Abstract
Occupational therapy practitioners serving rural homebound older adults should consider providing interventions to address loneliness and facilitate activity engagement.
Approximately 10.6 million older adults, or 23% of the older adult population, in the United States live in rural areas (Smith & Trevelyan, 2019). Lack of quality health care and specialty providers, transportation difficulties, poor water quality, limited nutritional resources, and social isolation can create health-related barriers for rural older adults (Goins et al., 2005; Hartley, 2004). These barriers are even more substantial for rural older adults who are homebound or have difficulty leaving their home because of a medical condition (Medicare Interactive, 2017), who constitute about 5.6% of the U.S. older adult population (Ornstein et al., 2015). This vulnerable population is understudied and at greater risk for health complications associated with depression, which is often accompanied by decreased social participation and activity engagement and increased feelings of loneliness.
Depression is a common chronic condition in older adults that can lead to declining health, lower quality of life, higher health care costs, and increased mortality (Casey, 2017; Schiller et al., 2012). A national survey indicated that 11.9% of older adults reported feelings of sadness during the previous 30 days, with a higher rate in rural areas (13.0%) than in urban areas (11.7%; Schiller et al., 2012). Another study examining depression in homebound adults showed a prevalence of 43.9% (Xiang & Brooks, 2017). The results of these studies indicate that the prevalence of depression in rural homebound older adults may be higher than in older adults in general.
Depression and loneliness are often associated with each other and can coexist in older adults (Domènech-Abella et al., 2017). Loneliness is defined as a subjective unpleasant or distressing experience of having less than the desired amount of companionship or support (Peplau & Perlman, 1982). Rural homebound older adults may be at risk for loneliness because the physical layout of rural settings can limit opportunities for social engagement. Although studies have shed light on the detrimental effects of loneliness in older adults, few have been conducted in rural areas. One study found that feelings of loneliness were more prevalent in older adults who lived in a rural setting and had fewer social interactions and smaller social networks, as well as in those with major depression (Domènech-Abella et al., 2017). Although it may be difficult to untangle the direction of causality between loneliness and depression, a review of longitudinal studies showed that loneliness is a significant risk factor for depression (Crewdson, 2016). Loneliness also correlates with other health problems, such as hypertension and poor cardiovascular health (Courtin & Knapp, 2017; Crewdson, 2016), cognitive decline (Boss et al., 2015; Donovan et al., 2017), and difficulty pursuing daily living activities (Hacihasanoğlu et al., 2012; Perissinotto et al., 2012; Shankar et al., 2017). In addition, older adults who were dependent on others or experienced challenges in completing activities of daily living (ADLs) were found to have a higher degree of loneliness than older adults who were independent in these activities (Hacihasanoğlu et al., 2012).
Nonpharmacological interventions, such as the use of behavior activation to increase rewarding activities (Alexopoulos et al., 2016; Cuijpers et al., 2007), exergames (exercise-based video games) to increase physical activity (Chao et al., 2015; Kahlbaugh et al., 2011), and technology to increase social contact and support (Khosravi et al., 2016), have shown some promising effects in reducing depression and loneliness in older adults. Many of the interventions studied were activity based and promoted greater engagement in selected activities.
Researchers have also become more interested in how older adults spend time doing everyday activities and how those activities are linked to their emotional health or well-being (Krantz-Kent & Stewart, 2007; Queen et al., 2014; Steptoe & Fancourt, 2019). In an analysis of data from the American Time Use Survey, Krantz-Kent and Stewart (2007) showed that as Americans age, the time they spend working in paid employment decreases, and the amount of time they spend participating in leisure activities, sports activities, and sleep increases. Leisure time for men is typically higher than for women, and approximately half of this time is spent watching TV. Queen et al. (2014) found that adults who felt lonely did not participate in different daily activities or spend more time alone than those who were not lonely; rather, lonelier adults tended to experience negative emotions when completing activities alone. Finally, Steptoe and Fancourt (2019) examined data from the English Longitudinal Study of Ageing and found that time spent alone and time watching TV were negatively associated with a sense that one is living a worthwhile and meaningful life, whereas spending time with family or friends, engaging in physical activities, and working or volunteering were positively associated.
Engaging in everyday activities provides people with purpose and a sense of meaning in life (Martela & Steger, 2016; Steptoe & Fancourt, 2019). Some activities also provide social interaction. Although activity-based intervention has been used to treat depression, little is known about the effect of activity engagement on loneliness in rural homebound older adults and whether activity engagement and feelings of loneliness are correlated with depression in this population. The first purpose of the current study was to describe the degree of depression, loneliness, and activity engagement in rural homebound older adults. The second purpose was to determine whether there were differences in loneliness and activity engagement between older adults with depression and those without depression.
Method
Design
This study used a cross-sectional survey design. The institutional review board of Indiana University approved the study. Exempt status was granted to the survey so that formal informed consent was not required; however, we provided participants with a letter describing the study, stating that participation was voluntary, and asking for their participation.
Data Analysis
IBM SPSS Statistics for Windows (Version 26) was used for statistical analysis. We used χ2 tests to analyze categorical data and Mann–Whitney U tests to analyze ordinal data.
Participants
Participants were recruited through a local Area Agency on Aging that serves two rural counties in south central Indiana. The agency served 350 homebound adults through nutritional and companion programs. The eligibility criterion for this study was participation in a nutritional or companion program at the Area Agency on Aging. Participants younger than age 60 were excluded.
Survey Procedure
An 11-page paper survey was developed for this study. The survey included a self-report questionnaire and assessments of depression, loneliness, and engagement in meaningful activities. The survey was printed in 14-point font with ample blank space for easy reading and answering. The estimated time required to complete the survey was 40 to 60 min. The staff and program volunteers at the Area Agency on Aging hand delivered the surveys while distributing meals or groceries or providing companion services. The participants were provided with a stamped and addressed return envelope and were allowed 6 wk to complete the survey and mail it to the first author anonymously.
Measures
Self-Report Questionnaire
The survey asked background questions about age range, living arrangement (alone or with others, whom they lived with), health status, chronic conditions, and social networks. Participants were asked to rate their perceived general overall health—excellent, very good, good, fair, poor, or very poor—and to share whether they had been hospitalized in the past 6 mo. Information on chronic conditions was gathered by asking whether they had been diagnosed with hypertension, congestive heart failure, arthritis, diabetes, heart disease, chronic obstructive pulmonary disease, depression, or cancer. To determine the status of their social networks, participants were asked how many times per day, week, or month they received visitors and who these visitors were—family, friends, medical professionals, religious participants, or other. The participants were also asked whether they felt lonely and, if so, how often—always, sometimes, rarely, or never.
Depression Assessment
The Geriatric Depression Scale–15 (GDS–15) was used to measure depression (D’Ath et al., 1994). This assessment uses 15 yes-or-no questions to measure how respondents felt over the past week; responses are scored 0 or 1 , and total scores range from 0 to 15. Scores >10 are categorized as “suggestive” of depression, 5 to 9 as “indicative” of depression, and <5 as no depression. The scale was found to be valid and reliable for major depression (Almeida & Almeida, 1999) as defined in the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994).
Loneliness Assessment
Loneliness was measured using the UCLA Loneliness Scale (Russell, 1996), which consists of 20 questions asking respondents how often they feel disconnected from others—always, rarely, sometimes, or never. Sample questions are “How often do you feel alone?” and “How often do you feel that there are people you can turn to?” The responses are scored using a 4-point scale; higher scores indicate greater loneliness. This assessment has demonstrated high test–retest reliability with older adults (Russell, 1996).
Engagement in Meaningful Activities
To determine the self-perceived meaningfulness of participants’ regular day-to-day activities and the frequency of their engagement in meaningful activities, two questionnaires were used: the Engagement in Meaningful Activities Survey (EMA) and the Meaningful Activity Participation Assessment (MAPA) Frequency items (Eakman et al., 2010a, 2010b). The EMA consists of 12 questions about whether respondents’ activities align with their values and provide a sense of mastery. Sample questions are “The activities I do are valued by others,” “The activities I do help me achieve something which gives me a sense of accomplishment,” and “The activities I do give me a sense of satisfaction.” Response options are rarely, sometimes, usually, and always. Scores <29 indicate low meaningfulness, 29 to 41 moderate meaningfulness, and >41 high meaningfulness. The EMA has shown good internal consistency and moderate test–retest reliability with older adults (Eakman et al., 2010a).
The MAPA asks respondents to rate how often they complete 28 activities—not at all, less than once a month, once a month, two to three times a month, once a week, several times a week, or every day. Example activities are homemaking, managing finances, socializing, writing cards, talking on the phone, watching TV, reading, traveling, gardening, and using the computer. For statistical analysis, we converted the frequency categories to a 7-point rating scale (0, not at all, to 6, every day). The MAPA has shown good test–retest reliability with older adults (Eakman et al., 2010b).
Results
A total of 91 surveys were returned, for a return rate of 26%. Thirteen of the surveys were excluded from analysis because of the age criterion or incomplete data. Table 1 lists characteristics of this sample, including age range, chronic health conditions, frequency of visitors, and recent hospitalizations.
Participant Characteristics (N = 78)
Participants with self-reported depression were not significantly different from those without self-reported depression in terms of living alone or not, χ2(1, N = 78) = 0.01, p = .93, hospitalization in the past 6 mo, χ2(1, N = 78) = 1.52, p = .22, or ability to leave home, χ2(1, N = 78) = 1.54, p = .22. In addition, no significant differences were found in frequency of visits, χ2(1, N = 78) = 1.97, p = .58, or in types of visitors, including family, χ2(1, N = 78) = 0.10, p = .75, friends, χ2(1, N = 78) = 0.05, p = .82, and medical professionals, χ2(1, N = 78) = 0.68, p = .41.
The mean GDS–15 score was 6.44 (SD = 4.45). Twenty-nine participants (37%) scored within the no depression range, 27 (35%) in the indicative of depression range, and 22 (28%) in the suggestive of depression range. Fifty-one participants (65%) showed high levels of depression on the UCLA. The mean EMA score was 32.38 (SD = 10.55). Twenty-nine participants (37%) were categorized as having low engagement, 24 (31%) as having moderate engagement, and 25 (32%) as having high engagement in meaningful activities.
Table 2 provides descriptive results for the number of chronic conditions and scores on the GDS–15, UCLA Loneliness Scale, and EMA for participants with self-reported depression and those without self-reported depression. Relative to those without self-reported depression, those with self-reported depression had more chronic conditions (U = −4.10, p < .05), higher GDS–15 scores (U = −2.47, p < .05), a higher degree of loneliness (U = −3.15, p < .05), and a lower level of engagement in meaningful activities (U = −3.26, p < .05).
Number of Chronic Conditions and Mean Assessment Scores of Participants With and Without Self-Reported Depression
Note. All differences between groups are significant at the p < .05 level (Mann–Whitney U test).
Table 3 shows descriptive results for the 28 items of the MAPA. Relative to participants without self-reported depression, those with self-reported depression showed less engagement in homemaking or maintenance activities (U = −3.07, p < .05), gardening (U = −2.29, p < .05), musical activities (U = −2.06, p < .05), community organization activities (U = −1.97, p < .05), computer use for email (U = −2.86, p < .05), and computer use for other purposes (U = −2.13, p < .05).
Mean Item Scores on the Meaningful Activity Participation Assessment for Participants With and Without Self-Reported Depression
Note. Response options for the Meaningful Activity Participation Assessment: 0 = not at all, 1 = less than once a month, 2 = once a month, 3 = two to three times a month, 4 = once a week, 5 = several times a week, 6 = every day.
p < .05 (Mann–Whitney U test).
Discussion
The first purpose of this study was to describe the degree of depression, loneliness, and activity engagement in rural homebound older adults. Although 40% of participants self-reported having depression, the GDS–15 results indicate that 63% might have had depression. Participants scored in the moderate range on the UCLA Loneliness Scale on average, and 55% self-reported feeling lonely. As a whole, participants’ engagement in meaningful activity was moderate.
The second purpose of the study was to examine differences in loneliness and activity engagement between rural homebound older adults with self-reported depression and those without. Participants with self-reported depression had not only a higher degree of loneliness but also lower engagement in meaningful activities. Low frequency of activity engagement was more prominent in self-care activities such as homemaking; leisure activities such as gardening, musical activities, and computer use; and socializing activities such as community organization activities and email writing.
The rural homebound older adults who participated in this study reported a considerably higher rate of depression compared with the national average for older adults; 40% of participants reported having depression, whereas the national average for older adults is 12% (Schiller et al., 2012). Our result is closer to the finding of a national survey that 44% of homebound adults reported depression (Xiang & Brooks, 2017). However, the low survey response rate may indicate that the actual depression rate in potential participants might have been much higher; those who experienced depression may have been less inclined to respond to the study survey.
Rural homebound older adults have not only a higher rate of depression, compared with older adults in general, but also a higher degree of loneliness. A study in Spain found that rural homebound older adults with smaller social networks and limited social interactions tended to experience more loneliness (Domènech-Abella et al., 2017). A national study in the United States found that 35% of adults age 45 and over were lonely (Anderson & Thayer, 2018). In contrast, results on the UCLA Loneliness Scale in the current study indicate that 65% of participants had a high degree of loneliness. The low population density in rural areas limits the size of social networks and social interactions and may have contributed to feelings of loneliness among these participants. Another factor limiting social networks and interaction may be the mobility issues that homebound people typically have, which can make it difficult to leave their homes to participate in community or other social activities; this possibility is supported by the low frequency of self-reported driving and public transportation use participants reported on the MAPA. The purpose of visits from family or friends might be instrumental, such as assisting in medical visits, as well as to provide companionship. Although family and friends were these participants’ most common visitors, the variety of visitors and the frequency of visits may have been limited in their rural areas.
In addition, adults who feel lonely tend to engage in activities alone (Queen et al., 2014) and to experience negative emotions when completing activities alone (Steptoe & Fancourt, 2019). The activity participants most frequently engaged in was watching TV, a finding consistent with the literature (Krantz-Kent & Stewart, 2007); participants watched TV almost every day. In contrast, they participated in networking activities much less often; they socialized or talked on the phone only once a week to two to three times per month and wrote letters or cards or participated in community organization activities once a month or less.
One way homebound adults can increase their networking and socializing is through computer-based communications. Studies have shown benefits of online social interactions equal to those of face-to-face communication (Rhoads, 2010), including a sense of community and increased life satisfaction (Oh et al., 2014). The lower use of computers reported on the MAPA by participants with self-reported depression may have been related to their feelings of loneliness.
Participants engaged in leisure activities, including gardening, crafts and hobbies, cultural and musical activities, creative activities, and game playing only once a month or less. Leisure activities are recognized as a useful coping resource for depression (Nimrod et al., 2012). Adults with depression may participate less in their preferred activities, which can lead to increased depression and decreased engagement in activities, creating a vicious cycle. Accordingly, participants with self-reported depression engaged less in leisure activities compared with those without self-reported depression.
Participants with self-reported depression also engaged less in homemaking and home maintenance activities than those without self-reported depression. The lower frequency of participation in these activities may have been related to having more chronic conditions that limited the ability to participate. In addition, older adults who are dependent on others or have difficulty completing ADLs have been shown to have a higher degree of loneliness (Hacihasanoğlu et al., 2012), so limited participation among participants with self-reported depression could have been related to their feelings of loneliness.
Leisure activities, homemaking and home maintenance activities, networking activities, and community activities are all types of occupations. Occupations are characterized by three properties: active participation, meaning to the person, and a process that produces results (Schkade & Schultz, 1992). Occupational therapy practitioners use the occupational adaptation frame of reference to enable clients to experience relative mastery over occupations through the process of looking at the person, the environment, and the challenge (Schkade & Schultz, 1992). Practitioners take a holistic approach, using the occupational profile and occupational adaptation as tools to help modify activities to allow for greater participation and meaningfulness.
To our knowledge, this study is the first to measure engagement in meaningful activities in rural homebound older adults. Activity participation is associated with improved mental health and overall better well-being in older adults, and older adults with low activity engagement have poorer health and higher depressive symptoms than those with high activity engagement (Morrow-Howell et al., 2014). Although activities that provide opportunities for social interaction have traditionally been thought of as taking place outside the home, technology offers many opportunities for social interaction through virtual means, including online musical events, book clubs, classes, and many other activities. Future studies are needed to identify additional means to increase activity engagement among rural homebound older adults.
Limitations
The findings of this study should be interpreted with caution because of the low survey response rate; one reason for the low response rate may be the length of the survey. The results cannot be generalized to the entire rural older adult population because this study was conducted only in two rural counties in Indiana. In addition, we were unable to screen for cognitive impairments in the participants. These limitations can be addressed in future research that covers a wider area of rural United States.
Implications for Occupational Therapy Practice
The results of this study have the following implications for occupational therapy practice:
Occupational therapy practitioners can use the information from this study to gain insight into the factors affecting rural homebound older adult clients with depression and develop new ways to encourage their participation in activities.
Practitioners can also use the results to advocate for positions within local professional organizations to help facilitate the implementation of new interventions and provide meaningful activities to this vulnerable population.
Agencies that provide services to rural homebound older adults can use these findings in pursuing funding to develop new activities or offer occupational therapy services for this population.
Conclusion
This study provides evidence that rural homebound older adults have high rates of depression, high degrees of loneliness, and low engagement in meaningful activities relative to the general population of older adults. In addition, our findings indicate that compared with rural homebound older adults without self-reported depression, those with self-reported depression experience greater degrees of loneliness and less engagement in meaningful activities, including homemaking, leisure, and socializing activities. Future studies are needed to develop and evaluate occupational therapy interventions that encourage social engagement and participation in meaningful activities with the intention of decreasing loneliness and depression in this population.
Footnotes
Acknowledgments
We thank staff and program volunteers at the partnered local Area Agency on Aging for distributing the study surveys. This study was completed in partial fulfillment of the requirements for a postprofessional clinical doctoral degree in occupational therapy to Alissia A. Garabrant at Indiana University. Portions of this study were presented at the 2019 American Occupational Therapy Association Annual Conference & Expo in New Orleans, LA. Neither author has conflicts of interest to report.