An Analysis of Aging-Related Needs and Programming Across the Extension North Central Region

According to the Pew Research Center (2017), each day in the United States 10,000 people reach age 65—a trend that is expected to continue through the year 2030, when all members of the baby boomer cohort will have experienced their 65th birthdays. By then, 18% of the nation will be comprised of the 65-and-older age group, compared to 13% today (Pew Research Center, 2017). In rural areas specifically, older adults are particularly plentiful. Compared to suburban or urban areas, higher shares of the rural population are aged 65 or older, primarily due to a combination of older adults' desire to age in place and the out-migration of young adults seeking employment opportunities in urban areas (Gerrior & Crocoll, 2008; Skoufalos, Clarke, Ellis, Shepard, & Rula, 2017).

Despite waning age diversity in rural areas, diversity exists in many other ways. First, the term rural itself is broad. Federal definitions vary concerning how densely populated a geographic area can be to qualify as rural (Skoufalos et al., 2017). States vary widely regarding the racial demographics and economic and social trends of rural areas. Some regions are predominantly White, whereas others are primarily Black or Hispanic. Economically, some rural regions are dominated by the manufacturing, oil, and natural gas industries, and other communities comprise mostly farming and ranching enterprises—these latter communities have a much greater percentage of older adults due to farm consolidation efforts pushing young adults out to other regions to find work. Rural areas also vary in terms of social or health services and educational and cultural opportunities. For example, some rural places have natural tourist attractions (e.g., Jackson Hole, Wyoming) or colleges and universities that offer unique opportunities to older adults, not to mention imbue the surrounding communities with more stable and vibrant economic and social infrastructures (Semuels, 2017). Other rural communities are crippled by poverty, are depicted as food deserts and health care wastelands, and have inadequate transportation services, safe or affordable housing, or opportunities for healthy social interaction. Unfortunately, due to broader economic issues (e.g., declining government support), such deeply impoverished rural communities are on the rise (Padilla, 2017). It comes as no surprise, then, that the Centers for Disease Control and Prevention (2017) recently reported that older rural people have a strikingly higher burden of chronic disease and a greater chance of dying a preventable death compared to their urban counterparts.

Moreover, the opioid crisis, which has hit rural communities disproportionately hard, has implications for older adults in these communities (National Advisory Committee on Rural Health and Human Services, 2016). Rural older adults are dying from opioids at a higher rate than the national average of older adults. They also suffer other nonaddiction-related impacts associated with the opioid problem, including elder abuse and an increased burden of caring for their grandchildren because of an adult child's opioid addiction (Benson & Aldrich, 2017).

Given the cultural, economic, and social diversity that exists among rural older Americans, it is essential to understand the unique needs of this population. Although national level data certainly provide a useful portrait of the broader rural society in the United States, the accuracy of our understanding about the needs of older rural Americans improves through additional evaluation efforts that involve collecting data on a more granular level—efforts that are region-specific, are diverse in methodology, and include multiple informants. For example, needs assessments are commonly conducted by organizations to analyze systems and help acquaint service providers with the needs, strengths, and available resources of specific populations they serve (Beverly, Mcatee, Costello, Chernoff, & Casteel, 2005). The results can then serve as a basis for planning and developing strategic, cost-effective interventions and programs that have a greater potential for success because they are based on region-specific data. Therefore, to better understand the specific needs of rural older adults residing in the Extension North Central Region (NCR), we conducted a needs assessment of Cooperative Extension professionals to gain their perceptions about aging-related needs in their communities, existing aging-related Extension programming, and the need for future resource and curricula development.

Method

Procedure and Sample

A 14-question needs assessment was developed, pilot tested, and disseminated electronically by the North Central Region Aging Network (NCRAN). NCRAN is a cohort of gerontologists and aging-related Extension professionals, of which we are a part, with the collective purpose of enhancing the capacity of the Extension system regarding various aging-related topics across the NCR. The objective of the sampling approach was to ensure adequate coverage of the available population of NCR Extension professionals. Using the available communication methods at their institutions, NCRAN members recruited respondents via state-specific Extension electronic mailing lists and newsletters and in person at Extension professional trainings. Due to the ever-changing number of Extension professionals across the NCR, a response rate was not calculated. Participants who completed the assessment were entered to win a gift card; three gift cards were distributed per state.

Approximately 1,776 Cooperative Extension professionals started the survey. The final sample consisted of 1,028 who completed the survey. The sample consisted of professionals working in family and consumer sciences (36%), agriculture and natural resources (28%), 4-H (20%), and Extension administration (8%) and others who did not identify with a specific professional designation (8%). The sample represented all states within the NCR: Michigan (16%), Indiana (15%), Kansas (12%), Wisconsin (10%), Illinois (8%), Iowa (8%), Minnesota (7%), Missouri (7%), Ohio (6%), North Dakota (5%), South Dakota (5%), and Nebraska (1%). Participants had worked for Extension an average of 14 years and served a variety of geographic areas: 39% served a single county, 35% served multiple counties, 24% served the state, and 2% served multiple states. Of those participants who identified as both being a family and consumer sciences professional and having programming duties, 36% indicated that they had delivered programs addressing aging-related topics in their communities. Of those family and consumer sciences professionals who reported having programming duties but not conducting programming on aging-related topics, the top three reasons for not doing so were that the subject matter was outside their program area (49%), they had a lack of expertise in the subject matter (12%), and they had a lack of training in the subject matter (8.2%).

Needs Assessment

We designed a needs assessment to explore existing needs and perceived future needs related to aging to gain a more thorough understanding of existing aging-related Extension programming and Extension educators' perceptions regarding aging-related curricular needs. Participants first identified the top three existing aging-related needs in their communities. After identifying these needs, participants indicated whether they had a program or educational material to support each specific need; if participants responded affirmatively, they were asked to provide the name of the program or educational content that most directly aligned with the identified need. These questions were repeated with regard to the top three future needs related to aging.

Ranking was the selected strategy for determining the top aging issues perceived by Extension professionals. In the survey development process, NCRAN members identified nine categories into which many aging-related programs and initiatives could be classified. These categories, determined by collapsing common programming initiatives, perceived community needs, and current trending topics in the empirical literature, included ageism; aging-friendly communities; aging-friendly homes, ranches, and farms; brain health; end of life planning; family-related topics; finances; formal (paid professional) caregiving; healthy aging; and informal (friends/family) caregiving. On the survey instrument, each category included a brief description of potential relevant topics (e.g., brain health—dementia risk reduction, Alzheimer's disease, steps to better brain health). Participants were asked to rank-order the identified categories according to importance of aging-related concerns in the communities they served. Following survey design recommendations, the rank list was limited to fewer than 10 items (Vannette, 2015).

Next, those participants who reported having delivered aging-related programming in the preceding 12 months were asked to list up to 10 programs they had presented. Participants were then asked to choose the three most valuable programs they had delivered from the programs listed. The term valuable was not defined and was left to be interpreted by the participant. Participants were then asked to identify the programs, if any, which they were no longer delivering but still believed would benefit their communities or address current aging-related needs.

In the next set of survey items, participants identified three topic areas for which Extension programming materials were needed and determined the preferred mode of information delivery for those topics (in-person program, fact sheet publication, or online resource/tool). The survey concluded with three demographic questions addressing location, geographic service coverage, and length of time employed with Extension. The complete needs assessment survey can be reviewed by contacting the lead author.

Analytic Approach

We calculated descriptive statistics for the seven closed-ended questions. Three trained coders, consisting of two undergraduate students and one graduate student, coded respondents' open-ended responses inductively. The first coding attempt was for the purpose of developing a list of themes stemming from respondents' answers to the open-ended questions. After developing and solidifying the initial list of themes, the coders went back a second time to review and code participant responses. Coders then met to review their codes, and any discrepancies about a specific response were discussed until a consensus emerged. The resulting codes and themes were reviewed and approved by NCRAN members.

Results

Current and Future Community Needs

Participants identified a plethora of diverse aging-related needs their communities were facing. The top three identified existing needs were access, availability, and affordability of health care; chronic disease prevention and management; and transportation. Respondents reported not having resources to address the needs of health care (49.5%) and transportation (53.2%), but many (46.3%) reported having resources and curricula to address chronic disease prevention and management. See Table 1 for complete results.

Table 1.
Existing Aging-Related Community Needs (N = 1,028)

		Resources to address need
Identified need	%	Yes (%)	No (%)	Unsure (%)
Access, availability, and affordability of health care	9.3	21.0	49.5	29.5
Chronic disease prevention and management	8.4	46.3	33.6	20.1
Transportation	7.9	18.6	53.2	28.2
Informal caregiving and caregiver support	6.2	30.2	45.9	23.9
Access to affordable and safe housing	5.4	16.1	53.9	30.0
Nutrition and food safety	5.1	43.3	36.1	20.6
Social connectedness	4.5	24.7	44.3	31.0
Retirement planning and funds management	3.8	33.1	33.4	33.5
Food access, security, and affordability	3.6	29.8	44.1	26.1
Medicare education and assistance	3.3	33.9	36.6	29.4
Aging in place	3.2	27.1	42.5	30.4
Farm succession	3.0	41.1	36.7	22.2

When asked about aging-related needs communities will face in the future, participants continued to identify health care and transportation as top needs, but access to affordable and safe housing was viewed by more respondents as a top future need than was chronic disease prevention and management. Consistent with the question about existing needs, majorities of respondents reported not having resources to address the future needs of health care (55.4%) and transportation (65.3%), and 59.1% reported not having resources to address the future need of affordable and safe housing. Additional areas that were identified as future needs but were not mentioned as existing needs were financial security, economic and workforce vitality, community programs and services, long-term-care housing availability, and improved technological aptitude. Complete results are presented in Table 2.

Table 2.
Future Aging-Related Community Needs (N = 1,028)

		Resources to address needs
Identified need	%	Yes (%)	No (%)	Unsure (%)
Access, availability, and affordability of health care	11.7	9.6	55.4	35.0
Access to affordable and safe housing	8.0	8.5	59.1	32.4
Transportation	7.3	7.9	65.3	26.8
Chronic disease prevention and management	5.6	27.5	43.0	29.5
Financial security	5.3	11.6	51.9	36.5
Informal caregiving and caregiver support	5.2	15.1	52.3	32.6
Social connectedness	4.1	10.3	55.8	33.9
Economic and workforce vitality	4.1	8.5	47.3	44.2
Need for community programs and services	3.9	11.9	48.0	40.1
Long-term care housing availability	3.9	12.0	50.5	37.5
Retirement planning and funds management	3.6	22.7	43.7	33.6
Improved technological aptitude	3.2	6.8	60.7	32.5

After the opportunity to qualitatively identify existing and future needs, respondents were asked to rank-order the importance of 10 topics vital to optimal aging. The rankings, from most to least important, were as follows:

1. finances;
2. healthy aging;
3. aging-friendly communities;
4. brain health;
5. aging-friendly homes, ranches, and farms;
6. family-related topics;
7. informal (family/friends) caregiving;
8. end of life planning;
9. formal (paid professional) caregiving; and
10. ageism.

Existing Aging-Related Programming

Respondents who identified as family and consumer sciences professionals were asked to provide information about their aging-related programming activities over the preceding 12 months. For those family and consumer sciences professionals who had presented aging-related material over the preceding 12 months (n = 217), the most prevalent programs presented focused on the following topic areas, ranked in order from most often to least often presented (names of common curricula are identified in parentheses):

1. nutrition (e.g., Nourishing the Boomer, Cooking for 1 or 2);
2. financial considerations for retirement (e.g., Writing Your Retirement Paycheck);
3. fall prevention (e.g., Matter of Balance);
4. brain health (e.g., Alzheimer's 101);
5. physical activity or exercise program (e.g., Stay Strong, Stay Healthy/Strong Women);
6. farm succession (e.g., Design Your Succession Plan);
7. diabetes prevention and management (e.g., Dining with Diabetes);
8. caregiving (e.g., Powerful Tools for Caregivers);
9. health and wellness across the life span (e.g., Keys to Embracing Aging); and
10. health insurance programming and/or counseling (e.g., Medicare Basics, Senior Health Insurance Counseling).

After identifying provided programs, respondents were asked to identify the aging-related topics they addressed and considered most valuable. Of topics listed, respondents indicated the topics shown in Table 3 to be most valuable.

Table 3.
Most Valuable Extension-Addressed Topics (n = 294)

Topic	%
Nutrition	17.5
Physical activity/exercise program	7.4
Fall prevention	7.0
Brain health	6.4
Succession planning	6.0
Caregiving	5.4
Financial considerations for retirement	4.0

Needed Curricula and Materials

Finally, respondents who identified as family and consumer sciences professionals provided information about aging-related topic areas for which development of Extension curricula was needed and the preferred methods of information delivery for such topics (i.e., in-person programming, fact sheet publication, online resource/tool). The top aging-related topic areas for which respondents indicated needing curricula and the preferred delivery methods they identified for those topics are presented in Table 4.

Table 4.
Topics for Which Curricula Are Needed and Associated Preferred Delivery Methods (N = 1,028)

		Preferred delivery methoda
Topic	%	In person	Fact sheet	Online
Nutrition and food safety	13.0	1	2	3
Chronic disease prevention and management	9.0	1	2	3
Informal caregiving and caregiver support	8.0	2	3	1
Brain health	6.0	1	2	3
Financial considerations for retirement	4.0	1	2	3
aPreferred delivery method is listed from 1 (most preferred) to 3 (least preferred).

Discussion

We evaluated the existing offered programs and programming needs of Cooperative Extension educators across the NCR. Overall, the results indicate that Extension professionals, even those who use aging-related programs and materials, perceive a continued need for aging-related resources and programs. Extending awareness and reach of existing programs that target high-priority aging areas—including extending programs across state lines—can improve educators' ability to build aging-related capacity in their communities. In addition, the findings suggest a need for new program development to meet aging-related programming needs.

The top existing aging-related needs included health care, chronic disease prevention and management, transportation, and housing. The top future aging-related needs were vastly similar and included access to affordable and safe housing, rather than chronic disease prevention and management, among the top three needs. However, the majority of respondents also indicated that no resources were available to address those needs or that they were unsure of existing resources.

Among those topics presented by respondents, the majority of the most prevalent programs focused on various aspects of healthy aging and brain health. None of the top 10 programming topics focused on aging-friendly communities or homes despite those topics being listed as the third and fifth most vital to optimal aging, respectively. This circumstance indicates a need for more curricula or materials that address these critical topics and/or better awareness of and access to existing curricula. For example, the University of Wisconsin–Madison recently developed a facilitation guide called Creating Aging-Friendly Communities to help Extension educators inform and engage community leaders about the changing demographics of communities and to invigorate discussion and the necessary planning to address how changing needs may inform community leadership groups. Similarly, although survey respondents overall listed finances as the topic most vital to optimal aging, only one element of finances (financial considerations for retirement) was featured among the programs most often presented. This may indicate a need for additional or more thorough programming and materials addressing the many nuanced financial issues that affect older adults. Improving outreach, training, and professional development opportunities across state lines may increase educator knowledge about programming opportunities and enhance the reach of such programs. Perceived gaps in program availability also may indicate a need for new program development and evaluation. A comprehensive assessment of existing curricula and materials across states, paired with interstate agreements and training opportunities, will be needed to facilitate the broader use of effective, well-packaged programs and the identification of areas for which research- and evidenced-based programs are still needed.

Respondents explicitly indicated that curricula and other materials were needed on many topics. Interestingly, although nutrition was identified as the most prevalently presented aging-related program topic, respondents also indicated that additional materials were needed in this area. It is possible that this perception reflects the interests or expertise of respondents in addition to an actual community need. Chronic disease prevention and management also was indicated as a high-need curricula topic despite the prevalence of evidence-based programs in this area (e.g., diabetes self-management) (Lorig et al., 2010). This discrepancy further supports the need for professional development and training opportunities to highlight existing curricula and materials that can help educators meet the needs of their communities.

Regarding participants' reflections on the need for curricula addressing particular topics and preferred delivery methods, it is interesting to note that although in most cases in-person curricula were preferred—followed by fact sheets and online delivery methods—for informal caregiving, online delivery was the preferred delivery method. This circumstance likely is reflective of awareness among educators of the challenges and benefits of online education. For example, online programming can help overcome barriers of time and distance, especially in rural geographical areas (Dromgoole & Boleman, 2006). For informal caregivers, online programming may significantly increase their ability to overcome competing demands of time and emotional commitments to attend an educational event. However, use of online education also involves challenges such as lack of access to broadband and computer literacy issues. Although 59% of older adults use the Internet (Pew Research Center, 2014), this demographic group may also be the most likely to experience barriers to the technology needed for online learning.

In sum, our study indicated a need for both new programming and greater awareness of existing programming that meets high-priority aging-related needs in communities across the NCR. Although the study reflects Extension professionals' assessment of their communities' needs, it is unclear how these assessments align with the perceptions of community members, policy makers, or community organizations. The study highlights opportunities to better match existing programs from across states with community-level needs. In addition, new programming that targets unmet curricula or materials needs will be necessary to address current and emerging aging-related needs in communities across the country.

Author Note

M. Hunter Stanfield is now an assistant professor at Lipscomb University in Nashville, Tennessee.

Acknowledgments

We would like to express sincere gratitude to all members of the NCRAN for their collaboration and partnership in the work described herein: James Bates, Barbara Beaulieu, Leacey Brown, Cheryl Eschbach, Jeongeun Lee, Jane Strommen, and Marlene Stum. Additionally, we express many thanks to the over 1,000 Extension professionals across the NCR who responded to the survey request. Without their participation, our work would not have been possible.

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