Differing Perceptions of Older Adults’ Reasons for Refusing Services Among Staff, Caregivers, and Older Adults

Context: Among the populations of the United States and Canada, 1 in 6 are older adults aged 65 years or older. While older adults strongly prefer to age in their own homes, they often refuse home- and community-based services (HCBS) which can support their ability to age in place, prevent health decline, mitigate functional problems in living, and ease burden on caregivers. This community-based participatory study explored factors influencing older adults’ choices not to use HCBS to inform development of interventions to strengthen service utilization.

Objective: Describe differences and similarities among older adults, caregivers, and HCBS staff in their perceptions of factors influencing older adults’ choices not to use HCBS.

Mixed Methods Design: Focus group discussion and ranking of strength of influence and modifiability of 12 themes of HCBS refusal.

Setting: South-central United States.

Participants: Older adults with a chronic health condition or a functional disability who have considered using a HCBS (n=15; 80% female, ages 65-77 years), caregivers for older adults (n=17, 88% female, ages 45 to 77 years), HCBS staff (n=17, 76% female, ages 39 to 72 years).

Results: Older adults’ top ranked reasons for refusing HCBS are lack of knowledge, lack of accessibility, and financial barriers. Kruskal-Wallis tests with Bonferroni correction on post-hoc comparisons were conducted on the three groups. Relative to older adults’ perspectives, caregivers underestimated the influence of accessibility (p = .039) and HCBS staff overestimated the influence of independence and self-reliance (p = .039). All three groups agreed that lack of knowledge was the most modifiable. Older adults perceived accessibility of services as less modifiable relative to the other 2 groups, though this was not statistically significant.

Conclusions: Older adults, caregivers, and HCBS staff demonstrated some important differences in perceived factors influencing older adults’ refusal of HCBS. The three groups were largely in agreement on the extent to which these factors are modifiable. Findings have important implications for patient-centered interventions.