innovations, such as accessible housing and walkable neighborhoods. Second, communities whose population enjoys a higher socioeconomic status may not perceive a strong role for local government in terms of creating more aging-friendly communities, and these residents may get their needs met through nongovernmental sources. Third, while there was no significant association between per capita government spending and the adoption of aging-friendly innovations, interviews suggest that funding plays an important role, and perhaps grant funding, slack resources, and recent increases or decreases in local government financial resources are a better measure of this factor. Finally, qualitative interviews indicate that future studies should explore additional factors, including communication, collaboration, and state and federal mandates.

The findings of this study suggest a number of research and practice implications that should be further explored in future research. First, the results and limitations of this research suggest that it should be replicated to determine whether the findings explain local government adoption of aging-friendly innovations in general or are specific to the population and methods used in this study. This replication should not only expand the sample size and explore the generalizability of findings to other geographic regions, but use a modified internal determinants and diffusion model that takes into account findings of the present study. Second, given the limitations of the current study, results offer a number of strategies that residents, advocates, service providers, and policymakers could employ in their efforts to create more aging-friendly communities. These strategies include mobilizing public support of and pressure for aging-friendly innovations, targeting advocacy efforts at individuals working within government who could become policy entrepreneurs, and working towards vertical diffusion of innovations via state and federal mandates and funding. Finally, survey and interview results hint at additional lines of inquiry that should be pursued as part of a larger aging-friendly communities research agenda. First, what exactly is an aging-friendly innovation or an aging-friendly community? Second, how can communities change their physical and social environment in such a way that the needs and wants of older residents do not impede those of other residents? Finally, and perhaps most importantly, what impact do these policies, programs, and infrastructure changes on the health and well-being of older adults and their ability to age in place?

Abstract

The Differential Impact of Suicide Type on Provision of Social Support: A Qualitative Comparison

by Daniel Paul Villa

Doctor of Philosophy in Social Welfare

University of California, Berkeley

Professor Andrew Scharlach, Chair

The objective of this exploratory study was to examine how various modes of death impact the availability, perception, and allocation of social support to bereaved survivors. Specifically, case vignettes describing different types of suicide were utilized to address the following inquiry: What factors typify how and why social support is offered to survivors of traumatic death, particularly suicide? Twenty-five participants, consisting of graduate students and older adults, engaged in semi-structured interviews to explore responses to four fictitious instances of suicide and one instance of non-suicide as a control case. Data analysis via selective coding, immersion/crystallization, and content analysis generated ten themes (reflective of three overarching categories) as the most salient features typifying the provision of aid to mourners: Patterns and Variations in Type of Aid ("Core" versus "Vignette-Specific" Support), General Considerations in the Provision of Aid (The Culture of Helping, "Filling the Void," "Let the Need Be My Guide," Identification, Survivor Relationship ("Closeness"), Degree of Immersion, "Casserole Lady" Dilemma), and Vignette-Specific Considerations in the Provision of Aid (Social Significance of the Death, Perceived Culpability).

Based upon these findings, various conclusions can be drawn. First, there exists an inherent proclivity within observers to offer aid to survivors, as all respondents indicated the need to provide support regardless of the individual conditions surrounding the death. Second, the manner in which a death occurs appears to affect the degree to which support is rendered, especially if the death somehow deviates from social norms or raises inquiry regarding culpability on the part of the decedent and/or the survivor. Third, the survivor's own adjudication of the situation, as evidenced in his or her personal experiences, perceived relationship to the survivor and/or decedent, and assessment of needed support, also influences what is offered. Interestingly, while some themes related more directly to suicide-specific vignettes, most reflected generic features indicative of how respondents would offer aid under any case of death, signaling the need for continued research within this domain. Considerations to address in future research include the further exploration of other typologies of suicide and the incorporation of other methodological techniques to compare different modes of death.

Implications for future practice are also considered, underscoring the significance of identifying social factors related to specific instances of suicide. Because the study could not possibly capture the full scope of this type of death, individual assessment of survivor needs by social workers and allied professionals becomes crucial in addressing and attenuating a range of potentially negative grief experiences, including stigma, shame, guilt, and depression. Overall, the study's findings are intended to advance the scope of qualitative attitudes research with respect to social support availability and modality of suicide, as the current body of literature contains no studies that investigate the nuances of this particular phenomenon.

Medicare Part D is health insurance for people who are either disabled or over 65 years old or suffer from End Stage Renal Disease. It provides coverage for outpatient prescription drugs and is a departure from the traditional Medicare program in which the benefits are uniform. Coverage has a minimum drug formulary packaged in standard plans or actuarially equivalent plans that offers varying additional benefits.

Objective: (1) to examine the effects of coverage on utilization of select antipsychotic drugs: olanzapine, quetiapine, risperidone, and haloperidol, (2) to understand out-of-pocket expenditure patterns among beneficiaries with schizophrenic and bipolar disorders in Washington State. Design: a descriptive and analytical cross-sectional, retrospective study design that used 2008 Part D Event data (1922 unique individuals). Measurements: utilization of four antipsychotics (in number of claims and medication adherence measured in Proportion of Days Covered) and out-of-pocket expenditures before the gap-in-coverage period (pre-ICL), during the gap-in-coverage period (ICL), and post gap-in-coverage period (post-ICL). Results: Beneficiaries who experienced all three benefit phases (i.e. pre-ICL, ICL, and post-ICL) comprised a very small percentage, 1.36 percent, of the study population and generated only 141 claims. Among these beneficiaries, 70.92 percent had low PDC adherence that primarily occurred during the ICL period (35.46 percent), followed by the pre-ICL period (21.3 percent), and the post-ICL period (14.19 percent). Only 29 percent of beneficiaries who experienced all three benefit phases had high PDC, with the highest percentage (13.5 percent) occurring in the post-ICL period (13.48 percent), followed by the pre-ICL period (11.35 percent) and the ICL period (4.26 percent). Beneficiaries spent far more in average our-of-pocket expense during the gap period ($36.43) than averages in the pre-gap period and the catastrophic coverage period combined ($14.19). Non-adherent beneficiaries paid a greater average than adherent beneficiaries: low PDC beneficiaries paid an average of $27.95 and a median of $2.25, while high PDC beneficiaries paid an average of $7.50 and a median of $ 0. Conclusion: Utilization of antipsychotics is affected by the extent of Part D plan coverage beneficiaries choose and elements of Part D plans effect medication utilization differently.

Passive monitoring systems installed in the homes of older adults have been proposed as a way to revolutionize home healthcare by enabling earlier detection and prevention of health events and delaying health related relocation; however, the processes and social implications are poorly understood, uptake is low, and these purported benefits have not been fully realized. This study combines data from 47 interviews and system alert records to understand lived experiences with the technology of ethnically diverse older adults, family members and staff of low-income independent living residences. A sensor-based passive monitoring system has been on offer to residents as a voluntary subsidized intervention for six years. This study examines the 1) processes involved in decision making about adoption and discontinuation, 2) the procedures of using the technology, 3) experiences with and articulations of privacy, and 4) how participants assess the usefulness of this passive monitoring system. The three papers that comprise this dissertation are outlined below. They provide complementary presentations of my analyses of the most significant findings that correspond to the study's primary research questions. The three papers examine the following:

1) Resistance on a spectrum: Shaking the `pro-adoption bias' in studies of passive monitoring and aging.

Given the low uptake of passive monitoring, the concerns, needs and perspectives of users, nonusers and former users is a rich area for inquiry. In this first paper, I present the range of ways older adults relate to passive monitoring, including experiences of adoption, nonadoption, discontinuation and creative `misuse.' The priorities of users (e.g., safety, privacy, control, contact) are shown to be more diverse and multi-faceted than those of the housing organization and family members (e.g., safety, efficiency). The tension between needs, desires, and the daily lives of older adults and the technological solutions offered them is made visible by their active appropriation of and resistance to them. The broad spectrum of resident resistance challenges the dominant image of passive subjects of a passive monitoring system that is designed with little room for resistance or creative use, exposing the active and meaningful qualities of older adults' decisions and practices.

2) Breathing room in monitored space: Opportunities for privacy in boundary management.

While scholars have been quick to note that privacy intrusion is a primary issue to be explored with the use of passive monitoring, academic writing about how privacy is impacted has be limited by our conceptual tools. Information privacy has been the focus of study to the exclusion of personal privacy. In this paper, I examine the ways in which privacy in passive monitoring practices is articulated by participants. These findings reveal where breathing room is eclipsed and where changes to passive monitoring design and practice could create opportunities for residents to manage their own boundaries.

3) Calculating risk and the management of living: Social workers in a bind.

In the final paper I describe the practices and rationalities formed around the selling of the passive monitoring technology to independent living residents who were largely uninterested. Data reveal that the pressure exerted on social workers by their supervisors trickled down into negotiations with residents over adoption. These findings highlight the importance of understanding and respecting older adults' reasons for nonuse as well as relieving frontline staff from having to navigate untenable paradigms in the name of independent living technology.

Kathleen Woodward explores the workings of reminiscence and of life review--one fragmentary, the other totalizing--and their importance, what they have to offer to a life as it passes into old age. Reminiscing is less concerned with truth than with creating an atmosphere with a promise of trust and security. Woodward, Fabe and Scharlach explore these themes in terms of what they mean to human life, human relationships and the process of aging.

This article describes the Consortium for Social Work Training in Aging (CSWTA), a unique partnership among 3 schools of social work and 6 county departments of adult and aging services. Using an innovative collaborative training model that included structured rotations and curricular support, CSWTA contributed to increased student interest in aging, improved knowledge about aging and aging services, and enhanced training capacity of county departments of adult and aging services. This model represents a promising approach for increasing the number of professional social workers trained to provide effective service and leadership to the public sector in the field of aging.

This exploratory study elicited descriptions of the experience of depressed mood in later life as well as older adults' knowledge about depression. The researcher purposively recruited thirty-six participants age 75 and older, who participated in an in-depth, in-person interview. The research design and analysis were informed by a conceptual framework integrating Pearlin's Stress Process model and social learning theory.

Three major themes emerged from the data: the importance of context and life experience, the power of personal choice, and the disconnection between knowledge and personal experience. Study participants, in describing their experiences of depressed mood, reported the importance of the context in which their depressed mood developed. Further, they saw themselves in light of their whole life experience and conveyed the relevance of earlier significant life events to their late life depressive symptoms. Early life events shaped both how they saw the world and how they coped with stressful life events in later life. Study participants also described the power of their own attitudinal and behavioral choices to improve their mood, often choosing to do things by sheer force of will, even though they didn't feel like doing these things because of their depressive symptoms. Participants understood depression in terms of both social and biological explanatory models. However, though they understood that depression may be caused by biological factors, none of the participants attributed such causes to their own depressed mood, but instead, relied on social causes to explain their own experience. In other words, no one spoke about biological causes of their own depressive symptoms even though they knew about such possible causes when relaying their knowledge about depression. This finding has possible implications for the stress process theory, which suggests that knowledge influences the judgments we make about our own experience. However, these study findings suggest that the influence of external knowledge may not be as powerful an influence on the judgments and meanings older adults ascribe to their own experience of depressive symptoms as are the context and lived experience of the individual.

Practice and research implications of these findings include the need to explore across more diverse samples of older adults the choices older adults make related to improving their mood. Research exploring the knowledge older adults have about depression and the explanatory models they use to describe their own experience is an important next step. Study participant's stress on the importance of context in understanding depressive symptoms in later life should cause clinicians to rethink their dependence on diagnostic and treatment tools that ignore the larger experience in which depressive symptoms arise for older adults.

The present study used structural equation modeling to examine the potential mediating effect of family conflict on caregiver strain in a randomly drawn household sample of 650 adults with primary care responsibility for an adult age 50 or older with a mental disability. Caregiver strain was directly influenced by the conflict, disagreements, and hardships experienced by the caregiver's family. Specifically, family conflict was found to mediate the impact of care recipient mental impairment and caregiver educational level on caregiver strain, and mediate partially the impact of caregiver income and caregiver-care recipient relationship. Findings suggest the importance of considering family-centered approaches when designing interventions to assist family caregivers.