Attendance in adult day care centers of cognitively intact older persons: reasons for use and nonuse.

432141 ch and BidermanJournal of Applied Gerontology

JAG32510.1177/0733464811432141Iecovi

Article

Attendance in Adult Day Care Centers of Cognitively Intact Older Persons: Reasons for Use and Nonuse

Journal of Applied Gerontology 32(5) 561–581 © The Author(s) 2012 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0733464811432141 jag.sagepub.com

Esther Iecovich1 and Aya Biderman1

Abstract The article aims to (a) examine the reasons for nonuse of ADCC, and (b) explore the reasons for use of adult day care centers (ADCCs) among users. The sample includes 819 respondents of whom 417 are users of 13 day care centers and 402 are nonusers, matched by age, gender, and family physician in the southern region of Israel. Data collection includes interviews that used a structured questionnaire.The most frequent reasons for nonuse of ADCCs are accessibility barriers, characteristics of participants and of the ADCCs, “no need for this service,” and personal difficulties. Those who use this service report that it improved their well-being, met their needs, enabled them to establish social relationships, and alleviated their family caregivers’ burden. ADCCs should be more responsive to the needs of various constituencies of frail older adults and be more accessible to those who do not use this type of service. Keywords frails, utilization of service, reasons

Manuscript received: June 20, 2011; final revision received: November 2, 2011; accepted: November 14, 2011. 1

Ben Gurion University, Beer Sheva, Israel

Corresponding Author: Esther Iecovich, Ben Gurion University of the Negev, P.O. Box 653, Beer Sheva, 84105, Israel. Email: [email protected]

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Journal of Applied Gerontology 32(5)

Introduction Adult day care centers (ADCCs) compose a core, community-based, long-term care service for frail older adults. ADCC play an important role in the communitybased long-term care continuum: (a) From the perspective of the frail older person, they help in sustaining and preserving the functioning of older people, allowing them to age in place, and meet some of their long-term care needs (Anetzberger, 2002; Gaugler & Zarit, 2001), including social and emotional needs that can help alleviate feelings of loneliness, boredom, and solitude, improve quality of life (Baumgarten, Lebel, Laprise, Leclerc, & Quinn, 2002; Bilotta, Bergamaschini, Spreafico, & Vergani, 2010; Jacob, Abraham, Abraham, & Jacob, 2007), reduce levels of depression, buffer stress, and increase levels of life satisfaction (Garcia-Martin, Gomez-Jacinto, & Martimportugues-Goyenechea, 2004; Valadez, Lumadue, Gutierrez, & de Vries-Kell, 2006; Williams & Roberts, 1995); (b) From the perspective of the family caregiver, ADCCs form a kind of respite service (Jarrott, Zarit, Berg, & Johansson, 1998) that helps reduce the family’s burden and distress (Gaugler et al., 2003). They enable family members to lead normal lives, encourage them to assume this responsibility for a longer period, and alleviate care-related stress among caregivers of Alzheimer patients (Shacke & Zank, 2006). Despite the important goals that ADCC aim to achieve, a high proportion of frail older people who live in the community do not use them. For example, in Israel only about 7% of those who were entitled to use this type of service under the Long-term Care Insurance law (Iecovich & Carmel, 2011) actually used this service. In the United States, Travis, Steele, and Long (2001) found in Oklahoma that only 15% of the older adults who would be expected to use this type of service were participating in its programs, mainly because such programs do not meet their needs. A study conducted among African American older adults with mental health impairments in Washington State found that respite services, including ADCCs, were the least utilized among an array of supportive services (Li, Edwards, & Morrow-Howell, 2004). Underuse of ADCCs was also reported in Canada (Gutman, Milstein, Killam, & Lewis, 1991; Ritchie, 2003). In most cases, the reasons for underutilization were found to be related to lack of awareness, stigma in terms of childcare connotation ascribed to ADCC, clients’ preferences, including a reluctance towards participating in group activities, and clients who considered the days too long and who were too ill to attend (Gutman, Milstein, Killam, Lewis, & Hollander, 1993; Montgomery, Marquis, Schaefer, & Kosloski, 2002). Other reasons for nonattendance focused on the system, including bureaucratic processes, limited accessibility, activities, and inappropriate transportation and the variety of services that were provided at the

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ADCC (Ritchie, 2003). Hong (2004), for example, found that the most frequent unmet service need was adult day care. The major reasons for use were as follows: It enables aging in place; it provides respite service for family caregivers and key features of facilities/services provided also include the following: program components that include health promotion and physical assessment and care, program characteristics in terms of flexibility in meeting clients needs, physical setting that is culturally sensitive, and staff characteristics, in particular their knowledge and skills to address complex needs of the participants (Gaugler & Zarit, 2001; Ritchie, 2003); it also provides social activities, increases contact with friends, or enables individuals to make new friends and keep themselves active (Tse & Howie, 2005). Previous studies that examined differences between users and nonusers of ADCCs focused mainly on differences in sociodemographic characteristics of the respondents, their health, and their functional and economic status (e.g., Gutman et al., 1993; Montgomery et al., 2002). Surveys conducted in the United States showed that typical day care users were disabled and aged between 75 and 79 (Montgomery et al., 2002; Reifler, Henry, & Cox, 1995; Weissert, Wan, Livierators, & Katz, 1980). Most participants were White, non-Hispanic women who lived with their spouses or other relatives. Other studies showed that unmarried women with lower income used ADCC more frequently compared to married men with higher income. Also, health conditions, such as Alzheimer disease, stroke, heart disease, hypertension, and diabetes, and functional status were connected with utilization of ADCCs (Cohen-Mansfield, Lipson, Brenneman, & Pawlson, 2001; Kirwin, 1988; Reifler et al., 1995; Weissert et al., 1980). An Israeli study (Iecovich & Carmel, 2011) found users of ADCCs were comprised of participants whose group in general had the following demographic characteristics: Participants were younger, were unmarried, were living alone, had less education, were living longer in Israel, were functionally less limited (in instrumental activities of daily living [IADL] and activities of daily living [ADL]), had appraised their health status as better, had a larger family network but seldom met with their family members, and were less likely to have a homecare worker compared to nonusers. However, a study that compared between the characteristics of cognitively impaired participants of American and Swedish ADCCs found that clients’ characteristics were similar, suggesting that ADCCs were a widespread solution to the common problem of supporting disabled older persons, in particular those with mental health impairments (Jarrott et al., 1998). Yet most studies that examined use or underuse of ADCCs were conducted in the United States and they focused mainly on family caregivers whose older family members were cognitively impaired (Beisecker, Wright, Chrisman, & Ashworth, 1996; Cohen-Mansfield, Besansky, Watson, & Bernhard, 1994).

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There are several models of ADCCs: social, medical, and integrated (Dabelko & Zimmerman, 2008; Van Beveren & Hetherington, 1998; Weissert, 1976). The medical model includes assessment, care, and rehabilitation, and the social model focuses on socialization and prevention. The third, integrated model, includes two elements from the other two models. In addition, there are ADCCs that serve specific population groups of older persons such as cognitively impaired or physically disabled but cognitively intact. In the United States, for example, 37% of the ADCCs operate according to the social model (20% of them serve cognitively impaired patients), 42% operate according to the integrated model, and only about 21% operate according to the medical model (Nadash, 2003; Robert Wood Johnson Foundation [RWJ], 2003). Furthermore, most ADCCs in the United States follow a medical or an integrated model rather than a social model, whereas in Israel the vast majority of ADCCs follow the social model. In order to gain a more global perspective, more research is needed to assess the various reasons for use or nonuse of ADCCs among different groups of consumers in different countries.

Adult Day Care Centers (ADCCs) in Israel In Israel ADCCs compose a core, community-based service for frail older persons that started to develop in the early 1980s. After the enactment of the Long-Term Care Insurance Law in 1986 that aimed to provide care to functionally disabled older adults and to support their family caregivers, many new ADCCs were established. Today, there are 172 ADCCs that serve approximately 15,500 people (Brodsky, Shnoor, & Be’er, 2011). Studies (Be’er, 1994; Iecovich & Carmel, 2011) conducted in Israel found that most ADCCs follow the social model and actually serve for the most part older persons who are moderately frail and who belong to lower socioeconomic status, whereas severely disabled older adults barely use this type of service though it is optional to all frail older persons regardless of their ethnicity or socioeconomic status. Only a very few ADCCs in Israel aim to serve cognitively impaired older persons, compared to 52% of such facilities in the United States (National Adult Day Services Association [NADSA], 2011). The core services provided at the ADCC include personal care, social activities, health promotion, meals, recreation, physical activities, laundry, transportation, and personal counseling. However, no health care services are provided in these facilities. Most of the centers operate 5 days a week, 5 to 6 hr a day. They are heterogeneous in their physical size, number of participants, characteristics of the participants, variety of services, auspices, and operators. Expenditures are covered by the long-term care benefits (Schmid, 2005) that enable beneficiaries to replace all home care services with ADCC or have mixed care. Thus, payment


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using an ADCC, per day, ranges from US$22.50 to US$31.00, approximately, depending on the level of functional dependency of the participant; these fees are covered by the National Insurance Institute. The ADCCs provide transportation and two meals a day (breakfast and lunch) for which the participants copay about US$5 a day. For each participant, an individual care plan is prepared and provided by a multidisciplinary team. However, due to the paucity of studies that examined these issues from the perspective of the older persons themselves who visit or do not visit in ADCCs, more research is needed to learn about the factors that affect utilization or underutilization of this type of community-based service among physically disabled but cognitively intact older persons. Considering the many types of resources invested in establishing and operating ADCCs, it is important to identify the factors that affect their utilization from the perspective of the users themselves. It is also important to investigate the reasons for underuse of ADCC from the perspective of the relevant potential users, an issue that has been barely examined. Therefore, this study aims to examine the reasons for use and nonuse of ADCCs from the perspective of the target population.

Methods Study Design and Ethics A quasiexperimental design was used to recruit respondents. Participants were recruited from 12 ADCCs in the southern region of Israel that serve altogether about 1,000 registered frail older adults. The study was reviewed by an institutional board and was approved by the ethics committee of the Clalit HMO. Informed consent was obtained from all participants prior to the interviews. Inclusion criteria were as follows: Age above 60, ability to speak in Hebrew or in Russian (about a third of the respondents were immigrants from the erstwhile USSR, who immigrated to Israel after its collapse in 1989), frail in terms of having difficulties in performing ADL, and members of Clalit Health Service Organization, which is the largest HMO in Israel. In Israel there are four HMOs that operate under the National Health Insurance Law that was enacted in 1994 and provide universal health care services to all its citizens. The Clalit HMO provides health care services to more than half of the population in Israel, and the vast majority of older adults are insured in this organization (Bendelac, 2010). Only those who met the inclusion criteria and gave their consent to be interviewed were included in the study.

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Sample The sample included 417 frail older adult users of ADCCs and 402 nonusers. From a total of 1,000 ADCCs users, 417 accepted to be interviewed, 165 refused to be interviewed, 75 were not members of the Clalit HMO, and the rest of the participants could not be interviewed due to language barriers, cognitive impairments, or general unavailability. In the first stage, a letter was posted to managers of the ADCCs explaining the goals of the study and asking their permission to enable the interviewers to present the research goals to the users of the ADCCs. In the second stage, users of the ADCCs were approached by the interviewers and were asked to volunteer to be interviewed. The 402 nonusers were recruited through family physicians of the respondents who were asked to prepare lists of patients (nonusers) who had characteristics similar to the users’ in terms of age (same age or up to 5 years difference between user and nonuser), gender, functional status and who were treated by the same family physician, to control for differences between the clinical approaches of the family physicians treating those in the comparison group. In case a nonuser was unavailable or reluctant to participate in the study the physician was asked to provide another name that met the same criteria. Thus, 402 nonusers were interviewed, 111 refused to be interviewed, 65 were unavailable, 91 were unable to be interviewed, and 7 died. For 15 users no matched nonusers were found. Nonusers were sent a prenotification letter explaining to them the goals of the study, asking their consent to be interviewed, assuring them of confidentiality and notifying them that an interviewer would contact them the next week via telephone. A week later, interviewers called the older persons and asked their consent to be interviewed. Once they agreed, appointments were made at the home of the respondents.

Data Collection Data were collected during the period 2009-2010 through face-to-face interviews that used a structured questionnaire. All interviewers were trained to interview older people and in administering the questionnaire. All respondents underwent a Mini-Mental State (Folstein, Folstein, & McHugh, 1975) screening at the beginning of the interview, and only those who were cognitively intact were interviewed. Interviews with users of ADCCs were conducted privately in one of the rooms at the ADCC, to assure confidentiality, and with nonusers at their homes.


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Measures Dependent Variables Reasons for nonuse. Based on interviews with directors of two ADCCs who were asked to provide reasons for ADCC underuse, a list of 20 items was composed to probe reasons for nonuse. These items were classified into six categories: awareness of the service (three items), accessibility barriers (four items), characteristics of the ADCC user participants (four items) and of the ADCCs (four items), “no need for such a service” (three items), and personal difficulties (three items). Respondents were asked to give dichotomous answers for each item: 1 = yes or 0 = no. Scores for each category were summed with scores ranging from 0 to 3 or 4 (depending on number of items in each category) and then recoded with 1 = yes when answer to at least one of the items in the category was positive and 0 = no when all the answers in the category were negative. Reasons for use. Users of ADCCs were presented with a list of 10 statements pertaining to reasons for visiting the ADCC with dichotomous answers for each item: 1 = yes and 0 = no. The list of statements were classified into four categories: promotes well-being (four items), provides social benefits (two items), meets needs (two items), and serves as respite for caregivers (two items). Scores for each category were summed with scores ranging from 0 to 2 or 4 (depending on number of items in each category) and were then recoded into 1 = yes when the answer to at least one item in the category was positive and 0 = no when answers to all items in the category were negative. In addition, the respondents were asked an open-ended question regarding how ADCC was helpful to their family caregivers.

Independent Variables Instrumental activities of daily living (IADL). Fillenbaum’s (1985) measure was used to examine the ability to perform IADL. The measure includes eight items, including home chores, laundry, cooking, and so on. Scores for each item ranged from 1 (no difficulty at all) to 5 (very much difficult). The final index was based on the sum of scores ranging from 8 to 40. The internal consistency (Cronbach’s alpha) in this study was .94. Activities of daily living (ADL). ADL was measured using Katz and colleagues’ (Katz, Downs, Cash, & Grotz, 1970) measure that includes eight items (washing, dressing, toileting, indoor mobility, eating, etc.), with scores for each item ranging from 1 (no difficulty at all) to 5 (very much difficult). The sum of scores produced an index of values ranging from 8 to 40. The internal consistency (Cronbach’s alpha) in this study was .91.

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Self-Rated Health. The respondents were asked to rate their present health status with scores ranging from 1 (excellent) to 6 (very poor). Comorbidity. Based on the CALAS study (Modan et al., 2002), comorbidity was measured by the number of self-reported chronic health conditions, for example, “Do you suffer from or has a physician ever told you that you suffer from. . .?,” and a list describing 14 major medical conditions was read out. The 14 conditions included cancer, diabetes, high blood pressure, heart attack, other heart disease, cardiovascular accident, circulatory disease, respiratory disease, gastrointestinal disease, osteoporosis, Parkinson’s disease, thyroid disease, arthritis, and nephrological problems. Score for each condition was 1 = yes and 0 = no. Scores were summed to arrive at an average, with higher scores indicating more morbidity. Economic Status. The respondents were presented with seven categories of income and asked to choose the category that was relevant to them. One participant indicated the lowest monthly income, which was the poverty line in Israel, whereas seven participants indicated the highest level of income. In addition, respondents were asked to rate their perceived economic status with scores ranging from 1 (very good) to 6 (very poor). Covariates The covariate variables included sociodemographics characteristics: age; gender; education (included 7 categories ranging from 1 = partial elementary school to 7 = graduate degree and above); ethnicity (coded as 1 = Europe/North America, 2 = Asia Africa, and 3 = born in Israel, with new immigrants from the European part of former Soviet Union, like Russia, Ukraine, or Moldova, included in Category 1 and those who came from the Asian part of the former Soviet Union, like Uzbekistan, Georgia, and Tajikistan, included in Category 2); marital status that included four categories: married/lives with a partner, widowed, divorced/separated, or single/never married (coded 1 = married and 0 = unmarried); living arrangements (coded 1 = live alone, 2 = otherwise); number of children; number of children living in proximity; household size; and length of time living in Israel.

Analyses A range of descriptive analyses (percentages, means, and standard deviations) were initially performed to present the characteristics of the respondents and the dependent and independent variables. Also, t and chi-square tests were carried out to examine the differences between the users and the nonusers. Distribution of frequencies and crosstabs were used to examine the main reasons for use and


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nonuse of day care centers and combinations of reasons. To examine which of the independent variables was significantly associated with reasons for use and nonuse and correlations between reasons for nonuse, bivariate analyses were performed, including Pearson correlation coefficient analysis and chi-square tests, depending on the type of variables. To examine the factors that predict each of the categories of reasons for ADCC nonuse, logistic regressions analyses were performed. Data storage and analysis were performed using SPSS package version 17.

Results Characteristics of ADCCs Table 1 presents several selective characteristics of the ADCCs that were included in the study. Three of the ADCCs were located in a big city, six in small towns, and three in rural areas. All the ADCCs were operated by nonprofit organizations. All the ADCCs were open 5 days a week, 5.5 to 7 hr a day. The variety of services provided in the each of the ADCCs was very similar, taking into account the governmental guidelines that determine types of services that ADCCs should provide to their participants. These include transportation, two meals a day, social and recreational activities, personal care, and several health promotion activities such as physical movement. Nevertheless, ADCCs also provide some extra services such as pedicure, manicure, hairdressing, dentistry, and laundry. Mean number of participants who visited ADCCs every day ranged from 18 to 120.

Participants’ Characteristics Respondents’ characteristics by ADCC utilization are presented in Table 2. The findings show that the vast majority (about 76%) were women whose average age was about 78 years. No significant differences were found between users and nonusers of ADCCs in their functional status, number of children living in near proximity, and perceived economic status. Nevertheless, significant differences were found between the two groups of respondents in ethnicity, marital status, level of education, number of children, living arrangements, household size, length of stay in Israel, monthly income, and health status (self-rated health and comorbidity). Among those who attended ADCCs there were significantly more widowed persons, more with lower levels of education, more who were born in Asian African countries, more who were living alone with good to moderate levels of self-rated health, compared to their counterparts in the control group who were married, were more highly educated, who lived with spouses or adult children, and were born in European/North American countries but rated their health status as poorer. In addition, users of ADCCs had significantly more children, lived

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Table 1. Characteristics of Respondents by Use of Day Care centers. Users Variable Gender Women Age Ethnicity Asia/Africa Europe/ North America Israel Marital status Married Widowed Divorced/ separated Education Elementary Secondary High education Number of children Number of children living in proximity Living arrangements Alone With a spouse With a child Otherwise Length of stay in Israel Household size Monthly income

%

M

SD

Nonusers Range

75.7

%

M

SD

Range

75.6 77.95 7.09 60-100

77.78 6.09 62-95

χ2/t values 0.52 0.59 17.24***

62.9 35.6

50.6 44.1

1.5

5.2

21.3 72.4 6.3

46.4 46.4 7.2

63.22***

70.2 20.1 9.7

52.9 29.7 17.4

25.85***

4.45 3.03

0-15

3.92 2.90

0-17

2.56*

1.59 1.96

0-13

1.58 1.88

0-11

0.13

56.1 21.3

36.2 44.4

15.8 6.8

11.4 8.0 45.17 17.12

0-84

1.69 1.03 2.42 0.97

1-6 1-5

52.87***

41.85 18.12 1.83 0.90 2.88 1.18

0-80

2.61**

1-8 1-7

-1.99* 16.13*** (continued)

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Iecovich and Biderman Table 1. (continued) Users Variable Perceived economic status Very good Good Moderate Poor/very poor Self-rated health Very good Good Moderate Poor/very poor Comorbidity ADL IADL

%

M

SD

Nonusers Range

%

9.7 34.1 48.0 8.2

M

SD

Range

8.3 30.8 46.8 14.1

6.7 26.1 54.7 12.5

8.85

6.8 19.5 48.5 25.2 3.39 2.20 14.31 5.69 20.13 7.35

0-11 8-32 8-38

χ2/t values

24.04***

4.27 2.16 14.84 6.11 20.60 7.46

0-10 5.73*** 8-32 -1.30 8-36 -0.91

Note: ADL = activities of daily living; IADL = instrumental activities of daily living. *p < .05. **p < .01. ***p < .001.

longer in Israel, lived in smaller households, a lower monthly income, and reported less comorbidity compared to their peers in the control group. Among those who attended ADCCs the average duration of visiting the ADCC was 49.17 months (SD = 50.35) and the average of weekly visits was 3.83 (SD = 1.23). Table 3 presents the distribution of reasons for nonuse of ADCCs. The findings indicate that the most prevalent reasons for nonuse were personal difficulties, accessibility barriers, characteristics of the ADCCs’ participants and of the service, and “no need for this type of service.” After summing the scores for each category of reasons, the findings indicate that only a negligible proportion was unaware of this type of service. The main reasons for nonuse were “no need for this type of service,” personal difficulties, accessibility barriers, as well as participants’ and ADCCs’ characteristics that were discouraging for the older persons to consider using this type of service. The vast majority (90.2%) of respondents provided four or more reasons for nonuse of ADCCS.

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Table 2. Reasons for Nonuse of Day Care Centers (Yes Only). Reason Awareness of service I didn’t know about this type of service Do you know about the day care center that is located in your neighborhood Do you know what services are provided at the day care center Accessibility barriers The day care center is too far from my home It’s too difficult to get out from my apartment (no elevator) The transportation is inconvenient Characteristics of the participants Emotional difficulty to see disabled people Only miserable people visit in day care centers The people who visit the day care center are not interesting for me The people who visit the day care center are not from my milieu Characteristics of the day care center The day care center has a negative image The operating hours of the care center are inconvenient The activities at the day care center are low level The activities at the day care center are not interesting Need for service I don’t need this type of service I prefer to stay at home Personal difficulties I cannot visit the day care center due to my health status I cannot leave my spouse alone Difficulties to pay the copayment

% 97.2 17.3 86.0 84.8 57.1 30.9 39.3 38.3 55.9 40.8 11.2 31.1 12.2 53.1 2.3 17.3 13.5 43.1 96.2 36.5 88.3 75.8 59.7 29.8 11.5

Note: N = 392.

To examine the factors that explain nonuse of ADCCs, logistic regressions were performed for each of the reasons for nonuse, and the findings are presented in Table 4. The equations included the same variables: participants’ sociodemographic characteristics, health and functional status, and economic status. The findings show that for each reason for nonuse a different combination of variables were found to explain the outcome variable. Thus, longer stay in Israel was associated with a 7% increase in the likelihood of awareness, whereas independence in ADL was associated with an 18% decrease in the likelihood of awareness. Being married was associated with a 65% decrease in the likelihood of accessibility difficulties,

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Table 3. Zero-Order Correlation Coefficients Between Reasons for Nonuse of ADCC. Variable 1. Awareness of service 2. Accessibility barriers 3. Characteristics of the participants 4. Characteristics of ADCC 5. “No need for service” 6. Personal difficulties

1 -.03 .03 .01 -.01 -.06

2

3

-.12* -.13** .49*** .16** .24*** .31*** -.12*

4

5

.20*** -.11*

-.01

Note: N = 392. ADCC = adult day care centers. *p < .05. **p < .01. ***p < .001.

and lower income was associated with a 31% decrease in the likelihood of accessibility. Morbidity and economic status were associated, respectively, with a 13% and 19% decrease in the likelihood of not attending an ADCC due to participants’ characteristics. Gender and morbidity were associated, respectively, with a 46% and 12% decrease in the likelihood of not attending an ADCC due to its characteristics. Length of stay in Israel was associated with a 2% decrease in the likelihood of nonuse due to personal problems, morbidity was associated with an 18% decrease in the likelihood of personal problems, and functional status (ADL) was associated with a 10% increase in the likelihood of nonuse due to personal problems. All the regression models were found to be significant. With regard to users of ADCCs, the findings in Table 5 show that the vast majority reported the same and all reasons for visiting the ADCCs. Besides, lower levels of education and poorer functional status (IADL) were significantly correlated with socializing (r = .14, p < .01, and r = –.11, p < .05, respectively). Longer residence in Israel and poorer functional status (ADL and IADL) were significantly connected with reduced family burden (r = –.15, p < .01; r = .22, p < .001; r = .21, p < .001, respectively). Lower levels of education, shorter residence in Israel, and fewer children were connected with lower levels of well-being gained due to use of ADCCs (r = .11, p < .05; r = –.12, p < .05; r = –.10, p < .05, respectively). It should be noted that gains from using ADCCs were interconnected; higher level of well-being was significantly connected with social benefits (r = .55, p < .001), met needs (r = .50, p < .001), and ADCCs serving as respite for family caregivers (r = –.11, p < .05). Social benefit was significantly connected with met needs (r = .31, p < .001) and ADCCs serving as respite for family caregivers (r = –.11, p < .05).

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0.16 0.44

−0.14 0.31

0.01

1.02

3.25

0.82 0.99 0.67

0.22

0.02

1.58

0.96 0.16 1.17 1.51 1.07

−0.19* 0.08 5.27 −0.01 0.09 0.00 −0.41 0.38 1.16 31.65** 0.04 0.29

0.94

1.18

0.62 1.98 0.41 0.22 6.78

0.87 1.36

0.06 1.21 0.25 0.87 0.02

−0.04 −1.70 0.16 0.41 0.06**

Odds Wald ratio

0.69 0.49

SE

B

0.05 0.23 0.12 0.73

0.06 0.04

9.57 2.78

2.10

1.78

0.37 2.37 0.43 2.27 0.03

Wald

0.02 2.97 0.02 1.88 0.10 4.74 52.37*** 0.06 0.10

0.05 0.12

0.05

1.01 −0.07

0.98 −0.14** 1.11 −0.20

0.25

0.02 0.24 0.07 0.26 0.01

SE

0.33

1.00

1.03 0.01 0.73 −0.37 0.94 −0.05 0.35 −0.40 1.04 0.00

B

0.96 1.03 0.81

0.87 0.82

0.93

1.39

1.01 0.69 0.96 0.67 1.00

Odds ratio

Participants characteristics

0.03 0.03 0.69 1.03 −0.04 0.04 0.02 3.50 1.04 0.03 −0.37*** 0.11 12.56 0.69 −0.21* 111.56*** 0.13 0.21

−0.03 0.11

0.01

0.30 0.00

−0.00

3.74 1.79 0.75 12.28 0.31

Odds Wald ratio

0.02 0.24 0.07 0.30 0.01

SE

0.03 −0.32 −0.06 −1.04*** 0.00

B

Accessibility

−0.03 0.01 −0.06

−0.13* −0.15

−0.03

0.43

0.00 −0.61* −0.04 −0.34 0.01

B

8.36 1.74

0.52

3.43

0.01 6.42 0.42 1.83 3.35

B

0.97 0.10* 1.01 0.05 0.94 −0.24

0.88 −0.20** 0.86 0.24

0.97 −0.02

1.54 −0.02

8.97 2.52

0.08

0.00

3.07 0.03 2.50 1.61 4.01

1.10 1.05 0.79

0.82 1.28

0.98

0.98

1.04 1.06 0.87 1.64 0.98

Odds Wald ratio

0.05 4.55 0.03 2.65 0.13 3.47 73.96*** 0.09 0.18

0.07 0.15

0.07

0.35

0.02 0.31 0.09 0.39 0.01

SE

Personal problems

1.00 0.04 0.54 0.05 0.96 −0.15 0.71 0.49 1.01 −0.02*

Odds Wald ratio

0.02 1.75 0.02 0.05 0.10 0.38 57.28*** 0.07 0.11

0.05 0.11

0.05

0.23

0.02 0.24 0.07 0.26 0.01

SE

ADDC characteristics

Note: ADCC = adult day care centers; ADL = activities of daily living; IADL = instrumental activities of daily living. *p < .05. **p < .01. ***p < .001.

Age Gender Education Marital status Length of stay in Israel Living arrangements Number of children living in proximity Morbidity Self-rated health ADL IADL Income χ² Cox & Snell R² Nagelkerke R²

Variable

Awareness

Table 4. Summary of Logistic Regression Analyses for Variables Explaining Reasons for Nonuse of ADCC.


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Table 5. Reasons for Use of Day Care Centers (Yes Only). Reason Improves well-being Visits to day care centers improve my life The day care center improves my mood Visits to day care centers reduce feelings of loneliness Visits to day care centers improve my health Social benefits Gives me a sense of belonging Day care centers enable me to increase the number of friends Meet needs The services at the day care center meet my needs The day care center is a good place for people like me Respite for family Visits to day care centers decrease family burden My family is satisfied that I go to the day care center

% 99.0 97.6 97.4 94.2 94.0 97.1 96.6 92.3 99.5 97.8 98.8 100.0 50.0 97.4

Note: N = 417.

Discussion In brief, the findings show that a multiplicity of reasons caused potential users of ADCCs to avoid using them, including accessibility barriers, factors depending on the social milieu of this service, factors depending on the content of the service, “no need for this type of service,” and personal difficulties that hindered use of service. However, lack of awareness was not a significant deterrent to use of ADCCs, as found in several previous studies (e.g., Shibusawa, Ishikawa, & Maeda, 2001). This might be because most ADCCs that were examined in this study were located in relatively small towns and rural areas with only one ADCC in each of them. Therefore, residents of these towns may know each other and be more aware and familiar with the services that exist in their localities compared to those who live in bigger cities. The vast majority of nonusers provided a combination of reasons for nonuse, including accessibility, system, and personal factors, rather than identifying a singular reason. This reflects the multiplicity of factors that play a role in hindering the use of ADCC. However, what almost all nonusers reported as a reason for avoiding use of ADCC—that is, they did not need this type of service and prefer to stay at home—is perhaps due to their perception that the ADCCs do not meet their expectations and are unavailable to them and the negative image of ADCCs

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among the older adult population; thus, all such impediments deter older adults from using this type of service. This explanation is further supported by the multivariate analyses that showed that various sociodemographic characteristics of respondents, including their health, functional, and economic status, were connected with reasons for nonuse. This suggests that it might be that the programs offered in ADCCs do not meet the health care needs of frail older adults who do not use this service because they view the ADCC as a “lowerclass” service and feel less need for day care as a “social event.” In other words, it might be that the organization and delivery of services of ADCCs in Israel provide social links to those frail older adults who are relatively healthy but have “eroded” social networks. Therefore, those who are frail but have social links and support perceive that visiting an ADCC would not meet their real needs. In addition, the findings indicate that two factors were significant in explaining accessibility barriers: marital status and economic status. This might be because those who are unmarried have more difficulties in getting ready in the morning and wait for transportation, compared to their married counterparts who have spouses who can help them to get ready. Therefore, they may need somebody who can come in the morning and prepare them and accompany them to the transportation. Furthermore, inappropriate transportation for those who are severely disabled may also deter potential users from using this type of service. Regarding people with low economic status, it might be that because they have to choose between ADCC use and receiving homecare services provided under the longterm care insurance law, they may not be in position to pay for home help and, therefore, avoid visiting an ADCC. Morbidity was found to be a salient factor that decreased the likelihood to use ADCCs, due to participants’ and ADCCs’ characteristics as well as personal problems on the part of the participants. This emphasizes the role that morbidity plays in nonattendance of ADCCs; that is, nonusers perceive that due to their morbidity the ADCCs may not meet their needs. However, one should exercise caution in drawing conclusions using these interpretations because these issues were not examined in this study and, therefore, merit further investigation. Users of ADCCs reported that ADCCs played a significant role in their lives in terms of improving their well-being, enabling them to maintain social relationships, and meeting their needs as well as relieving their family caregivers from the burden of carrying out caregiving tasks. Thus, such user reports suggest that ADCCs indeed meet the various needs of those who opt for using the services provided by them.

Conclusions Accessibility to ADCCs’ programs should be promoted and barriers should be addressed to enable frail older adults avail services provided by such programs, who are often isolated in their homes and spend several hours in daytime outdoor activities, especially in light of the growing number of frail older adults who


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prefer to age in place. Older persons who live alone need help in the morning to help them get ready to go to the ADCC. Those who need home help and cannot afford it should receive this service in addition to visits to ADCCs and not as an alternative. To meet the needs of current nonusers, ADCCs should shift from a social model orientation to a more balanced model that includes health care components to better meet the socialization needs as well as a variety of health problems faced by those who are more disabled and chronically ill. Health promotion activities such as health-monitoring activities and geriatric assessment and counseling, as well as prevention programs such as intake of vaccinations, can better meet the needs of those who prefer to stay at home due to personal problems, including those related to health. This is of paramount importance, given the fact that users of ADCCs derive many benefits from the services provided, which can promote their quality of life in tandem with alleviating caregiver burden. However, more research is needed to better understand the needs of nonusers and which aspects of ADCCs operation and content should be reconsidered and reformed to be more responsive to various needs of disabled older persons. In addition, it is important to learn the perspective of family caregivers of nonusers about the reasons for nonuse and thus gain further insights into this issue, which has been insufficiently studied.

Limitations There are several limitations to this study; first, generalization of the findings is limited because the sample and the sampling procedure do not guarantee representativeness of both users and nonusers of ADCCs on a national level. This is because the sample was not randomly selected and included only ADCCs in the southern region of Israel. Second, interviews with day care users were conducted at the ADCCs. Although interviews were conducted in privacy, in order to maintain confidentiality, we cannot ignore the fact that, because interviews were conducted at the ADCC, to some extent the responses of the participants may have been positively biased, which is well reflected in the overwhelmingly positive statements they made with regard to the benefits they derived from the ADCCs. The other limitation is the nonrepresentativeness of all ADCCs of Israel, because they operate under social model only, in contrast to ADCCs in other countries that operate under various models. In addition, the questions used in this research are limited in scope. A qualitative design could bring more insights into reasons for nonuse that may not have been identified by researchers when designing the questionnaire. Despite these limitations, the study adds to our knowledge in understanding the reasons for use and nonuse from the perspective of the older persons themselves and points to the need for further research in order to understand how ADCCs can be more effective in achieving their goals to promote quality of life of frail older people.

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Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by the Israel National Institute for Health Policy Research.

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Author Biographies Esther Iecovich is a gerontological social worker and was the head of the master program in gerontology at the Faculty of Health Sciences in Ben Gurion University of the Negev in Israel where she is currently a senior lecturer and researcher. She is also the chairperson of board of a non-profit organization that supplies domiciliary services to disabled older adults. She occupied various senior management positions in the field of eldercare in both community-based and institutional long-term care services in Israel. Aya Biderman graduated and studied at the Hebrew University Medical school, and she specialized in Family medicine. She is currently the chairperson of the Division of Community Health at Ben Gurion University of the Negev, working as a family physician at a community clinic and teaching medical students and residents in family medicine.

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