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We invited participants to discuss any type of support, intervention, or service provision, whether medical, social, family-provided, paid or unpaid. We found that the people in our sample engaged in a recursive process, evaluating their needs on an issue-by-issue basis. In lieu of seeking assistance, participants engaged in self-management, but also received unsolicited or emergency assistance. Our findings offer four stages for policymakers, service providers and carers to target to address the uptake of assistance.
Legislation places an onus on UK local authorities to be aware of care needs and to prevent and reduce care needs in their locality i. Challenges to achieving these aims include identifying people needing assistance before they require extensive care packages, and reaching non-users of specific services. Although considered heavy users of services older adults often do not take-up available health and social care due to barriers to access, denial of need or lack of information [ 2 — 5 ]. The extensive literature details these and other reasons e.
Unlike other studies, we did not recruit participants based on their health status or service use. We sought similar s of men and women, and individuals living with and without a partner. Recruitment procedures followed respective survey guidelines.
KC telephoned these individuals to answer questions and confirm agreement to participate. As CFAS Wales hosts, the authors sent information letters to 22 individuals inviting them to be interviewed, then telephoned them to answer questions and ask if they would like to participate. We digitally recorded, transcribed and anonymised all interviews. We used NVivo to store, retrieve and manage the combined datasets. To avoid arbitrary divisions between health, social and other types of assistance, we prompted participants to include any type of support, advice, intervention or service, whether medical, social, financial, housing or transport.
We enquired whether assistance was provided by family, friends, neighbours, professionals or others and whether they paid or not. KC and CM tly developed a coding framework by open-coding [ 13 ] their own interviews maximising meaningful interpretationdouble-coding and comparing several transcripts, and frequently discussing the data, codes and.
KC and CM then combined the English and Welsh datasets and conducted thematic analysis [ 17 ] of different e. Examining the interrelationships between these axial coding [ 13 ] led us to develop the four-stage process of evaluation described in the findings. Our approach drew on Grounded Theory [ 13 ], combining the inductive—deductive cycles of data collection, analysis, hypothesis-testing and additional selective coding [ 14 ] to refine our development of the process. Table 1. Sample characteristics.
s given in brackets show how many participants took part in a couple interview. Participants evaluated their need and desire for assistance on an issue-by-issue basis. Their considerations can be conceptualised as a recursive process comprising four stages Figure 1. This was the case even for participants who described potentially risky circumstances, such as C14M74A who despite a recent stroke, several falls and being unable to get out of the bath, saw his walking stick as temporary and did not have or use any other assistance aids at home.
One reason for this lack of perception is that over time, participants modified their expectations, behaviour and environment. Others described lowering their housework and gardening standards. All described modifying behaviour to avoid triggering or aggravating issues, e. They also described making modifications to their home and garden and responding to emerging issues by, e. You tend to switch off. We found that even where participants acknowledged a need for assistance, Seeking lady needing some assistance did not necessarily want to perceive themselves—or be perceived—as someone who needed, sought and received assistance.
While participants varied in terms of their financial means, none described ruling out assistance due to cost, only principle or preference.
Where participants perceived assistance as synonymous with inability to cope and compromising independence, they managed their own needs rather than assert a need for assistance. Participants revealed increased preparedness to receive assistance when they were unable to undertake their usual activities, i. Other tipping points included overwhelming pain, embarrassment, anxiety and loss of confidence: It was perfectly level and I just tripped. So now I am a bit timid, you see and I feel a bit better with the stick.
Overall, they reported preferring people they knew and recommended providers to ensure quality and reduce the risk of exploitation not least due to negative past experiences.
Such assurances were more common for those living in small, close-knit communities. When participants needed general assistance e. For some, however, family assistance was limited or unavailable. Passivity was another factor: some participants expected to be told e.
Opportunities were limited in other ways.
A few participants described being unable to access services following closure or withdrawal e. Some—but not all—perceived that their age precluded certain types of surgery: My doctor has said [a new hip] would be a bit of a risk anyway at my age. U2M90P; awaiting shoulder surgery. Others were unaware of potential assistance and how to acquire it: U5M82A did not know that hearing aids were available on the NHS, while C14M74A did not realise he could Seeking lady needing some assistance a GP home visit or that charities offer home adaptations.
I value my independence. They also expressed concern about ineffectiveness e. Several participants reported that their needs remained unmet after accepting assistance. In such circumstances, participants revisited one or more stages in their evaluation, e. Participants reported managing without assistance in the absence of acknowledging needs, when they lacked preparedness to receive assistance or opportunity to assert their need and when they needed to compensate for the inadequacy or inappropriateness of assistance: I think you have to do as much as you can on your own.
My legs are giving me gyp [trouble] but I want to keep them going on the stairs as long as I can. Very important, yes, it is. I give it a good rub […]. Self-management included actions described already, i. Additionally, participants bypassed asserting a need for assistance by meeting their needs via alternative means. They reported using, e. Some received support from a partner sometimes reciprocated and reflected how, if this ended, they would be unable to manage alone. Receiving assistance did not always depend upon participants seeking it but resulted from third parties intervening without invitation.
Some perceived that age triggered these unsolicited interventions: I think [GPs] have to see you every so often. Some unsolicited assistance was unwanted, e. C11F81A described feeling pressured into receiving an internet provider and C12F82A admitted misleading her children who encouraged her to carry her mobile in case she fell. Unsolicited assistance was viewed positively if unobtrusive, e.
Others described the benefits of discovering health conditions e. Several participants reported receiving emergency care following the onset of infection, injury or stroke that, while not preventable might have benefitted from a speedier response or having a personal alarm, e.
U13F90A had a stroke and was discovered by chance. C17F72P with prolapse. Participants who described these events did Seeking lady needing some assistance necessarily alter their subsequent behaviour to prepare for or minimise future incidents. We found that our sample of older adults evaluated their need for assistance on an issue-by-issue basis, engaging in a four-stage recursive process. This process was not influenced by the type of issue arising, e. Participants told us that, in lieu of assistance, they employed a plethora of self-management techniques.
They also revealed how, despite not seeking assistance, they received unsolicited and emergency assistance nevertheless. Like Sarkisian et al. While Dixon-Woods et al. Instead, participants adapted to those changing circumstances by engaging in self-management, modifying their behaviour, environment and expectations i.
Some participants living with their partner described co-dependency which too may have had a similar impact. Participants were especially concerned about the stigma of being someone who needs assistance, equating assistance with being a burden or scrounging which was incompatible with their self-image of being active and independent.
They also expressed concern about exploiting free assistance, including that provided by family. Accordingly, they repeatedly indicated that asking for assistance was a last resort, regardless of provider. Other studies refer to the stigma of symptoms and conditions [ 22 ], but not stigma related to being a recipient of assistance per se. There is some overlap between the process that we describe and other models. The Selective Optimisation with Compensation model [ 24 ] explains how people manage losses through successful adaptation or regulation of their behaviour, optimising assets and compensating for reductions in functioning.
Although the similarities with these models lend some credibility to our findings, the process we describe here is distinct in several ways. First, we derived our process from the analysis of a wide range of needs and types of assistance, not just health or social care.
In contrast, our process acknowledges that prior to identifying oneself as a legitimate candidate for services, one must acknowledge a need for assistance and be prepared to be a recipient of assistance from any provider including family. Third, our process illuminates unsolicited and emergency pathways into assistance. None of these models capture all these elements. Understanding why older people do not seek or receive assistance is key to the development of policies and services that enable local government to meet their obligations to provide preventative care.
This is problematic if it means that preventative services are underutilised and resources are spent instead on crisis intervention. The process that we describe here highlights four stages that policymakers, service providers and carers can target to address the uptake of assistance. Improving the availability and accessibility of assistance for older adults is important Stage 3but our findings suggest that attention must also be paid to Stages 1 and 2. It is at these earlier stages that interventions could target expectations, the stigma attached to receiving assistance, and preconceptions about independence and responsibility.
Services could, for example, reframe assistance as promoting independence. Crucially, the recursive nature of the process where individuals constantly reassess emerging issues and needs present multiple opportunities for practitioners and others to offer assistance. This is particularly important given that individuals might not necessarily change their behaviour following a crisis or intervention and may be unwilling to voluntarily assert their need for assistance.
The transferability of our findings might be limited by our purposively sampled group of overs, who were selected regardless of health status or use of services. It is precisely this, however, that makes the study stand out from the existing literature and sheds light on aspects of service uptake that are so often overlooked.
Older people might avoid assistance and treat public services as a last resort even in urgent circumstances. We would like to thank all the participants for their contributions to this study. The sponsors played no part in the de, execution, analysis or interpretation of data or writing-up. All participants gave written informed consent to participate in the study and for their anonymised interview to be used to write articles and reports. Do older adults expect to age successfully? The association between expectations regarding aging and beliefs regarding healthcare seeking among older adults.
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Consultation and illness behaviour in response to symptoms: a comparison of models from different disciplinary frameworks and suggestions for future research directions. Soc Sci Med ; 86 : 79 — Mitchell JCrout JA. Discretion and service use among older adults: the behavioral model revisited.
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