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This presentation provides an overview of elder financial abuse, including causes and effects.

Implementing quality assurance (QA) programs in unregulated noninstitutional settings remains a challenge for home and community-based service providers. A sample of 65 Elderly & Disabled (E&D) Waiver providers in Virginia were presented with eight problem scenarios commonly found in home-care services. Each of the respondents was able to identify strategies they would use to recognize and address each problem. Findings suggest providers currently use multiple mechanisms as part of their overall QA program. Discussion focuses on the strengths of using multiple approaches and on increasing provider awareness of complementary QA strategies and reducing the reliance on staff report as a major QA strategy.

Little is known about home and community based services (HCBS) and even less about the quality of those services. As part of a “Real Choice Systems Change” grant received by the Virginia Department of Medical Assistance Services, the Center for Gerontology at Virginia Tech conducted a survey of agencies providing HCBS under the Medicaid Elderly and Disabled (E & D) Waiver. A written survey was sent to 160 providers across the state, based on a sampling plan designed to ensure representation of all planning districts and services mixes. Seventy surveys were returned for a response rate of 44%.

Public guardians are individuals appointed by the state to care for the interests of incapacitated citizens. The nature and quality of their care is examined at sites in Maryland, Delaware, Tennessee, and Virginia. In the first three states public guardianship programs have been running for at least ten years; in Virginia two pilot projects are currently underway. All sites use different service delivery models. In addition to studying case file notes, public guardians, program supervisors, and wards were observed and interviewed with regard to their background, their views on public guardianship, accountability and effectiveness, and services provided. The aim of this study is to contribute to a better qualitative understanding of how well state public guardian programs intersect intimately with individuals for whom no other responsible decision maker exists. The study concludes with recommendations regarding the roles of the public guardian in improving wards' quality of life through substitute decision making and in enhancing democratic governance to give voice to wards through their own participation in decision making and relationships with their public guardian. Ph. D.

The National Diabetes Prevention Program (National DPP) was established by Congress in 2010, with a focus on disseminating the evidence-based Lifestyle Change Program (LCP). This 12-month program consists of 26 lessons covering various topics related to goal setting, tracking food and physical activity, motivation, and support groups. Many organizations, including Cooperative Extension (CE), have adopted this program. In the first study conducted by the Virginia Cooperative Extension (VCE), the outcomes of the prediabetes LCP were examined across different age groups and delivery modalities. It was found that distance learning LCPs had slightly higher enrollment levels compared to in-person programs (51% vs. 49%). Moreover, participants aged 60 and older had a significantly higher attendance rate in the distance learning program. The VCE LCP resulted in 49 participants (35%) achieving at least a 5% weight loss, with 29 of them being 60 years or older. When considering the program delivery method, a higher percentage of individuals enrolled in distance learning programs (53%) achieved at least a 5% weight loss. Additionally, 86 participants (62%) engaged in an average of 150 minutes of physical activity per week, with a higher percentage in the in-person programs (64%) and among those aged 60 and older (67%). In Study 2, the distance learning LCP implementation fidelity was evaluated across five states, along with its association with program outcomes. The evaluation tool assessed structural and instructional implementation components. The results indicated that certain structural components directly influenced increased physical activity among participants. Additionally, the coaches' preparedness for the sessions directly impacted participants' weight loss. In addition to implementation fidelity, age was identified as an independent factor affecting weight loss percentage and attendance. Overall, the findings from both studies underscore the significance of effective implementation fidelity to program design in achieving desired health outcomes. The LCP shows promise as an intervention for individuals at risk of developing type 2 diabetes and can be effectively implemented through both in-person and distance learning methods by Cooperative Extension programs nationwide. Doctor of Philosophy The prevalence of diabetes and prediabetes in the United States is a significant concern. The Centers for Disease Control (CDC) reported that around 34.2 million people in the U.S. have diabetes, with approximately 96 million adults having prediabetes in 2022. Lifestyle changes, such as increasing physical activity and losing weight, can reduce the risk of prediabetes progressing to diabetes. In response, the CDC established the National Diabetes Prevention Program (National DPP) in 2010, focusing on an evidence-based Lifestyle Change Program (LCP). The LCP is a 12-month program covering various topics and has been adopted by organizations like Cooperative Extension (CE). Two studies were conducted to assess the effectiveness and implementation of the LCP. The first study, carried out by the Virginia Cooperative Extension (VCE), compared outcomes of distance learning and in-person LCPs among adults of different ages. It found slightly higher enrollment levels in distance learning programs and observed a higher attendance rate among participants aged 60 and older in the distance learning program. The study showed that the VCE LCP resulted in a 35% weight loss for 49 participants, with 59% of them being 60 years or older. Distance learning programs also had higher success rates in achieving a 5% weight loss and 150 minutes of physical activity per week. The second study evaluated the implementation fidelity of the distance learning LCP conducted by Cooperative Extension in five states. It found that certain program components, both structural and instructional, directly influenced participants' physical activity levels. The preparedness of coaches for the sessions significantly impacted weight loss outcomes. In addition to implementation fidelity, age was identified as an independent factor affecting weight loss and attendance. Both studies underscore the importance of effective program implementation fidelity to program design in achieving desired health outcomes. The findings support the LCP as a promising intervention for individuals at risk of developing type 2 diabetes. It highlights its effectiveness through both in-person and distance learning methods implemented by Cooperative Extension programs nationwide.

Grandfamilies, or families in which grandparents are raising their grandchildren, often form due to adverse childhood experiences (ACEs) experienced by the grandchildren. ACEs have been linked to multiple negative short- and long-term behavioral and emotional consequences for children. Yet, having an ACE history does not guarantee negative outcomes, as protective factors such as positive relationships with a safe and caring adult, healthy family functioning, and utilization of formal services can mitigate the negative effects of ACEs. Researchers have regularly called on families to seek timely intervention and services for ACEs; however, many grandparents raising grandchildren report negative interactions with service providers as well as service delivery. Limited research has explored the extent to which grandfamilies with ACEs may have experienced similar interactions while seeking and using formal services. Guided by Andersen's (1995) Behavioral Model of Health Service Use, this qualitative study sought to explore (1) the service needs of grandchildren with an ACE history who are being raised by their grandparents; (2) the service needs of grandparents raising grandchildren with an ACE history; (3) the process of seeking services when grandparents raising a grandchild with an ACE history look for services for their grandchild; and (4) best practices for delivering services to grandfamilies with an ACE history. The research questions were primarily addressed through via interviewing 10 grandparents from Central Appalachia who were raising a grandchild with an ACE history and by conducting two focus groups of 8 to 12 formal service providers with experience working with grandparents raising grandchildren with an ACE history. Interview data were analyzed using grounded theory and focus group data were analyzed through thematic analysis. Study findings indicated that grandchildren have emotional and developmental needs. Grandparents described needs related to the emotional impact of raising a grandchild with an ACE history, family and parent involvement, and parenting a grandchild with an ACE history. Study results also highlighted how grandparents can expect to encounter barriers throughout the service seeking and delivery process. Study results also highlighted the critical nature of having a strong relationship with a service provider and the importance of a service provider reducing barriers, being attentive to grandfamily needs, and involving the grandparent in the treatment process. Finally, results from the focus groups revealed best practices such as providing grandparents with education on ACEs, being aware of intergenerational ACE cycles, and engaging in assessment and intervention when working with this population. Implications for clinical practice as well as directions for future research are discussed. Doctor of Philosophy Historically, grandparents have long been called upon to assist with caring for their grandchildren. In the last forty years, grandparents have increasingly shifted to a new role—that of parent. Grandfamilies are commonly created due to adverse childhood experiences, or ACEs, which can include child abuse, child neglect, or household challenges such as parental substance abuse or parental incarceration. Experiencing ACEs does not guarantee negative outcomes in a child's life, but their presence and number can affect it, particularly when a child has experienced numerous ACEs. Professional services or treatment are one way to support these children. However, negative interactions with service providers or unfulfilled expectations with service delivery can dissuade grandparents from continuing services. This study sought to understand how grandparents raising a grandchild with an ACE history identify the grandchild's needs, come to the realization that their grandchild needs professional help, the process and experience of receiving that professional help, as well as what happened after the grandchild received professional services. After interviewing 10 grandparents raising a grandchild with an ACE history, study findings revealed how grandparents identify grandchild needs, and then manage those needs as well as grandchild behaviors. Study findings also illustrated a recursive relationship between grandparents managing grandchild needs and building a relationship of trust with the formal service provider once services have started. Building a relationship of trust with a formal service provider can then result in creating change or the grandparent deciding to end services. Finally, grandparent interview data revealed that throughout the entire process of service seeking, grandparents raising a grandchild with an ACE history commonly experience barriers hindering their access to services including personal, availability, and systemic barriers. Finally, the study sought to understand best practices for working with grandparents raising grandchildren with an ACE history, which include assessing for and creating interventions targeting ACEs, providing education on ACEs to grandparents, and being aware of intergenerational ACE cycles with these families. Strategies for clinical practice are also identified.

Limited knowledge is available about the experiences and outcomes of family members, specifically those of children who were raised by parent(s) with disability. This gap in research is highly consequential, influencing the development of policies that are based on prejudiced assumptions about disabled parenting, rather than on empirical evidence. This study examined the experience of 13 adult children who were raised by at least one parent with disability in order to obtain a first-hand account of their perspectives. A transcendental phenomenology facilitated objectivity while capturing the essence of their experience. Research questions presented were the following: (a) What has been the experience of adult children who grew up with parent(s) with disability? (b) What familial, interpersonal, and/or personal contexts (if any) have produced a strengths-based retrospection of the experience? The study utilized Walsh's family resilience framework as a theoretical guide to counter deficit-focused research that has dominated disability research. Findings suggest the highly systemic and contextual quality of the experience, with children reporting overall strengths-based retrospections. Participants described family processes that were critical to the development of individual resilience, including belief systems, organizational processes, and open communication. Findings also demonstrated the development of favorable child outcomes such as empathy among adult children who were raised by parent(s) with disability. The findings have research, policy, and clinical implications, emphasizing the need to amplify disability discourses within the field of family science. Doctor of Philosophy Discrimination against parents with disability is a long-standing issue in US history, impacting policies that lead to the involuntary separation of families. Assumptions about disabled parenting that focus on individual impairment may have contributed to this issue. The purpose of this study was to examine the experience of adult children who grew up with a parent(s) with disability, to obtain a first-hand account of their perspectives. The research questions presented were (a) What has been the experience of adult children who grew up with parent(s) with disability? (b) What familial, interpersonal and/or personal contexts (if any) have produced a strengths-based retrospection of the experience? Based on an analysis of 13 single interviews, Walsh's family resilience framework was utilized to present the findings. Findings revealed three broad themes that characterize the experience. Overall, children report strengths-based perspectives, describing the family processes that were critical to effective navigation. The experience was also highly contextual and relational, challenging traditional perspectives that have historically prevailed. The study offers research, policy, and clinical implications, directing attention to the need to amplify disability discourses within the field of Family Science.

Associations between the built environment and walking are well understood among the general population, but far less is known about how features of the built environment influence walking in older adults. As compared to other age groups, older adults, defined as those 65 years of age and older, are more likely to experience declines in physical activity, social interaction, and loss of community connectivity. Animal companionship can provide older adults the motivation to stay physically active and help them mitigate the feelings of isolation. Built environments that align with the needs and abilities of older adults and their animal companions, like dogs, can encourage and help sustain walking habits. The aim of this study was to identify and prioritize features within the built environment pertinent to older adult dog walkers. Existing literature served as the basis for identifying neighborhood design features associated with general walking and dog walking. Through the use of a three round Delphi study, 25 experts from urban planning and design, management of outdoor spaces, public health, gerontology, and human-animal relationships modified and rated the importance of the identified features as it pertains to older adult dog walkers. Following the Delphi study, 12 older adult dog owners from the Warm Hearth Village participated in a guided walk and interview using the Photovoice technique. The goal was to gather their perceptions of the outdoor walking environment. Among expert panelists, safety from motorized traffic, crime, unleashed dogs, and personal injury was paramount (mean (M)= 93.20, standard deviation (SD) = 11.54). Experts also saw the value and agreed upon the importance of dog supportive features within the built environment, like dog waste stations dog waste stations (desirable; M = 87.95, SD = 11.37), and dog policy signage (desirable; M = 79.91, SD = 11.22). Older adults also believed safety was important. They saw their dog as a protective safety factor against walking deterrents like aggressive or unleashed dogs. However, the feature that resonated most with older adult dog walkers in this study was their interaction with nature. They described the pleasure of observing seasons change and the connection with nature that came from the tree canopy cocooning the walking path. Path design is also a necessary consideration. Older adults emphasized the importance of having options between paved and unpaved walking paths. The panelists stressed the need for creating lines of sight (desirable; M = 66.46, SD = 20.71) and lighting (desirable; M = 77.92, SD =19.77). Those who plan, develop, and maintain spaces that support older adults can prioritize the features I identified in my research. Incorporating these features into the design of spaces for older adults has the potential to translate into increased walking and opportunities to socialize, contributing to mental and physical health. Doctor of Philosophy Associations between the built environment and walking are well understood among the general population, but less is known about how features in the built environment influence older adults. As compared to other age groups, older adults are more likely to experience declines in physical activity and social interaction. Animal companionship can provide motivation to stay physically active and help them mitigate feelings of isolation. Built environments that align with the needs of older adults and their animal companions, like dogs, can encourage and help sustain walking habits. My research identified and prioritized features within the built environment pertinent to older adult dog walkers. I implemented an iterative three round study to gain consensus among expert panelists and guided walks and interviews with older adult dog walkers. Among expert panelists, safety from motorized traffic, crime, unleashed dogs, and personal injury was paramount. Experts also saw the value of dog supportive features within the built environment, like dog waste stations. Older adults also believed safety was important. They saw their dog as a protective safety factor against walking deterrents like aggressive dogs. The feature that resonated most with older adult in this study was nature. They described the pleasure of observing seasons change and the connection with nature that came from the tree canopy cocooning the walking path. Path design is also a necessary consideration. Older adults emphasized the importance of having options between paved and unpaved walking paths. Those who plan, develop, and maintain spaces that support older adults can prioritize the features I identified in my research. Incorporating these features into outdoor spaces has the potential to translate into increased walking and opportunities to socialize, contributing to mental and physical health.

Approximately 63% of all incarcerated individuals in the U.S. identify as a parent (Glaze and Maruschak, 2010), with as many as 7% of children experiencing parental incarceration at some point in their lives (Murphey and Cooper, 2015). Historically, much of the parental incarceration literature has relied on between-groups comparison research, highlighting risks and determinants of pathology for youth with an incarcerated parent. However, significantly less research has attempted to understand resilience processes in the context of parental incarceration from a within-group resilience perspective. The overall goal of this dissertation research was to empirically test the theoretical Family Inequality Framework (Arditti, 2018) and better understand how family resilience processes influence the relationship between material hardship and child outcomes within the context of parental incarceration. Structural equation modeling was used to perform a mediational cross-sectional analysis. Results of these analyses suggest that parental mental health processes play an important role in mitigating adverse outcomes for families by mediating the effects of material hardship on youth academic adjustment in the context of parental incarceration. Theoretical, clinical, and policy implications, as well as future research directions are discussed. Doctor of Philosophy Approximately 63% of all incarcerated individuals in the U.S. identify as a parent (Glaze and Maruschak, 2010), with as many as 7% of children experiencing parental incarceration at some point in their lives (Murphey and Cooper, 2015). Historically, much of the existing research on parental incarceration is problem focused, painting these families in a negative light. In contrast, there is very little research highlighting the unique strengths and resiliences of families impacted by parental incarceration. The goal of this dissertation research was to better understand how family resilience processes, such as social support, parenting practices, and parental mental health, might reduce the negative impact of parental incarceration. Results suggest that parental mental health processes play an important role for overall family wellness during parental incarceration. In particular, the more a parent says they are doing well from a mental health perspective the better their kids appear to be doing in school. In this way, parental mental health wellness appears to provide a buffering effect against the common risks parental incarceration can introduce into a family. Theoretical, clinical, and policy implications, as well as future research directions are discussed.

The region of Appalachia in the United States is a diverse region that is full of beauty, mountains, art, and culture. Due to a history of abuse from large corporations, the impact of the decline in coal mining and generational poverty, the region is currently on a road toward recovery. Substance misuse rates are disproportionality high, and there are limited resources available to address the issue. Literature suggests that church leaders may be a potential resource. The goal of the study was to provide a better understanding of the substance misuse epidemic through the eyes of church leaders. Interpretative Phenomenological Analysis guided this qualitative study. Church leaders (n = 10) were interviewed and four significant themes emerged: narratives used to describe their experiences with substance misuse, the stigma associated with substance misuse, the community impact that substance misuse has on Appalachia, and the lack of understanding and need for training on substance misuse for church leaders and healthcare practitioners. The results of the study are discussed and connected to discussions of the implications for clinical practice, recommendations for further research, and limitations of the study. Doctor of Philosophy Appalachia is a mountain range located in the eastern portion of the United States. It is a diverse region that is full of beauty, mountains, art, and culture. Due to a history of abuse from large corporations, the impact of the decline in coal mining and generational poverty, the region is currently on a road toward recovery. Substance misuse rates are disproportionality high, and there are limited healthcare resources available to address the issue. The goal of the presented study was to provide a better understanding of the substance misuse epidemic through the experiences of church leaders, which are abundant in the region. Church leaders, a sample of 10, were interviewed and four significant topics emerged from their stories shared: narratives used to describe their experiences with substance misuse, the stigma associated with substance misuse, the community impact that substance misuse has on Appalachia, and the lack of understanding and need for training on substance misuse for church leaders and healthcare practitioners. The results of this study suggest that church leaders may be used as a resource to help lower the impact of substance misuse. The experiences of the church leaders gained from this study can help provide training to church leaders and healthcare providers on ways to work together and lower substance misuse in Appalachia.

The diagnosis of Alzheimer's disease (AD) is stressful for both patients and their family caregivers (FCG). As the disease progresses, the patient's memory, functioning status, and behavioral problems get worse, and the needs of the patient that must be addressed by family caregivers increase dramatically. This research examines the impact of the subjective burden with the objective stressors on FCG's depression and to determines which psychosocial resources can be used to either mediate or moderate this relationship. I examine the baseline data that was collected from 670 family caregivers of Alzheimer's patients in the Resources for Enhancing Alzheimer's Caregiver Health (REACH) II clinical trial (REACH II), 2001-2004. The measurements used in the current study are caregivers' background and context factors, objective stressors, subjective burden, psychosocial resources, and symptoms of depression. Three research questions will be investigated in this study: (1) How do the caregivers' background and context factors affect FCGs experiences of objective stressors and subjective burden during the caregiving process? (2) What is the relationship between the objective stressors and subjective burdens, and what impact, if any, do they have on FCGs'depressive symptoms? (3) How do psychosocial resources mediate and or moderate the relationship between the primary stressors and FCGs'depression experiences? Master of Science The diagnosis of Alzheimer’s disease (AD) is stressful for both patients and their family caregivers (FCG). In 2018, an estimated 5.7 million Americans have been diagnosed with Alzheimer’s disease (Alzheimer’s Association 2018). As the disease progresses, the patient’s memory, functioning status, and behavioral problems get worse, and the needs of the patient that must be addressed by family caregivers increase dramatically. As Aneshensel, Carol S., Leonard I. Pearlin, Joseph T. Mullan, Steven H. Zarit, and Carol J. Whitlatch (1995) noted in their book Profiles in Caregiving: The Unexpected Career, the role of caregiving is generally an ‘unexpected job’ for FCGs (Aneshensel et al. 1995). Based on Pearlin’s stress process model (SPM), the primary goal of my thesis is to compare the impact of the subjective burden of caregiving with that of objective stressors on FCG’s depression, and to determine whether psychosocial resources can either mediate or moderate this relationship. Objective stressors refer to the AD patient’s memory and behavior problems, his or her cognitive impairment, self-care activities, and functional status. Subjective burden is the FCG’s emotional response to objective stressors. Objective stressors and subjective burden are associated with each other, and they are primary stressors in the SPM. Psychosocial resources include FCG’s religious coping, their positive experiences of caregiving, their social networks and whether they were satisfied with social support that they received from others. The present study is important for two reasons. First, rather than focusing on subjective burden alone, the model examined how objective stressors (i.e. burden) influence mental health through their impact on subjective burden. Second, previous influential studies of the stressors of caregiving either did not include the moderating effects of psychosocial resources (Pearlin et al., 1999), or included a limited number of resources and found that they did not play a significant role in how caregiving stress influences caregivers mental health (Aneshensel et al. 1995). In my thesis, I will explore both of the mediating and moderating effects of four types of psychosocial resources. I examine the baseline data that was collected from 670 family caregivers of Alzheimer’s patients from the Resources for Enhancing Alzheimer’s Caregiver Health (REACH) II clinical trial (REACH II), 2001–2004 (Schulz, Burgio, and Stevens 2006). The study participants target on FCGs who are vulnerable to the caregiving stressors. The purpose of the baseline data was to describe the AD patients’ cognitive impairment and behavior problems at the initial stage of the REACH II study, the demands caused by the impairments imposed upon FCGs, the psychosocial resources adopted by FCGs to relieve the caregiving stress, and the consequences of the primary stressors on FCGs’ daily lives. I will explore three research questions in the current study: (1) How do the caregivers’ background and context factors affect FCGs experiences of objective stressors and subjective burden during the caregiving process? (2) What is the relationship between the objective stressors and subjective burdens, and what impact, if any, do they have on FCGs’ depressive symptoms? (3) How do psychosocial resources mediate or moderate the relationship between the primary stressors and FCGs’ depression experiences? The measurements used in the current study are caregivers’ background and context factors, objective stressors, subjective burden, psychosocial resources, and symptoms of depression. Data analysis is primarily based on multiple linear regression. I will also use the post-hoc probing methods to specifically test the significance of the moderating test. There are four key findings in the present study. First, caregivers’ background and context factors have some significant associations with objective stressors and subjective burden, but overall, their impact is minimal. Second, subjective burden has a stronger impact on depressive symptoms than all of the objective stressors do. Third, subjective burden undermines all four psychosocial resources tested in the current study. Fourth, the mediating and moderating effects of psychosocial resources have a negligible impact in the caregiving stress process. Surprisingly, the effect of subjective burden on depressive symptoms among FCGs remained largely unchanged after all psychosocial resources were included in the model as mediators and moderators. In the mediational test, the effects of subjective burden on depression decreased by only 14 percent after all psychosocial resources were taken into account. Likewise, each of these psychosocial resources had only a negligible effect on moderating the impacts of stressors. The study suggests that unless there is a full understanding of the effects of these stressors on caregivers’ well-being, any interventions or preventive actions will be of limited utility. Future research should pay more attention to exploring the relationships between the subjective burden and objective stressors, and examining their different impacts on FCGs’ depression experience. Additionally, the fact that none of the psychosocial resources have a buffering effect in the caregiving process suggests that there is little in the lives of caregivers that mitigates the deleterious effects of caregiving stress on Alzheimer’s caregivers. Policymakers and mental health providers should consider the stress of caregiving, as reflected in both its objective and subjective aspects, as a major risk factor in the lives of those who care for family members with Alzheimer’s disease. Those factors may play a causal role in caregivers’ mental disorders and suicidal ideation.

The goal of this investigation was to assess service use, self-management strategies, and health status of older adults (60+ years) with perceived need who sought assistance from the Virginia Medicaid Elderly and Disabled Consumer-Direction (EDCD) waiver services. A sequential explanatory mixed method design was used to address the overall research question: How do older adults manage unmet needs? Using health services data from two independent State agencies, regression techniques were used to examine predictors of service use, hospitalization, and mortality among 1,008 individuals. A purposive subsample of eight rural-dwelling waiver-ineligible individuals was identified for follow-up semi-structured telephone interviews to explore self-management strategies for confronting functional care needs. Waiver-ineligible individuals were at risk for hospitalization and mortality; rural-dwelling individuals were more likely to be waiver-ineligible and had increased risk of mortality. Analysis of interviews revealed individuals had ongoing unmet needs and relied on family and community services and used internal and external strategies to manage them; plans were not in place should their health continued to decline. For this group of near-risk older adults who are waiver-ineligible and do not have financial means to pay for more help, accessible preventive services are necessary to reduce risk of adverse health outcomes. Policymakers are encouraged to advocate for preventive services that assist individuals before care needs become unmanageable. Agencies responsible for service delivery need to target efforts toward this group, particularly those residing in rural areas. Researchers must continue forging partnerships that permit use of health services data to identify when and how older adults use services, and explore how self-management strategies influence health and functioning over time. Ph. D.

The purpose of this study was the examination of age bias in social work professionals who have direct and influential contact with a growing segment of the population: older adults. Those who work most closely with older people may be at risk for age bias, although much of the research on age bias has been conducted with students rather than with those who work with older people. This study adds to the research on prejudice; the sources from which attitudes, values, prejudices, and stereotypical thinking arise were addressed. Key experiences with older individuals were found to predict age bias. Because social work ethical principles closely align with conditions known to reduce prejudice, it was hypothesized that higher ethics adherence would be associated with less age bias. Specific experiential factors were found to influence prejudice toward older people. Influences from family beliefs and from television and other media were associated with a non-biased attitude, as were influences from caregiving to older people. These sources of one's values and beliefs about older individuals were also found to predict the extent of one's knowledge of aging processes. Although ethics adherence was not a predictor of age bias, the discovery of the influence of family beliefs, media portrayals, and caregiving experiences revealed a need for awareness of ageist beliefs in a professional population that works extensively with older adults. Ph. D.

Older people are as diverse a group as they were as younger people. Home environments should reflect these diverse individuals' varying interests, preferences, and needs. In spite of efforts to remain independent and at home, some elderly people have to leave conventional housing and move into long-term care facilities because of factors such as mental or physical health problems or the loss of family members. Most elderly people who move into these facilities do not feel "at home" in their new living arrangements. Assisted living facilities (ALFs) have been developed as a response to these issues. The major goal of assisted living is to create a supportive social setting that elderly residents can call home. Although assisted living is the fastest growing long-term care alternative, it still needs to continually change in response to the needs of older residents and the desires and interests of family members. The purpose of this study was to examine the features that make residents feel "at home" in ALFs in Southwest Virginia and to suggest further policy and design guidelines for better quality of ALFs as a "home." For this purpose, residents' needs, experiences, and opinions of the physical environment, the social environment, and the organizational environments such as policies and programs of ALFs were identified. As a multi-site case study, I studied five ALFs in Southwest Virginia and did a cross-case analysis. In addition to face-to-face interviews with 25 residents and five administrators of five ALFs, I also conducted observations and recorded my feelings in a personal journal with document review. To analyze the data gathered in this study, I used the constant comparative method of data analysis. The respondents' age range was between 64 and 95 and the average age was 82. There were 6 males and 19 females among the respondents and most of them were widowed. They came from a wide geographic area, and most of them have lived in single-family homes for a long time. Many had children or family members nearby. Overall, the five sites selected presented homelike features showing the philosophy of assisted living which combines housing and services. Each facility was designed to be a single-family house or multi-family dwelling in outside appearance. However, the older the structure, the fewer homelike features were provided. As a whole, residents felt isolation and loneliness and they did not have active interaction with other residents because of diverse background among the residents. During meals, people had active interaction with one or two residents. However, all of them had close relationships with the staff. The staff's attitude and behavior seemed to influence greatly the residents' feeling "at home." Friends and family members also provided an important role for the residents to adjust to their new environment. Despite the provision of diverse activities by the facilities, many residents did not participate in the programs. Among the services provided, there were only a few complaints about food and mealtimes. Most of the residents agreed that the rules and regulations were fair; however, one person disagreed with the smoking rules. For the meaning of "home," many residents talked about love, fellowship, privilege, stability, and security. The administrators tried to make the residents feel "at home;" however, they mentioned the limitation of providing a real "home" for the residents due to the residents' diversity. Some categories which could contribute to the perception of ALFs as a "home" were classified by the researcher: safety and security, services and care, autonomy/privacy, independence, social life/friendship, family support, daily routine, personalization, physical environment, and management. Regardless of the type of facilities and the residents' characteristics, most of the respondents were satisfied with their current dwelling. In spite of high satisfaction with the facility, many people did not think of their current dwelling as a real "home." As the biggest difference between living in their own homes and living in the ALF, people pointed out a lack of independence, freedom, and autonomy. Moreover, they talked about the loneliness stemming from living with strangers who are not their family or friends. Residents of ALFs may have reordered their priorities in their current life situation so that safety, security, and care were more important to them than feeling "at home." Among the four factors --personal, physical, social, and organizational-- that affect the residents' perception of ALFs as a "home," many emphasized the importance of social factors such as relationships with the staff and residents, and social support from their family or friends. Ph. D.

The purpose of this study was to examine factors that influence the experience of urinary incontinence (UI) as it relates to sexual intimacy for older women. Additionally, I wanted to identify perceived areas of intervention that might positively influence the experience of UI as it relates to sexual intimacy for participants. The sample consisted of 10 women who ranged in age from 65 to 81. The theoretical framework guiding this study was a systemic perspective in which how participants make meaning is given prominence. Symbolic interactionism, social constructionism, and systems perspective are interwoven to provide the foundation for this study. Data were collected utilizing in-depth interviews. Self-portraits were introduced to enrich conversation during the second interview. Three conclusions were drawn from this study. First, feelings of secrecy that permeated this project were manifested in the lack of willing participants as well as brevity of responses during interactions with participants. Second, participants indicated a tendency to minimize their incontinence and to manage their symptoms without formal medical intervention. Third, participants offered perceived potential interventions that might positively influence the experience of UI. These included the provision information related to UI in a way that does not require individuals to request the information, such as brochures at physicians' offices, post-surgical follow-up, and individuals from whom participants would be most comfortable receiving such information. Ph. D.

Hip fracture in older adults may be the sentinel event leading to functional decline, long-term disability, and death. For the substantial number of older persons who fracture a hip each year, the chances of full functional recovery remains relatively low. The purpose of this study was to examine the differences between older persons with hip fracture who recover fully and those individuals who do not fully recover. A chronic disease trajectory framework guided the theoretical design of the research. Data were collected from the medical records of 102 persons aged 60 years and older who sustained a proximal hip fracture from 1993 to 1998 at a medical center in North Carolina. Data included personal characteristics, prefracture health status, hospital factors, rehabilitation features, and functional outcomes. The analysis consisted of a two-step hierarchical logistic regression model with the control variables of age, prefracture ambulation status, and prefracture cognitive status entered first and the variables of type of therapy program, frequency of therapy, number of therapy provider organizations, and location of therapy at 4 weeks entered second. Significance of the final model was observed, Chi-Square(7, n = 99)=43.55, p < .05. Significant individual predictors (p < .05) in the model were prefracture ambulation status (43.56 odds ratio) and cognitive status (6.44 odds ratio). Post-hoc analysis of the cases revealed a substantial lack of stability in ambulation status from three months post-fracture to the six-month and one-year follow-up. Findings support other research studies that indicate prefracture personal characteristics of older persons who fracture a hip are the most influential factors in predicting successful recovery. Linkage of the findings to the chronic disease trajectory model suggests that intervention efforts should focus on prevention, health promotion, and policies that extend the ability of health care providers to assist older persons with hip fracture in managing their conditions. Ph. D.

The purpose of this study was to explore older adults' perceptions of participation in physical exercise throughout the life course. Using a life course perspective as the theoretical framework for this study, I identified the factors in older adults' lives that may or may not lead to continuous participation in physical exercise throughout life. Through in-depth interviews with nine men and six women who are members of the Wellness Center in Southwest Virginia, I gained a precise understanding of how societal processes and opportunities, life course roles and transitions, and individual meanings of physical exercise influenced perceptions of participation in physical exercise. Several conclusions were drawn from the findings of this research. First, the older adults' reported perceived changes in their perceptions and definitions of physical exercise in accordance with life stages and particular roles (i.e., parenthood and career) throughout their lives. Second, the older adults' believed that geographical location and societal influences and opportunities had a tremendous impact on their participation in physical activity as children. Third, the older adults' indicated that childhood involvement in physical activity was very influential to their participation in physical activities and exercise throughout life. Fourth, changing patterns of physical activity and exercise participation were associated with altered role transitions and altered opportunities during young and middle adulthood. Fifth, retirement provided the older adults with a great deal of freedom and opportunity to participate in physical exercise. Finally, the older adults' participation in physical exercise contributed to their quality of life. Master of Science

Comparisons of aging services in Canada and the United States reveal similarities and differences in the structure and function of the two systems. In both countries, adult day services (ADS) is an integral component in the array of services available to older adults. In this study, I compared structural characteristics of programs, participant characteristics, and examined the National Adult Day Services Association classification model of ADS in demographically similar areas of Canada and the United States. Directors of 47 ADS programs in demographically similar provinces and states in Atlantic Canada, Maine, and Vermont responded to a mailed survey. Adult day services programs in each province and state exhibited some unique structural and participant characteristics. Statistically significant differences emerged between ADS programs in the two countries on the following structural variables: town population, center affiliation, center location, levels of government support, participant fees, organizational structure, hours of operation, months of attendance, hours attended per day, service frequency, and service provision. Participant characteristics that significantly varied between the two countries involved educational level and functional characteristics. A minority of programs exhibited a match between participant needs and services provided. However, very few programs belonged to the most mismatched category of providing core services to intensive level participants. The findings of this study support the importance of individual programs providing services appropriate to meet the needs of participants rather than adhering to a predetermined model of care. Ph. D.