“So I am stuck, but it´s OK”: residential reasoning and housing decision-making of low-income older adults with disabilities in Baltimore, Maryland

ABSTRACT

Housing preferences and housing decision-making in later life are critical aspects of aging in place, which is a public health priority in many Western countries. However, few studies have examined the economic, social, and health factors that guide older adults’ preferences and decisions about where to live, and even less so among older adults with low income or disabilities who may face greater barriers to aging in place. We sought to understand what housing decision-making and residential reasoning means for low-income older adult homeowners in Baltimore, Maryland. Using a grounded theory approach, we interviewed 12 older adults in June 2017 and February 2018. Our findings revealed how the strong desire to age in place turned into the realization that they had to age in place due to limited resources and options. The overarching category “shifting between wanting to age in place and having to age in place” was influenced by family needs, being a homeowner, the neighborhood, and coping at home. In conclusion, for low-income older adults with disabilities, it is important to acknowledge that sometimes aging in place may be equivalent to being stuck in place.

KEYWORDS:

• Community living
• housing
• meaning of home
• relocation
• aging in place
• disability

Introduction

With numerous studies showing that most older adults prefer to stay in their home, policies and programs supporting aging in place have received increased attention. As populations age and residential care facilities face a shortage of public funding, promoting aging in place seems to be a win-win situation. There has been criticism about over-emphasizing the importance of aging in place, that some places might be unsuitable to age in, that aging in place takes for granted the support of family members, and that new generations of older adults will change their residence more often than previous generations (Byrnes, 2011; Golant, 2008). Aging in place can be defined as staying put in the current home during later life; however, it is also defined as aging in a self-determined home despite the need for care (Wiles et al., 2012.) Older adults’ preferences for relocation likely differ, depending on whether it concerns a move within the community or a move to residential care.

Housing decision-making is a process that extends over several years (Nygren & Iwarsson, 2009). In a recent systematic review examining factors that influence housing decisions among frail older adults, the authors identified numerous factors related to the home, health, and socioeconomics, and argued for the need to examine the influence of a broader range of factors as a whole (Roy et al., 2018). The decision to relocate in old age is intricately linked to thoughts and desires to stay in the familiar home but is influenced by day-to-day life and struggles. In an earlier paper, we suggested labeling the process residential reasoning. Based on repeated interviews with older adults over the age of 80 who were living in single households, we showed that their residential reasoning and decision-making were influenced by changes in health, end-of-life issues, and changes in their attachment to home (Granbom et al., 2014). The study was conducted in Sweden and Germany and our participants were financially well-off, relatively healthy, and represented upper-middle class citizens. We suggested that residential reasoning could be an appropriate concept to investigate further and to expand the theoretical discussion on aging in place and relocation as one reasoning process (Granbom et al., 2014).

Koss and Ekerdt (2016) explored the residential reasoning of older adults in the Midwestern United States and found that for older adults around retirement age, their anticipation of future health vulnerabilities shaped their reasoning well before they experienced any health problems. Participants who did not think that their home would be suitable in the last stage of life were positive toward moving, and some even had a destination in mind. They also found that social relationships with spouses and offspring were important for choosing housing for later life, not only with respect to sources of support, but also to perceived obligations toward family members. At the time of the interview, the participants were living in the community or a retirement community, were relatively healthy (referred to as being in the third age), White, and the majority had obtained a college or university education.

Older adults face many barriers to aging in place. Age-related health decline, reduced income due to retirement, and a shrinking social network challenge the possibility of managing daily life at home and obtaining access to at-home care when needed (Gaugler et al., 2007; Dupuis-Blanchard et al., 2015). Also, homes may not meet the changing needs of older adults. For example, older adults who live in old buildings are vulnerable because the home may need major modifications and repairs to qualify as an age-friendly dwelling (Johnson et al., 2018; Torres-Gil & Hofland, 2012).

Aging at home may be more of a possibility for older adults who have the financial resources to make home adaptations and pay for home care services. On the other hand, low-income older adults are expected to be less likely to age-in-place. However, financial barriers to aging in place are likely also barriers for changing residences. Research on older adults suggests that limited options to decide and act on housing preferences will lead to a growing group of older adults who are stuck in place – i.e. they are aging in place not because they prefer to, but because they have no other options (Perry et al., 2013; Torres-Gil & Hofland, 2012). However, a different strand of research emphasizes the emotional attachment to home and how older adults become anchored in their communities and might prefer to stay, even in an inadequate dwelling. Older adults’ sense of belonging to where they live grows stronger when their health declines and when aging reduces their agency (Erickson et al., 2012; Severinsen et al., 2016; Wahl & Lang, 2003). Thus, aging in place might still be the desired option. The literature addressing these questions primarily focuses on middle to upper income people. Whether aging-in-place is desired for low-income older adults needs further examination. How economic factors influence housing decision-making have to a large extent been studied with only quantitative methods (Roy et al., 2018). To increase knowledge on the complexity of housing preferences and decision-making beyond staying versus moving, we interviewed 12 low-income older adults with disabilities who were homeowners in Baltimore, Maryland. The aim was to further investigate the concept of residential reasoning of low-income older adults with disabilities and explore how their housing preferences and housing decision-making were influenced by economic, social, or health-related changes.

Methods

We used a qualitative design with data from interviews conducted during home visits with 12 older adults. We interviewed each participant twice, first in the summer of 2017 and then approximately eight months later. We based our methods on a grounded theory approach and a qualitative analysis aiming to capture the older adults’ reasoning process and changes in that process, and to elaborate on the concept of residential reasoning from our previous work, as described by Strauss and Corbin (1994; Saldana, 2003; Corbin & Strauss, 2015).

Participants

We recruited participants from the Community Aging in Place, Advancing Better Living for Elders (CAPABLE) study in Baltimore, Maryland, sponsored by the National Institute of Aging and the Robert Wood Johnson Foundation (Szanton et al., 2014). The intervention study aimed at improving function and addressing disabilities of low-income, older adults living at home by providing services from a nurse, an occupational therapist, and a handyman. The 300 participants in the CAPABLE study were homeowners and were low-income (below 200% of the U.S. federal poverty level), 65 years and older, and faced difficulties with Activities of Daily Living (ADL) or Instrumental ADLs (IADL). Of all participants, 259 (86%) self-identified as Black, 40 (13%) as non-Hispanic White, and one as Asian (Szanton et al., 2014). Participants from both the intervention and the control group expressed thoughts and concerns about aging in place when they met with study team members (Szanton et al., 2014). That awareness, in combination with the inclusion criteria of the study, made the participants a suitable group for recruitment to our study. Thus, CAPABLE participants who stated an interest in participating in future research constituted the pool of possible participants (N=215).

To obtain a heterogeneous sample, we used purposeful sampling based on diversity regarding gender, age, and race, whether they were living alone or not, and the number of ADL/IADL difficulties, based on information available from the CAPABLE study. The sampling was also guided by a negative case analysis, i.e. recruiting additional participants who might offer contrasting information to preliminary findings (Corbin & Strauss, 2015). Thus, recruitment, data collection, and analysis were made in parallel as recommended in the grounded theory methodology (Corbin & Strauss, 2015). The first author contacted 13 participants, and all but one were willing to participate. The Johns Hopkins University’s Institutional Review Board (IRB00131315) approved the study. The participants signed a written consent form before the interview and received a 20 USD gift card after a completed interview.

Interview guide

We developed a thematic semi-structured interview guide based on the aim of the study and previous findings on residential reasoning (Granbom et al., 2014; Koss & Ekerdt, 2016). The interview guide included questions on how the participants reasoned about aging in place versus moving, emotional attachment to the home, housing options, strategies to stay in the home, and challenges to staying in the home. We included a temporal aspect in all themes by asking for previous and current experiences and reasoning, as well as thoughts about and expectations for the future. We focused specifically on whether changes in daily life and life events led to changes in reasoning. Thus, we prepared probing questions on how their perceived economic, social, and health situation influenced their reasoning, decision making, and view on the years to come.

Data collection

The interviews took place in the participants’ homes. They were conducted by the first author of the study who has experience interviewing older adults for both research and clinical work. The first set of interviews was completed in June 2017. The interviews ranged from 30 to 75 minutes. The follow-up interviews were conducted in February 2018. We used the same interview guide on both occasions to capture changes in reasoning (Saldana, 2003). However, we made two adjustments. First, we began the follow-up interview by asking how the summer and fall of 2017 had been and if any notable events had occurred since we last met. Second, based on the initial analysis, we added prompting questions concerning 1) health care plans and health care expenses, and 2) emotional attachment to the neighborhood. The follow-up interviews ranged from 32 to 100 minutes. All interviews were recorded and transcribed directly after each interview. The transcripts were used to facilitate initial analysis, guide recruitment, and verify the findings against the overall impression of the participant’s situation. We used NVIVO 12 software to organize the data and facilitate the analysis process (QSR International, P. L., 2018).

Analysis procedure

The first author did the initial analysis with open coding during recruitment and data collection by using recordings and transcripts. The purpose of the initial analysis was to guide recruitment and to let previous interviews inform follow-up interviews.

The first, second, and third author read and conducted open coding of one interview each. Then we discussed initial codes and impressions and agreed on an analytical approach for the remaining interviews. Then we conducted open coding of three interviews each, which resulted in an extensive code list. At the next step, we grouped the codes and identified 21 preliminary concepts. These preliminary concepts included reasons to move, reasons to stay, getting help, giving help, the upkeep of the home, daily chores, moving in with family, being stuck, neighborhood, loneliness, money issues, and dealing with different types of losses, for example, the loss of functions and the loss of loved ones. To analyze changes, we then took a different approach, and contrasted the first with the second interview of each participant. With these two approaches we analyzed by comparing findings across and within cases. Finally, at the last stage, we combined the two analysis approaches by contrasting the preliminary findings from each approach with each other, resulting in the final findings.

Findings

The participants are described in Table 1. Eight women and four men with an age range from 69 to 86 years participated in the study. Nine participants were African-American and three were non-Hispanic White. All participants had lived in their homes for more than 25 years, most of them more than 40 years. Three participants lived in detached homes, four lived in townhouses, and five in duplexes. At the time of the first interview, six participants lived alone, one lived with her spouse, and five had children, grandchildren, or relatives living with them. Two participants reported that they were in good health at the first interview, the remaining participants had difficulties in either performing ADLs, IADLs or had walking difficulties, due to pain, heart conditions, arthritis, diabetes, or COPD (see Table 1).

Table 1. Background characteristics of the participants

Name^a	Gender	Race/Ethnicity	Age	Living … ^b	Type of house	ADL/IADL difficulties^b	Mobility problems^b
Anne	♀	Black	79	with spouse	Duplex	IADL	No
Barbara	♀	Black	83	with son	Duplex	No	Stairs
Cheryl	♀	Black	81	with son and relative	Townhouse	ADL & IADL	Outdoors and indoors
Deborah	♀	Black	76	alone	Detached	IADL	Stairs and outdoors
Emma	♀	Black	76	alone	Townhouse	IADL	No
Fred	♂	Non-Hispanic White	69	alone	Townhouse	No	No
George	♂	Black	86	alone	Duplex	IADL	No
Hannah	♀	Black	76	with son and grandsons	Detached	No	No
John	♂	Non-Hispanic White	73	alone	Detached	No	Stairs
Jerry	♂	Non-Hispanic White	67	alone	Townhouse	ADL & IADL	Indoors and outdoors
Kathy	♀	Black	75	with granddaughter	Duplex	IADL	Stairs
Lisa	♀	Black	70	with daughter and granddaughter	Duplex	No	Stairs

^aPseudonyms.

^bAt the time of the first interview.

The analysis resulted in an overarching category which represents a reasoning process we named shifting between wanting to age in place and having to age in place. The shift in reasoning was influenced by four categories: family needs, being a homeowner, the neighborhood, and coping at home (see Figure 1).

Figure 1. Several factors influenced the participants’ reasoning process to shift along the continuum: family needs, being a homeowner, the neighborhood, and coping at home

Shifting between wanting to age in place and having to age in place

The participants’ opinions covered a continuum of reasoning. Some of the participants strongly expressed that they wanted to stay where they were. They felt that they were in a good place and had planned or prepared to remain there in the future. They strongly wished to remain independent. They stated that all their life they had been managing, taking care of children and older family members, working hard to support their family, and taking care of a house. The home became the symbol for maintaining independence. Deborah said: “I refuse to give up. I like my independence. I don´t wanna just have to depend on someone.” The wish to stay could be strongly expressed, George stated:

I´m satisfied here. I´m not thinking about moving. And like I say, the only way I´m going to move, they´ll have to carry me out of here.

To others, staying was more of a practical solution and expressed as more of a matter of fact. Jerry said: “I´m here because I have no reason to move.” Other participants acknowledged that life at home had turned into a struggle and that it was increasingly difficult to manage on their own, but they did not see that as a reason for starting to plan for future housing or care needs. Others expressed that, no matter what the future held, there was no need to worry. They put their trust in the hands of God, faith, or chance.

While some participants said that they would prefer to move, others shifted back and forth between wanting and having to stay. The shift in reasoning seemed to have happened slowly and was the result of life at home becoming too big of a challenge. To some, daily life had turned into a struggle. Stories unfolded which revealed gradual changes in health, social networks, the financial situation, or the neighborhood, that eventually made them realize they no longer wanted to stay in the house. Fred explained:

If you had asked me … 10 or 12 years ago I would´ve said no. I really wanted to stay in the house … Somewhere along the way I made peace with it. As much as I love it, in order to get security, the peace of mind, and to be able to live in a community where I´m not dealing with trash and crime and murder, I would give it up in an instant.

Some participants were clear that it was a struggle to live where they had lived for all kinds of reasons. Nevertheless, they were fine because they wanted to stay. With some weariness, John said:

So I am stuck, more or less. […] I don´t mean like `Holy crap, I am stuck here` kind of way. I´m just stuck. I mean, where could I go for what I´m paying and what income I have? There´s nowhere I could go.

Below we present how the categories and changes within the categories family needs, being a homeowner, the neighborhood, and coping at home influenced the shifting reasoning process in both directions along the continuum. For most participants, the changes in reasoning were subtle, could go in either direction, and were accompanied by ambivalence.

Family needs

At a time in life with transforming social networks and changing health, the participants described how they had lost friends and family members. However, one participant expressed how reuniting with his daughter in recent years had enriched his life with two grandchildren. Currently, some participants did not have any strong connections with family members, and could therefore not rely on support from family. Receiving support from and giving support to family members was part of day-to-day life for most participants. Thus, family members could make it easier to age in place, but they could also have needs that compel older adults to remain in the home, causing feelings of being stuck in place.

Family members, who either lived with them or visited regularly, made it possible for participants to stay in the home thanks to help they provided. Some helped financially, others with support in daily activities such as laundry, cooking, or with maintenance and upkeep of home and garden. Children or family members who co-resided with participants sometimes contributed to housing costs, which helped participants afford to stay in the home. Cheryl was grateful to her son: “By my son being here, I get a few dollars from him every month. That helps me with the gas and stuff like that.”

Family members provided a sense of safety and security, which prevented loneliness or isolation. Kathy, who lived with her son and a grandchild, said:

I have a very close-knit family. Me and all of my sisters and brothers, we’re very, very close. We do pretty much everything together ‒ nieces and nephews. It’s never dull around here. Somebody is always in and out, coming and going.

If circumstances were to change, due to financial hardship or declining health, some participants preferred the hypothetical option of family members moving in with them than the options of moving in with their children or to an assisted living facility. Others preferred to move to a facility so they would not turn into a burden for the family. Interestingly, the desire to be autonomous and not become a burden to family members were reasons for both of those options.

In other cases, family members relied heavily on the participant, and the needs of family members ruled out moving somewhere else as an option. Several participants provided care, stability, and a good home to family members in need. Children and grandchildren lived with the participant to get access to good schools or because they could not afford a place of their own. One participant took in a grandchild due to the child’s mother having substance abuse problems and Child Protective Services getting involved. The needs of family members such as accommodation, care, or financial help sometimes clashed with the needs of the older adult, especially when the older adult’s needs changed over time. To meet the needs of family members, the participants felt obliged to stay in the home. Participants recounted taking on a second mortgage to help children and grandchildren with college tuition or siblings with medical payments. Providing generous financial assistance to their families was something they could not do if they had not owned a home. Lisa was trying to save money for a roof repair but admitted:

I can’t save because my granddaughter is in college and I have to help … I know how difficult it is being a single parent. I’m helping as much as I can. So as far as saving, that’s out right now. We don’t save. We don’t even have enough sometimes to meet all of our needs.

Lisa had also considered moving to a smaller, less expensive place just for her, but felt ambivalent: “I want to, kind of, have a place for my daughter and granddaughter to live if they can’t make it out there”.

Participants who were caregivers to children and grandchildren could not move to age-restricted housing, because the family member would not be allowed to move with them. One woman took care of her son with a disability who needed constant care. He used to be in a nursing home, but she decided several years ago to take care of him at home with the help of relatives. Now she used a wheelchair to move around because of pain, and could barely manage herself. She was concerned about what would happen to her son if she could no longer keep the house.

In several cases, the need for help was not one-directional. Both the older adult and the family members simultaneously needed help and provided help. This interdependence added to the complexity of deciding where to live.

Being a homeowner

All participants were homeowners, which they found both a blessing and a burden. Owning a home helped them stay, as well as forced them to stay. Many participants, especially the women, recalled the struggles they had over the years to buy the house in the first place. They were proud that they had overcome those struggles and the home became a symbol of what they had accomplished. Participants valued being a homeowner and being able to say, “It is mine.” Deborah summed up her reasons for living where she did: “Because it is mine and I worked hard to get it. I raised my children here and I am comfortable here.” Being able to pass an asset on to children and grandchildren was also stated as an important benefit of homeownership. However, managing a home could be demanding and cause much worry.

Not being able to keep up with maintenance caused a lot of stress, especially when they realized that they were not in a position to move. Keeping the home warm in the winter was costly. Urgent repairs required them to use money saved for medical needs, such as a dental procedure or hearing aids. Problems with the furnace or holes in the roof superseded a new hearing aid. Sometimes, the only solution was to ignore the fact that repairs had to be done. The participants, like Barbara, verbalized concern and sadness about their inability to maintain their homes:

I have problems with the furnace. You have to get that fixed, ‘cause you have to have the heat. I’m beginning to think maybe I might be better off in an apartment, more so than what I used to think … It’s just more problems sometimes than you got money to handle.

The fact that they did own a home was also a relief for the participants. It opened up possibilities for a reverse mortgage, a home equity loan, or a second mortgage on the house. Some took out loans to supplement their social security payment, which would not have been possible if they had not owned the home. However, with time, they felt trapped by their loans. Fred took out a reverse mortgage several years ago and now expressed:

While it was an exceptional thing to do and it bought me time and it allowed me to be more comfortable, I didn’t realize it was going to continue to lock me in further.

Not taking maintenance costs into account, staying in one’s own home compared to renting in a senior retirement community was the most inexpensive option. Jerry said: “It doesn’t cost me anything to live here except my taxes every year. I don’t have rent or a mortgage.”

Renting out a spare room meant that a house could also generate extra income. It was an option currently used only for family members, but one woman used to rent a room to students at a local university.

The neighborhood

The neighborhood was an important part of home and how the participants perceived the neighborhood influenced their residential reasoning. A neighborhood that suited participants’ needs made it easier to age in, while a neighborhood that did not meet their current needs made them feel unsafe, and contributed to participants’ sense of being trapped in their homes.

A neighborhood that suited participants’ needs had convenient amenities, such as accessible bus lines and a grocery store. Participants valued the support they received from friendly neighbors. Some neighbors cared a lot and helped out. This could be seen in brief chats over the fence, offering a ride to the food bank, or by bringing covered dishes over. Just knowing the people living around them gave the participants a sense of security and comfort. Anne explained:

Everybody around here has been so nice. You know, even the new neighbors came around when my husband passed. Some of them I had never met, old neighbors and new neighbors, they told me, ‘Do not worry. We are going to take care of you.’ And they have been around asking if I need them.

All participants had lived in the same neighborhood for many years, several of them since the 1980s or 1990s, and they reflected upon how the neighborhood had changed over time and how they themselves had aged with it. Most participants thought that the change in the neighborhood was for the worse, such as more vacant and boarded up houses, or that the area had not kept up as it used to be. To some, the sense of living in an unsafe and sometimes violent neighborhood contributed to the sense of feeling trapped. As stated in an earlier quote, Fred, who loved his home, stated that he would give it up in an instant if he could move to a safer neighborhood. Even though some participants revealed that they had been victims of serious crimes in the neighborhood such as break-ins, being held up at gunpoint when unloading the car, and sexual assault, they considered their particular street or local community to be better compared to other areas they had lived in, visited, or heard about. Some participants, like Emma, preferred to stay in the challenged neighborhood they knew than moving to an unknown neighborhood:

I wouldn’t want to move in just a regular apartment building because I don’t want to go anywhere where there are children, teenagers, you know … My children grew up around here so I know most of the people. They’re in their 30s now but still they know me. They speak to me because they know me from my children. I don’t have a fear of walking anywhere.

Not liking the neighborhood did not necessarily mean the participant wanted to leave the house, but they expressed how they had started to avoid certain places and they now stayed indoors more than they used to.

Coping at home

The participants had lived in their homes for a long time. For some, their homes made life and adapting to health changes and loss easier. For others, their homes could also make coping and adapting harder, for example, with the onset of walking difficulties, as the layout of the home may make rooms inaccessible. Thus, the home could be both a reason for why the older adult wanted to age in place and a reason why they considered other options. The participants knew their homes inside out, and when they described why their homes were good places to age in, most of them said that the homes were convenient and comfortable, making life easier.

The home allowed them to do the things they loved to do and carry out activities that gave them meaning, which made it easier to cope with health decline and hardship. The homes were spacious enough to host guests when mobility problems made it hard to visit friends in other parts in the city. Others enjoyed having a garden to be and work in. One participant described in the first interview that she felt down and sad because of recent family matters. At the follow-up interview she described how working in the garden had kept her from becoming depressed. Several participants, like Kathy, appreciated not having neighbors as close as they would have in an apartment building: “I’ve never lived like in an apartment-type situation. You know, with people living on top of me and right next to me. I’ve never experienced that, so I don’t want to.”

But managing daily life on their own in the house was not always easy. The participants aged and so did the homes. It was not the house per se that was challenging, but the change in health that turned day-to-day life at home into a struggle sometimes. For example, Jerry reflected on his changing ability and worsening health by giving examples of tasks and activities around the house that turned problematic:

My trash can has to be in the back alley. It used to be no problem at all. I’d just go out and throw the trash out. Now I have to really think about doing it …. I don’t like that, and usually when I’m finished, I’m so tired, I have to just sit down and rest for 20 minutes.

The home became harder to work with when health problems gradually made day-to-day life tougher. John reported, “The stairs never used to be a problem,” but with increasing pain and immobility, the home brought new challenges. For some, doing laundry had turned into an impossible mission due to pain in the knees, heavy laundry baskets, and navigating steep stairs to access the washer and dryer. Several participants avoided stairs as much as they possibly could, but they found themselves being restricted to only some parts of the house. Barbara stated, “I just can’t carry and come up – When I go up and down the steps, I have to hold onto the bannister.”

Participants came up with multiple strategies to cope and to continue to manage day-to-day life. Those who had family members and neighbors who offered support were willing to accept more help. However, the desire to be independent was strong, and not everyone had someone to ask for help. The determination to manage life in the home they lived in resulted in various innovative management strategies. Deborah explained her strategy:

And cooking – I walk and cook, and I stand for a while, then I sit for a while. And I clean for a while and I sit, and I do something for a while and then I sit. I’m managing that way.

Several participants mentioned using stair glides to better manage the stairs. One woman had installed one a couple of years ago, but most participants did not have the money needed to buy one. Some family members had offered to help them with a contribution, while others had contacted the City´s Commission on Aging in hopes that there would not be a long waiting list to obtain a free stair glide.

Between the first and second interview some participants experienced overwhelming changes. Anne´s husband died. Lisa´s basement flooded and she had to temporarily move out of her home. Jerry´s back pain increased dramatically during the winter. However, it seemed to be the small constant changes that eventually influenced managing daily life at home which changed their reasoning in one way or the other. Some of the participants expressed that they lost the battle against the home, and because of that they preferred to live somewhere else. Jerry said:

I’ve just come to the point where the house wins. I’m tired. I concede. Sometimes you have to lose the battle to win the war. In this case, I’ve lost the battle AND I’ve lost the war, ‒ so be it.”

Discussion

This study adds knowledge on the residential reasoning of low-income, older adults with disabilities, aging in place in Baltimore, Maryland. In particular on how housing preferences and housing decision-making are influenced by economic, social, or health-related changes in later life. The desire to age in place is challenged by declining health, loss of independence, and an income that does not cover basic needs (Torres-Gil & Hofland, 2012). This study shows the double burden of being both low-income and having disabilities. Being low-income restricts the options for moving or adapting the home, while the presence of disabilities make the need for age-appropriate housing even greater than for older adults in general. This double burden was reflected by their ambivalence and reasoning about their situation and the future. The reasoning, thoughts, and feelings of the participants shifted along the continuum from being happy to age-in-place to the realization that they were stuck in place. Changes within the family, neighborhood, the home, and their possibilities to cope with health problems at home pushed them in different directions on that continuum. For low-income older adults, their financial situation not only impacts daily life, but also influences the possibilities to plan, prepare, and adjust to future health and housing needs (Sörensen & Pinquart, 2000). It is not surprising that low-income, older adults are more vulnerable to the challenges of later life. Understanding how they reason and why they shift along the continuum from happily aging in place to having feelings of being stuck in place can give better insight into residential reasoning and how to better support this group of older adults.

The participants described how homeownership had helped them over the years by leveraging their home as a financial resource (Mudrazija & Butrica, 2017). However, unlocking some of the home equity, for example, with a reverse mortgage, was also perceived by some participants as a strategy that locked them in further (Keene et al., 2019). Even for participants who in theory could sell their house, the value might be too low to relocate to an assisted living facility. Research has shown that homeowners consistently report better health than those who rent, but it is still debated whether tenure is merely a proxy for socioeconomic status or is associated with housing characteristics such as quality and location (Connolly, 2012). Owning a home can be a financial asset that provides stability in life, which can positively influence health and wellbeing. Likely for our participants, it was not only homeownership per se but also an attachment to the home, possibilities for social interaction and participation in valued activities in the home that had a positive effect.

Being proud of owning a home was part of a strong emotional attachment to the home. Previous literature shows that emotional attachment is influential in the desire to age in place, and that emotional attachment grows stronger when capabilities and agency decrease (Wahl & Lang, 2003). However, owning a home and being strongly attached to a home that no longer meets the daily life needs of an aging individual also contributed to the feeling of being stuck in place. For participants who no longer thought that the home suited them, the attachment also seemed to be less strong. It was practical and financial reasons that kept them at home, that is, stuck in place.

Not surprisingly, our study confirms that relationships with family members influenced the residential reasoning process in several ways (Koss & Ekerdt, 2016). The satisfaction of knowing that they could pass on the house as an asset on to their children and grandchildren was important to many of the participants.

Not having access to care from family members is known to be a threat to aging in place but for our participants it was also a threat to not aging in place in the manner they wanted to (Dupuis-Blanchard et al., 2015). Several of the participants were part of a family support system that included family members’ housing and care needs, as well as the older adults’ needs for care and social interaction. Multi-generational households constitute approximately one fifth of all U.S. older adult households and are more common among low-income older adults and older adults with disabilities (Henning-Smith et al., 2018; Johnson & Appold, 2017). For our participants, the primary reason for living together over generations was to accommodate needs of younger family members. However, with increasing age of the participants, the need for receiving care emerged (Pfeiffer et al., 2016). Both the role of being a caregiver and a care receiver contributed to the older adults’ inability to relocate (Lee et al., 2017).

The neighborhood was an important part of how the participants reasoned about the suitability of the home. The neighborhood provided support, comfort, and assistance. Even if all participants described that the neighborhood had negatively changed, they also appreciated neighbors and acquaintances living close by who cared for them in different ways. Attachment to the neighborhood increases with age and the number of years the older adult has lived in the neighborhood but our study participants seemed to have a more practical stance toward the neighborhood (Gilleard et al., 2007). Our participants expressed how neighbors were important and that they were confident they would help out if needed, but also how they appreciated the privacy of the home and not having too close relationships with neighbors. This might be a sign of accommodative coping techniques, adjusting their mind-set to the circumstances because they could not leave, but also the fact that neighborhoods and communities have both positive and negative attributes (Golant, 2011).

It did not appear that the increasing health problems impacted participants’ residential reasoning . Instead, how they could cope with increasing health problems was crucial, and the home was instrumental in being able to adapt and manage day-to-day life. For example, living with pain was common among the respondents, and they used all kinds of techniques to adapt and manage at home. However, when the challenges became too great and they could no longer adjust the home or their behavior, they started to change their mind about moving. A change of mind is in accordance with the theory on residential normalcy in which older adults who cannot achieve their needs and goals at home strive to return to their comfort and mastery zones (Golant, 2011). We saw that our participants used both assimilative (i.e. adapt the home or behavior) and accommodative techniques (i.e. change of mind-set, e.g. lowering expectations). Possibly, when the struggle to keep in comfort or mastery zones became too tough, they expressed feelings of being stuck in place. Programs helping older adults to cope despite disabilities by providing new techniques to manage at home or by making environmental modifications at home, may help more individuals not only to age in place, but also continue to desire to age in place and avoid feelings of being stuck in place. To support individual and family-based decision-making, programs also need to address the financial situations of older adults. Programs are needed that include low-cost or free home modifications and rehabilitation, sufficient affordable senior housing options or mutual aid organizations such as village models (Granbom et al., 2018; Greenfield et al., 2012; Szanton et al., 2016).

Study limitations

In our study we focused on residential reasoning as a process that can change over time. For our qualitative analysis we utilized Saldana’s (2003) analytical tools focusing on process and change. However, our findings are limited to two interviews with each participant conducted within an eight-month timespan. This interval between interviews may not have been long enough to capture significant changes in older adults’ residential reasoning or decision-making. In future studies, it would be valuable to conduct additional interviews over a longer period of time. The sample size of 12 participants might appear limited, but strategic sampling and negative case analysis during data collection and recruitment contributed to the heterogeneity of the sample and richness in data. Unfortunately, in terms of race and ethnicity, the sample was restricted to individuals self-identified as Black or as non-Hispanic White. In terms of transferability, the participants were low-income adults over 65 who owned homes in Baltimore. Several had family members or relatives living with them, which make them unique compared to low-income older adults who are renting, live alone, or live in rural settings across the U.S.

In conclusion, this paper adds to the knowledge on how low-income, older adults with disabilities in Baltimore perceive their housing situation and how owning a home can be both a facilitator for a continued desire to age-in-place and a burden that ties the older adult to the home and makes them feel stuck. Our study shows the consequences of financial strain on residential reasoning. More research is needed across various groups that take for example race and ethnicity and urban, suburban, and rural factors into account to incorporate these influencing aspects into the theoretical development of residential reasoning. In addition, increased attention is needed to acknowledge long-term consequences of interventions primarily intended to support older adults to age in place. Future aging-in-place intervention development should take socioeconomic disability factors into account to achieve successful aging in place. Without sufficient affordable senior housing options and programs including low-cost or free home modifications and rehabilitation, we need to acknowledge that for some low-income older adults, aging in place can shift into feelings of being stuck in place.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

The study was conducted at the Center for Innovative Care in Aging at Johns Hopkins University School of Nursing. First author was supported by the Swedish Research Council FORMAS (RF: 942-2015-403), The Crafoord Foundation, Sweden (RF: 20160604), and the Helge Ax:son Johnsons Foundation, Sweden.The second author was supported by the Robert Wood Johnson Foundation Health Policy Research Scholar program and the National Institute on Aging (NIA# 1F31AG057166-01). The authors are solely responsible for the content of this study which does not necessarily represent the official view of the funders.

Notes on contributors

Marianne Granbom

Marianne Granbom PhD, Reg OT, is an occupational therapist by training and she has a PhD in Health Science from Lund University, Sweden. She is Assistant Professor at the Department of Health Science Lund Univeristy, and belongs to the transdiciplinary Centre for Ageing and Supportive Environments (CASE). In 2016 to 2108 she was International Reasearch Faculty at Johns Hopkins School of Nursing where the current study was conducted. Her research focus on housing in later life with a specific interest on residential relocation and theoretical perspectives on perievced housing, aging in place and active and healthy aging.

Manka Nkimbeng

Manka Nkimbeng, PhD, MPH, RN is a Robert L. Kane Postdoctoral Fellow at the University of Minnesota School of Public health. She received her PhD in Nursing from Johns Hopkins School of Nursing and her MPH from Boston University School of Public Health. Dr. Nkimbeng’s research interests center around understanding the causes of health inequities in minorities and improving health outcomes for older adults. Encompassing her research and policy training, her long-term goal is to develop and test interventions that can be translated into health policies and practice to improve health and eliminate health inequities for older adults.

Laken C. Roberts

Laken Roberts, MPH, is a PhD candidate at the Johns Hopkins School of Nursing in Baltimore, MD. She graduated from the Pennsylvania State University in 2010 with bachelor of science degrees in Environmental Resource Management and Toxicology. She received her master of public health in Epidemiology from the Boston University School of Public Health in 2012. Before joining the PhD program, Laken worked with Sarah Szanton, PhD, ANP, FAAN, as a senior research assistant for the CAPABLE study at the Johns Hopkins School of Nursing. She is interested in exploring how home and neighborhood environments influence the health outcomes of their residents.

Laura N. Gitlin

Laura N Gitlin is Dean and Distinguished University Professor at Drexel College of Nursing and Health Professions. She is an an applied research sociologist, is nationally and internationally recognized for her research on developing, evaluating and implementing novel home and community-based interventions that improve quality of life of persons with dementia and their family caregivers, enhance daily function of older adults with disability and address mental health disparities. In all of her research, she applies a social ecological perspective and person-family-directed approach to examine, intervene and support individuals. Her efforts involve collaborating with community organizations, health and human service professionals, older adults and other stakeholders to maximize the relevance and impact of such interventions. She is involved in translating, disseminating and implementing proven programs for delivery in diverse practice settings globally and in the United States. She is the author of close to 300 scientific publications including authoring or coauthoring seven books, the most recent published in 2016 on behavioral intervention research, and 2018, on Better Living with Dementia: Implications for Individuals, Families, Communities, and Society. She has also published tip books for family caregivers and for older adults with functional challenges.

Janiece L. Taylor

Janiece L. Taylor, PhD, MSN, RN, FAAN is Assistant Professor at Johns Hopkins School of Nursing in Baltimore, MD. While still in high school in Albuquerque, NM, she became a licensed practical nurse and volunteered with nursing groups in the area. She also worked in long-term care centers as she attended college, earning bachelor’s, master’s, and PhD degrees in nursing. Her dissertation focused on predictors of disability among middle-aged and older African-American women with osteoarthritis. Taylor came to the Johns Hopkins School of Nursing on a two-year postdoctoral assignment (gerontological pain and intervention research) and, as faculty, joins the Center for Innovative Care in Aging.

Sarah L. Szanton

Sarah L Szanton PhD, ANP, FAAN is Endowed Professor for Health Equity and Social Justice and Director of the Center for Innovative Care in Aging at Johns Hopkins School of Nursing in Baltimore, MD. She is a nurse by training and based on her experiences from making house calls as a nurse practitioner to homebound, low-income older adults she has developed a program of research on the role of the environment and stressors in health disparities in older adults, particularly those trying to “age in place” or stay out of a nursing home. The result is a program called CAPABLE, which combines handyman services with nursing and occupational therapy to improve mobility, reduce disability, and decrease healthcare costs. She has tested the program’s effectiveness through grants from the National Institutes of Health and the Innovations Office at the Center on Medicaid and Medicare Services. She has also conducted a study, funded by the Robert Wood Johnson Foundation, of whether food and energy assistance improve health outcomes for low-income older adults. A former health policy advocate, Dr. Szanton aims her research and publications toward changing policy for older adults and their families.