Differences in community- and home- based service utilization between older adults living in rural and urban areas: The roles of structural and cultural factors

Background and Purpose: Despite their great unmet needs due to poor health, poverty, and social isolation, older rural populations often have low rates of formal services use. Most studies, which often use Anderson's behavior model, have failed to examine the effects of structural and cultural factors on service use. Drawing upon the perspectives of system theory, this study hypothesized that structural service barriers (i.e., few available services, access difficulties, and lack of trust in formal services) and cultural factors (i.e., reliance on informal support systems, religiousness) would explain the rural/urban differences in service use. This study has three specific aims: (1) To describe a rural older population living outside city limits in a rural county, (2) To examine whether such a rural population differed with an urban group in their use of formal services and (3) To examine whether the rural/urban differences in formal service use can be explained by the mediators of perceptions of structural barriers and cultural influences.

Methods: Analyses were based upon survey data collected by an Area Agency on Aging (AAA) in Alabama on 300 community-dwelling older adults, aged 60 or older, in collaboration with the University of Alabama. Participants averaged 72.9 years of age. Twenty percent of participants lived in an area defined as rural, 33% were African-American participants, 75% were female, one-third were currently married, and half lived alone. Mediation analysis was conducted using SPSS macros for estimating direct and indirect effects of mediators. Mediators included the perceptions of structural barriers (measured by service availability, accessibility and acceptability) and cultural factors (measured by existence of informal support, frequency of church attendance, and use of prayer). The outcome variable of service use was determined by the involvement with up to 14 service types provided by the AAA.

Results: Older rural adults were found to be less likely to use formal services than their urban counterparts (p< .05). Perceived barriers in service acceptability and perceived informal support failed to be statistically associated with formal service use. Older adults who reported less service availability, perceived more difficulties accessing services, attended church more frequently, and prayed more often tend use fewer formal services. Mediating analyses found that there were indirect effects of residence on service availability (β = .13, p <.05) and church attendance (β =.08, p <.05) on formal service use. These findings suggest that rural/urban differences in the use of formal services can be explained by differences in the number of perceived barriers in service availability and in the frequency of church attendance.

Implications: Given limited funding for rural community-based aging services, program administrators and social workers need to ensure existing programs are accessible to older adults living in remote and rural areas through innovative outreach activities. Findings suggest that rural agencies for older persons should consider partnerships with religious organizations in addressing the unmet needs of this population.