The Challenges of Intersectionality in the Lives of Older Adults Living in Rural Areas with Limited Financial Resources

Abstract

The objective of this study was to use intersectionality to better understand the challenges of having the combined statuses of being an older adult, living in a rural area and having limited financial resources. Eight focus groups and 38 individual interviews were conducted in southern Georgia. Participants included program participants and staff, community members, and community leaders. Thematic analysis was done using verbatim transcripts from focus groups and interviews. Results demonstrate that the multiplicative and intersecting statuses of the study population create challenges in the areas of transportation, health care, food, and housing. The challenges of these intersectional statuses limit access to services in ways that each individual status did not, thereby compounding challenges. While previous literature describes the challenges of one or two of these statuses, this work explores the multiplicative effects of the combination of the three statuses using intersectionality. Programmatic and policy recommendations and implications are discussed.

Keywords

older adults intersectionality qualitative analysis

Introduction

The concept of intersectionality was first used by Crenshaw (1989) to describe the interactions and multiplying effects of inequalities within individuals. At first intersectionality focused on issues of race and gender to understand the interaction of these multiplicative social statuses (Carastathis, 2016; Carbado et al., 2013). The work of Choo and Ferree (2010) explored intersectionality as a process focusing on the multiplication of oppressions. Intersectionality works to give voice to the oppressed through the exploration of individuals and groups that fall into more than one marginalized category. Over time the concept of intersectionality enlarged to include multiple demographic categories, and issues related to individual and group power, and larger social systems (Brown et al., 2016; Carbado et al., 2013).

Intersectionality has explored relative socioeconomic status and other statuses (Brown et al., 2016) and geographic location (Roy et al., 2020). Calasanti and Giles (2017) added a life course perspective to the discussion of intersectionality. They discussed how older adults enter into late life with “the intertwining of their various categorical memberships within systems of inequalities” (p.70). They also noted that old age itself is a disadvantaged status. Individuals may have lived their lives in privileged statuses such as being financially secure, White and male only to come into late life and enter disadvantaged status of being old.

Carbado et al. (2013) stated, “there is potentially always another set of concerns to which the [intersectionality] theory can be directed, other places to which the theory might be moved, and other structures of power it can be deployed to examine” (p.304). This study adds to the current understanding of intersectionality by exploring the intersection of three uniquely challenging statuses: advanced age, rural living, and limited finances. This allows for an expanding of our understanding of intersectionality through the lived experiences of those that fall into these three disadvantaged statuses. Interventions designed to support older adults living in rural areas who have financial limitations need to incorporate strategies that take the intersection of these statuses into account.

Literature Review

Rurality

Roy et al. (2020) conducted research on late life functional limitations including the intersecting categories of gender, education, and geography. Their research found an individual’s geographic location is considered a category for either advantage or disadvantage in intersectionality. People living in rural areas face challenges in regard to the access and availability of services. The geographic dispersion of the population means that individuals must travel farther to access services and that service providers delivering services such as home health care are challenged in their ability to bring services to individuals living in rural areas (Bull, 1998; Krout & Bull, 2006). In rural areas, 17.5% of the population is age 65 and older, compared with 13.8% in urban areas in the United States (Smith & Trevelyan, 2019). There are a number of reasons for this higher concentration, including the aging in place of the Baby Boom generation, the out-migration of younger family members in search of better employment opportunities, and the in-migration of older adults seeking rural retirement destinations (Brown & Glasgow, 2008; Oberdorfer & Wiley, 2014). Growing older in rural areas is especially challenging due to limited access to the support of both formal service and informal support from family members.

Poverty

People living in rural areas are more likely than those in more densely populated areas to live in poverty. In 2018, the nonmetropolitan poverty rate was 16.1% compared with 12.6% for metro areas. This difference was highest in the south with 20.5% of nonmetropolitan people living in poverty compared to 14.4% in metropolitan areas. The rural poverty rate for people 65 and older was 10.2% compared to a metropolitan rate of 9.1% (Economic Research Service, 2019). In 2014, the median income for rural older adult households was $4,665 less than the national average and almost one-third lived on less than $20,000 annually (Oberdorfer & Wiley, 2014). Having lower than the national level incomes in rural area has life course consequences in that many older adults in rural areas come into late life with fewer resources as compared to their counterparts in more densely populated areas.

Transportation

In order remain at home and age in place, older adults need access to transportation (Dize, 2019). Most often this transportation is private cars (Anarde, 2019). Due to low population density in rural areas, residents of these areas must travel farther to access groceries and medical care compared to those in more populated areas. They are also less likely than individuals in more densely populated areas to have access to public transportation options (Dize, 2019). According to the National Aging and Disability Transportation Center (2018) 49% of older adults living in small towns and rural areas have quality alternative transportation if they are no longer be able to drive compared to 62% in large cities and suburbs. Ride share options like Uber and Lyft are often unavailable in rural communities (Dize, 2019). In rural areas, services such as medical care are often only accessible by traveling across county lines or other geographic boundaries yet programs such as Title III transportation services either only cover a single county or charge additional fees for transportation across county lines (Dize, 2019; Government Accountability Office, 2015). All of this complicates issues related to access for rural older adults, especially those with limited financial resources.

Health and Health Care

According to the Federal Interagency Forum on Aging-Related Statistics (FIFARS, 2016), most older adults have multiple chronic conditions that interfere with their quality of life leading to high health care costs. They also found that hypertension, heart disease, and arthritis are some of the most common and costly chronic conditions for older adults and that those diseases that are costliest are also some of the leading causes of death for older adults in the United States.

Medicare is health insurance that is available to most older adults in the United States. Health care services including hospital stays, outpatient physicians’ visits and prescription drugs are covered under Medicare. Older adults have higher health care costs compared to younger adults and low-income individuals pay out a larger proportion of their income on health care (FIFARS, 2016).

Health care access is especially challenging for older adults in rural areas since they are more likely to have a greater distance to travel to access services and fewer transportation options than those from more densely populated areas. According to the Health Resources and Services Administration (HRSA, 2019), 63% of all health professional shortage areas are rural. According to Hing and Hsiao (2014) the availability of primary care physicians decreases as population density decreases. Many hospitals in rural areas are critical access hospitals which are limited to 25 beds and provide emergency, inpatient, and outpatient services. Many rural hospitals, especially in the southern United States, are closing due to financial issues (MacKinney et al., 2019).

Food Insecurity

The United States Department of Agriculture measures food insecurity or access by exploring whether people can get sufficient food to live healthfully rather than focusing on hunger (Lloyd, 2019). Gundersen and Ziliak (2017) found that older adults with food insecurity are two times as likely to report fair or poor health, more than twice as likely to suffer from depression, and 57% more likely to have congestive heart failure than older adults that are food secure.

Older adults are also challenged regarding food access. Older adults can have functional, mobility, and transportation limitations as well as financial constraints that limit food access (Feeding America, 2015). Feeding America (2015) found that older adults living in the southern United States are more likely to struggle with choosing between food and medical care than older adults in more densely populated areas of the county. In rural areas these issues are often exacerbated since there is greater distance to grocery stores, limited transportation options, and limited support from family members (Garasky et al., 2006; Lloyd, 2019).

Housing

Oberdorfer and Wiley (2014) found that older adults in rural areas are more likely than those living in more densely populated areas to be home owners. Unfortunately, many of these homes are older, in need of repairs, and lack energy efficiency (Anarde, 2019). Nearly one quarter of all older adult homeowners are struggling to afford their homes (Oberdorfer & Wiley, 2014). Oberdorfer and Wiley (2014) found that more than half of rural older adult renters are struggling with affordability issues. Older adults in rural areas who can no longer live independently in their homes have fewer options than those living in more densely populated areas (Oberdorfer & Wiley, 2014).

From prior research, we know there are challenges of growing older, living in rural areas and living with limited financial resources. These statuses and resulting challenges are often explored separately. Using the lens of intersectionality allows revelations regarding how these three statuses interact and multiply the challenges.

Research Design

The initial impetus for this study was a community needs assessment of low-income families and individuals in southern Georgia for a regional non-profit. Focus groups and qualitative interviews were conducted to determine the needs of low-income individuals in a rural region of southeast Georgia. During the data analysis, the application of the theory of intersectionality to the data became obvious. After the completion of the needs assessment the coded data and emergent themes were recoded for examples of intersectionality.

An Institutional Review Board application from the university where the researcher works was applied for and approved prior to the start of the research. This study took place in fourteen counties in southern Georgia in the summer of 2018. The population density of these counties ranged from a low of 8 to a high of 104 individuals per square mile (United States Census Bureau [USCB], 2018). The percentage of the population age 65 and older in these counties ranged from 11% in a county housing a university to 18%. The range of individuals living in poverty went from 17% to 29% with all but two being over 20%. People age 65 and older living in poverty ranged from 12% to 16% (USCB, 2018).

A purposeful sampling strategy (Patton, 2002) was used to recruit a range of individuals across various roles, geographic areas, and demographics. Individuals were recruited for focus groups by staff members of local offices of the non-profit requesting the needs assessment. This included four Head Start Programs and four Senior Centers dispersed across a 19-county region. There were four focus groups with parents in Head Start Programs (36 individuals) and four focus groups with senior center participants (39 individuals). Participants in one-on-one phone interviews were also recruited by staff of local non-profit offices using a purpose sampling strategy (Patton, 2002). Since there were a total of 19 regional offices, there was broad geographic representation. Participants in phone interviews included clients (n = 9) and staff (n = 17) from local offices of the regional non-profit, and community leaders (n = 12). Community leaders were neither employed by nor clients of the non-profit requesting the needs assessment. Community leaders were recruited by staff of the local offices of the non-profit based on their knowledge of the local community and individuals they felt played an active role in the lives of low-income individuals in their communities. Community leaders included the directors of other non-profits, town and county officials such as mayors and county commissioner, school administrators, and a church pastor.

A total of 113 individuals participated in the study. Sixty-six percent identified as women and 34% identified as men. Thirty-eight percent identified as African-American, 12% identified as Hispanic or LatinX, and 50% identified as White. Participants read the consent form and provided either written (for face-to-face interviews) or verbal consent (for phone interviews).

Questions for focus groups included what the strengths, challenges and gaps of the county were when it came to serving low-income families and individuals including older adults, how they would prioritize the challenges and gaps, and what could be done to address the challenges and gaps. Questions for clients focused on their individual challenges, how those challenges were being addressed and strategies for improving the services they received. Individual staff members were asked to describe the program they worked for including its strengths and challenges and how the program could be improved. Community leaders were asked about the strengths, challenges, and gaps of their county in serving low-income families and individuals and what could be done to address the challenges and gaps. Since questions focused both on families and individuals, all interviews included information regarding the lives of older adults, either as individuals or as family members, therefore data from focus groups and individuals’ interviews relative to challenges of older adults were included in the data set.

Focus groups and interviews were recorded and transcribed verbatim. Transcripts were coded using NVivo software (QSR International, 2018). An a priori codebook (Crabtree & Miller, 1999) based on the notes taken during data collection and on the focus of the needs assessment and literature on low-income rural older adults was created for purposes of coding and was imported into NVivo. Unlike other types of coding, the use of an a priori codebook acknowledges understandings gained during earlier phases of the qualitative project. It is not a static codebook and as additional codes emerged from the data during the coding process these codes were added to the codebook. Data, including all interview transcripts, were then coded using the imported codebook and additional codes as they emerged. Once that was completed, the data were then recoded with the overarching theme of intersectionality. Results reflect transcript data that were coded according to four emergent themes relative to intersectionality: transportation, health care, food, and housing.

Providing an accurate representation of study participants is essential in qualitative research. A key component to determining accurate representation in qualitative research is an analysis of trustworthiness of the design and implementation of the research (Maykut & Morehouse, 1994). This is especially important in this case since there was only one researcher coding the data. This study utilized several strategies to substantiate trustworthiness including an ongoing reflective process by the researcher through journal writing; member checking by reflecting back to participants’ summaries of the information they provided and the triangulation of data through the use of multiple sources including individual interviews, focus groups and field notes, and a variety of types of participants (Maykut & Morehouse, 1994; Patton, 2002). All quotes are verbatim as expressed by study participants. Grammar and punctuation is intact except for some minor changes where needed for clarity.

Results

Transportation

Transportation was the most commonly cited challenge among study participants. For some there were transportation services, but they had limitations. For instance, the services were too expensive, covered only certain areas of the county, or were limited to certain purposes but not others. The informal network of family, neighbors, and friends was also discussed regarding both strengths and limitations when reflecting on transportation.

While transportation was an issue for several people, the issue was greater for those people who lived in the more remote areas of a rural county. A county manager described rural transportation as their number one concern for the people of their county.

The county is structured, (city name) is pretty much in the center of the county and it stretches in, in about a 3 mile radius across so then, you have got probably 25 miles in each direction where you have individuals that may have grown up on a farm and they live in the unincorporated areas of the community, and they are limited to access, whether it is to get to the grocery store, or for a doctor's appointment, for healthcare reasons. (African-American man, individual interviewee)

Even when there were transportation services that seemed inexpensive, the cost could add up to be well beyond what someone with low-income could afford. A senior center participant discussed the challenges of someone she knew.

She says she pays $4 for a trip which, $4 is $4, but some people may not, have not, have that $4 and if they got to go to the doctor a couple of time a week, or go to the grocery store or what have you. I think we need a different type of. . .or a subsidy for the transportation. (White woman, focus group participant)

From an intersectional perspective, the multipliers here are rurality and low-income statuses. If the individual was living in a rural area but could afford the cost of the transportation services, their access to services was not affected by a lack of transportation. However, combining being low-income with living in a rural area meant that access to services was severely limited.

Some focus group participants said they had a car and would not charge for rides, but some talked about the costs of using someone in their informal network for rides. There were several examples provided by study participants. A White woman senior center participant stated during a focus group, “We have somebody that once a month will take us out, another person take us out to pay our bills and we go as far as (town name) and do something there but they will charge us $20 each.” An African-American woman senior center participant stated, “I got a neighbor that got food stamps same as I do and so we try to work out where that she take me but I pay $5 for her taking me.” The variation in costs within the informal network ranged from no cost to $25 for the same ride. Living in a rural area and having limited income combined to make the use of help from friends additionally expensive

While owning a vehicle was an asset, it could also be a liability in that other people looked to you for rides, which entailed the cost of providing transportation to others, particularly when one had limited income and an older car in need of repairs. Those living father out from the more populated areas of a county, or in a county that was entirely rural, had greater challenges to access services. This senior center attendee talked about the challenges of living out in the country even with a car.

I've been out in the country and I don't get in on nothing. Like, some of them get free trips and things to the center and back? I drive my car. If I don't have the money to get the gas I stay home. (White man, focus group participant)

Being an older adult with limited income in a rural area multiplied challenges and limited access that most other older adults who did not live in more remote areas did not have to deal with. At times participants could not access services if they were older and had multiple issues including mobility challenges, limited income to cover the cost of services, or were in more remote areas of a rural county. These were not separate issues. These issues intersected and multiplied each other to the point of creating challenges too difficult to overcome.

Health Care

Overall older adults have more chronic diseases and higher health care costs than younger adults (FIFARS, 2016). This disparity means access to health care is more salient for older adults. Having limited financial resources and living in rural areas limits access to health care. This issue of needing health care but not being able to access it was expressed by several participants in the study. A county manager described it this way:

I don't feel that healthcare is to the point where it is affordable for everyone, and I feel like there are a lot of people who know that they have a medical condition and they are not doing anything about that condition, because they can't afford to. (African-American man, individual interviewee)

Even when older adults had Medicare there were limitations to access for poorer individuals. A senior center participant stated:

If you go to the doctors and you don't have that copayment they won't even see you. They'll tell you you have to reschedule and as long as you ain’t got that copayment you not going to see the doctor. (White woman, focus group participant)

Where transportation to the health care was available, the population dispersion of rural areas contributed to the challenge of access. An elder services case manager describes the journey many older adults took in order to get to their health appointments.

They are gone all day. . .They may have several spread out in different areas, well our client might get through at 10 o’clock but they don't come back to pick them up maybe until 2, you know. (African-American woman, individual interviewee)

Since older adults require more health care and are less likely to drive, the statuses of being older and living in a rural area combined and multiplied the challenges of effective access to health care services.

Some participants lived in counties where there were no hospitals and a limited number of doctors. One senior center participant discussed the issue.

I think for us, a lot of our doctors are moving away. We have to travel to [town in another county] now, two or three times a week and that's, we just can't afford it. So there again, a lot of appointments get missed because we can't afford to drive that far. (White woman, focus group participant)

For participants with multiple disadvantaged statuses, access to health care was a challenge. Contributing factors, including relatively high costs of health care and great distances to travel for health care services, were interrelated, and their intersections multiplied the challenges.

Food

According to the participants in this study, in rural areas access to grocery stores, home delivered meals, and food pantries was limited. Here again things intersected. If you were poor, you likely had limited transportation to grocery stores or food pantries. If you lived in more remote areas of a county these challenges multiplied. If you were homebound and lived in more remote areas services such as home delivered meals might not be an option for you. A White woman director of a local non-profit explained, “Well, in some of these little towns. . . [convenience store name] is a grocery store or the gas station on the corner that has like a [store name] or something in it.”

Many towns and some counties had no grocery store. People who were poor and could not afford transportation to the nearest grocery store purchased their groceries from places that were more expensive than regular grocery stores, carried mostly processed foods, and had little to no fresh produce. Having the dual statuses of limited income and living in a rural area multiplied the challenges of access to affordable food.

Some elder services in the area covered by this study were provided by local senior centers supported by funds from the local area agencies on aging. They provided home delivered meals for homebound older adults. One senior center staff member, African-American man, stated, “We have a waiting list, I think right now we probably have like 20 to 30 people on that list.” He also described how those that lived farther out in the county were less likely to receive home delivered meals since delivery was a challenge.

Food pantries were an option for some older adults but in rural areas they were often far away and limited in what they could provide. One senior center participant, White woman, stated, “There's been times that I have needed food badly and I've gone to the [food pantry name] and they gave me two cans of cranberry sauce and a can of spaghetti. Why is that?” Others went hungry. Another White woman senior center participant stated, “There were times in the past when we had no food in the house at all but my husband would not let, would not ask so we just had popcorn for supper a lot of time.” The three statuses, old, rural and poor combined and multiplied the challenges of food access for study participants.

Housing

Findings around housing related primarily to the costs and quality of housing. These two issues were intertwined. If you had limited income you could not afford needed repairs on your housing and as you aged the quality of your housing would deteriorate therefore the statuses of having limited income and being older multiplied the challenges of having affordable and adequate housing.

While average rent in rural southeastern Georgia was lower than other parts of the state and country, so were incomes. Lower incomes over the life course lead to lower Social Security payments and less likelihood of receiving private pensions. One senior center staff member described the consequences this way.

Why a 80 year old person have to pay almost $300 for just a one bedroom apartment? Okay, okay $350 out of their check, and light bill, water, grocery. Cause you are not gonna get any food stamps, maybe about, $15 worth. You have got to buy groceries, you know, clothes, can't keep wearing the same clothes, but to me, it is ridiculous. (African-American woman, individual interviewee)

The challenges of housing were compounded for older adults living in rural areas with limited financial resources. One staff member from a weatherization program explained.

I've been to homes to where it. . .looks that bad, like no one is living there, but you go there, and you got this little old lady that's sitting there, with grandkids and great-grands and all that around and the house is falling apart around them. (White man, individual interview)

It could be that at one time the housing was adequate but over a life course of poverty needed repairs were unaffordable. One senior center participant described her concerns.

I am very afraid to be in my house sometimes with heaters and stuff like that because I look down and I see it got hot and I'm scared that the whole house need rewiring and other things too, but that's what I'm saying. I don’t have air conditioning either. I haven't had any heat so I turn the oven on and stuff like that. But I'm really scared that you know it might catch on fire and I plug in something, I be watching it and I never go to - to sleep with nothing plugged in. (African-American woman, focus group participant)

In this case the woman owned her home, but the quality of the home made it unsafe. Individuals with low-incomes often did not have the funds to afford renovations and repairs. The state of disrepair developed over time and older adults with low-income were especially vulnerable to having substandard housing.

Housing quality deteriorated significantly over time. A county manager explained the challenges of deteriorating housing in his community:

Now, there are areas in the county where even though the individuals have a roof over their head, the conditions in which they live, I still feel like they are, I would place them in a homeless capacity, because they don't have electricity and they may or may not having running water. (African-American man, individual interviewee)

When asked about services for the homeless in his community, the same community leader explained that the nearest homeless shelter was 60 miles away and that the county was unable to apply for state support because of the limited population in the county. The intersections of the three statuses: old, rural, and poor multiplied the challenges of having adequate housing for many of the older adults in this study.

Discussion

Intersectionality explores the ways that multiple disadvantaged statuses interact with each other to create challenges and to limit the power of the individual. This study focused on the statuses of being an older adult, living in a rural area, and having limited financial resources. While previous literature described the challenges of one or two of these statuses, this work explored the multiplicative effects of the combination of the three statuses. This study explored the ways that each of these individual statuses interact with each other to create multiplicative challenges in the areas of transportation, health care, food, and housing.

We know that older adults in rural areas have father to travel to access health care when compared to those living in more densely populated areas and that there is an increase in the need for health care as we age (Bull, 1998; Krout & Bull, 2006). Adding the status of having limited economic resources multiplies this challenge. For example, while there were transportation services available in the counties where the study took place, the cost of those services, when considering the need for multiple trips, created an intersectional challenge beyond just the two statuses of being older and living in rural areas. The three statuses together can make access to health care difficult if not impossible.

Older adults have more chronic conditions compared to younger adults and therefore higher health care costs (FIFARS, 2016). The single status of being older leads to higher health care costs. When this is added to the status of having limited income there is multiplicative effect. A county manager discussed this when stating that people he knew were not accessing the health care they needed because of having limited financial resources. In addition, there are shortages of health professionals in rural areas and rural hospitals are closing, particularly in the rural southern United States leading to a lack of available health care (Hing & Hsiao, 2014; HRSA, 2019). One senior center participant discussed how a lot of doctors are moving away. It becomes an intersectional issue because rural older adults who have financial resources can pay for transportation or have their own cars. They can access health care even when it is not close by. When you combine the statuses of being an older adult living in a rural area, and having limited financial resources, you get intersectional results such as those stated by that same older woman senior center participant, “a lot of appointment get missed because we can’t afford to drive that far.”

We know that issues around food insecurity are intensified when there is greater distance to travel to grocery stores and food support services such as food pantries (Garasky et al., 2006; Lloyd, 2019). According to participants in this study, even when they are able to access food pantries what they receive is limited. In addition, local stores selling food had limited healthy options and higher costs. If these individuals lived in or could access more densely populated areas they might have more options, but the statuses of living on a limited income in a rural area created an intersection that limited food access.

Older adults living in rural areas are likely to have homes in need of repairs and lacking energy efficiency (Anarde, 2019; Oberdorfer & Wiley, 2014). Participants in this study described the low quality of housing for rural older adults with limited financial resources. This is an excellent example of intersectionality. Here the process of aging happens not just for the individual but also for their housing. These older adults were more likely to be homeowners (Oberdorfer & Wiley, 2014). While this may seem like an asset it is also a responsibility. When living with the status of having limited income you do not have the funds for needed repairs. Older adults may have acquired decent housing in their younger years but over their life courses the housing needed repairs that they could not afford which leads to having substandard housing in late life. The intersection of being older, living in a rural area and having limited funds multiply the challenges of having adequate housing.

Conclusion

While results are presented as individual themes of transportation, health care, food, and housing, it is easy to see that the challenges related to these themes are also multiplicative. For instance, if you could remove challenges related to transportation you would still have challenges related to increased health care needs for older adults and limited healthcare options that come from living in a rural area. Results here add to our understanding of the challenges of being an older adult living in a rural area with limited financial resources by utilizing the lens of intersectionality. They add to existing literature by expanding the application of the concept of intersectionality to those that have multiplicatively challenging statuses.

Several programmatic and policy recommendations came as a result of this community needs assessment. These stemmed from asking participants what they would recommend if they had, “a million dollars and a magic wand.” Here are a few recommendations from study participants that directly related to the intersectionality challenges discussed in this work. A White woman senior center attendee who was a part of a focus group recommended that programs should make vouchers for transportation services available to individuals who have limited financial resources, live in more remote rural areas far from health care and other services, and need multiple rides per month to access groceries, health care and other needed services. An African-American woman who founded a local non-profit recommended in an interview that food pantries must receive the support they need in order to provide food to low-income individuals, including adequate food stuffs to create nourishing meals. An African-American man who worked for a non-profit felt that additional funds must be allocated to allow SNAP to more adequately support the food needs of low-income individuals and to provide additional home delivered meals to low-income older adults living in remote rural areas. SNAP benefits for older adults average around $106 a month and are insufficient to pay for all the food needs of any individual (Lloyd, 2019). An expansion of the benefits from this program would be very helpful. A White woman interviewee from a local non-profit recommended additional coordination between agencies in both the provision of services and the pursuit of funding options as a way of expanding options for struggling older adults. A White woman senior center attendee stated in a focus group that information was key. She wanted to be sure there were adequate ways to get information about services out to older adults, particularly those living in isolation in the more remote areas of her rural county. Many of these improvements would require additional state and federal funds be allocated to rural areas. Often allocations are based on population and this existing system does not take into account the challenges, such as geographic dispersion of the population, that are unique to rural areas. Population density must be factored in when allocating resources rather than just using population numbers. A White woman who worked for a local non-profit strongly recommended that the collaboration and coordination of service providers be increased as there are limited resources available in rural areas and collaboration would allow for better service provision to those in need.

Future research on this topic should explore additional regions beyond the rural southeast. In addition, an expansion of intersectional issues for older adults can include subgroups not explored here including gender, race, and ethnicity. Finally, future research can include quantitative measures that can work from these findings to develop research instruments that could capture intersectional issues for those belonging to these three intersecting statuses of being older, living in a rural area, and having limited financial resources.

Footnotes

Declaration of Conflicting Interests

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Adrienne Cohen

References

Anarde

(2019). Home sweet home: Aging in place in rural America. Generations, 43(2), 17–23.

Brown

D. L.

Glasgow

(2008). Rural retirement migration. Springer.

Brown

T. H.

Richardson

L. J.

Hargrove

T.W.

Thomas

C. S.

(2016). Using multiple-hierarchy stratification and life course approaches to understand health inequalities: The intersecting consequences of race, gender, SES, and age. Journal of Health and Social Behavior, 57(2), 200–222. https://doi.org/10.1177/0022146516645

Bull

C. N.

(1998). Aging in rural communities. National Forum, 78(2), 38.

Calasanti

Giles

(2017). The challenge of intersectionality. Generations, 41(4), 69–74.

Carastathis

(2016). Intersectionality: Origins, contestations, horizons. University of Nebraska Press.

Carbado

D. W.

Crenshaw

K. W.

Mays

V. M.

Tomlinson

(2013). Intersectionality: Mapping the movements of a theory. Du Bois Review: Social Science Research on Race, 10(2), 303–312. https://doi.org/10.10170S1742058X13000349

Choo

H. Y.

Ferree

M. M.

(2010). Practicing intersectionality in sociological research: A critical analysis of inclusions, interactions and institutions in the study of inequalities. Sociological Theory, 28(2), 147–167.

Crabtree

B. F.

Miller

W. L.

(1999). Using codes and code manuals. In Crabtree

B. F.

Miller

W. L.

(Eds.), Doing qualitative research (2nd ed., pp. 163–177). Sage.

10.

Crenshaw

(1989). Demarginalizing the intersection of race and sex: A black feminist critique of antidiscrimination doctrine, feminist theory and antiracist politics. University of Chicago Legal Forum, 1889(1), 139–167.

11.

Dize

(2019). Getting around in rural America. Generations, 43(2), 33–39.

12.

Economic Research Service. (2019). Rural poverty & well-being. United States Department of Agriculture. https://www.ers.usda.gov/topics/rural-economy-population/rural-poverty-well-being/

13.

Federal Interagency Forum on Aging-Related Statistics (FIFARS). (2016). Older Americans 2016: Key Indicators of Well-Being. Federal Interagency Forum on Aging-Related Statistics. U.S. Government Printing Office. https://agingstats.gov/data.html

14.

Feeding America. (2015). Baby boomers and beyond: Facing hunger after fifty. https://www.feedingamerica.org/sites/default/files/research/senior-hunger-research/baby-boomers-executive-summary.pdf

15.

Garasky

Morton

L. W.

Greder

K. A.

(2006). The effects of the local food environment and social support on rural food insecurity. Journal of Hunger and Environmental Nutrition, 1(1), 83–103. https://doi.org/10.1300/J477v01n01_06

16.

Government Accountability Office (GAO). (2015). Older Americans act: Updated information on unmet need for services. GAO. https://www.gao.gov/assets/680/670738.pdf

17.

Gundersen

Ziliak

J. P.

(2017). The health consequences of senior hunger in the United States: Evidence from the 1999–2014 NHANES (Report for Feeding America and the National Foundation to End Senior Hunger). https://www.feedingamerica.org/sites/default/files/research/senior-hunger-research/senior-health-consequences-2014.pdf

18.

Health Resources | Services Administration (HRSA). (2019). Designated health professional shortage areas statistics. Bureau of Health Workforce. https://data.hrsa.gov/topics/health-workforce/shortage-areas

19.

Hing

Hsiao

(2014). State variability in supply of office based primary care providers: United States 2012 (NCHS Data Brief, No. 151). U.S. Department of Health and Human Services.

20.

Krout

J. A.

Bull

C. N.

(2006). Service delivery to rural elders: Barriers and challenges. In Goins

R. T.

Krout

J. A.

(Eds.), Service delivery to rural older adults (pp. 21–36). Springer.

21.

Lloyd

J. L.

(2019). From farms to food deserts: Food insecurity and older rural Americans. Generations, 43(2), 24–32.

22.

MacKinney

A. C.

Dudley

Schoephoerster

(2019). Aging well in rural America—the role and status of healthcare. Generations, 43(2), 46–54.

23.

Maykut

P. A.

Morehouse

(1994). Beginning qualitative research: A philosophic and practical guide. Falmer.

24.

National Aging and Disability Transportation Center (NADTC). (2018). Transportation needs and assessment: Survey of older adults, people with disabilities and caregivers. NADTC. http://www.nadtc.org/wp-content/uploads/FINAL-NADTC-KRC-Polling-report.pdf

25.

Oberdorfer

Wiley

(2014). Housing an aging rural America: Rural seniors and their homes. Housing Assistance Council. http://www.ruralhome.org/storage/documents/publications/rrreports/ruralseniors2014.pdf

26.

Patton

M. Q.

(2002). Qualitative research and evaluation methods (3rd ed.). Sage Publications.

27.

QSR International. (2018). NVivo 12 [computer software]. http://qsrinternational.com

28.

Roy

Bhatta

Burnette

J. D.

(2020). Intersectional effects of gender, education, and geographic region on functional health disparities among older adults in India. Journal of Aging and Health, 32(9), 1188–1197. https://doi.org/10.1177/0898264319899246

29.

Smith

A. S.

Trevelyan

(2019). The older population in rural America: 2012-2016 [American Community Survey Reports ACS-41]. https://www.census.gov/content/dam/Census/library/publications/2019/acs/acs-41.pdf

30.

United States Census Bureau (USCB). (2018). Quickfacts. Retrieved July 2, 2018, from https://www.census.gov/quickfacts/fact/table