A mixed methods exploratory study of ageing

‘Níl aon tinteán mar do thinteán féin’ / ‘There’s no place like home’

A mixed methods exploratory study of ageing in place

Candidate Margaret Mc Grath MSc.,(Rehab.);BSc.,(Hons)Cur.Occ.;PgDip., (Academic Practice) Discipline of Occupational Therapy, School of Health Sciences, College of Medicine, Nursing and Health Sciences, National University of Ireland, Galway.

Supervisors Professor Agnes Shiel, School of Health Sciences, Discipline of Occupational Therapy, National University of Ireland, Galway, Ireland. Dr. Karin Johansson, Department of Neurobiology, Care Sciences and Society, Division of Occupational Therapy, Karolinska Institutet, Stockholm, Sweden.

October 2013

Acknowledgments I wish to express my sincere gratitude to everyone who has helped me and been supportive and understanding throughout the long process of writing this thesis. I particularly wish to acknowledge the following people:

The participants in the study who so generously shared their experiences, thoughts and feelings about ageing in place with me. I am eternally grateful for your generosity and only hope that I have done your experiences justice.

My supervisors Professor Agnes Shiel and Dr. Karin Johansson for welcoming me as your doctoral student and for enabling me to take part of your excellent inspiring constructive and educative guidance.

My colleagues at the National University of Ireland, Galway for your support and encouragement throughout this process.

The staff at the Division of Occupational Therapy, Karolinska Institutet, Stockholm, Sweden for welcoming me as a visitor and for including me in so many thought provoking discussions. In particular thanks to Professor Staffan Josephsson for welcoming me to the ageing in place research group.

My colleagues and friends in occupational therapy who have shared so many fun and challenging discussions. Thank you to Dikaios Sakellariou, Inés Viana-Moldes, Sarah Kantartzis, Saskia Hofstede-Wessels, Melissa Park, Soemitro Poerbodipoero, Aideen Gallagher, and Hetty Fransen. To my dear colleague, friend and mentor, Hanneke van Bruggen thank you for all of the opportunities you have given me and for encouraging me to do more than I thought was possible.

My family and friends in Ireland and around the world for sharing and caring through the ups and downs of this process. My parents Seámus and Rose for encouraging me to undertake this journey and for your unfailing love and support. To Tom, thank you for your patience and understanding – it’s finally done done! My sisters, my brother and my friends who kept me grounded throughout the many months of reading and writing and reminded me of another world outside of my PhD. To each of you my heartfelt thanks.

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Abstract Background Ageing in place refers to the practice of older adults continuing to live in their own homes. Existing research has highlighted both the importance and complexity of ageing in place for older people, however limited attention has been paid to the associated processes. This study explored these processes among a sample of older people living in Ireland. Methodology This study used a two-phase mixed methods exploratory design. In phase one a cross sectional survey design was used to explore older adults’ (N=159) beliefs regarding control over their home environment. Sequential multiple regression analysis was used to identify how housing related control beliefs could be predicted by selected demographic, housing and health related characteristics. Phase two of the research used a case study design. Nine cases were purposively selected from participants who were involved in phase one of the study. Data in the form of in-depth interviews, diary entries and photo elicitation text were collected over a period of 12 months. These data were analysed using the principles of constructive grounded theory. The findings of phase one and phase two were integrated using a three-step inference process. Results Housing related control beliefs do not appear to influence the nature of practices of ageing in place. A substantive theory of practices of ageing in place was developed suggesting that ageing in place is an (in)visible process made up of maintaining (an independent) self and (re) constructing space to (re) create home. Conclusions Practices of ageing in place are embedded in everyday life and are often rendered invisible. Research and intervention to support ageing in place must recognise the on-going character of older people’s lives and should attempt to build upon existing practices.

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Table of Contents Chapter 1 ...................................................................................................................... 1 1.1 Introduction ................................................................................................................... 1 1.2 Theoretical approaches to understanding person-environment relations in later life ......................................................................................................................................... 3 1.2.1 Ecological Theory of Ageing ................................................................................... 3 1.2.2 Housing Related Control Beliefs ............................................................................. 4 1.2.3 Theories of Place Attachment and Place Integration ............................................... 5 1.3 Practices of Ageing in Place ......................................................................................... 9 1.4 Occupational Therapy Interventions to support Ageing in Place .......................... 10 1.5 Conclusion.................................................................................................................... 12 1.6 Research Aims ............................................................................................................. 13 1.7 Research Context ........................................................................................................ 15 1.7.1 Healthcare services in Ireland ................................................................................ 16 1.8 Research Rationale ..................................................................................................... 18 1.9 Implementation ........................................................................................................... 24 1.10 Glossary...................................................................................................................... 25 1.11 Thesis Outline ............................................................................................................ 29

Chapter 2 .................................................................................................................... 31 2.1 Introduction ................................................................................................................. 31 2.2 Home ............................................................................................................................ 31 2.3 Ageing in Place ............................................................................................................ 33 2.4 Understandings of person-environment relations in later life ................................ 36

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2.4.1 The Ecological Theory of Ageing ......................................................................... 36 2.4.2 Housing Related Control Beliefs – An extension of the Environmental Proactivity Hypothesis ...................................................................................................................... 42 2.4.3 Housing Related Control Beliefs and Ageing in Place .......................................... 50 2.4.3 Theories of Place Attachment ................................................................................ 53 2.4.4 Place Integration .................................................................................................... 57 2.5 Practices of Ageing in Place ....................................................................................... 57 2.6 Occupational Therapy Interventions to support Ageing in Place .......................... 61 2.6.1 Non Usage of Environmental Modification........................................................... 62 2.7 Gaps in existing knowledge of ageing in place .......................................................... 64 2.8 Conclusion.................................................................................................................... 65

Chapter 3 .................................................................................................................... 67 3.1 Introduction ................................................................................................................. 67 3.2 American Pragmatism ................................................................................................ 67 3.3 Deweyan Pragmatism and Occupational Therapy .................................................. 69 3.4 Deweyan Pragmatism and Mixed Methods Research ............................................. 70 3.4.1 Holism.................................................................................................................... 72 3.4.2 Provisionality ......................................................................................................... 73 3.4.3 Situated Inquiry ..................................................................................................... 73 3.4.4 Value Laden Inquiry .............................................................................................. 74 3.5 Implications of adopting a Pragmatic stance for this research study. ................... 75 3.6 Conclusion.................................................................................................................... 76

Chapter 4 .................................................................................................................... 77 4.1 Introduction ................................................................................................................. 77 4.2 Research Design .......................................................................................................... 78 4.3 Procedure for Data Collection, Analysis, Interpretation and Mixing .................... 80 4.4 Phase 1 Cross Sectional Survey Design ..................................................................... 83

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4.4.1 Sampling ................................................................................................................ 85 4.4.2 Recruitment............................................................................................................ 86 4.4.3 Measurement Device ............................................................................................. 87 4.4.4 Pilot Study ............................................................................................................. 91 4.4.5 Data Collection Procedures ..................................................................................... 94 4.4.6 Data Analysis ......................................................................................................... 94 4.5 Point of Interface 1 – Connecting between the quantitative phase and the QUALITATIVE phase ..................................................................................................... 96 4.6 Phase 2 Processes of Ageing in Place ......................................................................... 97 4.6.1 Research Methodology .......................................................................................... 99 4.6.2 Data Collection Methods ..................................................................................... 110 4.6.3 Data Collection Procedures ................................................................................. 121 4.6.4 Data Management ................................................................................................ 123 4.6.5 Data Analysis ....................................................................................................... 124 4.6.6 Trustworthiness of Data ....................................................................................... 130 4.7 Point of Interface 2 - Integration of Findings (Mixed Methods Interpretation) . 131 4.8 Ethical Considerations .............................................................................................. 133 4.8.1 Informed Consent ................................................................................................ 134 4.8.2 Confidentiality and Anonymity ........................................................................... 135 4.8.3 Respondents’ Wellbeing ...................................................................................... 141 4.8.4 Responding to Unmet Health and Social Care Needs ......................................... 144 4.8.5 Planning an Exit Strategy .................................................................................... 146 4.9 Conclusion.................................................................................................................. 147

Chapter 5 .................................................................................................................. 148 5.1 Introduction ............................................................................................................... 148 5.2 Response Rate ............................................................................................................ 148 5.3 Participants’ Demographic Characteristics............................................................ 148

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5.4 Participants’ Housing Related Characteristics ...................................................... 150 5.5 Participants’ use of home modifications and assistive technology........................ 152 5.6 Perceived Suitability of the Home Environment .................................................... 152 5.7 Housing Related Control Beliefs .............................................................................. 153 5.8 Predictive Models of Housing Related Control Beliefs .......................................... 155 5.8.1 Internal Housing Related Control Beliefs ............................................................ 156 5.8.2 External – Chance Housing Related Control Beliefs ........................................... 159 5.8.3 External – Powerful Others Housing Related Control Beliefs ............................ 161 5.9 Initial Discussion of Results...................................................................................... 164 5.9.1 What is the nature of the housing related control beliefs reported among a sample of older people living in Ireland?.................................................................................. 164 5.9.2 How can housing related control beliefs in a sample of older people living in Ireland be predicted by demographic, housing and health related characteristics? ...... 164 5.10 Limitations ............................................................................................................... 169 5.11 Point of Interface 1 – Connecting between the quantitative phase and the QUALITATIVE phase ................................................................................................... 171 5.12 Conclusions .............................................................................................................. 171

Chapter 6 .................................................................................................................. 172 6.1 Introduction ............................................................................................................... 172 6.2 Case Study 1:Josephine .......................................................................................... 175 6.3 Case Study 2: Raymond.......................................................................................... 178 6.4 Case Study 3 Patricia .............................................................................................. 182 6.5 Case Study 4: Seán ................................................................................................. 187 6.6 Case Study 5: Tom.................................................................................................. 190 6.7 Case Study 6:Nora .................................................................................................. 193 6.8 Case Study 7: Seámus ............................................................................................. 198 6.9 Case Study 8: Fiona ................................................................................................ 201

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6.10 Case Study 9: Desmond ........................................................................................ 205 6.11 Conclusion................................................................................................................ 208

Chapter 7 .................................................................................................................. 209 7.1 Introduction ............................................................................................................... 209 7.2 Everyday (in)Visible Practices ................................................................................ 209 7.3 Maintaining (an Independent) Self .......................................................................... 211 7.4 (re) Constructing Space to (re) Create Home ......................................................... 212 7.5 Influencing Factors ................................................................................................... 212

Chapter 8 .................................................................................................................. 216 8.1 Introduction ............................................................................................................... 216 8.2 Maintaining (An Independent) Self ......................................................................... 217 8.2.1 Not being like an old person ................................................................................ 218 8.2.2 Anticipating future possibilities and uncertainties ............................................... 228 8.2.3 Adapting occupation ............................................................................................ 234 8.3 (re) Constructing Space to (re) Create Home ......................................................... 252 8.3.1 Home Maintenance .............................................................................................. 253 8.3.2 Changing how space is used ............................................................................... 261 8.4 Influencing Factors ................................................................................................... 270 8.4.1 Economic Resources ............................................................................................ 270 8.4.2 Access to Informal Social Supports ..................................................................... 275 8.5 Tipping points............................................................................................................ 279 8.6 Conclusion.................................................................................................................. 281

Chapter 9 .................................................................................................................. 283 9.1 Introduction ............................................................................................................... 283 9.2 Theory of Practices of Ageing in Place .................................................................... 284 9.3 Critical Examination of the Theory......................................................................... 285

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9.4 Contribution of the Theory of Practices of Ageing in Place .................................. 288 9.5 Future Theoretical Developments ........................................................................... 290 9.6 Limitations of Phase Two of the Study ................................................................... 291 9.7 Conclusion.................................................................................................................. 293

Chapter 10 ................................................................................................................ 294 10.1 Introduction ............................................................................................................. 294 10.2 Research Aim 1- To Generate knowledge and understanding of the actions taken by older people living in Ireland to age in place. .......................................................... 294 10.3 Research Aim 2 - To develop understanding of how the process(es) involved in ageing in place are developed and maintained over an extended period of time ...... 302 10.4 Research Aim 3 - To bring together existing theoretical perspectives from environmental gerontology, occupational therapy, geography and psychology to generate a more complete understanding of the person-environment relationship in later life. ........................................................................................................................... 303 10.6 Conclusions ............................................................................................................. 305

Chapter 11 ................................................................................................................ 307 11.1 Introduction ............................................................................................................. 307 11.2 Key Findings ............................................................................................................ 307 11.3 Implications for future theoretical and empirical research ................................ 308 11.4 Implications for policy ............................................................................................ 310 11.5 Implications for occupational therapy .................................................................. 312 11.6 Contribution to Knowledge Development............................................................. 314 11.7 Study limitations ..................................................................................................... 315 11.8 Conclusion................................................................................................................ 316 References ........................................................................................................................ 318 Appendices ....................................................................................................................... 354 Appendix A: Search Strategy Used for the Initial Literature Review ....................... 354

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Appendix B: Participant Information – Phase 1 .......................................................... 355 Appendix C: Participant Consent Forms – Phase 1..................................................... 359 Appendix E: 17-item Demographic, Health and Housing Questionnaire .................. 362 Appendix F: Raw Data Code Book (Phase 1) ............................................................... 365 Appendix G: Phase 2 – Sampling Matrix ..................................................................... 368 Appendix H: Phase 2 – Data Collection Plan ............................................................... 369 Appendix I: Phase 2- Matrix of Information Sources for each Case ......................... 370 Appendix J: Phase 2 – Initial Interview Questions ...................................................... 371 Appendix K: Written Instructions for Camera Use .................................................... 372 Appendix L: Examples of Photo Elicitation Text......................................................... 373 Appendix M: Standardised Diary Format .................................................................... 375 Appendix N: Participant Information – Phase 2 .......................................................... 382 Appendix O: Participant Consent Form – Phase 2 ...................................................... 390 Appendix P: Examples of line by line coding ............................................................... 394 Appendix Q: Examples of Focused Coding .................................................................. 397 Appendix R: Examples of memos .................................................................................. 398 Appendix S: Examples of early and advanced diagrams ............................................ 400 Appendix T: Ethical Approval for the Research Study............................................... 402 Appendix U: Protocol for Managing Potential Participant Distress .......................... 403 Adapted from (Draucker et al., 2009) ........................................................................... 403 Appendix V: Protocol regarding unmet health and social care needs ....................... 404

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List of Tables Table Table Title 4.1

Outcomes of the Pilot Study (Phase 1)

94

5.1

Participants’ Demographic Characteristics (N=159)

151

5.2

Participants’ Housing Related Characteristics

153

5.3

Participants’ Home Modifications and Use of Assistive Technology (N=159)

154

5.4

Participants’ Perceptions of the Suitability of their Home Environment(N=159)

155

5.5

Overall Housing Related Control Beliefs

155

5.6

Participants’ Housing Related Control Beliefs

156

5.7

Results of Linear Regression Analyses of Internal Housing Related Control Beliefs

160

5.8

Results of Linear Regression Analyses of External (Chance) Housing Related Control Beliefs

162

5.9

Results of Linear Regression Analyses of External (Powerful Others) Housing Related Control Beliefs

165

6.1

Overview of Main Case Study Elements (N=9)

176

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List of Figures

Figure Figure Title 2.1 Ecological Theory of Ageing

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4.1

Overall Research Procedures

82

7.1

Overview of the Theory of Practices of Ageing in Place

216

8.1

Maintaining (an Independent) Self

218

8.2

(re) Constructing Space to (re) Create Home

254

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Declaration

I hereby declare this work is entirely my own and that I have acknowledged the writings, ideas and work of others. Furthermore I have not knowingly allowed another to copy my work. I followed the guidelines as outlined in the Discipline of Occupational Therapy policies and procedures handbook.

Student Identification Number: 07101930 Name: Margaret Mc Grath Signature:

Date:

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Chapter 1 – Introduction

Chapter 1 1.1 Introduction Global population ageing has drawn renewed attention to the relationship between older people and their physical and social environments (Schwarz, 2012; Vasunilashom et al., 2012; Wiles et al., 2009; Schiedt and Windley, 2006). Since 1994 health and social policies in the majority of the Organisation for Economic Cooperation and Development (OECD) countries have emphasised the need for older people to be supported to continue to live in their own homes (OECD, 1994). This policy objective of community living for older people has been labelled ‘ageing in place’ (Cutchin, 2003; Pastalan, 1990) and today is considered a key outcome of successful ageing throughout the world (Fänge, Oswald & Clemson, 2012; Schwarz, 2012; Wiles et al., 2012). The increased emphasis on ageing in place in later life has significant implications for the relationship older people have with their home environments (Fänge, Oswald & Clemson, 2012; Vasunilashom et al., 2012; Wiles et al., 2012). As Wiles et al. (2009) note, negotiation of ageing in place is a complex process. Home is more than a physical structure and the process of being at home or ageing in place is a ‘diffuse and complex condition that integrates memories and images, desires and fears, the past, the present and the future’ (Pallasmaa,1994, p. 114). 1

Chapter 1 – Introduction Golant (2011), suggests that the overall aim of older peoples’ approach to homemaking is to construct what he describes as a ‘residential normalcy’, that is ‘places where older people experience overall pleasurable, hassle free and memorable feelings that have relevance to them; and where they feel both competent and in control – that is they do not have to behave in personally objectionable ways or to unduly surrender mastery of their lives or environments’ (p.193). In this sense, home as a place in later life is a constant process involving on-going negotiation of meanings (Wiles, 2005), incorporating not just the physical aspect of the home but also operating on social and symbolic levels in interconnected ways (Wiles et al., 2012; Pallasmaa, 1994). While the dynamic nature of person-environment relations in later life has been recognised (Cutchin, 2003; Golant, 2011; Johansson et al., 2009) limited attention has been paid to the specific processes involved in ageing in place. Older people are ingenious in finding ways to handle the strains and losses that advanced old age can bring about (Torres and Hammarström, 2006). However, little is known about the ways in which people negotiate their environment in later life (Haak et al., 2011; Thoémse and Broese van Groenou, 2006; Wahl and Oswald, 2010). Such information is needed because home is a highly personalised and culturally informed place (Tanner et al., 2008) and interventions to enhance ageing in place may be more effective, if they are tailored to the preferences and goals of older persons (Stark et al., 2009).

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Chapter 1 – Introduction

1.2 Theoretical approaches to understanding personenvironment relations in later life A number of theoretical understandings of person-environment relations have been proposed including the ecological theory of ageing, (Lawton and Nahemow, 1973); housing related control beliefs (Oswald et al., 2003) and theories of place attachment (Golant 2011;Rowles 1978; 1983a; 1983c; Rubenstein 1992) and place integration (Cutchin, 2003).The contributions of each of these approaches towards understanding the actions of older people in relation to ageing in place are briefly summarised in the next sections. 1.2.1 Ecological Theory of Ageing The ecological theory of ageing, also referred to as a press-competence model seeks to explain the actions of older people in relation to their home environment using the concepts of environmental docility and environmental proactivity (Lawton and Nahemow, 1973; Lawton, 1989). The central tenet of the theory is that for each person, there are optimal combinations of available personal competence and environmental circumstances, leading to the highest possible behavioural and emotional functioning for that person (Gitlin, 2003; Kahana, 1982; Lawton, 1982, Lawton 1989; Lawton, 1998; Parmelee & Lawton, 1990). Personal competence refers to those personal characteristics including physical and psychological functioning and values that influence personal capacity to respond to environmental press. Environmental press refers to demands posed by the characteristics of the environment. 3

Chapter 1 – Introduction In the original theory, the behaviours and emotional responses of older people towards their environment were considered as a function of the level of personal competence and environmental press (Lawton and Nahemow, 1973). The actions of the older people are therefore reduced to docile reactions towards the environment – the environmental docility hypothesis (Lawton and Nahemow, 1973). Later work on the theory by Lawton (1989), introduced the concept of person-environment proactivity, which suggests that highly competent older people are able to purposefully shape their physical environment according to their own desires and needs, to maintain independence. In this way, these highly competent older people can cope with environmental press and benefit from environmental opportunities (Lawton, 1989). Although the model was adapted to recognise the potential for older people to act upon their environments, Lawton did not consider how this proactivity might be operationalised and so this aspect of the theory remained underdeveloped (Oswald et al., 2003). 1.2.2 Housing Related Control Beliefs The construct of housing related control beliefs [HCB] (Oswald et al., 2003) emerges from environmental proactivity/docility hypothesis (Lawton, 1989) and psychological theories of perceived control (Lachman, 1986). HCB attempts to explain whether everyday activity is perceived to be dependent upon one’s own behaviour in relation to the home environment (internal control), or whether housing is considered to be dependent upon external influences, such as powerful others, luck or chance (external control) (Oswald et al., 2003). 4

Chapter 1 – Introduction HCB provides an explicit mechanism to explore how ageing individuals interpret and respond to environmental press (Oswald et al., 2003; Wahl and Oswald, 2010). In this way it can be seen as a measure that examines environmental docility and environmental proactivity. Early research has found poor to moderate correlations between independence in activities of daily living and high internal and low external housing related control beliefs (Oswald et al., 2003; Oswald et al., 2007). However, the specific behavioural processes through which housing related control beliefs are enacted were not considered in this research. 1.2.3 Theories of Place Attachment and Place Integration The Ecological Theory of Ageing (Lawton and Nahemow, 1973; Lawton 1989) and the concept of Housing Related Control Beliefs (Oswald et al., 2003) place emphasis on the interaction between the person and his/her objective environment. However, other theorists have addressed the concept of person-environment relations from a more subjective perspective and have emphasised the how people relate to and practice place in their home environments. Theories of place attachment in later life (Golant, 2011; Rowles, 1978; 1983a; 1983c; Rubenstein, 1992) emphasise the subjective experience of ageing in place and offer suggestions regarding the various processes through which older adults constitute home and practice ageing in place. Place integration on the other hand offers a means of conceptualising a transactional perspective of the person-environment relationship and offers possibilities for understanding person-environment relations as a dynamic process. 5

Chapter 1 – Introduction 1.2.3.1 Place Attachment Place attachment is a term used to describe the bond between people and places or the extent to which a particular place has importance for people (Kudryavtsev, Stedman and Krasny, 2012). Arnberger and Eder (2008) propose that the concept of place attachment includes both place dependence and place identity. Place identity relates to the extent to which a specific place becomes part of personal identity or is embodied within the definition of self (Cuba and Hummon, 1993; Hauge 2007; Korpela, 1989; Manzo and Perkins, 2006; Proshansky, Fabian and Kaminoff, 1983; Trentelman, 2009). Place dependence on the other hand refers to the extent to which a particular place has the potential to satisfy an individual’s needs through providing a setting for his/her performance of preferred activities (Halpenny, 2006; Stokols and Shumaker 1981). The theory of ‘insidenenss’ of place draws from the concept of place identity to suggest that older people develop an intense sense of familiarity and belonging in their home environment (Rowles, 1983a; 1983b; 1983c; 1978). Rowles (2008) suggests that through this achieving ‘insideness of place’ people are enabled to create meaning in their lives. Rowles (2008) emphasises the need to adopt a life course perspective towards the construction of place identity and proposes that the formation of place identity involves people ‘as active agents in successively making and remaking place’ (Rowles and Watkins, 2003 p. 78). Rowles has used the theory of insideness of place to explore the place making processes of Appalachian elders (Rowles 1983a; 1983b; 1983c;1978) and to examine his own life trajectory (Rowles, 2008) 6

Chapter 1 – Introduction however the extent to which to these findings can be applied to older people living in Ireland is unclear. Drawing from anthropological perspectives of space and place, Rubinstein (1989) proposed a tripartite model of psychological processes which link person to place. Rubinstein’s (1989) work appears to be closely aligned to the concept of place dependence and he emphasises how people actively seek to adjust their home environments so that three groups of needs are met (i) social-centred needs (ii) person-centred needs and (iii) body-centred needs. Like Rowles (1978), Rubenstein (1989; 1990) emphasises the need for a life course perspective towards person-environment relations. For Rubenstein (1990) viewing the relationship between the person and environment from the perspective of the individual and his or her system of personal meaning allows researchers to explore how personal identity receives ‘environmental expression’ (p.132) and how such expression works in everyday life. More recently Golant (2011) has suggested that older people’s actions relating to their home environments can be understood as an attempt to create a sense of comfort and mastery. Golant’s (2011) theory of residential normalcy addresses both place dependence and place identity and suggests that when older people experience residential discomfort or lack of environmental mastery they are triggered to act upon their environment in order to restore a sense of normalcy. Although Golant (2011) suggests that the model can be used to predict whether older people will age in place or move to alternative living arrangements in later life, to date the model has yet

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Chapter 1 – Introduction to be tested in a real world context and it is not clear if the model can be used to explain the practices of ageing in place. 1.2.3.2 Place Integration Cutchin (2003) has proposed the concept of place integration to capture the dynamics of older peoples’ on-going lives in relation to the home environment using a transactional perspective. The unit of research, rather than being separated into person and environment, is considered to be a time specific context in which experiences and actions occur, providing a unique situation that is never repeated (Johansson, 2008). Place integration draws on geographical understandings of place and the philosophy of Deweyan pragmatism (Cutchin, 2003; Cutchin, 2004). Place is presented as a dynamic ever changing socio-cultural and physical experienced setting, that cannot be separated into parts (Cutchin, 2003; Cutchin, 2004). Applying the concept of place integration to the situation of older people living at home, suggests that when changes occur in the person-place whole, there is a disintegration of the person-place entity. This disintegration stimulates creative thoughts and actions in order to reintegrate the personplace entity (Cutchin, 2003; Johansson, 2008). The process of place integration has been used to examine processes involved in assisted living facilities and day centres (Cutchin, 2003), older community residents who receive home modification services (Johansson, 2008), and the experiences of ‘oldest old’ women with specific attention to occupation and meaning (Heatwole-Shank and Cutchin, 2010). However, to date it has not been

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Chapter 1 – Introduction applied to the experiences of older people who are ageing in place in the absence of on-going interventions from formal home modification services. It is suggested that using the concept of place integration to analyse the experiences of such older people may be beneficial, as it enables researchers to describe and understand actions taken by these older people as part of everyday ageing in place (Heatwole-Shank and Cutchin, 2010).

1.3 Practices of Ageing in Place Although existing theories of ageing in place offer some suggestions regarding why some older people successfully age in place and others do not, they offer limited description or explanation of how older people age in place. This information is important because they ways in which people ‘tackle’ ageing experiences may be the key to successful outcomes (Rubinstein, 1990; Torres and Hammarström, 2006). In this thesis the term ‘practices of ageing in place’ is used to refer to the variety of ways in which older people give meaning to and shape their lives and address problematic situations in their home environments. Existing knowledge regarding practices of ageing in place is limited and for the most part focuses on older persons experiences following acquisition of a disability (Ahluwalia et al., 2010; Renaut and Ogg, 2011; Thomése and Van Groenou, 2006) or following interventions to modify the home environment by health and social care professionals (Heywood, 2005; Johansson, 2008; Petersson, Lilja & Borrell, 2012; Rosenberg and Nygård 2012; Stark, 2009; Tanner, Tilse and DeJonge, 2008). Limited research was identified which

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Chapter 1 – Introduction specifcally considered how older people experience the process of ageing in place. Vrkljan, Leuty and Law (2011) used narrative based interviews to explore the experiences of older people living in Canada while Davey (2006) interviewed older people in New Zealand. While both studies provide insight into the lived experiences of older people who are ageing in place the extent to which the findings can be transferred to an Irish context is unclear and at present there is a lack of knowledge regarding how older people in Ireland age in place. This gap in the research is significant because understanding older people’s perspectives regarding practices of ageing in place which are significant to them and their efforts to manage person-environment relations in later life has considerable potential to inform strategies and interventions aimed at promoting quality of life and wellbeing.

1.4 Occupational Therapy Interventions to support Ageing in Place Several occupational therapy models highlight the importance of personenvironment relations for occupational performance and participation (Kielhofner, 2008; Law et al., 1996; Polatajko, Townsend and Craik, 2007). Within occupational therapy the environment is generally understood to encompass both the physical and social contexts in which occupational performance and participation occurs (Duncan, 2002). Occupational therapy models such as the Canadian Model of Occupational Performance and Engagement (Polatajko, Townsend and Craik, 2007) and the Model of Human Occupation (Kielhofer, 2008) suggest that each environment has the

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Chapter 1 – Introduction potential to offer opportunities, resources, demands and constraints which will impact upon occupational performance. The impact of the environment depends on how the person’s values, interests, roles and performance capacities and environments can be adjusted in order to reduce environmental demands upon the individual and thereby enhance occupational performance (Kielhofer, 2008; Law et al. 2006; Polatajko, Townsend and Craik, 2007). Given the strong emphasis placed on person-environment relations as a predictor of occupational performance and participation (Kielhofer, 2008; Law et al. 2006; Polatajko, Townsend and Craik, 2007) it is not surprising that a large body of research focusing on the use of environmental modifications to support ageing in place has developed (Fänge and Iwarsson, 2005a). This research suggests that environmental modifications can support older people to remain at home (Gitlin, 2003), enhance functional performance (Heywood, 2005), and reduce the impact of age related functional decline (Mann et al., 1999). However, environmental modifications are not always successful (Heywood, 2005) and Cumming et al. (1999), have reported high levels of non-usage of environmental modifications among older people. The outcome of environmental modification appears to be influenced by the extent to which the older adult takes/is given an active or passive role in the process. Clemson et al. (1999) identified that including the older adult in the final decisions about the type of environmental modifications that are implemented increases use of these modifications. Stark et al. (2009) reported similar findings and described how adopting a client-centred approach to 11

Chapter 1 – Introduction environmental modification with older people resulted in increased usage of the modification and improved performance of activities of daily living. One method of achieving an increased involvement of older people in home modification processes involves designing home modification interventions that capitalise on the strategies already used by older people to age in place (Johansson, 2008). However in order to adopt such an approach, comprehensive knowledge regarding the practices of ageing in place is needed. This research study attempts to generate such knowledge by exploring practices of ageing in place among older people living in Ireland.

1.5 Conclusion Ageing in place is a key indicator of successful ageing (Cutchin 2003; Pastalan, 1990; Wiles et al., 2012), however to date a comprehensive theoretical understanding of the processes of ageing in place has not been developed (Golant, 2011; Moore VanHaitsma, Curto and Saperstein, 2003; Scheidt and Windley, 2006; Wahl and Oswald 2009). Existing theories of ageing in place offer insights into different aspects of the person-environment relationships in later life, however more recently Wahl and Oswald (2010) have suggested that researchers must consider combining theoretical approaches towards person-environment relationships in order to generate a more complete understanding of the processes involved. In addition the lack of empirical evidence regarding how older people age in place has resulted in a failure to include older people’s perspectives when developing occupational therapy interventions to support ageing in place. The need to develop this

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Chapter 1 – Introduction knowledge has been highlighted by Johansson (2008) who proposes that older people’s own efforts and strategies towards ageing in place must be recognised by health and social care professionals. This study attempts to address the theoretical gaps in understandings of person-environment relationship by bringing together the ecological theory of ageing (Lawton and Nahemow, 1973; Lawton 1989), concepts of housing related control beliefs (Oswald et al., 2003), theories of place attachment (Golant, 2011; Rowles 1978; 1983a; 1983b; 1983c; Rubenstein 1992) and the concept of place integration (Cutchin 2003) in order to develop a more nuanced understanding of the processes of ageing in place. The study also contributes to the development of applied knowledge of ageing in place by exploring the practices of ageing in place of older adults living in the community in Ireland over an extended period of time. In the next section the overall research aims and objectives of the study are described in detail.

1.6 Research Aims This research has three overarching aims. Firstly, the research seeks to develop knowledge and understanding of the actions taken by older people living in Ireland to age in place. Secondly, the research seeks to generate an understanding of how the process(es) involved in ageing in place are developed and maintained over an extended period of time. Finally, the research aims to bring together existing theoretical perspectives from environmental gerontology, occupational therapy, geography and psychology 13

Chapter 1 – Introduction to generate a more complete understanding of the person-environment relationship in later life. Each of the three research aims are underpinned by a series of research questions which guided the collection and analysis of data. Research Questions Aim 1 To develop knowledge and understanding of the actions taken by older people living in Ireland to handle environmental barriers in their home as they age in place. Research Questions relating to Aim 1 

What is the nature of the housing related control beliefs reported among a sample of older people living in Ireland?



Can housing related control beliefs in a sample of older people living in Ireland be predicted by demographic, housing and health related characteristics?



How does a purposefully selected group older people practice ageing in place?



How are the practices of ageing in place used by older people who report different patterns of housing related control beliefs, qualitatively different to each other?

Aim 2

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Chapter 1 – Introduction To generate understanding of the processes involved in ageing in place over an extended period of time. Research Questions relating to Aim 2 

How do practices of ageing in place evolve and develop over time?

Aim 3 To bring together existing theoretical perspectives from environmental gerontology, occupational therapy, geography and psychology to generate a more complete understanding of the complex person-environment relationship in later life. Research Questions relating to Aim 3



Does bringing together existing theories of person-environment relationships lead to a more nuanced understanding of ageing in place?



Can opposing perspectives of person-environment relationships be reconciled in order to generate a more comprehensive view of personenvironment relationships in later life?

1.7 Research Context This research was conducted among older people living in the West coast of Ireland. By European standards the Irish population is relatively young; the proportion of people aged 65 and older in the population is just 11.6% 15

Chapter 1 – Introduction (CSO, 2011a) in comparison with a European average of 17.5% (EuroStat, 2011). However this population is expected to grow and by 2046 the Central Statistics Office (2013) has predicted that there will be 1.4 million people aged 65 or more living in Ireland represeting over 20% of the total popuation. 1.7.1 Healthcare services in Ireland Irish healthcare services are described as having a public/private mix of healthcare in terms of funding and delivery (Quin 1999). Public healthcare services refer to those which are fianced and devlivered using public funds while private services are those which incur fees which must be paid for by the individual using the service. In Ireland public healthcare services are primarily delivered by the Health Service Executive.There are four administrative areas within the Health Service Executive with each area having responsibility for the delivery of health, community care and personal social services to the people living within its area. Community care and personal social services are primarily delivered via local health offices and local health centres while access to hospital services is via General Practitioners or alternatively via Accident and Emergency (Health Service Executive, 2013). Eligibility to publically funded healthcare services is determined by residency and means rather than by payment of taxes or social insurance (Health Service Executive 2013; Quin 1999). All persons who are accepted by the public health service as being ordinarily resident in the State are

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Chapter 1 – Introduction classified as having either full eligibility (Category1) or partial eligibility (Category 2) for healthcare services. Persons who are determined to have full eligibility are eligible for General Practitioner services, prescription drugs and medicines, public hospital services, dental, optical and aural services, community care and personal social services (Health Service Executive, 2013) while persons who have partial eligibility are eligible to public hospital services (subject to in-patient and out-patient charges) subsided prescription drugs and some community and personal and social services (Health Service Executive, 2013). McNamara, Normand and Whelan (2013) report that approximately 30% of the population are categorised as having full eligibility for healthcare services with the remaining 70% paying for healthcare services either out of pocket or via private health insurance. In addition to this approximately 50% of the population hold supplementary private health insurance (McNamara, Normand & Whelan, 2013) that provides access to private services in public hospitals, access to private hospital in-patient care and payment of public hospital fees. In general private health insurance does not tend to provide access to primary care or outpatient services. Although the guidelines on eligibility for healthcare services provide clear criteria it is important to note that within the Irish healthcare system eligibility for healthcare services does not guarantee entitlement to healthcare services. The Health Service Executive is obliged to provide access to hospital care and general practitioners but provision of other services such as community services or social services is discretionary and

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Chapter 1 – Introduction is guided by the resources available to individual Health Service Executive Areas. The lack of legislative entitlement to these services means that access is reported to be ‘discretionary, unequal and problematic’ (Houses of the Oireachtas Seanad Public Consultation Committee, 2012) and the Ombudsman suggests that most people ‘do not know where they stand in terms of their entitlement and in terms of the HSE obligations to provide services’ (O’Reilly 2011). Considering the case of healthcare services for older people in Ireland Brennan (2008) suggests that these services are ‘patchy inconsistent and inequitable’ (p.130). O’Neill and O’Keeffe (2003) suggest that while stated Government policy regarding older people is to support community based living community services for older people are underdeveloped and access to social care services such as Home Help, Meals on Wheels is lower in Ireland than in other European countries. Access to community based rehabilitation services is sporadic and waiting lists for services such as occupational therapy, physiotherapy, and social work are lengthy (Begley, 2009; Health Service Executive, 2013).

1.8 Research Rationale This research is driven by existing theoretical gaps in understanding of person-environment relationships in later life and by the need to develop occupational therapy interventions to support ageing in place which builds upon older people’s own practices of ageing in place. As such the research is of particular relevance to researchers interested in person-environment

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Chapter 1 – Introduction relations in later life; to older people; to health and social care service providers and to healthcare professionals involved in the care of older people. Person-environment relations in later life have attracted researchers from a broad range of disciplines including social geography (Rowles and Watkins, 2003), anthropology (Miller 2001; Rubenstein and De Medeiros, 2004), architecture (Després, 1991; Pallasma, 1994; Tervo, 2007),sociology (Andrews and Phillips, 2005; Erickson,Call and Brown, 2012) occupational therapy (Fänge and Iwarsson, 1999; 2003; Johansson, 2008; Johansson, Josepehsson and Lilja 2008; Stark 2004; 2009), environmental psychology (Hay 1998; Hayward 1975; Manzon 2003; 2005; Morre 2000; Sixsmith 1986) and environmental gerontology (Oswald and Wahl 2005). As a result of this disciplinary diversity, a wide range of theoretical constructs have been developed to address housing and practices of ageing in place (Oswald et al., 2006), however several authors have identified the need for an integrative approach which would facilitate better understanding of the experiences of ageing in place on a conceptual and empirical level (Andrews et al., 2007; Golant 2012; Haak et al. 2011; Oswald et al. 2006; Wahl and Weisman, 2003). Golant (2011) suggests that such an integrated approach might lead to a comprehensive and nuanced understanding of ‘the conditions under which the residential environments or places of older adults are fitting or congruent with their current needs and goals’ (p. 193). This study contributes to the development of an integrated understanding of ageing in place, through bringing together diverse theoretical perspectives of person-environment relationships. The study also extends existing empirical research relating to

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Chapter 1 – Introduction the constructs of housing related control beliefs and offers an initial exploration of practices of ageing in place in an Irish context. Older people consistently report a desire to remain at home as they age (Gitlin, 2003; Heywood, 2005; Oswald et al., 2007) and with just 7% of older people in Ireland residing in long term institutional care (Centre for Ageing Research and Development in Ireland, 2011), it is clear that home is the primary context of ageing for the majority of older people living in Ireland. Despite this, little is known about the experiences of older people who continue to live at home in Ireland (Centre for Ageing Research in Ireland, 2009). A recent review of research priorities for older people described an urgent need for research that considers how home environments can be adapted in order to support ageing in place (Centre for Ageing Research in Ireland, 2009). The issue of supporting older people to remain at home as they age was also identified as a key priority area for the Health Service Executive (Health Service Executive, 2013). In its operational plan, the Health Service Executive suggests that services should be directed towards enhancing the quality of life of older people , through supporting them to remain in their homes for as long as possible (Health Service Executive, 2013). A primary mechanism through which this aim has been achieved is the provision of financial support to older people who wish to modify their home to accommodate age related functional loss (Citizens Information Board, 2013). An evaluation of this scheme, completed by the National Disability Authority (National Disability Authority, 2006), identified a large increase in 20

Chapter 1 – Introduction government spending on home modification grants, but did not identify any mechanisms for measuring the impact of such home modifications on the ability of older people to remain at home. Given that previous research has identified relatively low adherence to home modifications by older people (Cumming et al.,1999), investigation into alternative methods of supporting older people to remain at home is warranted. Healthcare professionals and health service providers in Ireland have consistently prioritised the need for research into the care of older people (Health Research Board, 2010). Specifically within occupational therapy, it has been suggested that a key research priority is to identify mechanisms through which older people could be supported to remain at home for as long as possible (Health Research Board, 2010). Occupational therapists have also prioritised the need to develop research methods that will generate new knowledge and understanding of success factors for independent living (Health Research Board, 2010; The American Occupational Therapy Foundation and the American Occupational Therapy Association, 2011; White and Creek, 2007). Furthermore, evaluation of the impact of home environment interventions on occupational performance capacity, was also highlighted as an important focus of research (Health Research Board, 2010). From the review of current government policy, key stakeholder research priorities and the wishes and desires of older people it is clear that this research is relevant to a broad range of stakeholders. The importance of the research relates to its capacity to contribute to improved health, wellness and quality of life, and more cost effective interventions. 21

Chapter 1 – Introduction The findings from this research have the potential for immediate impact on the health, wellness and quality of life of older people in Ireland. The ability to maintain independent living is a key factor in promoting quality of life in old age (Wahl et al., 2009). The research findings will enable occupational therapists working with older people, to become aware of and understand the strategies used by older people to handle environmental barriers. This knowledge can be incorporated into existing intervention strategies (i.e. home modification services) to increase the relevance of such strategies for older people and ultimately improve health, wellness and quality of life. There is evidence from the research literature that including the perspective of older people in the home modification process improves overall outcomes (Stark et al., 2009). However, to date the lack of knowledge relating to the processes involved in ageing in place has limited the extent to which the strategies used by older people have been included in occupational therapy interventions. This research addresses this gap by developing knowledge of how older people age in place. The primary issue relating to cost effectiveness in occupational therapy interventions for home modification relates to the high levels of non-usage and abandonment of modified home environments (Cumming et al., 1999). While no studies were identified which specifically examined non-usage of home modifications in an Irish context, previous clinical experiences and discussions with clinical colleagues indicates that similar patterns of nonusage are experienced in Ireland (Personal Communication, Association of Occupational Therapists of Ireland, Older Adults Advisory Group, 10th

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Chapter 1 – Introduction September 2013). This is particularly problematic given the current economic climate and the need to ensure that healthcare resources are used effectively (Health Service Executive, 2013; Wall, 2012; Moore 2011). Previous research has indicated that non-usage of home modification may be caused by a mismatch between the interventions offered by occupational therapists and the strategies used by older people (Heywood, 2005; Johansson et al., 2009; Stark et al., 2009).Developing home modification interventions, which build on the strengths of older people, has been found to reduce the level of non-usage of these interventions (Stark et al., 2009), however there is a lack of knowledge regarding the actions used by older people to handle environmental barriers in their home (Johansson, 2008). This research will respond to the existing knowledge gap by providing occupational therapists with theoretical and empirical knowledge of the actions taken by older people living in Ireland. Supporting older people to remain at home as they grow older is an important goal for healthcare professionals, service providers and older people. For older people growing old at home is associated with positive health and quality of life outcomes, while for policy makers and service providers maintaining older people in their own homes offers significant economic and social benefits. Existing research has highlighted the relevance of understanding and incorporating the efforts of older people into healthcare interventions that target the home care environment (Johansson, 2008; Stark et al., 2009). This research builds upon this earlier work by exploring the actions of older people in an Irish context. The findings of the research will 23

Chapter 1 – Introduction be of relevance and importance to older people, healthcare professionals and healthcare service providers.

1.9 Implementation A mixed methods exploratory design was used to address the research question. Phase one of the study used a cross-sectional survey design to explore patterns of housing related control beliefs among a sample of community dwelling older people. Analysis of these data led to the development of three predictive models of housing related control beliefs in this population. This information was used to guide purposive selection of participants for phase two of the study. Phase two of the study used a case study design (Stake, 1995;Yin, 2009) incorporating the principles of constructive grounded theory (Charmaz, 2006). Cross-case analysis led to the development of a substantive theory of practices of ageing in place. A threestage inference process (Tashakkori and Teddlie, 2003) was used to guide integration of findings from phase one and phase two. From this integration overall findings relating to each of the research questions were generated. These findings were then considered in relation to extant research literature and implications for future theoretical development, policy and practice were considered.

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Chapter 1 – Introduction

1.10 Glossary Activities of daily living (ADLs) The term activities of daily living (ADLS) refers to the basic tasks of everyday life including eating, bathing, toileting, dressing and transferring (Weiner et al., 1990). Ageing in place Refers to the policy ideal of supporting older people to continue to live (with some level of independence) in the community as they age (Cutchin, 2003). Assistive technology Assistive technology refers to any item, piece of equipment or product, which may be purchased off the shelf, modified or custom built that is used to increase, maintain or improve the functional ability of people with disabilities (Individuals with Disabilities Education Improvement Act, 2004). Environmental adaptation A temporary or permanent change to the physical structure of an environment made with the intention of increasing occupational performance and participation. Environmental barrier An environmental barrier refers to any aspect of the environment which interferes with or impedes occupational performance and participation.

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Chapter 1 – Introduction Home Home refers to a person’s dwelling or house. It encompasses both the physical setting of the house, and also the emotional, social and symbolic aspects that are generated through person-environment transactions over time. Interactional perspective on person-environment relations According to Dewey and Bentley (1949/1975) adopting an interactional perspective implies that ‘thing’ is balanced against ‘thing’ in a casual interconnection. In relation to person-environment relations an interactional perspective is one which positions the person against the environment or vice –versa and assumes that changes in one aspect will impact upon the other. Occupation Occupation as used within occupational therapy and occupational science refers to ‘groups of activities and tasks of everyday life, named, organised and given value and meaning by individuals and a culture’ (Townsend and Polatajko, 2007 p.369). Occupational performance Occupational performance refers to the ‘ability to choose, organise, and satisfactorily perform meaningful occupations that are culturally defined and age appropriate for looking after oneself, enjoying life, and contributing to the social and economic fabric of a community’ (CAOT 2002 p.18).

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Chapter 1 – Introduction Older person There are several ways of approaching a definition of the term older person and there is a lack of consensus among researchers, policy makers and practitioners regarding when the label older person should be used (Walsh and Harvey, 2011). In this study guided by the definition used in national census data (Central Statistics Office, 2007) an older person was defined as someone who is aged 65 years or over. Place Place is space with meaning attached (Tuan, 1977). Wiles (2005) suggests that place is a setting which is experienced, which holds meaning and which influences relationships between people. Place attachment Place attachment refers to a ‘positive affective bond between an individual and a specific place, the main characteristic of which is the tendency of the individual to maintain closeness to such a place’ (Carmen-Hidalgo and Hernnádez, 2001 p.274). Place identity Place identity has been described as a component of self-identify (Proshansky et al., 1983) and refers to a psychological investment with a setting, which develops over time (Williams and Patterson, 1999). This psychological investment reflects the symbolic importance of the place and may lead to a

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Chapter 1 – Introduction sense of belonging which gives meaning to life (Williams and Patterson, 1999; Tuan 1980). Place making Place making is described as an imaginative practice (Park, 2008). It can be understood as the on-going processes through which people transform sociophysical spaces into socially relevant and meaningful places (Paulsen, 2009; Schneekloth & Shibley, 1995). Person-environment relations Person-environment relations refers to the dynamic relationship between the person and his/her environment. Successful Ageing Successful ageing is a multidimensional concept which includes ‘avoidance of disease and disability, the maintenance of high physical and cognitive function and sustained engagement in social and productive activities’ (Rowe and Kahn 1997, p. 433). Critical gerontologists have noted that the concept of successful ageing is characterised by dissociation of age and disease; an emphasis on the postponement of old age; a stress on individual responsibility and a focus on activity as a means through which success is obtained (Rudman, 2006) and argue that it embodies neo liberal principles of containing costs and maximising individual responsibility for managing risk of disease and disability in later life (Rozanova, 2010).

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Chapter 1 – Introduction Situation Drawing from Dewey’s pragmatism the term situation is defined as a those ‘complex, temporally conditioned events whose components are integrally related to one another’ (Boisvert, 1998 p.53). Transactional perspective on person-environment relations A transactional perspective refers to conceptualisation of the relationship between people and their environments as an integrated co-dependent one. According to Garrison, (2001) explaining a transaction involves a complex hermeneutic challenge. In order to understand the parts of the transaction it is necessary to understand the whole transaction, but in order to understand the whole transaction it is necessary to understand the parts.

1.11 Thesis Outline Chapter one provides an introduction to the research topic and an overview of the thesis organisation. The second chapter contains a brief literature review that provides an overview of current research relating to housing for older people and examines theoretical frameworks for understanding how people age in place. Chapters three and four relate to the process of completing the research. Chapter three begins with discussion of the underlying paradigm that supported the research. Chapter four discusses the methodological approach adopted in this research. This chapter provides details of the overall study design including approach to sampling, data collection procedures, data 29

Chapter 1 – Introduction analysis and integration of findings from the quantitative and qualitative aspects of the research. It also sets out the key ethical issues encountered during this research and explains how the researcher addressed these issues. The findings of the study are presented in chapters five to nine. In chapter five the findings from phase one of the study are presented. This chapter also details how these findings were used to guide the development of phase two of the research. Chapter six provides a detailed account of each of the case studies included in phase two of the research. In chapter seven the substantive theory of practices of ageing in place, developed during phase two is introduced. Chapter eight provides a detailed account of this theory including the core categories and influencing factors. In chapter nine the theory of practices of ageing in place is critically examined in relation to existing theories of person-environment relations. In chapter 10 the findings from phase one and phase two of the research are integrated to address the original research questions. Chapter 11 considers these findings in the context of existing knowledge. The implications for theory, practice, policy and research are presented together with an appraisal of this study’s limitations.

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Chapter 2 – Literature Review

Chapter 2 2.1 Introduction In the previous chapter the research topic was introduced and the rationale for the research study was provided. The aim of this chapter is to provide a context for the research question. This is achieved through a review of existing research literature and identification of gaps in current knowledge relating to practices of ageing in place. A comprehensive review of the research literature was conducted (See appendix A for details of the search strategy used to identify relevant existing research) and from this review, the following key themes emerged: (i) home (ii) ageing in place (iii) understandings of person-environment relations in later life (iv) practices of ageing in place and (v) occupational therapy interventions to support ageing in place. Key issues that emerged from each of these areas, together with gaps identified in existing knowledge will be presented in this chapter.

2.2 Home The universality of the experience of dwelling and by default the significance of home has been recognised by Western philosophers and writers (Bachelard, 1958; Jung, 1963; Heidegger, 1971;Tognoli, 1987). For Heidegger (1971), the act of dwelling is the ultimate existential experience, while Bachelard (1958), argued that home is a haven and a corner of refuge from the world. However, despite the central role occupied by home in everyday life (Tervo, 2007), the concept of home is poorly understood and 31

Chapter 2 – Literature Review difficult to define (Moore, 2000). Some of the difficulties with defining home arise from its multidimensional nature. Peil (2009) suggests that home is at ‘once concrete and abstract’ (p.183) while Smith (1994) proposes that home is ‘more than a dwelling’ (p.31). Benjamin (1995) suggests that home might be defined as that spatially localised, temporally defined, significant and autonomous physical frame and conceptual system for the ordering, transformation and interpretation of the physical and abstract aspects of domestic daily life at several simultaneous spatio-temporal scales, normally activated by the connection to a person or a community such as a nuclear family (p.158)

Benjamin’s (1995) definition of home captures both the concrete meaning of the word, and its use as an abstract signifier of a wide set of associations and meanings. However Moore (2000) suggests that this definition does not reflect the shared cultural significance of home nor does it explain how the significance of home comes about. The process through which home is created and experienced is important to understand as research suggests that feeling at home is critical to one’s overall development of self (Altman and Werner, 1985; Baillie and Goeters, 1997; Hiss, 1990; Steele, 1981;Tervo, 2007; Venolia, 1998), and is closely linked to health and wellbeing (Cuba and Hummon, 1993; Phillips, Walford and Hockey, 2012; Winterton and Warburton, 2012). Moore and Ekerhdt (2011) describe the cultivation of home as a series of ongoing actions relating to both the physical and symbolic aspects of home. This view of home-making reflects Wiles’ (2005) suggestion that home as a place is simultaneously material, social and symbolic. For Moore and Ekerhdt, 32

Chapter 2 – Literature Review (2011) place is the product of three components (i) the individual and their intentions, actions and life experiences; (ii) the physical characteristics and attributes of the setting and (iii) the programme of the place i.e. the socially constructed and shared expectations and intentions linked to the physical setting, its participants and their roles. Thus, cultivation of place can been considered in terms of actions taken by people regarding both the physical setting and the programme with the intention of developing and sustaining their own sense of identity (Moore & Ekerhdt, 2011). While Moore and Ekerhdt, (2011) provide a conceptual framework for understanding homemaking limited research has been conducted which identifies what actions support the home-making process or how these actions might change over time. This information is needed because as Wahl and Weisman (2003) note, description and explanation of person-environment relationships is the first step towards generating modifications to optimise these relationships in later life.

2.3 Ageing in Place The term ageing in place is used to describe the policy ideal of older adults continuing to live in their own homes as they age (Cutchin, 2003; Pastalan, 1990). A rapidly growing ageing population, together with increasing costs of long term residential care and concerns regarding the impact of such care on the wellbeing of older adults have ensured that there is widespread government support for the idea that older adults should remain in their own homes for as long as possible (OECD, 1994; Sixsmith and Sixsmith, 2008; Wiles et al. 2012). Older adults consistently report a desire to age in place 33

Chapter 2 – Literature Review (AARP, 2000; Cullen, Delaney and Dolphin, 2007) and the vast majority remain in their own homes even when these homes are no longer entirely suitable for their needs. For these reasons ageing in place is frequently conceptualised as necessary for successful ageing (Black 2008; Johansson et al., 2013; Means and Evans, 2011 Peace et al. 2011) and has led to the often unchallenged assumption that discontinuity of place in later life is a problematic aspect of ageing (Johansson et al., 2013; Peace et al. 2011; Rudman 2006; Wiles, Leibing, Guber- man, Reeve, & Allen, 2011) Home is an integral part of how old age is experienced and constructed (Altman and Low, 1992; Kontos,1998). Sixsmith and Sixsmith (1991) propose that the increased significance of home in later life might be attributed to its importance as a physical-spatial location in which old age is experienced. Research on everyday life in old age suggests that older people spend more time at home than younger people do particularly when they experience functional limitations (Baltes et al.,1999; Lawton & Simon, 1968; Moss and Lawton, 1982; Stea,1970), and early researchers in environmental gerontology have suggested that the home in later life is a valuable resource that off-sets age related loss and disability (Lawton, 1970; Kellahar, 2001; Kontos 1998;Rubinstein, 1992; Sixsmith and Sixsmith 1991).In this way, place interpreted as home plays a critical role in the construction of identity (Rowles 1993; Rubenstein 1989; Shenk, Kuwahara and Zablotsky, 2004) and for older people it may provide a space where control over one’s life can be freely exercised (Fogel, 1992; Lawton et al.,1982;Rutman & Freedman, 1988).

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Chapter 2 – Literature Review Despite its popularity as a policy ideal (Hillcoat-Nallétamby and Ogg, 2013; OECD 1994; Sixsmith and Sixsmith 2008; Wiles et al. 2012) ageing in place cannot be assumed to be a universally positive experience. Ageing in place involves more than the ability to remain in one’s own home (Keeling, 1999), it also involves the capacity to make independent decisions regarding change and the ability to adapt to changing social, political and cultural landscapes (Andrews et al. 2007). Critical analysis of the concept of ageing in place suggests that this policy ideal embodies neo-liberal principles of cost containment and placing increased emphasis on individual responsibility for well being in later life (Rozanova, 2010; Rudman 2006). For older adults who do not experience capacity to respond to the dynamic nature of person-environment relations, ageing in place may not represent a desired outcome but rather reflect lack of real choice in terms of preferred living arrangements and social supports (Hillcoat-Nallétamby and Ogg, 2013; Minkler, 1996). Research suggests that remain in place may not always be the best option for maintaining wellbeing (Golant, 2008; Means, 2007; Oldman and Quilgars, 1999; Oswald and Rowles, 2006) particularly if for example older people experience difficulties with home maintenance (Fausset et al., 2011); have poor health and functional abilities (Rubenstein, Kilbride and Nagy, 1992), if costs associated with homeownership increase (Askham et al., 1999) and when family composition changes (Sabia, 2008). For these older adults the experience of ageing in place might be more akin to that of ‘a prison and a place of terror’ rather than the idealised concept of home as a ‘haven or place of love’ (Moore, 2000 p. 212.)

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Chapter 2 – Literature Review

2.4 Understandings of person-environment relations in later life The complexity of person-environment relations in later life means that there is a broad range of theories emerging from varying disciplinary perspectives and Wahl and Wiesman (2003) have suggested that pluralism is the defining characteristic of theorising in environmental gerontology. For this reason a diverse range of perspectives including the ecological theory of ageing (Lawton and Nahemow, 1973), the person-environment fit model (Kahana, 1982), and understandings of the subjective meaning of home and place attachment (Cutchin et al., 2003;Rowles, 1978; Rowles, 1983a; Rowles, 1983c; Rubenstein and Parmelee, 1992;Rubenstein, 1989) were included in the initial literature review. 2.4.1 The Ecological Theory of Ageing The ecological theory of ageing (Lawton and Nahemow, 1973; Nahemow, 2000) draws from adaptation level theory to explore the interactions of people and their environments. Adaptation level theory is built upon an assumption that people tend to adapt to external stimuli so that after a certain period of time elapses the stimuli are experienced as neither absent or present (Helson, 1964). At this time the individual is said to have achieved adaptation level. Although all individuals are thought to be capable of achieving adaptation level, Helson (1964) suggests that there are limits to adaptation and that adaptation can only be achieved in the mid-range of stimuli.

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Chapter 2 – Literature Review In developing the ecological theory of ageing Lawton and Nahemow (1973), applied Helson’s (1964) concept of adaptation level to the total environment. Thus a key assumption of the ecological theory of ageing is that most people reach an adaptation level in most environments. However there are environments to which it is almost impossible to adapt and there are some people who adapt with difficulty and require a benign environment to be able to reach their adaptation level (Nahemow, 2000 p.23)

The ecological theory of ageing draws from earlier work completed by Murray (1938) relating to environmental press to explain how the environment acts upon the individual to provoke a response. According to Murray (1938), environmental press refers to forces within the environment which combine with individual need to generate a response. Environmental press can be classified as alpha press (objective press relating to factors such as complexity) and beta press (subjective press relating to the perceived character of the environment). At an individual level Nahemow, (2000) argues that it is beta press which influences adaptation level. Within the theory the ability of the individual to respond to environmental press is conceptualised as competence. Competence is a multidimensional concept which includes biological, psychological and social components. It is concerned with the ability of the person to function in the environment. The relationship between personal competence, environmental press and adaptation level is described in figure 2.1.

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Chapter 2 – Literature Review

Figure 2.1 Ecological Theory of Ageing Adapted from Lawton MP, Nahemow L. Ecology and the ageing process. In: Eisdorfer C, Lawton MP, eds. (1973) The Psychology of Adult Development and Aging. Washington, DC: American Psychological Association. Reproduced with permission.

Figure 2.1 shows the degree of environmental press on the X axis, the level of individual competence on the Y axis and the theoretical adaptation level is represented by a central diagonal line surrounded by an adaptive range (Lawton and Nahemow, 1973). The diagrammatic representation of the theory highlights its dynamic nature and emphasises that none of the component parts remain fixed. In the adaptation-level theory (Helson, 1964), adaptation level is considered to be in continuous motion around a central point and because of this 38

Chapter 2 – Literature Review perpetual motion the concept of adaptation level is presented as a range of points rather than one specific point (Helson, 1964). In the ecological theory of ageing Lawton and Nahemow (1973) suggest that the adaptation level range is a function of individual competence and therefore is much wider for highly competent individuals than for those less competent individuals. They suggest that when individuals are within their adaptation level range they will be comfortable and will behave appropriately, however if they are outside of that range behaviours will be maladaptive and the individual will have a negative emotional response (Lawton and Nahemow, 1973). The environment is also considered to have dynamic characteristics and as a result the concept of environmental press is also ever-changing. Lawton and Nahemow (1973) argue that on the first encounter, all environments (no matter how low their demands are objectively) require a period of learning and adjustment to their demands. After an initial period of adaption to this new environment the individual will achieve adaptation level and the demands of the environment will no longer be recognised. Environmental press will therefore decrease as a function of the time spent in the environment, and the greater the competence possessed by the individual the quicker that adaptation level will be achieved (Lawton and Nahemow, 1973). Although designed to consider adaptation level across the lifespan the ecological theory of ageing has been primarily applied to the case of older people. Lawton and Simon (1968) considered that older people would achieve adaptation level at a slower pace than other people and proposed that due to the physical impairments which accompany ageing, older people were more 39

Chapter 2 – Literature Review likely to experience incomplete or absent adaptation level than younger adults. Using the Environmental Docility Hypothesis, Lawton and Simon (1968) postulated that individuals with lower levels of functioning are more dependent on the immediate environment and less able to adapt or leave that environment in order to achieve adaptation level. This is represented in the figure 2.1 by the relatively narrow bands of maximum comfort and performance associated with low competence compared with the wider bands associated with high competence. Research testing the validity of the ecological theory of ageing has produced mixed results (Nahemow, 2000). In an attempt to test the environmental docility hypothesis presented by Lawton and Simon (1968), Morgan et al., (1984) considered the relationship between three domains of potential competence (i) physical health or sensory capacity (ii) access to caregiver networks and (iii) personality characteristics commonly associated with successful coping and adaptability to increasing environmental demands. Using a sample of community living volunteers (n=102) between 60-92 years of age the researchers found positive correlations between classification of competence and ability to adjust to increased environmental demands across all three domains. Conflicting results were reported by Booth (1986) and Booth and Phillips (1987) who also tested the environmental docility hypothesis although this time using a sample of older people who were residing in long term residential care. In the first study Booth (1986) attempted to reduce the individual competence levels of nursing home residents by inducing dependency 40

Chapter 2 – Literature Review through introduction of restrictive regimes in nursing home environments. Using a three year follow up study with a sample size of 6,891 residents the researchers were unable to find any significant evidence to support the idea that sustained low environmental press would result in a reduction in individual competence. In a subsequent longitudinal study which compared outcomes for older people living in group homes (assumed to support independence) with those of older people living in nursing homes Booth and Philip (1987) again failed to find any evidence to support the environmental docility hypothesis. The failure of Booth (1986) and Booth and Phillip (1987) to generate empirical evidence to support the environmental docility hypothesis may be explained in two ways. Firstly, given that both studies were conducted with older people living in residential nursing home care it may be that that the functional competence of the older people sampled was already so low that subsequent reductions were not identified using the outcome measures designed for the study. Alternatively the older people in question may have adopted a more proactive stance towards their environment than was conceptualised in the original theory. Further development of the ecological theory of ageing by Lawton (1989) appears to acknowledge the potential for older people to act upon their environments in order to maintain desired levels of independence. Lawton (1989) used the concept of person-environment proactivity to capture this purposeful behaviour of older people and suggested that through acting upon

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Chapter 2 – Literature Review their environment older people are capable of responding to environmental press and maximising environmental opportunities. 2.4.2 Housing Related Control Beliefs – An extension of the Environmental Proactivity Hypothesis Although later versions of the ecological theory of ageing acknowledge the potential for environmental proactivity (Lawton 1989; Nahemow, 2000) the theory contains limited discussion of how this proactivity might be expressed by older people during everyday life. More recently Oswald et al. (2003) have addressed this gap by developing the concept of housing related control beliefs as means of operationalising the environmental docility and environmental proactivity hypotheses. As described in chapter one, housing related control beliefs draw from general psychological theories of perceived control (Lachman, 1986) and the ecological theory of ageing (Lawton 1989; Lawton and Nahemow, 1973; Nahemow 2000). Oswald et al. (2003) suggest that housing related control beliefs explain whether everyday activity in the home is perceived to be a consequence of one’s own behaviour in relation to the home environment (internal housing related control beliefs) or whether everyday activity in the home is believed to be dependent upon external influences such as powerful others, luck or chance (external housing related control beliefs).

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Chapter 2 – Literature Review 2.4.2.1 Generalised Expectancies for Internal Versus External Control of Reinforcement - ‘ Locus of Control’ The concept of housing related control beliefs draws heavily from psychological theories of perceived control (Oswald et al. 2003). Locus of control was first introduced by Rotter (1954) who drew upon theories of social learning to develop his understanding of the nature and effects of reinforcement on an individual’s behaviour. According to social learning theory, reinforcement of behaviour creates expectancy that this particular behaviour will be followed by that reinforcement in the future. Rotter (1966) argues that during the course of typical development humans learn to distinguish between events which are causally linked to preceding events and those which are not. This leads to a general hypothesis regarding reinforcement which suggests that if the reinforcement is not causally linked to the individual’s behaviour then the expectancy for a future behaviour reinforcement sequence will not be as strong as when the reinforcement is causally linked to the individual’s behaviour. Furthermore he argues that when an individual’s own behaviour is causally linked to the subsequent reinforcement then the non-occurrence of the behaviour reinforcement sequence will not reduce the expectancy for future events as much as when the reinforcement is not causally linked to the individual’s own behaviour. The development of causality will vary depending on the individual’s previous history of reinforcement thus accounting for variation in expectations for causality.

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Chapter 2 – Literature Review In developing his original theory Rotter (1954) went on to argue that individuals will generalise expectancies from a specific situation to other situations which they perceive as being related or similar. Thus a generalised expectancy relating to the nature of the causal relationship between one’s own behaviour and the consequences of that behaviour may have the capacity to influence a wide variety of behavioural choices across a diverse range of life situations. If an individual does not perceive a causal relationship between one’s own behaviour and its consequences then the individual is likely to believe that the consequences experienced occur as a result of external forces. The cultural context in which this behaviour and subsequent consequences occur will determine whether they are perceived as mediated by chance or by skill. 2.4.2.2 Locus of Control – A Uni-Dimensional or Multi-Dimensional Construct? The question as to whether the construct of locus of control should be considered as a uni-dimenional construct has caused much controversy within the research literature. In his social learning theory Rotter (1954) originally described locus of control as a multidimensional construct; however in subsequent studies which sought to measure locus of control he operationalised the construct as one-dimensional one (Rotter, 1966). In this later paper Rotter (1966) argues that those holding internal control beliefs are on one end of a control continuum, with those holding external control beliefs situated on the other end of this continuum. This is in contrast 44

Chapter 2 – Literature Review to his earlier work Rotter (1962) in which he identified four types of external control beliefs (i) belief that events occur due to luck (ii) belief that events occur due to fate (iii) belief that events are controlled by powerful others and (iv) belief that the world cannot be predicted because it is too complicated. Other researchers have argued that it is more useful to consider locus of control as a multidimensional concept (Lachman, 1986; Rodin and Timko, 1992). Levenson (1974) argues that the ‘either or’ approach to internal or external locus of control suggested by Rotter (1966) does not give an explanation for the idea that people can believe in luck whilst also believing that their personal efforts have the capacity to influence events in their lives. Levenson (1981) suggests that such thought patterns are probably reflective of an accurate world view as they account for socio-political situations outside of the direct influence of the individual. To overcome these deficits he developed a model of locus of control in which external control is presented as being constructed of a chance locus and a powerful others locus Levenson (1974). In a similar fashion Gurin et al., (1978) suggested that personal control should be distinguished from an ideology of control. In this way it is possible for researchers to differentiate between an individual’s belief about their capacity to exercise control in their own lives (personal control) and their beliefs about the role of internal and external forces in the distribution of rewards in society. This idea of control ideology was later developed by Wong and Sproule (1984) who proposed a bi-dimensional view of locus of control and suggested that those people who are bi-dimensional in their sense of control are better 45

Chapter 2 – Literature Review adjusted to real life, as they accept that they cannot exercise control over all events or situations. Rotter (1975) revisited the issue of dimensionality in later works and appears to have reverted to his earlier presentation of the construct, noting that arguments relating to the construction of locus of control have ‘been approached in an either /or manner. Either it is a unidimensional construct, or it is a multidimensional construct. Such thinking is contrary to a social learning approach to the nature of stable behaviour’ (p. 63).

In relation to ageing research Lachman (1986) suggests that a multidimensional conception of locus of control is likely to be more useful given that there appears to be differences in both the quantity and type of change which occurs between internal and external control within the same individual. Oswald et al. (2007) suggest that these differences may be particularly pronounced within the oldest old. 2.4.2.3 Domain Specific Locus of Control vs. Generalised Locus of Control Rotter, (1990) suggests that the concept of locus of control illustrates a generalised tendency which is relatively independent of behavioural domains; however later researchers have argued that locus of control may be more useful if considered within a specific domain (Mischel & Mischel, 1979). This work has led to the development of a variety of domain specific scales and results from studies using domain specific scales appear to support the situational nature of locus of control i.e. the same people achieve either

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Chapter 2 – Literature Review internal or external scores depending on the context of the scale used (Paulhus, 1983). Research which considered changes in locus of control across the lifespan (Heckhausen and Schulz, 1995; Lachman and Burack 1993; Lachman and Firth, 2004) suggests that measures of domain specific locus of control may be more sensitive and thus have more predictive value than assessment of general tendency towards internal or external control. This may because different life domains have different levels of significance depending of the life stage of the individual. Lachman and Firth (2004) have demonstrated that with age, perceived control in the domains of work, marriage and finances increases while perceived control of one’s children and one’s sex life decreases. 2.4.2.4 Factors which Influence Individual Variation in Locus of Control There is a general agreement within the literature that locus of control can vary according to the situation and does not refer to a fixed innate personality trait. Thus in order to fully understand locus of control and to use the construct to predict subsequent behaviour, it is necessary to examine locus of control in context and consider associated factors which may influence reinforcement. A number of studies have suggested that locus of control is strongly related to cultural norms. Rotter’s (1966) original conceptualisation of locus of control referred to American culture and thus may not easily translate to other cultures. Hofstede (1990) identifies two major types of cultures – 47

Chapter 2 – Literature Review individualist and collective - and argues that, depending on one’s culture, the way in which one’s self concept is expressed will vary. Thus differences in scores of control using constructs developed in another culture do not necessarily represent different control experiences, rather they may simply represent different ways of expressing control. Other research has focused on the influence of educational status and gender on locus of control ( Lachman & Weaver, 1998; Lachman & Firth 2004) . The results of this research indicate that both factors influence how locus of control is experienced, but that this influence impacts different dimensions of control differently and the impact of these external factors is dependent on whether the research is focused on general control or domain specific control. Lachman and Weaver (1998) suggest that in relation to a general sense of control, men typically express higher levels of general control with higher internal control and lower external control than women. The influence of gender on domain specific control is less clear cut and Lachman and Weaver (1998) found that although different levels of control were reported in relation to sex life, finances and marriage, the same general patterns of control beliefs were observed. Both men and women reported that they experienced the least amount of control regarding sex life and finances with the most control over marriage. This study also found limited difference between genders in health related control beliefs. With regard to education Lachman and Weaver (1998) found evidence that education is linked with higher sense of internal control; however once again

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Chapter 2 – Literature Review the relationship between education and domain specific locus of control is more complex. Lachman and Firth (2004) suggest that their cross sectional study of American adults demonstrates a relationship between higher levels of education and higher internal control in the domains of health, work, finances and making a contribution to the health of others. In the same study, educational attainment did not appear to impact on perceived control over children, marriage, and personal mastery. The authors of the study suggest that the variation in domain specific results can be explained by considering the availability of resources to persons with higher education versus those with lower education levels (Lachman and Firth, 2004). Penk (1971), drawing from the developmental hypothesis described by Rotter (1954), suggests that ageing is accompanied by increased levels of mastery which in turn should translate into increased levels of internal control in later life. This hypothesis is supported by evidence from both cross sectional and longitudinal studies which demonstrate that age influences perceived locus of control (Krause & Shaw, 2003;Lachman, 2006; Lachman and Prenda-Firth, 2004; Mirowsky, 1997). However when using a multidimensional conceptualisation of locus of control Lachman and Prenda-Firth, (2004) found that differences emerged in the patterns of changes in control beliefs. Specifically they reported that while internal control was maintained into old age, at the same time external control took on a greater significance in people’s lives. This change in control belief patterns which emerges in later life may reflect older people’s awareness of their increased vulnerability to

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Chapter 2 – Literature Review changes in the meso and macro environments as a result of age related losses (Knipscheer et al., 2000 ). 2.4.2.5 Relationship between Control and Wellbeing in Later Life There is evidence to suggest that key outcomes for ageing are associated with individual differences in perceived control (Rowe & Kahn, 1998). The presence of high levels of internal control is consistently linked with happiness, wealth and wisdom in later life (Lachman, 2006). In a national survey of midlife in the United States, (Lachman and Prenda-Firth, 2004) found that those with a high level of internal control experienced greater life satisfaction, were more optimistic for the future, had lower levels of depression, more positive self-rated health, fewer chronic conditions and less severe functional limitations. Control beliefs appear to moderate the previously demonstrated link between socio-economic status and health. (Lachman, 2006) argues that high levels of internal control can act as a buffer to mediate the impact of lower socioeconomic status on health. This idea is supported by an earlier study (Lachman and Weaver, 1998) which found that those with lower income but high level of internal control had similar health outcomes to those with higher income. 2.4.3 Housing Related Control Beliefs and Ageing in Place Although there is limited empirical research relating to housing related control beliefs, Oswald et al. (2007) report that housing related control beliefs

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Chapter 2 – Literature Review may have a significant influence on the extent to which older people are able to age in place. The significance of housing related control beliefs for ageing in place is related to the mediating role played by such beliefs in the relationship between housing accessibility and independence in activities of daily living among very old people (Oswald et al., 2007). In a pan-European study to explore the influence of housing related control beliefs on the impact of accessibility problems and ADL independence for older people Oswald et al., (2007) found independence in activities of daily living was associated with low levels of accessibility problems, high internal housing related control beliefs, and low levels of external housing related control beliefs. Participants who expressed high levels of external housing related control beliefs (i.e. those who perceived that their housing was contingent upon luck, chance, fate or powerful others) had more accessibility problems and were less independent in activities of daily living. However although housing related control beliefs appeared to mediate the impact of housing accessibility problems on ability to perform activities of daily living, the authors note that independence in activities of daily living was not fully mediated by housing related control beliefs, suggesting that housing accessibility also influenced performance of activities of daily living (Oswald et al., 2007).

The study also highlighted the complexity of the processes through which housing related control beliefs mediated the impact of housing accessibility

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Chapter 2 – Literature Review on performance of activities of daily living. In particular the authors found that the presence of external housing related control beliefs was more significant than the presence of internal housing related control beliefs (Oswald et al., 2007). Based upon this finding Oswald et al. (2007) concluded that within the domain of housing, external control beliefs were more important than internal control beliefs in determining ageing in place outcomes. Although earlier research relating to general control beliefs indicates that control beliefs are influenced by cultural context, Oswald et al. (2007) found that patterns of housing control belief were consistent among older adults in five different European countries (Germany, United Kingdom, Hungary and Latvia). This finding suggests that the construct of housing related control beliefs may have cross-cultural equivalence. However Oswald et al. (2007) note that they ways in which housing related control beliefs acted to mediate the relationship between housing accessibility and independence in activities of daily living appeared to be influenced by the broader cultural context. Specifically, in 4 of the 5 countries (Germany, United Kingdom, Hungary and Latvia) high levels of external control mediated the impact of accessibility problems, whereas in Sweden the impact of accessibility problems was mediated by internal control. To explain this finding Oswald et al., (2007) point to significant differences between health and social care policy for older people in Sweden when compared with the other four countries and suggest that the differences in

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Chapter 2 – Literature Review how control beliefs were experienced by different participants may reflect the wider influence of the social environment on ageing in place. Earlier work by Oswald et al., (2003) has found that similar to other domain specific control beliefs housing related control belief is influenced by age, educational status and income. In a small study of older people, higher age, lower educational status and lower income were found to be positively associated with higher levels of external control (Oswald et al., 2003). While further work is required to fully explain the relationship between these variables, the data currently available appears to support the earlier work of Lachman and Prenda-Firth (2004). In conclusion then, the construct of housing related control beliefs which emerges from general theories of control (Lachman 1986; 2006; Lachman and Burack 1993) and the ecological model of ageing (Lawton and Nahemow, 1973) offers one method of measuring housing proactivity in later life. Existing research using this construct suggests that it may play an important role in the outcomes of ageing in place however, the exact mechanisms through which this influence is operationlised are unclear. 2.4.3 Theories of Place Attachment Peace et al. (2007) suggest that research relating to the concept of place attachment moves away from focusing on an objective environment towards addressing the wide range of processes operating when people form emotional ties to a geographical location. Such emotional attachments have been labelled as place attachment and connect the person ‘to that place as a 53

Chapter 2 – Literature Review function of its role as a setting for experience’ (Rubenstein and Parmelee, 1992 p. 189) A number of different theories grounded in the concept of place attachment have emerged, including Rowles’ (1978, 1983a, 1983c) theory of ‘insideness’ of place; Rubenstein’s (1992) model of psychosocial processes linking person to place and Golant’s (2011) theory of residential normalcy. 2.4.3.1 Insideness of Place Rowles (1983b) proposes that older people experience what he terms an ‘insideness’ of place in later life whereby there is a notable distinction between the immediate community of the older person and the outside world. Based upon his work with older people living in an Appalachian community, Rowles (1983a; 1983b; 1983c) identified three key elements of place attachment. Physical insideness refers to the familiarity with an environment that is gained through performing routines in the same setting, resulting in the sense that the individual is able to ‘wear the setting like a glove’ (Rowles, 1983b p.14). The second element social insideness emerges from a sense of belonging, social integration and is fostered through everyday social exchanges over a long period of time. Through these exchanges older people obtain social credit and can rely on successive generations to support them as they experience age related impairments and disabilities (Rowles, 1990). The temporal aspect of place-based relationships is reflected in the third element, autobiographical insideness. Autobiographical insideness reflects past and present affiliation to place. It is developed through acquisition of placeassociated memories which

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Chapter 2 – Literature Review ‘provide a sense of identity and an ever present source of reinforcement for a biography interpreted from the retrospective vista of a life review’ (Rowles, 1983b p.114)

2.4.3.2 Psychosocial Processes Linking Person to Place Rubinstein’s (1989) model of psychosocial processes sets out an explanation for the ways in which older people and their home environments are meaningfully linked. According to this model there are three classes of psychosocial processes, through which older people comprehend the features of their environment. These psychosocial processes are directed towards three objects that serve as a point of reference for environmental meaning (i) sociocultural order (ii) the life course and (iii) the body. Rubinstein (1989) uses the term environmental features to describe any subjectively significant feature of the home environment including objects, behavioural routines, furniture etc. The first process links the person to the socio cultural order and is enacted through configuration of the home environment so that it meets the individual’s interpretation of the sociocultural rules relating to domestic order. The second set of processes is concerned with the way in which the individual expresses his or her life course through the features of his or her home. Rubinstein (1989) labels these processes as person centred processes. The third group of processes, the body centred processes refer to the on-going relationship between the body and the environmental features which surround it.

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Chapter 2 – Literature Review 2.4.3.3 Residential Normalcy Golant’s (2011) theory of residential normalcy is built around the concept of the home environment as a place where older people ‘ experience overall pleasurable hassle free and memorable feelings that have relevance to them; and where they feel both competent and in control – that is they do not have to behave in personally objectionable ways or to unduly surrender mastery of their lives of environments to others’ (p. 193). The theory, which adopts an interactional view of person environment relations proposes that the experience of residential normalcy is underpinned by feelings of residential comfort and residential mastery (Golant, 2011). Residential comfort refers to the extent to which older persons experience pleasure from their home environment and the broader community in which it is situated. Residential mastery is associated with feelings of competence and of being in control over one’s environment and one’s life (Golant, 2011). Golant (2011) suggests that the older person is actively involved in constructing a sense of residential normalcy and proposes that where either residential mastery or comfort are experienced negatively then the older person will take action to return to a state of normalcy. He identifies two forms of actions taken by older people (i) accommodative (mind) strategies and (ii) assimilative (action) strategies. These actions are combined to bring about change in the person, the environment or both and ultimately represent efforts to cultivate a sense of place that is acceptable to the older person.

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Chapter 2 – Literature Review 2.4.4 Place Integration The concept of place integration was developed by Cutchin (1999, 2003) in recognition of the need for a transactional perspective of person-environment relations

which

could

accommodate

the

interconnectedness

and

interdependencies between persons and environments. Drawing from geographical understandings of place as a dynamic process, and the philosophy of pragmatism, place integration is understood an on-going process of transactions into new situations (Cutchin, 1999, Cutchin, 2003, Johansson, 2008). Place integration processes are on-going, and occur when changes in the person-place whole result in disintegration of person-place and the emergence of problems and possibilities from a situation. These problems and possibilities stimulate creative thoughts and actions with the aim of reintegrating the person-place entity (Cutchin, 2003, Cutchin, 1999). Johansson (2008) suggests that the process of place integration should be conceptualised as a ‘spiral of transactions into new situations rather than a linear process’ (p.14).

2.5 Practices of Ageing in Place Despite the ongoing interest in person-environment relationships and specifically the construct of ageing in place limited knowledge exists regarding how older people age in place. As discusssed in chapter one, in this thesis the term ‘practices of ageing in place’ is used to refer to the variety of ways in which older people give meaning to and shape their lives and address problematic situations in their home environments. The idea of

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Chapter 2 – Literature Review ‘practices’ of ageing in place draws from Bury’s (1991) work regarding ways of coping with chronic illness. Bury (1991) suggests that people’s responses to chronic illness include cognitive process whereby individuals learn to cope with or put up with the effects of illness; the actions people take or what people do in response to illness and the way in which people represent these cognitive processes and actions through drawing upon symbolic meaning, social practices and cultural repertoires to present their altered physical appearance and social circumstances. Applied to the concept of ageing in place, Bury’s (1991) model of response suggests that practices of ageing in place would incude they ways in which people learn to adjust to changes in the person-environment whole (cognitive processes) the things people do to modify or adjust the environmental context (actions people take) and the how people represent themselves in relation to their home environment (sympbolic meaning, social practices and cultural repertoires). Existing research although not always using the same terminiology as Bury (1991) appears to support this conceptualisation of practices of ageing in place. Haak et al. (2007) suggests that among older people in Sweden (n=40) ageing in place involved an ongoing struggle to maintain independence despite the presence of significant functional limitations. This struggle was operationlised through maintaining prior activites and occupations; modfying the home environment; adjusting to and dealing with declining performance by lower self expectations and maitaining control over decision making processes. The idea of struggling to maintain 58

Chapter 2 – Literature Review independence was also identified by Ahluwalia et al., (2010) who explored how older people responded to difficulties with bathing. The findings of this study suggest that, driven by social expectations of what was needed to maintain independence older people attempted to modify their bathing routines so that the peformance demands were reduced but yet the social symbolism and meaning of the activity was maintained. While the focus of this research was confined to bathing activities the authors report that bathing was perceived by the older adults as a key component of ageing in place. Similar results were reported by Tanner (2007) who explored how older people (n=12) coped with self identified difficulties with domestic tasks such as shopping and cleaning and personal activities of daily living such as bathing. Analysis of in-depth interviews suggested that coping could be categoriesd into practical coping strategies and cognitive coping strategies (Tanner, 2007). Practical coping strategies refer to ‘doing’ strategies which older people used to manage difficulties that emerged in daily life. These strategies included (i) keeping busy and remaining active (ii) maintaining routines and maintaining standards of personal care and of domestic orderliness and (iii) attempting to maintain balanced relationships which emphaised reciprocity. Cognitive coping strategies refer to the processes through which participants maintained a sense of self while negotiating changes and losses encountered during ageing in place. These included (i) maintaining continuity between past, present and future and (ii) managing one’s own identity as an independent older person.

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Chapter 2 – Literature Review While Haak et al.’s (2007) and Tanner’s (2007) work emphasises the diverse nature of practices of ageing in place Davey (2006) suggests that ageing in place might be primarily focused on keeping one’s home in a good condition, suitable and comfortable. Analysis of interviews with older homeowners in New Zealand (n=30) led Davey (2006) to suggest that ageing in place requires a number of actions directed towards the home environment including (i) maintenance activities (ii) renovation activities and (iii) environmental adaptation activities. Davey (2006) does not specifically identify cognitive processes or self representation process relating to ageing in place, however she does highlight that for participants in the study home ownership was imbued with significant social and cultural values which contributed to their ability to ‘conform to the expectations of ‘middle New Zealand’ (p.137). This finding suggests that practices of ageing in place may be influenced by the cultural context and indeed even within the same culture social expectations and norms regarding ageing in place may differ between groups. The individualised, idiosyncratic nature of practices of ageing in place was also highlighted by Renaut and Ogg (2011) who explored how older people in France (n=30) handled barriers in the home environment. The authors note that the majority of respondents did not use standardised environmental modifications or assistive technology choosing instead to generate their own solutions to everyday envrionmental problems. Renaut and Ogg (2011) also identified the significant impact of economic and social capital on older people’s ability to sucessfully age in place.The authors suggest that those

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Chapter 2 – Literature Review older people with greater access to economic resources and social networks experience have a wider repertoire and greater choice regarding practices of ageing in place. The need to include the social envrionment when considering how older people generate adaptive strategies was also highlighted by Thomése and Van Groenou (2006) who found that among older people living in the Netherlands (n=819) increased use of informal care was the most frequent response to functional decline. Just over ten percent of participants in this study undertook environmental modification of their home in response to functional loss leading the authors to suggest that a broader view on adaptive strategies to support ageing in place is required if researchers and policy makers are to be able to support older people to age in place.

2.6 Occupational Therapy Interventions to support Ageing in Place Environmental interventions have been identified as a one method of reducing the level of disability experienced by these older adults (Gitlin, 2003; Mann et al., 1999). Environmental modifications are described as conversions or adaptations to permanent physical features of the home environment (Fange and Iwarsson, 2005).The overall aim of environmental modifications is to support older adults to remain in their homes for longer periods (Duncan, 1998). Cream and Teaford, (1999) suggest that these modifications may relate to safety, security, or ease of mobility. Viewed from the perspective of Lawton’s Ecological Theory of Aging (1973), 61

Chapter 2 – Literature Review environmental modifications act as a way of re-establishing the balance between the environmental demands and individual competencies. Evidence exists to support the use of environmental modifications to (i) increase independence (ii) ensure safety (iii) reduce admission to long term care institutions and (iv) reduce use of personal care services (Mann et al., 1999, Stark, 2004, Stark et al., 2009). Connell & Sandford (2001) found that following modification of their home environments people with disabilities had low to moderate difficulties in performing activities of daily living. Gitlin and Corcoran (1993) and Gitlin et al. (2001) reported that home modifications for older adults slowed the rate of functional dependency and enhanced caregiver self –efficacy. Similar findings were reported by Mann et al., (1999) who also highlighted the benefits of home modifications in reducing the cost of personal assistance and home care needed by older adults. More recently Stark et al., (2004; 2009) have suggested that modification of the home environment can enhance occupational performance and satisfaction. 2.6.1 Non Usage of Environmental Modification Despite a growing body of evidence to support the use of home modifications to support aging in place, older adults do not always seek out or indeed use home modification services. Adherence rates as low as 33-40% have been reported in the literature (Cumming et al., 1999; Devor et al. 1994 ; Haywood et al., 2005; Schoenfelder and Van Why 1997). Pynoos (1987) suggests that failure to modify the home environment may reflect lack of information, lack of assistance to undertake suitable modification, lack of financial resources

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Chapter 2 – Literature Review or that persons facing declining independence choose alternative solutions such as a seeking assistance or abandoning activities. Although there is limited information available concerning factors which motivate or prevent older adults from undertaking home modification activities, a study conducted by Gosselin et al., (1994) appears to challenge Pynoos’ ideas. Gosselin et al., (1994) as part of a larger randomised controlled trial of home modification sought to identify how many older adults would undertake home modifications if obstacles noted by Pynoos (1987) were removed. In a sample of 255 older adults (mean age 77.1 years) Gosselin et al. (1994) found that 18% of participants refused an assessment for home modifications by an occupational therapist, 4% of participants refused the modification recommended and a further 1% of participants failed to implement the modification which had been proposed and accepted within a period of six months. Subsequent analysis of factors influencing the decision to accept home modifications indicated that the perceived need for modification, together with experiencing difficulties in specific activities of daily living (using the toilet and completing transfers) were positively associated with acceptance of modifications. The study found no significant association between levels of disability and willingness to accept modifications. The results of this study appear to support the idea that some older adults choose alternative methods of coping with environmental barriers. Choosing alternative methods of coping with environmental barriers may offer older adults the opportunity to exert control over their home environment. Heckhausen and Schulz (1995) argue that exerting control over

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Chapter 2 – Literature Review one’s environment is a key mechanism through which older adults bring about positive affect and buffer threats or actual losses to personal abilities in order to control important life outcomes. Clemson et al. (1999) suggest that home modification services do not always facilitate older adults to exert this control over their environment and as a result they suggest older adults may decide not to comply with recommendations of experts. Similar theories are presented by (Stark, 2004, Stark et al., 2009) who argue that more positive outcomes are demonstrated when older adults are facilitated to be actively involved in decision making processes relating to home modifications.

2.7 Gaps in existing knowledge of ageing in place A number of gaps exist in current theoretical and empirical knowledge of ageing in place. In the first instance there is a lack of theoretical understanding of how older people age in place. While the concept of housing proactivity (Lawton, 1989) has been suggested as a means of explaining why some older people might act upon their environments it does not explain how these actions occur. Furthermore although Oswald et al. (2003) have attempted to measure housing proactivity in relation to housing related control beliefs it is not clear if this understanding of housing proactivity captures the diversity of practices of ageing in place nor is it clear the extent to which differences in patterns of housing related control beliefs translate into different practices of ageing in place. Secondly while housing proactivity (Lawton, 1989) and housing related control beliefs (Oswald et al., 2003) offer a starting point to examine

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Chapter 2 – Literature Review practices of ageing in place these concepts do not incorporate issues of place attachment (Golant 2011; Rowles, 1978; 1983a; 1983b; 1983c; Rubenstein 1992) or place integration (Cutchin 2003). Given the significance of the material, social and symbolic aspects of home (Moore and Ekerhdt, 2011; Wiles et al., 2009) it seems likely that practices of ageing in place will be influenced by practices of place making however existing knowledge has not yet fully explained how these aspects of ageing in place are experienced by older people. Thirdly most of existing research has focused on ageing in place from the perspective of older people who are ageing in place in the context of specific functional decline and disability and/or who are in receipt of health and social care services to support ageing in place. It is likely that the experiences of such older adults may be different to older adults who are ageing in place without professional intervention. Finally there is a lack of specific information regarding ageing in place in an Irish context. Given that existing research has indicated that ageing in place is significantly influenced by the socio-economic environment and cultural norms and expectations regarding home, ageing and ageing in place it seems important to develop theoretical and empirical knowledge which is grounded in the lives of older people living in an Irish context.

2.8 Conclusion This chapter has provided an overview of current research relating to ageing in place. A number of gaps in existing knowledge regarding how older people 65

Chapter 2 – Literature Review age in place have been identified and the need for innovative methodological approaches to increase understanding of this complex phenomenon has been highlighted. In the next section (chapters three and four) the philosophical assumptions and methodological choices made in the current study are presented.

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Chapter 3 – Philosophical Assumptions

Chapter 3 3.1 Introduction The previous chapter introduced the research topic and provided a brief overview of the existing research literature. Chapters three and four focus on the methodological choices made when addressing the research question. In this chapter the philosophical assumptions and interpretative framework that underpinned the study are presented. American Pragmatism, specifically the work of John Dewey guided the study. The chapter begins with a brief discussion of pragmatic thought as set out by Dewey, before considering the alignment between Deweyan pragmatism and occupational therapy philosophy and practice. The suitability of pragmatism for a mixed methods approach is then considered and finally the implications of pragmatism for the current study are presented.

3.2 American Pragmatism Albrecht (2003) describes American Pragmatism as a diverse philosophy which has had a pervasive influence on social sciences. Initiated in the 19th century by Pierce and James, American pragmatism had a significant influence over the work of Dewey, Schiller and Mead and is incorporated in the works of modern philosophers including Sellars, Quine, Putnam and Haack (Albrecht, 2003). The diverse nature of pragmatism means that it is difficult to identify a single thread running through this philosophy and each

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Chapter 3 – Philosophical Assumptions philosopher has developed pragmatic thought in different directions. However, Hacck (1996) suggests that at its core, pragmatism is Characterised by the method expressed in the pragmatic maxim according to which the meaning of a concept is determined by the experiential or practical consequences of its application (p. 643)

This research study is informed by Deweyan pragmatism. Dewey along with Schiller was one of the second generations of pragmatic philosophers. He is credited with moving pragmatism towards an increasingly activist direction (Albrecht, 2003). Rejecting the ‘quest for certainty’ that characterised Pierce’s early pragmatic thought, Dewey argued that knowledge is closely related to practice (Boisvert, 1998). Dewey proposed that good theories should be based in practice and should be modified as a result of experience (Albrecht, 2003). For Dewey, inquiry should be driven by a problematic situation instead of abstract philosophical positions (Cutchin, 2008b; Heatwole-Shank, 2013) and thus research questions and research methods must be co-ordinated in a way that addresses the complexity of real-world problematic situations. Teddlie and Burke-Johnson (2009) propose that the goal of pragmatism has been to find a middle ground between philosophical dogmatisms and scepticism. Dewey’s pragmatism rejects all forms of binary choices implied in traditional dualisms; dualism of knower and known (Boisvert,1998), of individuals and their environments (Cutchin, 2008b) and of objectivism and subjectivism (Maxey, 2003). Instead, Dewey’s work is characterised by unification and included themes such as (i) a holistic form of naturalism (ii)

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Chapter 3 – Philosophical Assumptions a perspective of continuity between humans, their contexts and their past, present and future experiences (iii) recognition of the uncertainty of experience (iv) avoidance of dualisms and (v) acknowledgment of the fallibility of knowledge and its implications (Alexander, 2009; Cutchin, 2008a; Cutchin and Dickie, 2013;Margolis, 2009).

3.3 Deweyan Pragmatism and Occupational Therapy Within occupational therapy research, pragmatism has been considered particularly useful for addressing complex issues of occupational performance and engagement (Dickie et al., 2006). Dickie et al., (2006) propose that occupational therapy research and practice is conceptually consistent with the philosophy of pragmatism and Cutchin and Dickie (2013) suggest that Dewey’s theory of action is particularly important to the study of occupation. Dewey’s understanding of action, places emphasis on the continuity of humans, their environments as well as past, present and future experiences (Cutchin and Dickie, 2013). Rejecting the ‘dualism of stimulus and response’ which had earlier being proposed by James, Dewey conceived action as a ‘circuit of coordination’, in which both the stimulus and response are phases in the on-going adjustment of the person with his environment (Alexander, 2009). Dewey’s concept of action has become known as transaction within the occupational science literature (Cutchin and Dickie, 2013) and in recent years has been used to re-orientate understandings of occupation in a way that address the limitations of ‘overly dualistic, individualised (decontextualised), linear and mechanistic theories’ (Cutchin and Dickie, 2013 p.3) 69

Chapter 3 – Philosophical Assumptions The adoption of a pragmatic stance in the study of person-environment relationships is also advocated (Schwarz, 2012). Cutchin (2008b) suggests that Dewey provides a ground map for a non-dualistic understanding of person-environment relations, which can support researchers to engage creatively with problems of place. Dewey’s focus on the relations which connect people, their context and their occupations, provides a useful framework to understand how people experience and reconstruct situations as centres of action (Cutchin and Dickie, 2013). Place integration, a philosophically-based conceptual tool developed by Cutchin (2003;1999) to explore the dynamics of people and their contexts, has been identified as a useful framework in which to generate understandings of people and their situations (Johansson et al., 2013). Johansson et al. (2013) suggest that because place integration emphasises a transactional relationship between the person-place, it enables researchers to adopt a more holistic approach to understanding older persons’ relationship with their environments. Rather than separating the person and environment into two constituent parts, adopting a transactional perspective enabled Johansson (2009) to understand older people’s home modification process as ‘directed towards creating situations with possibilities to perform activities in accordance with their values and preferences’ (p.50).

3.4 Deweyan Pragmatism and Mixed Methods Research Mixed methods research is described as the ‘third research paradigm’ (Johnson and Onwuegbuzie, 2004 p.15). Moving away from the earlier

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Chapter 3 – Philosophical Assumptions division between quantitative / post positivist and qualitative/subjectivist research traditions, mixed methods research has emerged as a methodological orientation which includes ‘mixing philosophical positions, inferences and the interpretations of results’ (Creswell and Plano-Clark 2011 p.2). Throughout its history mixed methods researchers have argued that pragmatic philosophers’ perspectives on inquiry and the nature of knowledge are suitable and supportive of mixed methods approaches (Creswell and PlanoClark 2011; Heatwole-Shank, 2013). For Taskakkori and Teddlie (2003) the central rationale for the use of pragmatism in mixed methods research is based upon the pragmatic belief that the research question is of primary importance and, therefore claims of knowledge should emerge from the research process, rather than from preexisting paradigmatic positions or beliefs. Pragmatism offers the researcher the possibility to develop research which emerges from an experienced problematic situation (Cutchin, 2008b), is driven by the particular research question (Tashakkori and Teddlie, 2003) and, whose methodological choices are made on the basis of how to best increase understanding of the problematic situation (Morgan, 2007). Heatwole-Shank (2013) suggests that while early mixed methods researchers frequently called upon pragmatisms a means of ‘ex post facto justification for the use of plural methods in research’ (p.183), there are a number of significant points of congruence between Deweyan pragmatic thinking and mixed methods research including holism, provisionality of knowledge, the situatedness of inquiry and the value-laden nature of research. 71

Chapter 3 – Philosophical Assumptions 3.4.1 Holism Dewey’s concept of transaction demands that researchers adopt a holistic approach to their work (Garrison, 2001). Adopting a transactional perspective means, recognising that the essential character of elements, is contingent upon and changes according to the composition of other elements in the situation (Aldrich, 2008). Research into action then must take a broader view, addressing the whole situation (Dickie et al., 2006) and any element of interest is ‘in-relationship- with-the-whole’ (Heatwole-Shank, 2013 p. 188). For Dickie et al. (2006), this anti-dualism present in Dewey’s pragmatism, means that researchers cannot expect to understand a transaction from an individualised subjective stance, while Garrison (2005) notes that methodological approaches which reduce situations to separate parts will fail to fully capture the emerging process involved in a given situation. HeatwoleShank (2013) suggests that mixed methods research, by allowing the researcher to focus on the elements of a situation as well as the relationship between these elements, is congruent with a transactional perspective. Furthermore, she suggests that the methodological flexibility offered by mixed methods research, enables the researcher to choose different approaches to examine both the elements of the situation and the relationship between these elements, while at the same time ensuring that understanding of the ‘transactional whole emerges when these data are integrated’ (Heatwole-Shank, 2013 p.188)

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Chapter 3 – Philosophical Assumptions 3.4.2 Provisionality For Dewey inquiry is an on-going process that is never complete and thus all knowledge is provisional and subject to revision (Boisvert, 1998; Fesmire, 2003). In contrast with a positivist paradigm, Dewey proposes that the process of inquiry should be grounded in previous enquiry i.e. ‘warranted’ and that the outcome of such inquiry should not be presented as a static truth but rather as the best judgement based on the available evidence (assertions) (Crick, 2010). Johnston and Onwuegbuzie (2004) describe the knowledge generated by researchers adopting a pragmatic perspective as ‘lowercase t truths’ (p.74) and suggest that such truths must be considered instrumental, partial and provisional. For Heatwole-Shank (2013) this approach to knowledge generation is consistent with the use of mixed methods, and she argues that in exploring situations using different methods, researchers are facilitated to generate multiple understandings of transactions which in turn can be combined to provide stronger basis for warranted assertions. 3.4.3 Situated Inquiry For pragmatists, inquiry is situated in and cannot be separated from a particular social, historical, political and cultural context (Heatwole-Shank, 2013). For Dewey the relationship between the knower and the known is itself a transaction, (Campbell, 1995) and the purpose of knowledge and understanding is to solve problems and bring about positive change. Heatwole-Shank (2013) suggests that this purpose-orientation towards the process of inquiry is a clear point of alignment between pragmatism and

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Chapter 3 – Philosophical Assumptions mixed methods research. The purpose-orientation ensures that both pragmatism and mixed methods research endorse pluralism and integrated eclecticism as a means of generating deeper understanding of people and the world (Johnson and Onwuegbuzie, 2004). 3.4.4 Value Laden Inquiry According to Johnson and Onwuegbuzie (2004) pragmatism acknowledges an explicitly value laden approach to research and recognises that values play a large role, both in the practice of conducting research and the process of drawing conclusions from research findings. Unlike positivists, who propose that research is value free, pragmatists acknowledge that the researcher and the researcher’s context will influence decisions concerning what questions to ask, which problematic situations to address and in what way (Morgan, 2007; Tashakkori and Teddlie, 2003). Dewey proposed that the knowing subject affects the object of knowledge (Maxey, 2003) and the implication of this assertion is that the research process cannot be separated from the researcher. Cherryholmes (1992) identifies this position of value laden research, as an essential component of pragmatism and suggests that ‘pragmatic research is driven by anticipated consequences. Beginning with what he or she thinks is known and looking to the consequences he or she desires, our pragmatist would pick and choose how and what to research and what to do’ (pp.13-14).

Heatwole-Shank (2013) proposes that having accepted the value laden nature of research, pragmatists are freed from the constraints of formalism and instead can focus on identifying and selecting the most appropriate methods

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Chapter 3 – Philosophical Assumptions to understand problematic situations and generate useful knowledge. She argues that this understanding of the nature of inquiry is embodied in mixed methods approaches, making them particularly well suited for researchers guided by the philosophy of pragmatism.

3.5 Implications of adopting a Pragmatic stance for this research study. The strong alignment between the philosophies of occupational therapy, the nature of person-environment relationships and mixed methods research, makes adopting a pragmatic stance particularly well-suited for studying processes of ageing in place. In relation to the current study adopting a pragmatic stance provides the researcher with a mandate to adopt a holistic perspective towards the phenomenon of ageing in place and provides support for data collection strategies which consider people, their psychological processes, the physical environment and temporal qualities of the phenomenon. A pragmatic stance grounded in Dewey’s transnationalism offers the opportunity to explore the multi-layered nature of ageing in place. In particular, the emphasis placed on the temporal characteristics of phenomena guided the decision to adopt a longitudinal approach during phase two of the study. Following pragmatic perspective that temporal qualities are integral to events, the researcher decided to follow participants over a period of twelve months in order to allow events of ageing in place to unfold at their own pace. Finally Dewey’s understanding of formal causality which draws from Aristotle’s formal ‘cause’, focused the direction of the research towards understanding how 75

Chapter 3 – Philosophical Assumptions different aspects of person-environment relations fit together to form a coherent experience of ageing in place, rather than attempting to look for cause and effect relations between events or entities.

3.6 Conclusion This chapter has set out the philosophical assumptions that guide the research study. In the next chapter these assumptions are operationalised through a detailed account of the research method used to address the research questions.

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Chapter 4 Methodology

Chapter 4 4.1 Introduction The need for new and novel approaches to explore person-environment transactions has been acknowledged within environmental gerontology (Gitlin, 2003; Schwarz, 2012;Vasunilashorn, Steinman, Liebig and Pynoos 2012; Wahl and Weisman, 2003). Existing research has yet to completely describe or explain the dynamic relationship that exists between older people and their home environments. This is of concern, because since the early 1920’s, researchers in the field of environmental gerontology have attempted to understand the reasons why older people respond differently to similar levels of environmental demands. Improved knowledge in this area, will contribute to the development of intervention strategies designed to maximise the efforts of older people to remain at home, thus improving health, wellness and

quality

of

life.

However,

despite

extensive

research

from

multidisciplinary perspectives 90 years later, the fundamental question of how to comprehensively explain successful or unsuccessful ageing in place remains unanswered and researchers continue to seek new approaches to generate understanding of the dynamics of ageing in place (Rowles and Bernard, 2013; Schwarz, 2012; Wahl et al., 2012; Wahl et al., 2010; Wahl and Oswald, 2010). The previous chapter provided an overview of the research paradigm that guides the present study. This chapter focuses on explaining how this 77

Chapter 4 Methodology paradigm is operationalised. The chapter provides an overview of the research design and details the approach taken during data collection and analysis. The overall research design is presented and a detailed account of each of phase of the research is provided. Particular emphasis is given to the approach taken to integrate methods throughout the study. The chapter also provide a discussion on ethical issues that were considered throughout the study.

4.2 Research Design This research used a sequential explanatory mixed methods design (Creswell and Plano-Clark 2011;Tashakkori and Teddlie, 2003) integrating a crosssectional survey design and a qualitative case study design, using the principles of constructive grounded theory (Charmaz, 2006). Mixed methods research is described as a method of collecting, analysing and integrating both qualitative and quantitative data at some stage during the research process within a single study (Ivankova et al., 2006). Morse (1991) suggests that through using mixed methods, researchers can obtain complementary findings that ‘strengthen research and contribute to theory and knowledge development’ (p.122). Creswell and Plano-Clark (2011) describe the sequential explanatory design as a two phase mixed methods design. During the first phase quantitative data are collected and analysed. The second qualitative phase of the study is designed so that it follows from or is connected to the first phase of the study. Typically, the purpose of the sequential explanatory design is to use qualitative data to explain the initial quantitative results (Creswell and Plano-

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Chapter 4 Methodology Clark, 2011). However, in this study, a variation of the explanatory design known as the participant- selection variant was used. Creswell and Plano-Clark (2011), consider the participant-selection variant as a study design where greater emphasis is placed upon the second qualitative phase rather than the first quantitative phase. Morgan (1998) describes this approach as a quantitative preliminary study design, where the knowledge generated by the initial small scale use of quantitative methods, guides the decisions made by the researcher in the qualitative part of the study. In the current study, the cross-sectional survey and resultant predictive models of housing related control beliefs were used to guide the selection of cases in the qualitative phase and to provide a context in which the qualitative findings could be understood. Thus information gathered during phase one of the study was used to categorise participants according to the type of housing related control beliefs they expressed. Furthermore the knowledge generated by the predictive models of housing control belief was used to develop as a sensitizing concept during data collection and analysis in phase two of the study.

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Chapter 4 Methodology

4.3 Procedure for Data Collection, Analysis, Interpretation and Mixing The value of visual models for graphically representing mixed methods procedures has been recognised within the research literature (Tashakkori and Teddlie, 2003). Using the notation system devised by Morse (1991), and following the recommendations of Ivankova et al., (2006) a graphical representation of the procedure used in this study is provided in Figure 4.1

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Chapter 4 Methodology

Figure 4.1 Overall Research Procedures The study was organised in two phases. During phase one, preliminary quantitative data were collected using a cross sectional survey design. In

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Chapter 4 Methodology phase two, a qualitative case study design, guided by the principles of constructive grounded theory (Charmaz, 2006) was used to collect in-depth data from nine participants who were purposively selected from phase one. The relationship between the two phases was an interactive one (Greene, 2007), that is although the two phases were conducted in sequence, data from phase one interacted and influenced the data collection and analysis during phase two. Creswell and Plano-Clark (2011) use the term mixing, to refer to the process of implementing this interactive relationship. Within the research procedure, the point at which quantitative and qualitative phases are mixed is known as the point of interface (Morse and Niehaus, 2009). These points of interface are highlighted in blue in figure 4.1. In this study mixing occurred following completion of phase one, prior to the design of phase two and following completion of phase two. At the first point of interface a connecting mixing strategy (Creswell and Plano-Clark 2011) was used and data analysis from phase one informed the recruitment of participants and collection of data in phase two. At the second point of interface following completion of phase two, the results from each of the two strands were compared and synthesised, in order to develop a final interpretation which reflects what was learnt from the combination of the both phases of the study. In the following sections, each of the phases of the study will be presented in detail.

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4.4 Phase 1 Cross Sectional Survey Design Phase one of the study used a cross-sectional survey design to explore patterns of housing related control beliefs among community dwelling older people. The overall aim of cross-sectional research is to provide a snapshot of a particular variable, (in this instance housing related control beliefs), in a population at a given point of time. Key advantages of this type of research design include the facility to collect data from large groups of people relatively quickly and easily, the potential to study multiple outcomes and measures simultaneously and the facility to generate both descriptive analyses of variables of interest, as well as hypotheses about possible associations between variables (Field, 2009). However, this type of study design also has a number of weakness, including the limited ability to draw firm conclusions about associations or possible causality as all variables are measured simultaneously and the potential for recall bias as the collection of information is retrospective. In addition, cross sectional research is susceptible to the problem of non-response, which may result in biased reporting. This becomes particularly problematic when the characteristics of non-responders are unknown or are different from responders (Field, 2009). Data for cross-section research can be gathered using a range of survey methods such as face-to-face interview survey, telephone survey, postal survey or electronic survey. Within the research literature there is on-going debate regarding the best approach to data collection in cross sectional research (Fowler et al., 1999; O'Toole et al., 1986; Sinclair et al., 2012,). De Vaus (2002) suggests that the choice of survey method is dependent on the 83

Chapter 4 Methodology nature of the survey, the need for representative samples, time and cost constraints, the relative importance of response rates and the types of questions that are included in the survey. In this study, a postal survey was chosen as the most appropriate form of data collection. Postal surveys have been described as a being particularly useful when the questionnaire is brief and individual questions are relatively straightforward. Postal surveys also enable researchers to access whole populations and are not constrained by issues of exclusion associated with telephone coverage or access to Internet. This is particularly important in an Irish context where recent research has suggested that only 64% of the population have access to fixed line telephones and that mobile phone ownership is significantly lower among older people than among younger people (ComReg, 2010). Similar challenges are associated with the use of Internet based surveys among older people. Access to the Internet by people aged 60 – 74 is limited to 27% of the population (Central Statistics Office, 2012) and among those aged 74 and older is as low as 3% (Amárach Research, 2011). Considerations of time and costs associated with data collection also supported the decision to use a postal survey. Arguably, face to face interviews enable researchers to collect higher quality information (Bowling, 2005) however practical considerations regarding the time and cost associated with collecting sufficient data meant that this approach was not realistic. Furthermore research has indicated that among older people , postal surveys led to higher response rates than face-to-face data collection (Doll et al., 1991, 84

Chapter 4 Methodology Smeeth et al., 2001). On the other hand, it has been noted that response rates to cross sectional survey are falling (Sinclair et al., 2012) thus reducing the effective sample size and increasing the likelihood of respondent bias. A number of papers have identified challenges of low response rates when using postal questionnaires (Asch, Jedrziewski & Christakisi, 1997; Maeda & Abe, 2010; Sinclair et al., 2010; Yu & Cooper, 1983). In this study several strategies were implemented in order to increase the likelihood of response to the postal survey. These were (i) signing the initial introduction letter by hand (ii) printing the questionnaire on single sided paper (iii) printing the survey horizontally (iv) including a stamped addressed envelope to facilitate return of the completed questionnaire and (v) making follow up contact with all participants within three weeks of sending out the initial questionnaire by sending reminder letters to gatekeepers. Edwards et al. (2009) suggest that these strategies increase the odds of response by between one tenth to more than a quarter. 4.4.1 Sampling A non-probability sample of older people (n=159) was recruited through organisations known to the researcher, which represented and provided support to older people. These organisations included active retirement groups, Church groups, disability support groups, organisations providing social supports such as meals-on-wheels and befriending services and housing associations. These organisations were chosen on the basis that the

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Chapter 4 Methodology populations they represented and/or provided services to fulfilled the inclusion criteria for the study. As the overall aim of the quantitative phase was to guide more extensive qualitative exploration, non-probability sampling was an appropriate choice, which enabled the researcher to gather the required data quickly and efficiently. Furthermore, as there was no intention to generalise the findings of the cross sectional survey beyond the target population sampled, random sampling was not necessary. Non-probability sampling is frequently criticised in the research literature for failing to address issues of sampling bias and for its limitations with regard to generalisability of results (Creswell and Plano-Clark, 2011) however given the overall purpose of phase one of the study these issues had less relevance for the research. The sample size required for the research was influenced by the aim of developing predictive models of housing related control beliefs and followed guidelines for sample size in regression analysis proposed by Field, (2009). Using the rule of thumb guide proposed by Field (2009) of 15 participants per predictor variable, a sample size of 150 was calculated in order to provide an adequate power for models of up to 5 factors, whilst also accounting for the possibility of missing or incomplete data (Grant, 2010 personal communication). 4.4.2 Recruitment Participants were recruited from older people (age 65 and over) living in the West of Ireland. Inclusion criteria were (i) aged 65 or over (ii) currently living 86

Chapter 4 Methodology in private home in the community i.e. not living in a nursing home or assisted living facility (iii) willing to give consent to participate in the study (iv) capable of completing the self-report questionnaire. All participants were provided with participant information sheets outlining the aims of the study together with the study procedure (See Appendix B for details). Written informed consent (See Appendix C) was obtained from all participants prior to commencing data collection. 4.4.3 Measurement Device During phase one of the study, data were collected using two self-report questionnaires. These were, (i) the Housing Related Control Beliefs Questionnaire (Oswald et al., 2003) and (ii) a short questionnaire developed for the study to collect information relation to participants’ housing, health and demographic characteristics (See Appendix E for a copy of this questionnaire). 4.4.3.1 Housing Related Control Beliefs Housing-related control beliefs were measured using the Housing Related Control Beliefs Questionnaire (Oswald et al., 2003). This 24-item questionnaire (See Appendix D for a copy of the questionnaire) examines three dimensions of housing-related control beliefs; internal control (8 items); external control: powerful others (8 items) and external control: chance (8 items). Each item is assessed in terms of the individual’s level of agreement with a statement relating to perceived housing control based on a Likert scale of 0 (not at all) to 5 (very much). 87

Chapter 4 Methodology The housing related control beliefs questionnaire was chosen as it provided an explicit mechanism for measuring perceived housing related control. Other measures of the home environment such as Housing Accessibility (Iwarssson & Stahl, 2005) or Usability in the Home (Fänge & Iwarsson, 2003) were considered however as these measures did not address issues of housing related control beliefs they were not used. This measure has previously been used in range of different cultural contexts and appears to have strong cross-cultural validity (Oswald et al., 2007, Oswald et al., 2003). However its psychometric properties are not well established. In the original development of the tool Oswald et al.(2003) reported Cronbach’s alpha co-efficients for the external control: powerful others subscale of between 0.66-072 and for the external control: chance subscale of 0.83-0.76. In order to increase the internal consistency of the internal control subscale, one item was removed from the scale and the resultant 7- item scale had a Cronbach’s alpha coefficient of 0.59 -0.68. In a later study the Oswald et al. (2007) returned to the 24-item questionnaire and reported a Cronbach’s alpha coefficient of 0.65 for the internal control scale, but in this study they combined the two external control scales to generate a Cronbach’s alpha coefficient of 0.72.In the current study, the Cronbach’s alpha coefficient was 0.75 for the internal control subscale, 0.74 for the external control powerful others and 0.55 for external control chance. Bland and Altman (1997) suggest that for comparing groups Cronbach’s alpha coefficient scores of between 0.7 to and 0.8 may be regarded as satisfactory and this figure is typically used within psychological and social 88

Chapter 4 Methodology science research. However lower levels of alpha coefficient may be acceptable in some situations and Schmitt argues there is ‘no sacred level of acceptable or unacceptable level of alpha’ (1996 p.353). Using these guidelines both the internal control scale and the external control powerful others scale were considered to have acceptable levels of internal consistency. Given its relatively low alpha coefficient further consideration was given to the external control chance scale. Examination of the data failed to identify any specific item variance and so no items were removed from the scale. The impact of the length of the scale was also considered; given that alpha coefficient is a function of the interrelatedness of scale items and the scale length (Cronbach, 1951; Cronbach, 1947). Given the brevity of the scale, it perhaps not surprising that the alpha coefficient is low and in fact the relevance of using alpha coefficients for very short scales has been questioned (Kline, 2000). Schmitt (1996) suggests that one solution to this problem is to lengthen the scale, however further development of the scale was beyond the scope of this research. Instead the researcher accepted what Romero (2012) describes as the ‘inevitable trade-off between psychometric purity and practicality’ (p.4) and used the scale in its original format, while acknowledging that the low alpha score could potentially indicate low reliability and a potential for underestimating interrelatedness of the test items.

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Chapter 4 Methodology 4.4.3.2 Variables with potential to predict housing related control beliefs A 17-item questionnaire (see Appendix E for details) was used to explore the potential predictive power of selected variables on housing related control beliefs. This questionnaire sought information on demographic, housing and health related variables considered likely to influence the outcome variable (housing related control beliefs). These predictor variables were selected through analysis of the related literature and earlier studies of housing related control beliefs among older people (Oswald et al., 2003; Oswald et al., 2007; Wahl et al., 2009). Some of the demographic information gathered was potentially sensitive in nature i.e. income levels, details of personal assets etc. Initial discussions with participants in the pilot study (detailed in the next section) indicated that older people in Ireland might have concerns about sharing data relating to income. While no data was available from an Irish context, there has been some research in the United Kingdom suggesting that inclusion of sensitive questions such as those relating to income or indicators of wealth can lead to increased levels of non-response or missing data (Office for National Statistics, 2011). However this research was conducted among the general population and an earlier randomised control trial by Shah et al. (2001) among older people in the United Kingdom indicated that inclusion of income questions did not reduce response rate. Based upon the lack of clear evidence of the impact of sensitive questions on response rates and given that previous research had indicated that socio-

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Chapter 4 Methodology economic status might impact upon sense of personal control (Lachman and Weaver, 1998), despite the potential to impact upon the response rate a question relating income was included in the survey. In an attempt to lower the likelihood of missing data or non-response, data relating to income were collected using categorical responses used with the national census survey (Central Statistics Office, 2007) and all participants were assured that the data would remain confidential and would not be shared with other agencies. 4.4.4 Pilot Study There is general agreement within the research literature that pilot studies are a useful method for trialling a study design and for testing the suitability of the research instruments (Gardner et al., 2003). Piloting of research materials is particularly important in studies where participants are required to selfcomplete forms (Lancaster et al., 2004). Van Teiklingen and Hundley (2002), suggest that effective pilot studies offer the researcher advance warning of issues which may cause the research project to fail and to unearth local politics and practices which may affect the research process. Gardner et al., (2003) argue that in order to be most effective pilot studies should, be based upon the methodological framework established for the main study, involve a sample size of 10% of the main study and should be focused on process outcomes in order to ensure successful operational procedures for the main study. Based on these guidelines a pilot study was designed which enabled the researcher to (i) validate recruitment and consent procedures; (ii) confirm the

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Chapter 4 Methodology inclusion and exclusion criteria and (iii) test the appropriateness of instruments used in the main study. The pilot study was completed in April 2011. 15 older people were recruited to the pilot study. Recruitment and data collection procedures followed those set out for the main study. Outcomes of the pilot study are provided in Table 4.1

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Chapter 4 Methodology Table 4.1 Outcomes of the Pilot Study (Phase 1)

Pilot Objective

Findings

Modifications made to the main study

Validate recruitment and Recruitment procedure was generally successful although the need for Gatekeepers were sent reminder letters consent procedures follow-up was highlighted after 3 weeks during the main study Confirm inclusion exclusion criteria

and Gatekeepers were uncertain regarding including older people who Further explanation of inclusion and lived in supported housing; a number of people who did not meet the exclusion criteria was included in the age criteria were recruited to the pilot study by gatekeepers cover letter sent to gatekeepers. Data collection instruments were found to generate appropriate No changes were made to the data information to address the research aims. collection instruments Survey questions were generally well understood by the participants.

Test the appropriateness of instruments used in the main study

Sensitive questions relating to income were adjusted to allow for categorical responses.

Some concerns were raised regarding the need for information relating Additional assurances of confidentiality to income. Participants were particularly concerned that this were included in the information pack. information might be subsequently shared with statutory service Categorical responses were guided by providers. national census formats (Central Statistics Office, 2007).

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4.4.5 Data Collection Procedures Data collection for phase one was completed between May and September 2011. The researcher identified staff within organisations and groups of older people in the community who could act as gatekeepers and assist with recruitment. The researcher contacted each of these key contacts and sought permission to recruit older people who participated in the activities of the group or were in receipt of services provided by the organisation to the study. Where such permission was granted, the researcher prepared a survey pack for each potential participant. Survey packs were distributed to older people who were interested in the study by key contacts in the organisations. Examples of types of organisations who granted permission to recruit older people included active retirement groups, organisations providing social supports for older people, neighbourhood groups, Churches and organisations representing specific needs of patient groups. Each survey pack contained (i) information relating to the study (ii) consent form (iii) Housing Related Control Beliefs Questionnaire (Oswald et al., 2003) and (iv) 17-item questionnaire. In addition participants were provided with a stamped addressed envelope to facilitate return of the survey. 4.4.6 Data Analysis Raw data in the form of completed surveys was coded (See Appendix F for details) and then entered into SPSS Version 18.0 for Mac. As advocated by Pallant (2010), the completed data set was systematically screened and checked for errors prior to commencing data analysis. 94

Chapter 4 Methodology Descriptive statistics were used to explore patterns of housing related control beliefs and housing, health and demographic characteristics among the sample population. Predictive models of housing related control beliefs were built from the following variables: age, household income, education, home ownership, perceived health, perceived suitability of the home environment, home adaptations, use of aids or appliances, marital status, length of time in current residence and gender. Sequential multiple regressions were performed; that is each predictor variable was entered or removed in one step in an order that was determined by the researcher. When determining the order of entry of variables into the model, variables previously identified as influencing housing related control beliefs (Oswald et al., 2003) were entered in earlier steps; the order of additional factors was determined arbitrarily. On this basis variables were entered into the models in the following order: Step 1, age; Step 2, household income; Step 3, educational attainment; Step 4, home ownership status; Step 5, perceived health; Step 6, perceived suitability of the home environment; Step 7, presence of home adaptations; Step 8, use of assistive technology; Step 9, marital status; Step 10, length of time in current residence and Step 11, gender. To assess the contributions of individual predictor variables the t- tests for the individual regression slopes were examined. Significance was set at p < 0.05. If the t-test for the individual regression slope was not significant then that predictor variable was excluded from the next model.

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4.5 Point of Interface 1 – Connecting between the quantitative phase and the QUALITATIVE phase At the first point of interface, the overall aim was to use the knowledge generated by the initial quantitative phase to guide the selection of participants for the qualitative phase of the research. Using the results generated during the quantitative phase of the study, participants who indicated willingness to participate in phase two of the study were categorised according to their housing related control beliefs. This led to the creation of four groups of participants (i) those who reported higher levels of internal housing related control beliefs, (ii) those who reported higher levels of external chance housing related control beliefs, (iii) those who reported higher levels of external powerful others housing related control beliefs, and (iv) participants who did not report a clear type of housing related control beliefs. Purposeful sampling (Patton, 2002) was used to select information rich cases from each of this group for in-depth study during phase two of the research. Using the principle of maximum variation i.e. heterogeneity (Patton, 2002), a sampling matrix was developed (See Appendix G for details), in order to identify a sample of cases in which each case was as different as possible from other cases in relation to characteristics which were previously found to predict type of housing related control beliefs.

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4.6 Phase 2 Processes of Ageing in Place Phase two of the research aimed to capture the processes of ageing in place from the perspective of older people living in the community, who reported different patterns of housing related control beliefs. Charmaz (2006) drawing from pragmatist conceptions of emergence, describes processes as consisting of ‘unfolding temporal sequences that may have identifiable markers ..the temporal sequences are linked in a process and lead to change’ (p.10). Similarly, Van de Ven and Huber (1990) describe process research as being concerned with both how and why things evolve as they do over time. The current study explores the process of ageing in place, and specifically the processes involved in responding to problematic situations in the home environment. The primary questions posed during this phase of the research was ‘how do older people practice ageing in place ?’ and ‘why do they practice ageing in place in this way?’ Van de Ven (2007), drawing from the work of Mohr (1982), suggests that two different understandings of process can be used to explore changes. In the first, process is seen as a ‘category of concepts or variables that pertain to actions and activities’ (p.3). This understanding of process is closely linked to variance theory methodology (Mohr, 1982) that explains phenomena in terms of the relationships that exist between dependent and independent variables. Researchers adopting a variance theory approach to studying processes, typically seek to examine the antecedents’ and/ or consequences of change (Van de Ven, 2007).

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Chapter 4 Methodology The second approach to process research draws from narrative accounts of how things develop and change to answer the question of how, rather than if change occurs (Van de Ven, 2007). Mohr (1982) suggests that in order to develop a ‘process’ theory that explains how change occurs, it is necessary to understand patterns in events and to explore temporal ordering and probabilistic interaction between entities. As the primary aim of this study was to understand how older people age in place, the second approach to process guided the development of phase two of the research. In this way the central focus during phase two was on what Van deVen (2007) refers to as a ‘progressions’ (p. 4) that is ‘the nature, sequence and order of activities or events that an entity undergoes as it changes over time’ (p. 4). Langley (1999), referring to studying processes of organisational change, cautions researchers that process data are complex and making sense of processes is challenging. She suggests that process data are composed of events rather than variables. The nature of events means that process data are fluid and spread out over time and space, thus making it difficult to isolate units of analysis in an unambiguous way. She also notes that although the use of the term ‘event’ signifies some type of temporal precision, the temporal boundaries of processes are rarely clearly defined. Langley (1999) also highlights that in order to capture background trends which moderate the progression of events, researchers may be required to combine historical data collected through retrospective interviews with current data collected in real time; and cautions researchers that comprehensive understanding of processes requires more than descriptions of discrete events, resulting in

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Chapter 4 Methodology complex data sets which makes analysis and interpretation of data complicated and time consuming. For Langley (1999) these characteristics mean that understanding how and why events play out over time, requires indepth exploration using sophisticated methods. Similar recommendations have been made by Johansson (2008) in relation to exploring older people’s experiences of home modification processes, and by Rosenberg and Nygård (2012) regarding people with dementia and the process of using assistive technology. 4.6.1 Research Methodology Patton (2002) proposes that qualitative research is particularly useful for studying processes because (i) clear description of processes requires detailed explanation of how people engage with and relate to each other (ii) the experiences of processes are different for different people and therefore it becomes important to capture peoples experiences of processes from their own perspective and in their own words (iii) the dynamic and fluid nature of processes mean that they cannot be captured or summarised on a single rating scale and (iv) participants’ perspectives are a key consideration in any understanding of process. In this phase of the study a qualitative research approach was selected, as it allowed the researcher to generate understanding of human action and to ask questions about practices of ageing in place as they occurred, rather than setting out to examine pre-determined hypotheses (Carter and Little, 2007; Schwandt, 2001). Within this framework following consideration of the

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Chapter 4 Methodology overall research objectives an interpretive case study design, (Stake, 2000) guided by constructivist grounded theory data gathering and analysis methods (Charmaz, 2006), was chosen as the research methodology, to develop an understanding of the processes of ageing in place when confronted by problematic situations in the home environment. Case study methodology (Stake, 1995; Yin, 2009) and grounded theory methods (Glaser and Strauss, 1967; Charmaz, 2006) are distinct traditions within a broader qualitative research framework (Creswell, 2013). Each offers different strengths and weaknesses in relation to the current research question and the decision to combine the approaches was driven by a desire to maximise the strengths of both. While combining case study design with grounded theory approaches is not new, (see for example (Bowyer and Davis, 2012; Lauckner, 2010), Glaser and Strauss (1967) caution that researchers who wish to combine grounded theory methods with other research designs, must be careful to ensure epistemological and methodological consistency between methods. In the next section the epistemological foundations of both constructivist grounded theory methods (Charmaz, 2006) and case study design (Stake, 1995; Yin 2009) are considered and the extent to which they are congruent is discussed. This is followed a description of the data gathering methods used during phase two of the research and a detailed account of the approach to data analysis.

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Chapter 4 Methodology 4.6.1.1 Constructivist Grounded Theory Grounded theory methods emerged from the seminal work of Glaser and Strauss (1967) on dying in hospitals. The constant comparative method (later named grounded theory) was developed to enable researchers to construct abstract theoretical explanations of social processes. Charmaz (2006) notes that from the outset grounded theory methods have accommodated diverse philosophical perspectives and in its original format, grounded theory combined the contrasting traditions of Columbia University positivism with Chicago School pragmatism. In his initial use of grounded theory methods, Strauss placed emphasis on the study of process, suggesting that humans are active agents who seek to create structure in their lives and their worlds. Charmaz (2006) suggests that Strauss brought a pragmatic perspective to grounded theory and she credits him for incorporating ‘notions of human agency, emergent processes, social and subjective meanings, problem-solving practices, and the open-ended study of action’ (p.7) into grounded theory methods. In contrast Glaser with a background in positivism, brought a tradition of empirical research with what Charmaz (2006) refers to as a ‘rigorous codified methods’ (p.7) that draw from

quantitative

research

methodologies.

Following

their

initial

collaborative work both Glaser and Strauss developed grounded theory methodology independently of each other, leading to Straussian and Glaserain versions of the method (Stern, 1994). Charmaz (2006) suggests that in developing separate versions of the methodology Glaser has remained consistent with the earlier discussion of the method relying on direct 101

Chapter 4 Methodology empiricism as a means of analysing basic social processes. Charmaz (2006) contrasts this approach with the direction taken by Strauss who she suggests has moved towards verification and emphasised new technical procedures rather than the use of the constant comparative method. The second generation of grounded theorists have continued to develop the work of Glaser and Strauss, with many of these theorists moving away from the positivist assumptions that are embedded in the original methods. Charmaz has been described as one of these second generation grounded theorists and is widely acknowledged for her work in developing an interpretive tradition in grounded theory commonly referred to a constructivist grounded theory (Creswell, 2013). Charmaz (1990; 2006) suggests that a constructivist approach to grounded theory is based upon an assumption that neither data nor theories are discovered, instead they are constructed through the on-going involvements and interactions with people, perspectives and research practices. For Charmaz (2006), constructivist grounded theory is explicitly different to traditional grounded theory approaches, because it assumes that any theoretical abstraction that emerges from data is an interpretive portrayal of the process studied rather than an absolute picture of it. For Charmaz (2006) the essence of constructivist grounded theory lies in the acknowledgment that the theory is not an objective explanation of events but rather is dependent upon the researcher’s view. Mills, Bonner and Francis (2006) describe constructivist grounded theory as ontologically relativist and epistemologically subjectivist. For Mills et al. (2006) the constructivist grounded theory approach requires that the 102

Chapter 4 Methodology researcher: (i) attends to creating a sense of reciprocity with the research participant, which facilitates co-construction of meaning and ultimately results in a theory which is grounded in both the participant’s and researcher’s experience; (ii) establishes a relationship between the researcher and research participant which explicates power imbalances and attempts to moderate these imbalances and (iii) provides clarification of the position of the researcher in producing the final text. This study used constructivist grounded theory (Charmaz, 2006) to guide the data collection and analysis during phase two of the study. The decision to adopt a constructivist grounded theory was driven by the overall pragmatic stance adopted throughout the study. As discussed in chapter three, pragmatism emphasises the provisionality of knowledge and the value-laden nature of research (Heatwole-Shank, 2013). Constructivist grounded theory (Charmaz, 2006) accommodates this perspective and facilitates the researcher to draw upon multiple methods of data collection and analysis in order to generate assertions. 4.6.1.2 Case Study Method Case study methods have been described as an appropriate research choice to explore how and why questions, particularly when these questions seek explanatory knowledge of how processes emerge over time (Yin, 2009).

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Chapter 4 Methodology Similar to grounded theory methods, case study methods have also traditionally incorporated both positivist and interpretive traditions. Yin (2009) positions case study methods within a positivist tradition and emphasises case study methods as an approach to empirical inquiry that investigates a contemporary phenomenon in depth within its real-life context. For Yin (2009) case study methods are most useful when the boundaries between the phenomenon and its contexts are not clear. Consistent with a positivist tradition Yin (2009) suggests that prior to data collection, the case study researcher should develop theoretical propositions to guide data collection and subsequent analysis. For this reason Yin (2009) advocates that researchers should conduct comprehensive reviews of existing research during the case study design phase and should use this knowledge as a template with which to compare the result of the study. Yin (2009) refers to this comparison process as analytical generalisation and suggests that it is the cornerstone of case study research design. Yin (2009) also proposes that when a researcher conducts multiple case studies (as is the case in the present study) then the selection of these cases should follow a replication logic, that is, each case should be selected so that it (i) predicts similar results (literal replication) or (ii) predicts contrasting results but for different reasons (theoretical replication). Stake (1995) adopts a more interpretative stance towards the use of case study methods. He proposes that the case researcher is an interpreter who recognises and substantiates new meaning and proposes that case study research has two roles; (i) generating descriptions which clarify the 104

Chapter 4 Methodology phenomenon and its context and (ii) developing interpretations of the case in order to create a more sophisticated understanding of the phenomenon in its context. Stake’s (1995) interpretative stance draws from principles of relativity and suggests that each researcher will contribute differently to each case study and that each reader will derive unique meanings from each case study. For Stake (1995) these contributions are important to overall purpose of generating increased understanding of the immediate situation of the case. While the use of case study methods in the current study was largely guided by Stake’s (1995) interpretive stance, the initial design of the study also drew from Yin’s (2009) guidelines for case study development. Specifically the study drew from Yin’s (2009) ideas regarding literal and theoretical replication during the selection of case studies. This resulted in the development of a sampling matrix (See Appendix G for details), which enabled identification of two cases relating to each pattern of housing related control beliefs (literal replication). 4.6.1.3Epistemological Clarity This study used a combination of interpretative case study research methods and constructive grounded theory to explore how differences in patterns of housing related control beliefs might influence practices of ageing in place among a sample of older adults living in the community. While mixing of philosophical positions is a hallmark of mixed methods research (Creswell and Plano-Clark, 2011), the need for epistemological clarity and consistency when mixing methods has also been highlighted in the research literature.

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Chapter 4 Methodology Differences emerged between the two methods regarding the development of theoretical propositions and the use of existing literature. Steenhuis and De Bruijn (2004) suggest that many of these differences can be addressed by developing what they term ‘a progressive case study’ (p.7) that is a inductive (theory developing) case study approach orientated in an interpretivist paradigm whose outcome is ‘some theory that should not be considered validated but rather it contains concepts and possible relationships which create new insight and that can be tested in subsequent research’ (p. 7). Using this progressive case study approach require three key issues to be addressed in order to combine the strengths of both approaches: preparation of the first case and the role of existing literature; credibility of case findings and selection of subsequent cases (Steenhuis & De Brujin, 2004). Preparation of the first case For Yin (2009) prior development of theoretical propositions, which guide data collection and subsequent analysis is a prerequisite to case study design. Charmaz (2006) on the other hand suggests that while researchers may begin their work ‘alert to certain possibilities and processes in their data’ (p.16) these ideas should be used as a point of departure to develop new ideas rather than limiting the focus of data collection and subsequent analysis. Charmaz (2006) suggests that the researcher’s prior assumptions and knowledge might be usefully considered as what Blumer (1969) refers to as sensitising concepts and proposes that this prior knowledge can assist the researcher in deciding which questions to ask and what topic areas to pursue.

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Chapter 4 Methodology In the current study guided by Charmaz (2006) and Yin (2009) the researcher drew from the findings of phase one to develop tentative theoretical propositions to guide data collection and analysis in phase two. However as suggested by Charmaz (2006) the findings from phase one were used as a starting point and the researcher through regular discussion and reflection with the research supervisors was careful to ensure that the emergent theory was guided by the data collected during phase two rather than preconceived ideas and theories from phase one. Within grounded theory much has been written regarding the timing and relevance of the literature review (Charmaz, 2006). Classic grounded theorists have suggested that the literature review should be avoided until the analysis of data is complete in order to avoid forcing data to fit preconceived ideas (Glaser and Strauss, 1967; Glaser 1978). Charmaz (2006) like other second generation grounded theorists advocates a more pragmatic stance towards the production of the literature review. She suggests that while researchers may need to produce a literature review in order to satisfy the demands of funders and /or supervisors existing knowledge and early interpretations should be subjected to careful scrutiny. Henwood and Pidgeon (2003) have labelled this approach to managing pre-existing knowledge as theoretical agnosticism and Wertz et al., (2011) propose this approach complements the abductive reasoning inherent in constructive grounded theory.

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Chapter 4 Methodology Yin, (2009) on the other hand suggests that a comprehensive review of the literature must be conducted during the design of a case study. Stake (1995) does not offer specific guidance regarding the use of the literature review. In the current study, the existing literature was reviewed prior to commencing the study. This enabled the researcher to plan phase one of the study and to develop tentative analytical propositions based on the results from phase one. However in line with Henwood and Pidgeon’s (2003) concept of theoretical agnosticism during phase two of the research the research attempted to engage in a process of abductive reasoning where by all theoretical explanations were considered for unexpected findings and following this further data were collected in order to check these explanations until the most plausible explanation for the findings was achieved (Charmaz 2006; Wertz et al., 2011). Credibility of Case Findings Charmaz (2006) suggests that the core of grounded theory analysis lies in successive and increasingly higher levels of abstraction through comparative analysis. For Steenhuis and de Brujin (2004) a similar method of constant comparison is used within the progressive case study in order to develop insights and achieve credible case study findings. Within case study research the primary method through which constant comparison is achieved is through multiple sources of data and mixed data collection strategies. In addition when using multiple case studies the

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Chapter 4 Methodology opportunity for cross case comparison enables the researcher to identify new insights and refine existing concepts (Steenhuis & de Bruijin, 2004). In the current study this was achieved by on going analysis of individual cases and by careful cross case comparison to identify areas of divergence and convergence which where then explored in subsequent interviews with participants. Selection of subsequent cases The benefits of using multiple cases to support theory development have been highlighted in the research literature (Dooley 2002; Eisenhardt 1989; Lynham 2002). For Steenhuis and de Brujin (2004) the use of multiple case studies provides two purposes in theory building (i) it allows for further development of new concepts and insights and (ii) the facilitates replication of earlier findings. Steenhuis and de Brujin (2004) propose that the first of these purposes is closely aligned with the grounded theory’s emphasis on developing building up concepts and insights from data. Within grounded theory the process of coding data supports researchers to identify emergent ideas and concepts that guide future data collection. A similar principle is used in the selection of multiple cases where each additional case enables the researcher to identify new concepts and to further develop existing concepts. The use of Yin’s (2009) replication logic in selection of subsequent cases enables the researcher to strengthen the credibility of emergent theory by providing a mechanism at the case level for constant comparison. Thus while validation is not a primary purpose of replication

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Chapter 4 Methodology logic when using case studies to build theory (Steenhuis and de Brujin, 2004) the ability to determine whether concepts identified in one case are relevant to another case supports the development of a more nuanced understanding of how different factors combine and interact with each other. In the current study selection of the use of multiple case studies enabled the researcher to develop cross case comparison of concepts and supported refinement of the emergent theory. Furthermore the use of Yin’s (2009) replication logic to select cases facilitate integration of findings of phase one with phase two of the study and allowed the researcher to explore how housing related control beliefs influenced practices of ageing in place. 4.6.2 Data Collection Methods Both case study research design and constructivist grounded theory methods place strong emphasis on the need for researchers to collect rich data. Charmaz (2006), proposes that collection of rich data offers researchers the possibility of building significant analyses, while Yin (2009) identifies the richness of the data as a key determinant in ensuring high quality case studies. To achieve what has been described by Geertz (1973) as ‘thick’ description (p.6), both Charmaz (2006) and Yin (2009) advocate the use of a variety of data gathering strategies including (i) interviews (ii) direct observations (iii) documentation and (iv) physical artefacts. In addition Yin (2009), proposes that throughout the development of case studies, data collection activities should be guided by three principles (i) using multiple sources of evidence (ii) creating a case study database and (iii) maintaining a chain of evidence.

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Chapter 4 Methodology These principles were used in this study to develop a comprehensive data collection plan for phase two of the research (See Appendix H for full details). A series of in-depth interviews were conducted with each of the case study participants and where appropriate, interviews were also conducted with significant others who were identified by participants as playing a substantial role in everyday practices of ageing in place. Photo elicitation methods in the form of digital images, created by participants were used during the interviews in order to generate rich process orientated accounts of everyday practices of ageing in place. Furthermore in order to capture the background trends, which guided the progress of specific events, participants were asked to complete reflective diaries, which sought to capture everyday thoughts, actions and feelings about ageing in place. In the following sections further detail is provided regarding each of the data collection strategies used during phase two of the research. At the outset of the data collection process, a case study database was established using online mixed methods software Dedoose Version 4.5.95 (Socio Cultural Research Consultants, 2013). Data from each of the cases was linked to the quantitative data collected from the participants during phase one of the research and each piece of additional qualitative data was given a unique data management code by the researcher, in order to facilitate accurate storage and retrieval of data. As suggested by Creswell (2013), a matrix of information sources for each case (See Appendix I for details) was developed in order to maintain a clear audit trail of information flowing into the study.

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Chapter 4 Methodology 4.6.2.1 In-depth interviews Intensive in-depth interviewing has been described as a useful tool for data generation in qualitative research (Charmaz, 2006) and frequently plays a central role in the development of grounded theory (Creswell, 2013). During phase two of the research, a series of four in-depth interviews were carried out with each participant over a period of 12 months. The data from these interviews were the primary source from which the grounded theory emerged. While it is recognised within qualitative research literature that interviewing can take many forms (Kalekin-Fisman, 2002), there is a general consensus that the purpose of intensive in-depth interviewing is to elicit participants’ interpretation of his or her experiences (Charmaz, 2006) and to facilitate the researcher to enter the other person’s perspective (Patton, 2002). Intensive indepth interviewing differs from other forms of qualitative interviewing, such as the general interview or the standardised open-ended interview (Patton, 2002), in that it relies on a few broad open-ended questions with the aim of facilitating unanticipated stories to emerge (Charmaz, 2006). The flexibility of the intensive in-depth interview makes it particularly suitable for use in grounded theory studies and Charmaz (2006), notes that ‘the combination of flexibility and control inherent in in-depth interviews fits well with the grounded theory strategy of increasing the analytic incisiveness of resultant analysis’ (p.29). A distinguishing feature of the in-depth interview is that it is interactive in nature (Legard et al., 2003). Material generated during the course of an in-

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Chapter 4 Methodology depth interview is constructed through the interaction of the interviewee with the interviewer. Although the interviewer may ask the same initial question to all participants, the subsequent questions are likely to be determined by the interviewee’s response. Throughout the in-depth interview the aim of the researcher is to ‘achieve depth of answer in terms of penetration, exploration and explanation’ (Legard et al., 2003 p.141). To achieve this goal, the researcher uses a range of probes and follow-up questions, to generate a fuller understanding of the participants’ experiences and perspective. Patton (2002) suggests that although in-depth interviews may be unstructured, this does not mean that researchers should approach the interviewing process with a lack of focus. Interview questions must be chosen carefully so that the overall objectives of the research are achieved. Following guidelines offered by Charmaz (2006), prior to the first interview with each participant the researcher prepared a series of open-ended questions to guide the initial exploration of participants’ experiences (See Appendix J for details). Consistent with the constructivist grounded theory approach adopted during this phase of the study, the questions attempted to elicit ‘participants’ definitions of terms, situations and events’ (Charmaz, 2006 p. 28), with the aim of generating understanding of participants’ assumptions, implicit meanings and tacit rules. Subsequent interviews with each participant, used open ended questions to support further elucidation and elaboration of insights generated from previous interviews. Based upon the principles of constructivist grounded theory (Charmaz, 2006), the goal of repeated interviews in this study was to narrow the range of interview topics, so that

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Chapter 4 Methodology specific data were gathered in order to develop a theoretical framework which could explain everyday practices of ageing in place. Different perspectives have emerged within qualitative research regarding the nature of the interviewer interviewee relationship during the in-depth interview and the extent to which knowledge is constructed during the interview, is a pre-existing phenomenon, or develops as a reflective retrospective process (Charmaz, 2006; Kalekin-Fisman, 2002; Kvale, 1996; Legard et al., 2003; Seale, 1998;Silverman, 1998). Seale (1998), suggests that these differences can be broadly classified into two opposing views (i) the interview data as a resource – where researchers believe that the interview data reflects the interviewee’s reality outside of the interview and (ii) the interview data as a topic – where data collected during an interview are seen as a reality which is jointly constructed by both the interviewee and interviewer. This study was grounded in a constructivist tradition, and therefore interview process was viewed as an artefact emerging from a joint collaboration between the interviewer and interviewee (Dingwall, 1997). 4.6.2.2 Photo Elicitation Harper (2002) suggests that in-depth interviewing, regardless of format, faces a key challenge of establishing communication between two people who rarely share taken-for granted cultural backgrounds. Similar concerns are raised by Charmaz (2006), who reminds researchers that interviews are not neutral, but instead are frequently sites at which relative differences in power and status may be played out. Such dynamics must be carefully managed as

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Chapter 4 Methodology they are likely to influence both the character and content of interviews (Charmaz, 2006).Clark–Ibáñez (2004) suggests that one way to address this potential limitation of in-depth interviewing is to use photo-elicitation techniques to supplement and deepen interview data. In its most simple format photo elicitation refers to the process of inserting a photograph into the research interview (Harper, 2002). These photographs may be created by the researcher or as is the case in this study, the researcher may ask participants to take their own photographs to be used later as interview stimuli (Clark-Ibáñez, 2004). A number of researchers have reported that inclusion of participant generated images as part of a photoelicitation interview, can assist in building rapport between the interviewer and the interviewee and may facilitate collection of different types of data other than would be possible if only relying on interviews (Butler, 1994; Clark-Ibáñez, 2004; Collier and Collier, 1986; Harper, 2002; Heisley and Levy, 1991; Mc Cracken, 1988; Schwartz, 1989, Wagner, 1979). Clark–Ibáñez (2004) suggests that although photographs themselves may not be inherently interesting, they can support better communication between the researcher and research participants. For researchers, photographs can be used as a tool to expand upon answers to questions. Harper (2002) found that photographs enhanced participants’ capacity to recall events and experiences concerning themselves, family and friends, while both Schwartz (1989) and Butler (1994) reported that informants responded without hesitation to photographs of themselves and consequently generated extensive verbal commentary. Some authors suggest that in addition to generating extensive 115

Chapter 4 Methodology verbal commentary, photographs also elicit a different type of information than verbal interviews (Clark, 1999; Clark-Ibáñez, 2004; Harper, 2002; Schwartz, 1989). Harper (2002) proposes that this difference may emerge as a result of the capacity of images to ‘mine deeper shafts into a different part of human consciousness than do words alone’ (p. 23). In this way, although images may not contain new information, they may trigger new meanings and new insights for the interviewee (Collier and Collier, 1986; Schwartz, 1989). In addition to generating new insights, Heisley and Levy (1991) propose, that using photo elicitation methods can foreground a ‘perspective of action’ (p.269) as the interviewee attempts to make the visual material presented relevant to the researcher. This active perspective was particularly useful in current study, where the ambition was to capture the dynamic nature of ongoing processes concerning person-environment relations. Of course not all photographs generate new insights. Harper (2002) proposes that to contribute something new photographs must ‘break the frames’ of normality (p.20). Although Harper (2002) does not specifically describe how researchers can facilitate this change in perspective, it is clear that in order to maximise their effectiveness, photographs should support participants to develop new awareness of their social situations and to take a more reflective stance towards taken-for-granted aspects of daily life. In this study, all of the participants were invited to engage in a process of documenting their daily activities and their relationship with the environment using a digital camera. During the initial visit, participants were provided with a small digital camera. Both oral and written instructions (see Appendix K 116

Chapter 4 Methodology for details) regarding the use of the camera were provided to participants. At each subsequent interview both the researcher and the participant viewed the images together, in what Schwartz (1989) describes as a ‘dynamic interaction between the photographer, the spectator and the image’ (p.120) through which meaning was actively constructed. Open ended questions were used to support participants to adopt a more critical stance towards the images depicted in the photographs and to achieve Harper’s ideal of ‘breaking the frames’ (Harper, 2002). Examples of dialogues relating to specific photographs are provided in Appendix L. 4.6.2.3 Solicited Participant Diaries Langley (1999), writing about researching organisational change, notes that very often the progress of specific events is modulated by background trends and that much of what is interesting for researchers may be unspoken, thus leaving no concrete trace of its passing. While Langley’s observations were made in relation to complex organisations, similar challenges are faced in attempting to capture the complexity of the sequence of events that may result in a modification of person-environment relationships, in the context of ageing in place. In an attempt to capture these modulating trends, all of the participants in phase two of the research were asked to complete a solicited diary for three days each month throughout the 12 month period of data collection. Solicited diaries have been described by Bell (1998) as ‘an account produced specifically at the researcher’s request by an informant or informants’ (p. 72).

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Chapter 4 Methodology Solicited diaries are distinct from personal diaries in that they are, from the outset, written with a particular reader and their agenda in mind (Elliott, 1997) and as such the writing process embodies subjectivities which are informed by the researcher- researched relationship (Meth, 2003). Zimmerman and Wieder (1977) suggest that in this way, the solicited diary can be seen as a way of accessing the participant, as both an observer and informant, who can provide the researcher with a ‘view from within’ (p. 484). Charmaz (2006), suggests that elicited texts such as solicited diaries are a useful data collection strategy within grounded theory methodology, as they may elicit ‘thoughts, feelings and concerns of the thinking, acting subject as well as giving researchers ideas about what structures and cultural values influence the person’ (p.36). Such information is important when attempting to understand how processes evolve over time and why they evolve in this way. Furthermore Elliott (1997) and Meth (2003) both note, that the contemporaneous nature of diary writing means that problems with remembering details are less likely than in other forms of data collection. The temporal nature of the insight provided by participant diaries was particularly important to the current study, where a key challenge for the researcher was to access the day-to-day experiences of participants as they aged in place. During phase two of the study participants were asked to keep the diary for three days each month. Elliott (1997) advocates this approach, as he suggests that discontinuous data collection enables flexibility and variation in stories and accounts to be presented by participants. Such variation or ‘breaks in logic’ (Meth, 2003) reflect the complexity of relationships between people 118

Chapter 4 Methodology and their cognitions and emotions, as they interpret and respond to altering person environment relationships that were central to this phase of the research. While solicited diaries offer the possibility of collecting rich data over an extended period of time, Charmaz (2006), notes that there are a number of challenges associated with this approach. In particular, participant diaries rely on the participants’ writing skills and practices and while some participants are likely to engage well with the concept of diary writing, others may not have the skill, comfort or confidence to write complete accounts of their daily lives (Charmaz, 2006; Jacelon and Imperio, 2005). In an attempt to address this limitation and to support participants to focus on the topic of interest, the researcher followed guidelines set out by Elliott (1997) and provided a standardised diary format for participants to follow (See Appendix M for details of the diary format). This format provided a space for the date, time and location of the activities and several prompts were given to cue participants to reflect on their daily activities. During the first interview when participants were provided with the diary, the researcher verbally explained the diary layout and discussed with the participants the purpose of the diary and the type of information that was being sought. Each diary also contained a sample entry to demonstrate the types of information the researcher was seeking. Charmaz (2006) also notes that, as with other forms of questionnaire construction, care must be taken when creating guidelines for elicited texts. In particular, the potential for misinterpretation or confusion must be 119

Chapter 4 Methodology considered. During this study the comprehensibility of the diary instructions and acceptability of the request for completing diaries was discussed with two older people, who were not involved in phase two of the study, as part of a pilot case study. Following these discussions some minor modifications were made to the language used in the guidelines and to the overall appearance and layout of the diary. A number of authors have also suggested that in order to ensure a maximum yield of rich data from solicited diaries, it may be useful to combine solicited participant diaries with face to face follow up interviews (Conti, 1993; Elliott, 1997; Jacelon and Imperio, 2005; Miller and Timson, 2004; Zimmerman and Wieder, 1977). This approach was adopted in this study. The researcher collected the diary entries from the participants during interviews. In the period before the next interview, the researcher read these diaries and then formulated questions based on their content for the next interview. As suggested by Jacelon and Imperio (2005) these questions were phrased so as to support participants to recall their earlier entries and then the researcher asked participants to elaborate on the entry. In this way the solicited diaries acted both as a data source in their own right and also as a means of generating rich data from participants regarding everyday practices of ageing in place. Finally, although the participants were provided with a structured diary, they were none-the-less free to select the dates and activities they recorded in the diary. Meth (2003) has suggested that the capacity for selective reporting may raise concerns regarding the validity of information presented in solicited diaries. However, consistent with the constructivist approach adopted during 120

Chapter 4 Methodology this phase of the study, the researcher took the view that the solicited diaries emerge from and are shaped by the experiences and relationships between the participants and the researcher. For this reason, as suggested by Jacelon and Imperio (2005), rather than focus on a singular ‘truth’, the researcher viewed the choices made by respondents about the activities reported and the nature of these reports, as providing insight into the importance of particular activities for individuals and their attitudes towards engaging in those activities. 4.6.3 Data Collection Procedures Data collection for phase two of the study was completed over a period of 12 months between April 2012 and June 2013. As illustrated in figure 4.1, participants for phase two of the research were purposively sampled from those older people who had provided data to phase one of the study and who had indicated willingness to engage in phase two of the research. The researcher contacted each of the selected participants to confirm their interest in continued participation in the research. Where participants indicated interest in phase two of the research, the researcher provided a study pack, which contained information relating to phase two of the study together with a participant consent form (See Appendices N and O for details). All of the participants who were purposively selected from the original sample (n=8) agreed to participate in phase two of the research. Prior to commencing data collection for phase two, the researcher met with each of these participants to further explain the nature of this stage of the research

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Chapter 4 Methodology and to answer any questions. One week later the researcher also obtained written consent for participation in this phase of the study from each participant. All interviews were conducted in participants’ homes and at time that were convenient to the participants. Seven of the eight participants were interviewed four times over a period of 12 months. One participant died following the first interview. Following discussion with the research supervisors and the research ethics committee, a decision was made to use the initial interview, diary and image data gathered from this participant in the final research. Following the death of this participant a ninth participant was recruited to this phase of the study. This participant was interviewed four times over a period of 12 months. Thus, data from nine participants were included in the final analysis. Interviews were scheduled in order to capture on going processes in participants’ lives and so took place approximately every three months. Individual interviews lasted between 45 – 150 minutes. With participants’ consent all interviews were recorded using a digital audio recorder. During the first interview each participant was provided with a participant activity diary and a digital camera. The purpose of both the diary and the camera were explained to participants and all participants were also provided with written instructions regarding this aspect of the data collection (See Appendices K and M). Digital images were used during subsequent interviews to elicit further narratives from participants regarding everyday

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Chapter 4 Methodology actions taken to age in place. Diary entries were also collected on subsequent visits and were reviewed by the researcher. The content of the diary was used to generate further questions that were included in the next interview. 4.6.3.1 Pilot Testing Creswell (2013) advises that prior to commencing in-depth interviews, researchers should pilot test interview questions and procedures. Similar suggestions are made by Yin (2009), who proposes that case study research can benefit from pilot testing of data collection plans and to ensure that relevant lines of inquiry are developed. Given the complexity of the data collection procedures being implemented, prior to commencing phase two of the study the initial interview questions, photo elicitation methods and solicited participant diaries were all pilot tested with two older people who were not involved in the main data collection. Following this pilot study no changes were made to the diary or interview questions. 4.6.4 Data Management DeDoose Software Version 4.5.95 (SocioCultural Research Consultants, 2013) was used for data management. All interviews were transcribed verbatim, reviewed for accuracy and entered into this software. Solicited diaries were transcribed into Word documents and these documents were uploaded to DeDoose 4.5.95 (SocioCultural Research Consultants, 2013) as were digital images produced by participants.

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Chapter 4 Methodology 4.6.5 Data Analysis Lauckner et al. (2012), suggest that when combining constructivist grounded theory methods with case study design, careful consideration must be given to the data analysis process, so that the richness of each individual case is preserved, whilst simultaneously achieving the overall aim of generating an abstract theoretical understanding of the phenomenon under investigation. To address this issue, data analysis occurred in two stages; stage one involved independent in-depth analysis of each individual case, while in stage two a cross-case analysis was used to render a more complete understanding of the processes involved in ageing in place. Consistent with the constant comparative method outlined in constructivist grounded theory (Charmaz, 2006), preliminary data analysis took place simultaneously with data collection and these initial findings informed subsequent data collection. 4.6.5.1 Stage 1 – Individual in-depth case analysis The individual in-depth case analysis commenced with the development of a case description for each of the nine case studies. Yin (2009) suggests that developing an overall descriptive framework can help the researcher to organise the case study material in a coherent fashion, which will aid subsequent analytical strategies. Development of the case description was an iterative process that occurred simultaneously with data collection. Preliminary case summaries and reflections on the case study material, guided the development of subsequent data collection activities, which in turn informed the development of the descriptive framework.

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Chapter 4 Methodology The in-depth analysis of each of the case studies was driven by strategies of constructivist grounded theory analysis (Charmaz, 2006). Holton (2007) describes coding as the core process involved in this type of analysis, and suggests that the conceptual code, is the cornerstone between data and theory. Although presented here in a linear fashion, it is important to note that, consistent with the constant comparative method (Charmaz, 2006; Glaser and Strauss, 1967), the process of data collection and data analysis was an iterative one that involved frequent movement between analysis techniques and returning to the raw data. In the first instance line by line coding was used to analyse the initial interview with each participant. Charmaz (2006) suggests that because lineby-line coding separates data into categories, it helps researchers to become aware of processes and to identify new ideas to be explored further in subsequent interviews. As suggested by Charmaz (2006), during the initial line by line coding the researcher remained close to the data and focused on preserving the actions that were found in the text. Examples of line-by-line coding are provided in Appendix P. Following the initial line by line coding a number of analytical leads emerged in each interview. These analytical leads were used to guide a process of focused coding in second and subsequent interviews. The process of focused coding has been described as ‘using the most significant and/or frequent earlier codes to sift through large amounts of data’ (Charmaz, 2006). Focused codes were developed through a process of comparing data with data and by returning to the original line–by-line coding in order to generate new 125

Chapter 4 Methodology understanding and insights about participants’ actions and processes. Examples of focused codes are provided in Appendix Q. Following the focused coding when main substantive codes had been identified, theoretical coding was used to identify and develop potential relationships between these codes. Glaser (1978) suggests that the purpose of theoretical coding is to ‘weave the fractured story back together’ (p. 72). During the initial in-depth analysis of individual cases, theoretical codes were used to develop an analytical story that provided a coherent conceptualisation of how the substantive codes were related. A number of different theoretical coding families were used during this process, and the choice of theoretical codes was guided by the earlier substantive codes. Although initially guided by the theoretical coding families presented by Glaser (1978, 1998), as Charmaz (2006) notes, several conceptual families are absent in this list including codes that focus on agency, action, power and control. Thus, during the process of theoretical coding, the researcher also drew from previously identified sensitising concepts in order to clarify and sharpen the analysis. Throughout the process of data collection and data analysis, the activity of memo writing was used to develop focused codes into conceptual categories. Charmaz (2006 ;1995) distinguishes between early and advanced memos. During the data collection phase early memos were written following interviews and data transcription in order to summarise key ideas and to identify emerging issues that required further exploration. During the process of focused coding early memos were also used to capture relationships between data and between the emerging categories. Advanced memos were 126

Chapter 4 Methodology used during the initial individual case analysis in order to compare data at different points in time and to compare categories with each other. During the cross-case analysis, advanced memos were also used in order to compare different cases and to consider the entire analysis with existing concepts of ageing in place. Examples of early and advanced memos are provided in Appendix R. The use of early and advanced memo writing facilitated the researcher to identify incomplete categories and gaps in the data analysis. In order to fill these gaps and develop the analysis further, the researcher used a process of theoretical sampling. Charmaz (2006), defines theoretical sampling as a ‘seeking and collecting pertinent data to elaborate and refine categories in your emerging theory’ (p. 96). She suggests that theoretical sampling can be used to develop early tentative categories and to follow up on analytical leads. According to Charmaz (2006), theoretical sampling strengthens grounded theory studies by (i) increasing the precision of categories, (ii) supporting the move from description to analysis, (iii) facilitating a more abstract and generalisable analysis, (iv) ensuring that conjectures are supported and grounded by data, (v) clarifying the links between and among categories, and (vi) enhancing the parsimony of resultant theoretical statements. Thus the process of theoretical sampling began with the initial ideas about the data and continued throughout the analysis. Although theoretical saturation (Glaser and Strauss, 1967) has been considered a hallmark of grounded theory, in this study the researcher adopted Dey’s (1999) position of theoretical sufficiency, when attempting to 127

Chapter 4 Methodology identify when the data collection and analysis process were adequately complete. Dey (1999) proposes that theoretical sufficiency is a helpful term to denote a set of categories that are robust, and well supported by the data. He proposes that complete saturation is a less flexible term as it has ‘connotations of completion [and] seems to imply that the process of generating categories (and their properties and relations) has been exhaustive’ (pp. 116-117). The adoption of a process of theoretical sufficiency is also more congruent with the constructivist grounded theory method adopted in the study and is consistent with Charmaz’s (2006) suggestion that claims of saturated categories may not always be legitimate. Guided by Charmaz (2006), theoretical development of the analysis was advanced by the use of theoretical sorting, diagramming and integration of memos. Written memos were printed and were initially manually sorted using the category titles. These categories were compared and were tentatively ordered and re-ordered, so that their order reflected the experiences of ageing in place. Several cycles of ordering and re-ordering were used to create what Charmaz (2006) has described as, ‘the best possible balance between the studied experience, your categories, and your theoretical statements about them’ (p.117) In addition to theoretical sorting, diagramming was also used to clarify the emerging relationships between categories. Charmaz (2006) advocates for the use of diagramming, both as a means of explicating relationships during the analysis process, and also as a means of demonstrating these relationships when presenting research findings. During the analysis the influence of larger 128

Chapter 4 Methodology social structures emerged as a significant influence on the processes which participants’ experienced and for this reason, Strauss and Corbin’s (1998;1990) conditional/consequential matrix was used as a means of visualising the macro and micro relationships that appeared to shape the situations observed during the research. Examples of early and advanced diagrams are provided in Appendix S. In anticipation of cross-case analysis, the individual case analysis did not seek to develop a single category. Rather, the emphasis was on considering how advanced memos could be integrated, in order to generate an interpretative understanding of each case, which was then used to support cross case analysis during stage two. 4.6.5.2 Stage 2 Cross-Case Analysis During stage two the categories that emerged from each case were compared in order to explore how processes of ageing in place varied across each case. Key issues which had emerged from the theoretical framework for each case, were re-considered in order to identify both common and divergent issues across each of the cases. Cross-case issues were identified through a process of comparing and contrasting salient case-specific issues. Charmaz’s (2006) stages of final analysis: diagramming, memo sorting and identification of core categories, were revisited in order to explore and interrogate the data combined from all of the cases. Memos from key categories and diagrams from individual cases were examined in order to determine shared and variant processes. As suggested by Lauckner (2010), common and unique aspects of

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Chapter 4 Methodology each case were identified, and raw data were re-examined in order to generate an analytical account of shared strategies and processes. Further memo writing was used to refine concepts and additional diagrams were generated to conceptualise cross-case processes. Integration of these memos and diagrams continued until an integrated theoretical framework was developed which was applicable to all of the cases. 4.6.6 Trustworthiness of Data Lincoln and Guba (1986) suggest that the trustworthiness or soundness of research conducted from social constructivist and interpretive perspectives should be judged by its credibility, transferability, dependability and confirmability. During this study a number of specific strategies drawn from both constructivist grounded theory methods (Charmaz, 2006), and interpretative case study design (Stake, 1995;Yin, 2009) were used to enhance the trustworthiness of the data collected during phase two. Prolonged engagement at each of the study sites over a period of 12 months enabled extensive data collection which facilitated the researcher to gain an increased understanding of the range of factors which influence people’s lives, the context in which these occur and to capture the temporal aspects of these changes. The use of multiple sources and methods of data collection at each case study site (interviews, solicited diaries and participant generated images), enabled the researcher to access different types of information and supported the researcher to access the temporal patterns associated with ageing in place, which would otherwise have been difficult to obtain.

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Chapter 4 Methodology Throughout the data collection and analysis process, the researcher engaged in a process of analyst triangulation (Patton, 1999) where raw data were coded and interpreted in discussion with the research supervisors. This process enabled the researcher to discuss emerging ideas with experienced researchers. These on-going discussions facilitated a more sophisticated interpretation of data and raised additional questions for consideration. Confirmability of the research process was enhanced through the use of a case study protocol and a case study database system (Yin, 2009). Throughout the analysis process a clear audit trail was maintained through careful recording and storage of early and advanced analytical memos and diagrams. Finally, the transferability of the findings from phase two of the study was enhanced through the development of individual case descriptions, which provided the reader with the sufficient information to feel as if they had ‘experienced’ the case, thus allowing for generation of naturalistic generalisations (Stake, 1995).

4.7 Point of Interface 2 - Integration of Findings (Mixed Methods Interpretation) The final phase of the research involved integration of the findings from phase one and phase two, in order to generate a more complete understanding of the processes and practices of ageing in place for community dwelling older people. Integration of findings, also known as mixed methods interpretation (Creswell and Plano-Clark 2011) has been described as the most important 131

Chapter 4 Methodology part of a mixed methods study (Bryman, 2006; Creswell, 2013;Tashakkori and Teddlie, 2003;Yin, 2006). Yin (2006) suggests that unless there is adequate integration of the findings from each strand of the research, each phase sits in parallel and the advantages offered by mixed methods approaches are not realised. Similarly Tashakkori and Teddlie (2003) suggest that the enhanced understanding of phenomena offered by using mixed methods designs can only be achieved, if (i) outcomes are effectively integrated, (ii) possible areas of agreement and disagreement are identified, and (iii) a higher order conceptual framework to explain the phenomenon of interest is developed. In the current study, a three-stage inference process (Tashakkori and Teddlie, 2003) was used to guide the mixed methods interpretation. In the first instance, the researcher returned to the original research questions and examined and summarised all of the results that were relevant to those questions. From this summary, tentative interpretations were generated about each part of the results. When this process had been completed for each research question, the researcher then examined all of the tentative interpretations in an attempt to combine them. Interpretations were compared and contrasted with each other, in order to identify areas of convergence and divergence. Where convergence occurred, the interpretations were combined to develop a more complete understanding of the processes of ageing in place. Where divergence occurred attempts were made to explain these divergences, however the researcher was guided by Teddlie and Tasahkkori’s (2003) position, that mixed methods research does not require implied or actual

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Chapter 4 Methodology agreement between strands and as a consequence no attempt was made to force agreement between interpretations. The process of interpretation was an iterative one and a number of cycles of interpretation were completed, until the researcher was satisfied that study questions had been adequately addressed by the findings.

4.8 Ethical Considerations This research meets the basic principles of ethical research as set out in the Declaration of Helsinki (Goodyear et al., 2007). Ethical approval for the research was obtained from the Research Ethics Committee at the National University of Ireland, Galway (See Appendix T for details) prior to commencement of the data collection. Although full ethical approval for the research was obtained prior to commencing the study, it is acknowledged that ethical issues are not black and white and do change over time. Ultimately then responsibility for ethical research remains with the researcher. With this responsibility in mind, a number of issues were considered during the research process; (i) informed consent, (ii) anonymity and confidentiality, (iii) researcher burden, (iv) responding to unmet health and social care needs, (v) participants’ emotional responses, and (vi) planning an exit strategy. Each of these issues and the response strategies developed to manage them will be presented in the next sections.

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Chapter 4 Methodology 4.8.1 Informed Consent Informed consent is a core issue in bioethics and the practice of obtaining informed consent is a key marker of ethical research (Helgesson et al., 2005). From an ethical perspective, informed consent requires that the individual understands that he/she is being invited to participate in a research study, that the decision whether or not to participate is up to him/her, that he/she retains the unrestricted right to withdraw from participating in the research at any time and that the potential benefits and anticipated costs of participation are clearly outlined (Brock, 1993; O'Neill, 2002) In order to achieve the requirements set out by Brock (1993) and O’Neill (2002) for informed consent, all participants were provided with detailed information regarding the aims and objectives of the study, together with an description of the types of data to be collected (See Appendices B and N), prior to making a decision whether or not to participate in the study. Heglesson (2005), notes that in order to be useful, this information should be relevant, unbiased, written in language that is easily understood and excessive detail should be avoided. Following these guidelines different study information packs were developed for each group of potential participants (i.e. older people in phase 1; older people in phase 2 and significant others in phase 2). Furthermore, every time information was provided about the research, participants were offered the opportunity to meet with the researcher and ask further questions about the study, or seek clarification about information contained in the information sheet. All participants were given a minimum of 1 week to decide whether or not to participate in the study. Once 134

Chapter 4 Methodology participants were satisfied that they had fully understood the study, they were asked to sign a consent sheet indicating their willingness to participate in the study and to share their data with the researcher (See Appendices C and O for copies of consent forms). All participants were reminded that their consent could be withdrawn at any time, without explanation and without penalty. For older people who engaged in phase two of the research, data collection took place at regular intervals over a period of twelve months. For these participants , the issue of on-going consent to participate in the study was examined at each data collection point. Thus at the end of each interview, permission was sought to contact the participant again by telephone to discuss further follow up. During this telephone conversation, the researcher discussed with the participant his/her willingness to continue with the study and when consent was obtained, organised the next interview. 4.8.2 Confidentiality and Anonymity Singleton and Straits (2009) suggest that while confidentiality and anonymity are frequently bundled together, it is necessary to think about the differences between the two constructs and to consider how possible it is for researchers to achieve one or both in any given study. Iphofen (2009) proposes that confidentiality can be conceptualised as a continuous variable, where some information is so ‘mundane’ that it does not need to be kept confidential and other information is perceived as highly confidential by research participants and therefore should not be shared with others. In contrast, he argues that

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Chapter 4 Methodology anonymity is a dichotomous variable and either the person’s identity is kept anonymous or it is not (Iphofen, 2009). Confidentiality is primarily concerned with protecting the research participants’ privacy. In this study, large amounts of data that conceivably might be perceived as highly private by participants, were collected e.g. income levels; presence of disability; details of housing arrangements etc. Following guidelines set out by Singleton and Straits (2009) and in compliance with the requirements of the Data Protection Acts 1988 – 2003 (Government of Ireland) and University policies regarding the retention and storage of data (NUI Galway Research Ethics Committee, 2006) a number of steps were put in place to protect participants’ privacy. During phase 1, an encrypted database file was established to store respondents’ names and contact details. This database file was stored on password-protected computer at the National University of Ireland, Galway. Each participant was allocated a participant identification code and only this code was used when entering data onto the SPSS file and in subsequent analysis. Written consent forms which contained respondents’ names and addresses were held in a secure storage facility at the National University of Ireland Galway. Survey responses were fully anonymised and these surveys were stored in a separate secure storage facility at the National University of Ireland, Galway. Access to this information was restricted to the principal

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Chapter 4 Methodology researcher and this information was not shared with other people or organisations. During phase two of the research, participants’ took part in a series of indepth interviews, completed solicited diaries and created a number of digital images. In addition participants’ were asked to identify significant others who played a role in their approach towards ageing in place. Consent forms for participants involved in this phase of the study, were stored in secure storage facility at the National University of Ireland Galway. Only the principal researcher had access to this information, and it was not shared with other people involved in the study or with other agencies. Participants’ privacy was protected during the data collection process, by ensuring that the interviews were arranged at times and in locations that were acceptable to the participants. Permission was sought from participants’ prior to approaching significant others with a request for participation in the study. Where interviews were conducted with significant others, information, which was disclosed by participants’ was not shared with these significant others. In addition, the privacy of significant others who participated in the study was assured by not disclosing the content of this interview with the participants. All interviews were audio recorded by the researcher. These audio recordings were stored on a password-protected computer at the National University of Ireland, Galway. The principal researcher listened to the audio recordings and made verbatim transcripts. Solicited diaries and digital photographs were collected from participants during each visit. Diary entries were transcribed 137

Chapter 4 Methodology to a Word document by the principal researcher. . Interview transcripts, diary entries and images were anonymised and were stored on a passwordprotected computer at the National University of Ireland, Galway. Only the principal researcher had access to these files. 4.8.2.1 Anonymity Guidelines issued by the Data Protection Commissioner (2007) on the use of personally identifiable information, suggest that anonymisation or pseudoanonymisation of data should be the optimal approach where such information is used for research purposes. During phase one of the research this was achieved through blanket anonymisation of the data set (Clark, 2006). Following guidelines for anonymisation of epidemiological data described by Horner (1998), each participant was allocated a participant identification code and this code was used when entering data onto the SPSS file and in subsequent analysis. Only the principal researcher had access to these codes. . In phase two of the research, due to the nature of the data collected the issue of protecting participants’ anonymity was more complex. The challenges of protecting participants’ anonymity during extended qualitative research have been recognised in the research, and some researchers have questioned whether complete anonymity is possible or indeed desirable when conducting qualitative research (Clark, 2006; Grinyer, 2002; Mattingly, 2005;Singleton and Straits, 2009; Van Den Hoonaard, 2003,).

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Chapter 4 Methodology Traditionally, in order to comply with legislative requirements, qualitative researchers have adopted practices of blanket anonymisation, whereby all people (including third parties) referred to during interviews, in diaries and other forms of data are anonymised at the earliest possible opportunity i.e. at the point of transcription (Clark, 2006; Grinyer, 2002; Morse, 1998). Typically, such anonymisation is achieved by replacing real names and places with pseudonyms, and by removing what is variously labelled as ‘background’ or ‘contextual’ data from the study. Clark (2006) argues that this type of blanket anonymisation raises questions about which data should be anonynmised and which should be left in its original format. Providing a ‘rule of thumb’ for the process of anonymisation Barnes (1979), suggests that data should be presented in such a way that participants are able to recognise themselves but that the reader / audience cannot identify participants. However, the extent to which small pieces of information may have potential to support deductive identification of particular participants, means that even blanket anonymisation of personal data relating to age, gender, ethnicity and location, may not be sufficient to preserve participants’ anonymity (Murphy and Dingwall, 2003). A second difficulty which arises relating to blanket anonymisation of qualitative data relates to the extent to which ‘background’ information, which might arguably be removed to protect participants’ privacy, actually provides essential context necessary for a comprehensive understanding of the study findings (Clark, 2006; Van Den Hoonaard, 2003). If qualitative research relies on ‘thick’ description (Geertz, 1973), then it is necessary to

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Chapter 4 Methodology include what might ordinarily be considered background information, in order to provide the reader with a context in which to place the research findings. The practicality of attempting to anonymise photographs and other types of visual material must also be considered. Wiles et al. (2008) note that while there are a number of strategies and techniques available to distort visual images in order to protect participants’ anonymity, the results of such work may be variable. Equally, Banks (2001) notes that the practice of pixelating images so that individuals cannot be identified, may also be problematic as it may dehumanise research participants and may also invoke associations with criminality that are potentially distressing and offensive. Finally, a number of researchers have challenged the idea that maintaining complete anonymity of participants is desirable (Clark, 2006; Mattingly, 2005; Van Den Hoonaard, 2003) with both Mattingly (2005) and Grinyer (2002) reporting instances where research participants expressed strong desire to have their identities made public. Van Den Hoonard (2003) suggests that the quandary of anonymity in qualitative research can only be resolved through negotiation between the researcher and the research participants, and this approach was adopted during this study. During phase two of this study, research participants were invited by the researcher to consider if they wished to be identified in the final research or remain anonymous. All of the participants indicated a desire to remain anonymous and as a result, each participant was provided with a pseudonym

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Chapter 4 Methodology that was used throughout the study. Following transcription, interviews were reviewed and identifying information (relating to both the participant and third parties) was removed and replaced with pseudonyms. The choice of pseudonym applied to participants was guided by Ipfohen (2009) who suggests that pseudonyms should be sufficiently different to participants’ real names to avoid deductive discovery. At the same time, the researcher was mindful of Grinyer’s (2002) argument that use of nonequivalent pseudonyms risks distorting the reader’s perception of the context in which the research occurs. Thus, an attempt was made to choose pseudonyms, which were different but equivalent in relation to social class, age and ethnic connotations. In relation to the use of digital images, it was agreed with each participant that visual data which might give an indication of the identity of a participant would not be used in the final thesis or any other outputs of the research. Furthermore, where images were used to illustrate the research findings, permission was obtained from the participants to (re)produce these images. As suggested by Pink (2007) and Chaplin (2004), this permission referred specifically to the images which were to be (re)produced, and also to the formats and contexts in which the image might be displayed e.g. books, journal publications, conference papers, or for illustrative purposes. 4.8.3 Respondents’ Wellbeing The need to consider and protect respondents’ physical, psychological and emotional wellbeing during the research process is a cornerstone of ethical 141

Chapter 4 Methodology research practice (Charmaz, 2006; Corbin and Morse, 2003; Iphofen, 2009). During this study the risk of physical or psychological harm to participants was negligible, however it is recognised that the process of engaging in a series of in-depth interviews, generating diaries and creating images over an extended period of time could arouse a powerful emotional response among participants. The potential emotional disruption to participants from participating in qualitative data collection has been highlighted by a number of researchers (Charmaz, 2006; Corbin and Morse, 2003;Lee, 1993; Patton, 2002; Richards and Schward, 2002). As Patton (2002) notes the process of engaging in a ‘directed reflective process’ (p. 405) as occurs during in-depth interviewing, solicited diary creation and production of images, can result in the person being interviewed knowing more about themselves and having increased awareness of their life, than they did prior to commencing data collection. Indeed, the use of photo elicitation methods and solicited diaries is grounded in the assumption that such methods evoke extended personal narratives, which would otherwise remain dormant and inaccessible to the researcher (Collier and Collier, 1986; Harper, 2002; Jacelon and Imperio, 2005; Zimmerman and Wieder, 1977).This increased knowledge can, on the one hand create possibilities for personal introspection and growth (Corbin and Morse, 2003; Hutchinson et al., 1994), but on the other hand, unless handled sensitively such introspection can open old wounds in an intrusive and harmful way (Patton, 2002).

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Chapter 4 Methodology Prior to commencing data collection a protocol for managing potential emotional distress was developed (See Appendix U for details). Guided by Legard et al. (2003), interviews were structured so that the questions moved from the ‘everyday social level to a deeper level’ (p.144), focusing on the specific topics of interest to the researcher. Towards the end of the interview, the researcher focused on returning the interview to the everyday social level. Throughout the interview the researcher remained alert for signs of distress, anxiety or discomfort on the part of the participant and where necessary followed the protocol for emotional distress. At the end of each interview the researcher provided participants with the opportunity to reflect on the interview experience and checked that participants were feeling comfortable and satisfied that they had sufficient opportunity to express their ideas and feelings. A further potential cause of emotional distress during the collection of indepth qualitative data relates to unintended disclosures by participants. Ramos (1989) suggests that the unstructured interview can be considered to be a shared experience in which both the researcher and interviewee collaborate to create a context of conversational intimacy. While such intimacy may result in the collection of rich data, Charmaz (2006) also notes that it may create situations where participants’ reveal stories to the researcher that they never imagined sharing. In order to minimise the potential for harm or regret following unintended disclosure the researcher re-confirmed participants’ willingness to consent to recording of data and at each interview,

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Chapter 4 Methodology confirmed for participants that only the researcher would have access to raw data. 4.8.4 Responding to Unmet Health and Social Care Needs Traditionally research ethics has set out a clear line between the responsibilities of health and social care professionals offering clinical care and the responsibilities of researchers, recognising that the central aim of research is to produce knowledge rather than to attend to participants’ healthcare needs (Rangel, 2010). Despite this there are frequent reports within health and social care research, of situations where researchers encounter unmet health or social care needs among research participants (Merritt, 2011). Wolf et al. (2008) describe such situations as ‘incidental findings’ where the term incidental finding is described as ‘a finding concerning an individual research participant that has potential health or reproductive importance and is discovered in the course of conducting research but is beyond the aims of the study’ (p.219). Although Wolf et al. (2008) went on to discuss incidental findings in relation to physiological and genetic/genomic research, they acknowledge that incidental findings may also occur in relation to social and behaviourally orientated research, such as the current study. Examples of possible incidental findings which had the potential to impact on the current study included, (i) need for environmental adaptation (ii) need for assistive technology (iii) elder abuse (iv) carer stress etc. Rangel (2010) notes, that for researchers, the identification of incidental findings raises questions about the researcher-participant relationship and the

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Chapter 4 Methodology extent of the obligations that researchers might reasonably be expected to hold towards participants’ well being. For Merritt (2011) the responses available to researchers, who identify incidental findings, can range from ‘do nothing about it’ to ‘make it your highest and most urgent priority to meet the need’ (p.314). Richardson and Belsky (2004), offer a comprehensive framework to guide the clinical care obligations of researchers who identify, what they term, a need for ‘ancillary care’ during the course of the research. Ancillary care as defined by Richardson and Belsky (2004), refers to ‘health care that research participants need but that is not necessary to ensure the safety or scientific validity of the research, to redress injuries caused by research participation or to fulfil morally optional promises’ (p. 26). Richardson and Belsky (2004) suggest, that research participants entrust various aspects of their welfare to researchers and therefore may be entitled to identification, evaluation and communication of relevant and important incidental findings. Wolf et al. (2008), offer a number of recommendations for responding to incidental findings including (i) planning for the discovery of incidental findings, (ii) planning to verify and evaluate a suspected incidental findings with an expert consultant if needed, (iii) determining whether or not to report incidental findings based on likely health importance, (iv) creating and monitoring a pathway for incidental findings. These guidelines were followed during this research and thus, the original research proposal set out a protocol for identifying and responding to unmet health and social care needs (see Appendix V for details). During the data collection a number of participants

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Chapter 4 Methodology sought the researcher’s advice regarding access to community based occupational therapy services. Based upon this protocol the researcher provided contact information for participants regarding access to these services. 4.8.5 Planning an Exit Strategy Holland (2007) suggests that for both researchers and research participants who engage in longitudinal qualitative research ‘escaping the field’ (p.6) is one of the most challenging aspects of the research process. The nature of qualitative research engenders the establishment of relationships between the researcher and participant, through building comfort, trust, and ultimately rapport between both parties (Dickson-Swift et al., 2006). While this relationship facilitates collection of rich data, prolonged contact may also generate feelings of dependency, emotional involvement and problems of closure (Holland, 2007). Reflecting on research involving a series of interviews with carers, Greenwood (2009) notes that despite the researcher’s attempts to plan for a smooth exit, ‘at the last interview the relationship between the researcher and the participant came to an abrupt end’ (p. 31). During phase two of the study, the researcher engaged in a period of sustained contact with participants over a period of 12 months. During this time researcher-participant relationships developed with the each of the participants and so to avoid the ‘abrupt’ ending described by Greenwood (2009) a number of ending strategies were employed. These were, (i) including a clear statement about the duration of the research process in the

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Chapter 4 Methodology initial information sheet and verbally reminding the participants of this during each interview, (ii) during the second last interview reminding participants that the research was coming to a close, and (iii) providing space in during the interview process for participants to discuss their experiences of the research process. During the final interview as suggested by Iversen (2009) all participants were provided with a token gift both to provide a cue to remind participants of the ending of the relationship and also to acknowledge participants’ help and contribution to the study.

4.9 Conclusion This chapter has provided a detailed account of the research design and method. Particular attention has been paid to ensuring epistemological congruence among the research methodologies employed to address the research question. The processes of mixing methods and managing extensive datasets have also been addressed. Finally, the chapter concluded with a discussion of the ethical challenges raised by the research. In the next section the results of the study will be presented. Chapters five and six will focus on the results of the quantitative phase of the study while chapters seven to eight will present the findings of the qualitative phase. In chapter nine both sets of results will be integrated and the overall findings of the study will be presented.

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Chapter 5 – Phase 1 Results

Chapter 5 5.1 Introduction This chapter presents the findings of the first phase of the study. The overall aim of this part of the research was to examine the nature of housing related control beliefs reported by a sample of older people living in Ireland. In addition, this phase of the study sought to identify the extent to which housing related control beliefs can be predicted by demographic, housing and health related characteristics.

5.2 Response Rate 722 survey packs were distributed to older people living in the community. A total of 159 completed surveys were returned to the researcher giving a response rate of 22.02%.

5.3 Participants’ Demographic Characteristics Table 5.1 provides a summary of participants’ demographic characteristics. Participants’ ages ranged from 64.88 to 91.79 years with a mean age of 76.72 years (SD ± 7.3 years). For the most part, participants were female (54.1% n=86), had obtained secondary level education (45.3% n=72) and were married (45.9% n=73). 51.6% of participants (n=82) had average monthly incomes of between €500 – €1500 and the majority perceived their health status as either fair or good (79.3% n=1).

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Chapter 5 – Phase 1 Results

Table 5.1 Participants’ Demographic Characteristics

Variable Age (Years) Gender Educational Attainment

Marital Status

Average Monthly Income (Euros)

Perceived Health

Time in current residence (Years) (n=157 )

Categories

n (%)

Male Female Primary School Secondary School 3rd level education Professional Qualification Other Married Widowed Never Married Separated or Divorced