Introduction
Participation in community and family activities is an important aspect of quality of life for older adults. The social participation literature shows that social participation is related to better functional skills [
1,
2], health-related quality of life [
3,
4], and even survival [
3,
5‐
7]. The favorite activities of older adults of almost any age include physical activities and activities that require leaving the house [
8]; however, many older adults have difficulty or are unable to leave their dwellings.
The homebound are increasingly recognized as a population of special needs [
9]. In the context of understanding the vital importance of community participation, it is important to study such participation in older homebound people. They are on a trajectory of decline in which inability to participate accelerates. The participation itself provides activation and motivation to prolong participation.
There has been prior quantitative and qualitative work on community barriers to participation by homebound older adults in small, geographically restricted samples. Sanders et al. [
10] found that among an all-female sample of homebound older adults in one housing complex in Canada (
n = 33), access to and cost of transportation, knowledge of available programming, and ability to access the programs offered limited activity participation. Bendixen et al. [
11] in a sample in western New York State (
n = 616) found that older adults were limited by transportation, poor health, lack of companionship, and accessibility. In a qualitative study of disabled older adults, Turcotte et al. [
12] (
N = 33) found that lack of social activities was the largest source of unmet need. However, little is known from nationally representative samples about what kind of social and community participation is important to this population of older adults and what issues they face in remaining active outside their homes. As locality, climate, supports, and building design may differ across regions of the USA, examining this issue in a nationally representative sample will provide a much-needed overview on the state of the homebound in the USA.
We used the NHATS sample to examine issues for homebound in the USA. In examining the association between homeboundedness and community participation, Verbrugge and Jette’s [
13] disablement theory posits that both intrinsic and extrinsic factors contribute to the development of impairment from pathology. According to their theory, intrinsic characteristics such as pain as well as extrinsic factors such as community services are separate domains with different intervention targets on the pathway to disability.
It is therefore important to examine both intrinsic and extrinsic barriers to participation among the homebound.
The conceptual framework for disability used in the NHATS study is Freedman’s framework [
14].
This conceptual framework for disability advances the work of the Nagi model [
15] and the World Health Organization International Classification of Functioning model [
16] to support investigations of the participation of older adults in social and community activities. This
advanced framework, which undergirds the National Health and Aging Trends Study (NHATS), serves four key functions: (1) allows for the study and consequences of participation; (2) explicitly includes testable links between the physical and social environment, participation, and disability; (3) supports research focusing on maximization of function in any stage of the disablement process; and (4) distinguishes between the capacity to perform and the actual performance, which allows study of assistive devices and environmental changes.
Thus, we apply the NHATS conceptual framework to test hypotheses about the importance of community and social participation of homebound older adults and the barriers to such participation. We hypothesized that the majority of homebound older adults would report that community participation was important but that both intrinsic (individual) and extrinsic (environmental) factors present barriers to participation among older adults. We currently know very little through nationally representative samples about outside activities older adults wish to engage in and what issues they face in remaining active outside their homes. Understanding this information can be useful to designing appropriate home and community-based social support programs that facilitate meaningful social and community engagement for a full range of older adults rather than just for physically robust ones.
Discussion
Findings
To our knowledge, this is the first study to report on valued family and community-based activities by community-dwelling homebound older adults using nationally representative data. We found that despite functional limitations, large percentages of homebound and semi-homebound older adults seek to participate in family and community life. Community participation can be an important part of health promotion [
23], can decrease depression [
24], and is actionable, which makes it an important intervention target.
As we hypothesized, we found that homebound older adults have more activity-limiting health problems (intrinsic factors) than their non-homebound counterparts. They also have transportation issues (extrinsic factors). These patterns are relevant because it is both harder to reach homebound older adults and more important to understand what deficits they need to overcome to engage in the community. It is important to note that in our sample, the homebound had the lowest percentage of valued activities of the three groups. On the positive side, we found that both the homebound and the semi-homebound are able to see family frequently. That was the most highly valued activity and is accomplished by 78.3 % of the homebound and 84.2 % of the semi-homebound. The semi-homebound group was the larger of the groups. This is a less restrictive definition and combines two subgroups of individuals that may not necessarily progress to homeboundedness—those who need help to go out and those who do not go out unaccompanied. The semi-homebound is potentially the more robust group for intervention because they are healthier, have less impairment, and have more available social support. Finally, from our findings, shopping for groceries, doing laundry, and preparing meals were the most common self-care difficulties. Each one of these is more amenable to outside help than ADLs like bathing and grooming. Targeted programs such as meals on wheels and also light housecleaning and laundry could provide semi-homebound or homebound older adults the ability to participate in valued activities.
Findings in context
Our findings add to the literature on homebound older adults’ participation preferences. Previous studies have examined single communities. Lack of opportunity for social and community engagement is among their prominent findings. Murayama et al. [
25] found that walkability and crime safety affect community participation of homebound older adults in a Japanese community. Turcotte et al. [
12] found that older disabled adults were not receiving enough social participation opportunities. Both home and community adaptations are associated with community participation among mobility-limited older adults in the US State of Georgia [
26]. Bendixen et al. [
11] found that those who cannot participate suffer lower self-esteem and may subsequently have more role losses. Hammel et al. [
27] found that toilet and bath modifications (even more than ramps or lifts for entrance/egress) had the largest association with going out into the community for those with mobility limitations. Our study findings extend those of others in their nationally representative scope.
Limitations
The current study has important limitations. First, although the definition of homebound and semi-homebound has strong convergent validity with illness and the same definitions have been used by others [
9,
25], the measure identifying homebound older adults is based on whether respondents left the house in the last month. This question has seasonality issues as someone in a cold wintry or hot summer locale may not leave in the recent month but not be considered homebound during temperate weather. Or, theoretically, it could have been an unusual month in an otherwise active life. This seems unlikely because an unusually weakened older adult would not likely volunteer for a 3-h research interview, but it is possible. A second limitation to our findings is the possible endogeneity. People may be more likely to say that an activity is important to them if they were able to have done it recently. Similarly, transportation difficulty could be confounded with homebound status because respondents could have answered that they did not go out due to transportation.
Also, we are unable to determine whether the fact that homebound older adults value participation less than the non-
homebound is due to other factors beyond the existence of intrinsic and extrinsic barriers to participation (e.g., overall interest). While the sample size of 473 is modest, this is a nationally representative sample of 473 people representing 1.5 million adults. Further, this sample size is larger than the overwhelming majority of previous work on homebound older adults who are especially difficult to recruit to research studies because of their poor health and inability to access routine medical care or other services. Also, those who were homebound were less educated than those who were not homebound. There may be a cohort effect as new generations of older adults are more educated.
Participation in general
For an aging society, having 6.3 million homebound and semi-homebound older adults who want to participate in societal life can be an opportunity. In recent years, many communal networks such as the village model and naturally occurring retirement communities have sprung up to meet community needs. If homebound and semi-homebound adults can more easily leave the house, they may be able to contribute to these communities. There are also new Internet-based options such as Skype, Magic Window, and Virtual Senior Centers which can remove barriers to participation using electronic connections.
For those who are semi- or fully homebound and want to get out into the community, their vulnerability makes their safe participation more difficult to facilitate. The high risk of falls in the homebound is of particular import as we think societally of how best to facilitate their social and community engagement. It will be important to target environmental needs [
28] and other services that might facilitate leaving home to participate in community events such as mobility services and other para-transit services.