Aging in place among home-dwelling older adults in Canton Basel-Landschaft: the INSPIRE Population Survey

Due to medical and technological advancements, many individuals in countries around the world are living longer (1). In Switzerland between 2020 and 2050, a rise from 18% to 26% for those aged 65 years or older and from 5% to 11% for those aged 80 years and older is foreseen (2). The gains in life expectancy, although a positive outcome, are not always enjoyed in full health and free of limitations. As individuals age, many of them may suffer from the presence of multi-morbidity and frailty (3, 4). Functional limitations as well as isolation and loneliness are also frequently reported among this population (3, 5-7). Moreover, these individuals usually receive care from different providers across various settings which can lead to their care being fragmented (8). Fragmentation of care is characterized by gaps in provision of care which could cause confusion and distress for older adults and their caregivers, as well as higher costs associated with unnecessary use of services (9). Despite challenges associated with aging, many older individuals prefer to remain living in their own environments for as long as possible (10, 11), an objective known as aging in place (12).
Aging in place is linked to the ability to maintain independence and live a thriving and highly qualitative life within an individual’s own environment (13). It can therefore be fostered by designing environments that facilitate the mobility and engagement in social activities, which are important components for the health and quality of life of older adults (14). There is also an opportunity for countries to exploit existing and new assistive technologies, another pertinent facilitator of aging in place (15). Assistive technologies are an umbrella term including any device, equipment, instrument or software whose purpose is to maintain or improve an individual’s functional status and independence (16).
To assist older adults to age in place and address their complex needs, the World Health Organization (WHO) has proposed an integrated care approach to support older adults’ independence and make aging in place possible (8, 17). Integrated care models are complex, dynamic interventions targeting multiple levels of the healthcare system, which often entail behavior change in the way various health and social care providers provide joint care (18, 19). To successfully develop and implement an integrated model of care, not only the perspectives of the healthcare providers, social care professionals or policymakers are essential, but also the needs and preferences of older adults and their informal caregivers (15, 20). Understanding the demographic and social characteristics of a target population, is also fundamental in planning, developing and implementing integrated care for older people (21).
In 2018, an opportunity for integrated care for home-dwelling older adults was put forward by a new care law in Canton Basel-Landschaft in Switzerland (22). The INSPIRE project is working together with the local policymakers to support the development, implementation and evaluation of an integrated care model for home-dwelling adults aged 75 and above living in this region (23). The INSPIRE project is an implementation science project, positioned within the three phases (development, feasibility and effectiveness evaluation) of the Medical Research Council (MRC) for developing and implementing complex interventions (18). The project incorporates the recommendations of the MRC framework with several implementation science components such as contextual analysis, stakeholder involvement, as well as using implementation strategies and implementation outcomes to ensure the successful implementation and sustainability of the care model in Canton BL.
During the development phase, an understanding of the context aids in ensuring the suitability of the intervention components for the implementation setting (23, 24). Therefore, we conducted the INSPIRE Population Survey (25, 26) as part of the contextual analysis, with the aim to understand the needs and preferences of older adults, as well as the support and services they currently require and anticipate needing in the future to maintain their independence and make aging in place possible.
The overall goals of this dissertation are threefold. First, we aimed to describe the development of the INSPIRE Population Survey and the marketing strategy we used to reach as many home-dwelling older adults as possible, a population that is known to be challenging to recruit in research (27). Second, we used an ecological approach to dive deeper into the health-related quality of life of this population, as one of the main goals of aging in place. Finally, we investigated factors associated with openness to use assistive technologies that can facilitate independence among home-dwelling older adults and support them to age in place.
Chapter 1 provides a general overview of challenges associated with caring for an aging population as well as the opportunities for integrated care for aging in place among home-dwelling older adults. The current literature on the concepts of quality of life and health-related quality of life, as well as the current state of the art on assistive technologies facilitating the autonomy of older adults is also provided. Chapter 2 follows with the dissertation aims.
Chapter 3 chronicles the research conducted to develop the INSPIRE Population Survey, as well as an outline of the variables and measurements used in the survey (25). The work also describes the marketing strategy used for disseminating the survey and briefly reports on the response rate and participant characteristics. This population-based survey achieved a response rate of 30.7%, which is considerably high for postal surveys (28), particularly in those involving older adults (27). This accomplishment can be credited to the ongoing stakeholder involvement strategies we used, including early engagement of all stakeholders during the development of the questionnaire as well as its marketing.
In Chapter 4, we evaluated HRQoL and factors related to it using an ecological outlook. The participants of our survey reported a high HRQoL, similar to findings from previous research (29, 30). We specifically looked at multilevel factors at the micro, meso and macro level related to how home-dwelling older adults perceived their HRQoL. This ecological perspective permitted the investigation of variables associated not only with the individual, but also with the environment around the older adult. We confirmed that among home-dwelling older adults, having a higher income, supplementary insurance, better education and generally a greater socio-economic status were associated with a higher HRQoL (31, 32). Our findings also validated previous studies indicating that individuals who report to be more frequently involved in one or more social activities, correspondingly report a higher HRQoL (33, 34). We also confirmed factors that negatively impact home-dwelling older adults’ HRQOL, as previously researched, like being older and female, having multimorbidity and polypharmacy, and being lonely or socially isolated (35-46).
Chapter 5 presents the results from our study aiming to describe the current and anticipated use of assistive technologies among our participants, namely telemedicine, phone/SMS, wearables and assistive robots; as well the factors associated with openness to use such assistive technologies. We showcased that the current use of assistive technologies was rather low amid participants, compared to findings from two other surveys conducted on this topic among Swiss older adults (47, 48). Our results highlight a new finding that compared to current use, a higher percentage of home-dwelling older adults were open to using wearables and telemedicine in the future. We also found that openness to use assistive technologies in this population was positively associated with their current use, and also with receiving support from a spouse or a partner. Similar to the two previous surveys in Switzerland, openness to use assistive technologies was negatively associated with older age and with being female (47, 48).
Chapter 6 presents a summary of the findings from the three preceding chapters and interprets them in the context of the current literature. Furthermore, methodological strengths and limitations of these studies are discussed. At last, reflections on the implication of this thesis for future research, policy and practice are presented.
In conclusion, this dissertation was part of the development phase of an implementation science project aiming to implement and sustain an integrated care model for home-dwelling older adults. Our findings provide some important insight into the areas requiring the attention of care professionals and policymakers. We brought forward the need for considering the role the environment and the social network surrounding home-dwelling older adults play in fostering care that augments their quality of life and supports them in maintaining their desired independence. We also showed the potential assistive technologies have in attaining this goal, possibly also alleviating some of the burden of informal caregivers who are providing care and support for home-dwelling older adults. From a research, practice and policy position, we believe our findings have the prospective to provide a better scientific and policy approach in assuring older adults are reaching their goal to age in place.