Rural Community Members' Perspectives on Mental Health and Aging: An Ecological Approach to Interpreting and Applying Focus Group Results

Introduction

The Mental Healthiness and Aging Initiative (MHAI) was created to raise awareness and increase knowledge about mental health and aging issues, particularly for those living in rural areas. In the first phase of the MHAI program, the investigators sought to understand the meaning and value of mental health to residents of rural communities as well beliefs about the behavioral components that protect and promote mental health while aging. For the purposes of the study reported here, mental healthiness was defined as a state of well-being that comes from maintaining and balancing personal traits such as routine activities, intellect, personality, and emotions throughout one's life.

Furthermore, recognizing that some level of change in personal traits should be expected when that change is in line with a person's usual patterns of behavior, impairment in mental healthiness is indicated by debilitating change in behavior, especially if it is sudden, unexpected, or persistent. Such changes may require a doctor's attention if an individual is to achieve personal goals and maintain independence and quality of life. The community-based intervention we developed focused on mental health because of community interest in that topic and because our focus group results highlighted the importance of mental health even in the presence of deteriorating or poor physical health.

Focus groups were used to stimulate conversation about community beliefs regarding mental health in rural eastern Kentucky and later used to design a community-based educational curriculum on mental health and aging. In addition to informing that curriculum, the data gathered through these focus groups can prove useful to Extension agents as they fulfill their public health roles and seek to meet the needs of their clients. To that end, the findings from the focus groups are presented and discussed in terms of applicability to Extension agents.

The import and relevance of the responses of the focus group participants are discussed within a framework of four ecological levels, following the lead of Sanders, Fitzgerald, and Bratteli (2008). The ecological model (Bronfenbrenner, 1977) has been described as an effective conceptual framework for health promotion interventions (McLeroy, Bibeau, Steckler, & Glanz, 1988).

Under the ecological framework, variables at four levels (micro-, meso-, exo-, and macro-systems levels) can influence people's behavior. Microsystem factors include character traits of individuals as well as face-to-face interactions. Microsystem variables interact within the level of the mesosystem, which includes family, school, work, and church interactions. The exosystem includes the broader social system in which people live, and variables at this level include the economic situation of society. The macrosystem refers to the values and culture in which the micro- and mesosystems operate. In addition to interpreting data from the focus groups in terms of the ecological applications of such information, suggestions are made for how Extension agents might incorporate the findings into mental health interventions at the various levels (from the individual [microsystem] to the community [macrosystem]).

Using the ecological model, data can be discussed in terms of the various levels at which mental health while aging affects the lives of and is important to the participants. Furthermore, future Extension programs and interventions can be designed to meet the needs of people at each level (McLeroy et al., 1988). This conceptual approach is particularly important in rural areas, where environmental factors have a strong influence on individual behavior.

Background

As the population of older adults in America swells, increasing attention is being paid to addressing quality of life issues within the older-aged demographic (e.g., Ganz et al., 2003; Glass & Knott, 1984). Mental health is a key component of quality of life for older adults, yet it often goes unaddressed in both the community and clinical settings (Smith et al., 1993).

Specifically, depression and anxiety are frequently overlooked in primary care settings (Kessler, Lloyd, Lewis, & Gray, 1999) where physicians have little time to assess the mental status of their older patients, generally spending more time addressing the somatic complaints of those patients. Furthermore, mental health resources are often sparse, particularly in rural areas (Chalifoux, Neese, Buckwalter, Liltwak, & Abraham, 1996), and resources designed to address the needs of older adults are generally non-existent.

With the dearth of mental health resources in rural areas, and specifically those that address the needs of older adults, alternative community resources must be developed to improve the quality of life for older adults. Local Extension agents, who serve as community liaisons and public health advocates, are well positioned to help develop and implement community-based educational interventions (Gerrior & Crocoll, 2008; Koukel & Cummings, 2002) that can provide their communities with needed information on mental health and aging.

In order to best prepare Extension agents to address their clients' needs, it is vital to increase awareness of the knowledge base and interests of Extension clients regarding mental health and aging so that appropriate resources (i.e., those that are appealing and culturally-relevant) can be developed. The purpose of this article is to disseminate crucial information about rural community members' perspectives on mental health and aging—what it means, why it matters, and how to protect it.

Methods

Participants

University of Kentucky Family and Consumer Science (FCS) Extension agents participated as community liaisons for the MHAI program. Twenty FCS Extension agents from the counties in Extension District 1 in eastern Kentucky were contacted by email about the MHAI project, and the first 12 agents who agreed to participate were asked to engage in community focus groups about mental health and aging. Extension District 1 was selected due to the rural nature of the district, as well as Extension agents' interest in implementing mental health and aging interventions in their communities.

The focus group approach for data collection was chosen so that participants could build upon one another's responses to questions (Knodel, 1995). Extension agents were asked to identify and invite opinion leaders (i.e., people who could represent their communities' opinions as well as take information back to their communities) to share their knowledge and beliefs about mental health and aging during the focus groups. Similar focus groups have been conducted in eastern Kentucky and other rural locales to identify community beliefs and knowledge surrounding physical health and various health behaviors prior to the development and implementation of interventions and programs to promote health and good health behaviors (e.g., Ahijevych et al., 2003; Lohri-Posey, 2006; Schoenberg, Hatcher, & Dignan, 2008).

Between 10 and 18 community members participated in each of the 12 focus groups, with a total of 183 participants. Participants' ages ranged from 20-30 to over 60 (exact ages were not collected). Of the 151 participants who reported gender and race, 131 (86.8%) were female, and 123 (81.5%) were white. Both lay community members and those who work with older adults participated, and agencies represented included area agencies on aging, Extension Homemakers, nursing homes, hospitals, churches, and schools. All participants signed informed consent forms as required by the Institutional Review Board at the University of Kentucky.

Focus Group Procedures

Focus groups were conducted by a trained study moderator. Extension agents worked with the moderator to take notes on oversized notepads in the participants' view to facilitate accurate representation of participants' opinions. Each meeting was recorded and later transcribed by a research assistant who was not present for the focus groups and who had no personal knowledge of the participants or the Extension agents. Figure 1 contains the discussion questions used at the focus groups.

Figure 1.
Discussion Questions Asked in Focus Groups

1. What does it mean to you to be mentally healthy as you age?

2. Describe someone you know over the age of 65 who is mentally healthy.

3. Why is mental health important to you as you age?

4. As a community, how can we promote mental health in adults over 65?

5. What resources/assets do we, as a community, have or need to promote mental health in the aging population?

6. What can you personally do right now to promote mental health for yourself?

7. What can you personally do right now to promote mental health for those 65 and older?

8. What can you do to promote mental health for your family?

Analysis

To analyze the qualitative data, content analysis was used to classify several themes that emerged from the focus group sessions. Open coding was used first to identify individual ideas expressed by participants, and axial coding was then used to group those ideas into key themes. Results of the data analysis were shared with the participating county Extension agents, who were asked to perform member checks, whereby they verified the accuracy, representativeness, and thoroughness of the results of the analysis.

Results

Table 1 highlights the themes that emerged in response to the questions and also includes supporting quotes from the focus groups.

Table 1.
Key Themes and Quotes from Focus Groups

Theme*	Focus Group Narrative
Question: What does it mean to you to be mentally healthy as you age?
Maintain independence:	"[Being mentally healthy as I age means] keeping my dignity by doing things for myself."
Possess emotional health:	"[I want to be able to] keep a good sense of humor and family involvement."
Stay aware and intellectually active:	"[Mental healthiness while aging means having] understanding; lack of confusion."
Maintain physical health:	"Good physical condition - healthy, active, muscle tone, flexibility, nutrition - [is part of being mentally healthy while aging]."
Have social support:	"[Part of mental health is to] recognize friends and family and to have them in the first place."
Be engaged in spiritual life:	"Spiritual life, able to go to church, and involved in faith community [are necessary to be mentally healthy as I age]."
Question: Why is mental health important to you as you age?
Maintain independence:	"With your mental health, you're more resourceful and creative in maintaining independence."
Lessen impact on family and friends:	"I want a meaningful life and not be a burden to my children."
Maintain self-identity:	"Without your mind you're not you."
Have a high quality of life:	"You don't have to be physically active to enjoy life if you still have your mental health."
Interaction of physical and mental health:	"If my mental faculties are there, I can always think of a way to overcome my surroundings (physical disabilities)."
Question: As a community how can we promote mental health in adults over age 65?
Provide activities for elderly:	"Provide more things for them to do and make seniors aware of opportunities."
Create intergenerational opportunities:	"We cheat our small children when we don't let them interact with the elderly."
Community education and awareness about aging:	"Educate family member on how to recognize early signs of mental health issues."
Provide transportation:	"[We need] transportation to activities or access to transportation for elderly to get to activities and educational opportunities."
Record oral histories:	"Promote telling of aged people's history (record for posterity)."
Question: What can you personally do to promote mental health for yourself?
Utilize preventive care (balance rest with activity, good nutrition):	"Remember you are #1 - can't take care of others if you don't take care of yourself."
Remain mentally active:	"[Engage in] mental exercises [such as] crosswords."
Question: What can you personally do to promote mental health for adults over age 65?
Provide instrumental help (connect to resources, cook for them, provide transportation):	"Volunteer to take people where they need to go."
Offer social support:	"Visit...listen carefully."
Question: What can you personally do to promote mental health for your family?
Record traditions and oral histories:	"Ask questions of family members to help them remember and recall, even if you know the answers."
Encourage good nutrition:	"Practice what we preach [to our families]: good nutrition."
* Themes are listed in descending order of frequency mentioned in focus groups

The most commonly mentioned themes are discussed below.

1. Desire to Maintain Independence

In every focus group, participants stated emphatically that independence was the most important aspect of maintaining good mental health. The meaning of independence varied from wanting to "be able to find your car," to knowing "when it is time to quit driving without being forced to." The following sentiment resonated from participants regarding good mental health, "If you're not mentally healthy, you might not realize that. You might hurt yourself or someone else." Participants reported that independence was necessary for making one's own decisions and especially for not "being a burden." One woman discussed the idea of being a burden in relation to her grandchildren, as far as not being a chore for them: "Oh, I've got to go to Grandma's." She would prefer they say that they get to go to Grandma's.

2. Importance of Emotional Health

Mentioned almost as frequently as independence, maintaining emotional health was another key benefit of preserving mental healthiness. This theme incorporated the idea of maintaining one's self-identity, to be "still worth something - can do something." One participant made the statement, "Without your mind, you're not you." Participants in many focus groups expressed the idea that emotional health meant having contentment and a sense of purpose rather than regret and depression.

3. Importance of Participating in Intergenerational Activities

Participants generally expressed wanting young people to have the opportunity to engage with older adults to familiarize young people with the experience of aging, allow older adults to pass on their knowledge to younger generations, encourage respect in the young, and provide opportunities for older adults to mentor younger people. One participant stated that, "We cheat our small children when we don't let them interact with the elderly." The desire for intergenerational mixing was not limited to school-aged youth and elders; focus group participants also saw much value in middle-aged community members being involved with the older adult population. Participants mentioned the importance of mentoring programs, wherein retired elders could share their skills with younger members of the workforce.

4. Value of Sharing One's Life History

The sharing of life histories was often linked to both intergenerational activities and mentoring others. For example, one woman said, "My grandchildren ask me 'what did you do?' I like teaching about heritage skills." Participants expressed the importance of remembering and sharing oral traditions and family history as both a benefit and a way of maintaining their mental health.

5. Remaining Active and Engaged

This theme encompassed productivity, creativity, and deriving enjoyment from life. Participants believed that for mentally healthy older adults to be able to "still enjoy life - [they] need to participate." According to the participants, to be productive, older adults must feel both needed and useful. Creative activity and engagement included having the "ability to do what you've put off (for example, play guitar)" as well as traveling and volunteering.

6. Being Respected

One frequently mentioned benefit of maintaining mental healthiness was being respected. Being respected included being visible, needed, valued, and treated with dignity. One participant felt that mental health was necessary for her to "be able to speak up and make people aware that I want to be treated with dignity." Participants felt that respect was owed to older adults regardless of physical ailments and that older adults should not be "seen as invisible." In line with being respected, one participant said "[I] do not want to generate pity just because I am old."

7. Educating Younger Community Members About Aging

In addition to intergenerational activities, participants discussed the importance of educating younger community members about aging as a way to promote mental healthiness in the aging, perhaps through the mechanism of reducing the stigma associated with aging. Education for the younger community was not limited to teaching them to respect their elders or getting older community members' life histories (although those were valuable components mentioned at the groups), but also included making sure that "children [are] educated to know what might happen to their parents." Participants felt that younger community members should be made aware of the possibility of Alzheimer's or other dementias and that "each generation has a role to play."

Discussion

Bronfenbrenner's (1977) ecological model framework is used for interpreting the results of the focus groups. Suggestions are included to demonstrate ways in which results of the current study may be employed in future Extension programs in an effort to address mental health and aging concerns at each ecological level.

Microsystem Implications

Microsystem factors include character traits of individuals as well as face-to-face interactions. The desire to maintain independence and the importance of emotional health were key themes that participants described that influenced them within their immediate environment.

Independence has been repeatedly identified by both older adults and rural residents as a key component of well being (e.g., Craig, 1994). The loss of independence due to mental health issues is a particularly frightening prospect for many older rural adults (Neikrug, 2003), and individuals are anxious to avoid that loss. Emotional health, viewed as distinct from mental health by the participants in the focus groups, is also an individual characteristic that was highly valued by the participants and is a dimension of wellness the contributes to older adults' health (Kang & Russ, 2009).

Future mental health interventions developed and implemented by Extension agents and aimed at microsystem targets (e.g., individuals and immediate families) might be more readily adopted by rural community members if those interventions incorporate the ideas of maintaining independence and promoting emotional health.

Mesosystem Implications

Microsystem variables interact within the level of the mesosystem. The mesosystem includes family, school, work, and church interactions. Participants described the importance of participating in intergenerational activities and the value of sharing one's life history as both methods and outcomes of mental healthiness while aging.

These themes incorporate many mesosystem variables (e.g., extended families and members of various age groups within the community) and demonstrate potential targets of mental health interventions within the mesosystem. For example future Extension mental health interventions might target the level of the mesosystem by integrating multiple generations in the mental health-promoting activities. Such interventions might incorporate both of the themes that the participants identified by developing an intergenerational activity that involves the sharing of life histories. Providing opportunities for community members to engage in intergenerational interaction is a logical means for Extension agents to promote mental health while aging as intergenerational activity has been shown to enhance mental health (i.e., alleviate depression) in older adults (Davey & Eggebeen, 1998). Furthermore, mental health and nursing research has indicated that the sharing of life histories can promote mental health (Foster, McAllister, & O'Brien, 2006).

Extension agents might develop community mentoring programs, which would facilitate older adults remaining connected to people in their extended family and their community, while at the same time allowing for multiple generations to interact. Through such mentoring programs, older adults could pass on the skills and knowledge they have developed throughout their lives, increasing the knowledge of those around them as well as improving younger generations' understanding of the experience of aging.

Exosystem Implications

The exosystem includes the broader social system in which people live. Variables at this level include the economic situation of society. When older adults remain active and engaged in an effort to promote mental healthiness, a byproduct of that activity and engagement could be the economic benefit of having a pool of experienced volunteers to teach life skills to the underserved rural population (e.g., Hutchins, Seevers, & Van Leeuwen, 2002).

By incorporating the theme remaining active and engaged into mental health interventions, Extension agents can affect change at the level of the exosystem. Interventions at this level might target increasing volunteering, for example, which can contribute to both the productivity of older adults as well as the economy of the community.

Macrosystem Implications

The macrosystem refers to the values and culture in which the micro- and mesosystems operate. When the participants discussed being respected and educating younger community members about aging, they were referring to aspects of the values and culture of rural residence. Research on quality of life in older adults has indicated that older adults believe being respected contributes to their quality of life (Bryant et al., 2002).

Interventions that encourage respect for older adults or help reduce the stigma associated with aging are likely to appeal to community members in rural areas. As suggested by Glass and Knott (1984), Extension agents can go about educating their community members, thus creating change in perspectives on aging, encouraging respect for older adults, and reducing the stigma associated with aging through workshops highlighting, for example, the myths and realities of aging and changes associated with aging. Such macrosystem intervention is likely to improve quality of life for people as they age.

Conclusion

Our study found that Extension programs designed to promote mental health among the aging population in rural areas are more likely to be successful if such programs incorporate the ideas of maintaining independence, promoting emotional health, including intergenerational activities, encouraging older adults to share their life history, and remaining active and engaged, while also encouraging respect for older adults and educating younger community members about aging. By adopting an ecological approach to this data, the differing levels at which interventions might address mental healthiness while aging become evident. Extension agents, particularly those in rural areas, should find this data useful for informing the development of programs and materials for their communities that can be implemented at any level (from that of individuals through community-wide interventions). Such interventions are likely to promote mental health among aging people, ultimately leading to maintenance of independence and improved quality of life.

Acknowledgments

This research was supported by grants from the USDA:CSREE (2007-46100-03962), the Research Trust Challenge Grant awarded to the Graduate Center for Gerontology at the University of Kentucky, and a BIRCWH training grant (NIDA 5K12 DA014040).

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