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. 2022 Dec 16;11(11):6646–6653. doi: 10.4103/jfmpc.jfmpc_2150_21

Concept development of “Aging in place”: Application of hybrid model

Farzaneh Barati 1, Homeira Khoddam 2, Mahnaz Modanloo 2,✉
PMCID: PMC10041179  PMID: 36993074

ABSTRACT

There are various methods and services which help elders protect their independency and ability and take care. Like aging in place (AIP), that is a home and community-based model. Despite its importance, this concept is still ambiguous and there is no comprehensive definition for it. This study aims to clarify and conceptualize the meaning of AIP and to develop a context-based definition. In this qualitative study, the concept was developed using a hybrid model during three theoretical phases, fieldwork and final analysis. In the theoretical phase, 30 selected articles, following a systematic search in Web of sciences-Scopus-PubMed databases using the keywords “Aging in place”, “Aging at home” and “Aging in community”, during 2000–2019 were screened and analyzed. After providing the working definition, the fieldwork phase directed qualitative content analysis was performed on interviews conducted with seven eligible elderly. Finally, in the final phase, after comparing the findings of the previous two phases, the final definition was presented. The results of the hybrid model extracted and identified various definitions of AIP and attributes, antecedent and consequences of AIP. attributes included; independency, belonging to the place, maintaining network, living in one’s own home and community, safety, comfort, non-institutionalization, first preference, and life routines continuity. Antecedents included; health, physical environment, financial ability, socialization, information support, technology, AIP antecedent prediction, community services and transportation. Finally, Consequences included; Individual acceptability and community acceptability. Also final definition was provided. If the AIP and its related factors are known and provided so that elders can stay in their homes, then they do not have to choose a nursing home and thus stay out of the community. As a result, following the AIP, both the elderly and community will be satisfied.

Keywords: Aging in place, concept analysis, elderly, hybrid model, qualitative study

Introduction

Aging is a gradual process, encompassing changes in the structure, and function of living organisms, which occurs over time and is not caused by major illness or injury and ultimately leads to an increased risk of death.[1] Anyone over 60 years is considered elderly. However, some sources consider the age 65 years as the determining limit.[2] Nowadays, due to the increasing life expectancy and decreasing fertility in the world, aging has turned into a global phenomenon.[3] Based on the World Health Organization, the elderly population will touch 2 billion by 2050. Therefore, the elderly population has the fastest population growth rate among different age groups and approximately, two-thirds of all the elderly people live in developing countries.[4,5] Currently, the population aging is rapidly increasing and it is necessary to develop appropriate concepts, programs, and services to meet the expectations of the elderly population.[6] Therefore, ensuring the type, method, and quality of life of the elderly is important. Accordingly, there are various methods and care services in different countries of the world that aid the elderly to maintain their independence and ability and take care.[7] Senior centers, Community-based adult day care centers, Respite Care, Hospice Care, Palliative Care, Rehabilitation Ward, Skilled Nursing Home, Residential Long-Term Care, Assisted-Living, Tele Care, and Home Care are among these models and care services.[8] The most common form of classification of these models is based on where the elderly reside This classification includes two categories; LTC1 settings such as nursing homes, and HCBS2 models, that in developed countries in the field of aging, efforts are focused on HCBS models.[9] One of the models is aging In place (AIP). AIP is a model of home and community-based elderly life, with the aim of allowing the elderly to live as much as possible in the community and at home. Staying at home is the favorite of the elderly and also the community by reducing long-term care costs.[10,11,12,13,14] Basically, AIP aims at keeping the elderly in their homes and thus prevent unnecessary admission of elderly people who can get the care they need from their community environment instead of nursing homes.[7,11,15] Admission to a nursing home is considered as the breaking point of the elderly life and the elderly wait for the end of their life by staying there.[1,16,17] This is while it can certainly be controlled by early interventions and monitoring and preventing the transfer and residence of the elderly in such places.[18] By knowing and examining AIP as much as possible and identifying the factors affecting it, it is possible to help the elderly to stay in their homes. Addressing this concept and recognizing it can be considered as one of the effective solutions in the face of rapid population growth and controlling and planning this issue, and since there is still no single, clear and comprehensive definition for experts to agree on and refer to, this made the researcher to develop the concept of AIP. Therefore, this study aims to clarify and conceptualize the meaning of AIP and to develop a context-based definition.

Method

This study is a qualitative study in which the concept analysis method with hybrid model has been used to develop the concept of AIP. The hybrid model was proposed by Schwartz Barcott and Kim in 1986 which is a method to create, develop, and extend concepts, and is especially widely used in nursing for concept disambiguation concept.[19] This model is a practice-based approach that consists of three phases: Theoretical, fieldwork, and final analysis, each of which has steps [Figure 1]. The theoretical phase reviews the relevant studies. The second phase, the fieldwork phase, is often based on qualitative research and confirm and clarify the issue. The final phase includes a conceptual analysis of the findings from the theoretical and fieldwork phase.[19,20]

Figure 1.

Figure 1

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Steps of concept analysis with a hybrid model (Rodgers and Knafl 2000)

Theoretical phase

The theoretical phase was performed in four steps [Figure 1].[21] First step started by selecting the concept of AIP and systematic search after setting up the search strategy using the keywords “Aging in place-Aging at home-Aging in community”, was performed in Scopus-Web of science-PubMed databases [Table 1]. All qualitative and quantitative studies related to AIP published during 2000–2019 were researched and independently reviewed by two authors. 2280 records export to EndNote10 software and after removing duplicates, and screening articles in the phases of title, abstract, and full text, according to the inclusion and exclusion criteria, finally 30 studies were selected. Criteria include; the presence of keywords in the title or abstract of studies, having basic elements and dimensions related to AIP and English language. Records such as books, letters to editor, interventional studies, conferences and lectures, dissertations, and trial studies were excluded [Figure 2]. The text of the selected articles was entered into MAXQDA10 software and to dealing with meaning, the articles were read several times to immersing in those concepts and then qualitative content analysis was performed to identifying the definitions, attributes, antecedents, and consequences of the AIP. Finally, a working definition was provided.

Table 1.

Details and results of systematic searches in databases

Data base PubMed Scopus Web of Science
Syntax (“Aging in place” OR “Aging in community” OR “Aging at home”) (“Aging in place” OR “Aging in community” OR “Aging at home”) TS=(“aging in place” OR “aging in community” OR “aging at home”)
Language All All All
Date 2000–2019 2000–2019 2000–2019
Document type Journal Article Article, Review Journal Article
Meta-Analysis Observational Study Meta-Analysis Observational Study
Review Review
Introductory Journal Article Introductory Journal Article
Systematic Reviews Systematic Reviews
Search Field Title/Abstract Title/Abstract Title/Abstract
Search Results 364 1183 733
Total results 2280
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Figure 2.

Figure 2

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Results of systematic search and screening steps of the study

Fieldwork phase

In the first stage of the fieldwork phase, the home of the elderly was considered as settings where the concept occurs, and stage tow focused on developing criteria for participants that were extracted from reviewing resources. Criteria including; being age of 65 years and above, living in their own homes, full level of consciousness, and verbal communication ability. In the next stage, unit of analysis was conducted at the individual level and sampling was purposeful based on Wilson’s typology. In Wilson’s typology, alternative cases that are not exactly similar to the concept are also used to determining characteristics.[22] Therefore, beside the model case, borderline case, and contrary case were also considered and for maximum variation, difference in demographic variables of the participants were considered. in the hybrid model and three to six people are enough and it was possible to repeat the interview with them.[23] Semi-structured interviews were conducted with seven eligible seniors after obtaining the approval of the ethics committee as well as informed written consent and permission to record interviews with the participants. The interview began with the open question “Please describe the experience of a day of your life?” Also, in order to probing the ambiguities in-depth questions were used in this way; “What do you mean?”. Each interview lasted between 45 and 70 min, for one or two sessions, over a period of five months (January to May) and progressed until data saturation. The last participant (p7) has been selected to ensure that there are no new data. At this stage, according to the findings of the theoretical phase and categories formation, directed qualitative content analysis was used to analyze the data. Due to the categorize matrix design, the new data were also organized into separate categories to avoid losing any proper data.

Final phase

In the final phase, the theoretical and fieldwork findings were compared to produce a final definition, and finally the concept of AIP was defined based on comparison and analysis, and the main themes were extracted.

Rigor

The accuracy and validity of the data were determined using Lincoln and Guba criteria[24] for immersing in the information, attempts were made to transcribe and analyze it immediately. Copies of interviews were provided to all participants for member check. The validity of the codes, clusters, and data analysis was verified by research team members. Also, the documentation of information is done completely to enable the future follow-up.

Ethical considerations

This study is the article extracted from the doctoral thesis entitled “Presenting a model for Aging in place in the elderly” Golestan University of Medical Sciences with the ethics Code No. IR.GOUMS.REC.1398.340.

Findings

Theoretical phase

Characteristics and definitions of AIP

“Aging In place” in the Oxford English Dictionary has no definition.[25] Following the systematic search, it was found that AIP was first mentioned in 1980, Of course, indirectly mentioned[26] and most studies consider AIP as; ability to stay at home and in the community,[10,27,28] or in the form “the tendency and desire of the elderly to stay in their current housing units with levels of independence compared to the elderly care centers”.[26,29,30,31] The concept of “independence” in this definition distinguishes it, just as “comfort” and “safety” in the Centers for Disease Control (CDC) definition of AIP are next to “independence”[32] and some studies have cited this definition.[27,29,33,34] Overall, there was no unit definition of AIP [Table 2] and each of the definitions addresses an issue related to AIP, like “Meeting the needs of the elderly”,[35] “Connecting the elderly to the care agencies”,[36] or “delay of transfer to long-term care setting”,[37] also “the ability to choose and receive support”.[10]

Table 2.

Definitions extracted from the selected articles

Authors Definition
Iecovich E (2014) cited by )Rantz et al. 2005) to remain as autonomous, active, and independent as long as possible and live at home surrounded by family and friends.[28]
Iecovich E (2014) remaining living at home in the community, with some level of independence rather than in residential care.[28,38]
Schorr AV (2018) cited by (Davey et al. 2004)
Kendig H (2017) The desire and tendency of older persons to stay in their current dwelling units for as long as possible.[26,29,30,31]
Vasunilashorn S (2011)
Lee MO (2016)
Wick JY (2017) cited by (Pynoos. 2007)
Weil J (2016) cited by CDC growing older without having to move from one’s home.[27]
Janine L (2011) staying in one’s home or community.[10]
Janine L (2012) cited by Dalziel, L (2001) Ability to choose in later life about where to live, and receive the support needed.[10]
Marek & Rantz (2000) aging in one’s home and community as long as possible and to delaying any potential relocation to a long-term care setting.[18,37]
Bigonnesse C (2019)
Kendig H (2017) Continuing to live in the community with independence in daily living, and good self-rated health and psychological well-being.[30]
Finlay JM (2019) the ability to live in one’s own home and community safely, independently, and comfortably, regardless of age, income, or ability level.[27,29,33,34]
Weil J (2016)
Benefield LE (2014)
Wick JY (2017) cited by CDC
Weil J (2016) ability to remain in one’s own home or in a community setting over one’s life, until old age.[27]
Weil J (2016) cited by (Rowles 1978) Rowles described aging in place by focusing on place as a sense of belonging and security, and providing physiological comfort, or social insiderness.[27]
J Weil (2016) aging in one’s house or apartment over the course of one’s.[27]
Bookman A (2008) remaining in the homes where they live, and connecting to elder care agencies.[36]
Tang E (2011) cited by (Ball et al. 2004) growing older in their own homes or community without moving out to residential setting.[35]
Tang E (2011) aging in place essentially involves the matter of individual independence and family/community support networks that enhance that independence, in turn decreasing the risk of moving to assisted living or a nursing home.[35]
Tang F (2011) cited by (Cutchi MP 2003) maintenance of independence through meeting the support needs of an aging individual and an aging community.[35]
Iecovich E (2014) cited by (Cutchin MP 2003) being able to remain at home while ageing.[28]
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Attributes

The eight attributes of the AIP concept extracted from studies included; staying independent, place attachment, maintaining networks, living in his or her own home and community, being safe, being comfortable, non-institutionalization, and first preference. It was found that AIP is preference of the elderly. Almost all seniors want to stay at home as long as possible[29] to have control, autonomy, lifestyle choices, and decisions by living independently.[31,39] Safety and comfort are also attributes of AIP.[33] The elderly want to stay at comfortable and safe home and enjoy daily living, conversely, an uncomfortable and insecure environment makes them want to move.[31,34,36] About belonging, definitions of AIP emphasize place familiarity.[37] This familiarity and personal memories of the environment reinforce belonging and attachment to the home.[40] Regarding the non-organizational attribute of this concept, AIP is outside the organizational environment And allows the elderly to stay in the non-organizational space of their homes,[36] staying in this space, the home, is a priority for 90% of the elderly.[36] Conversely, they do not choose to stay in a nursing home.[41]

Antecedents

In the theoretical phase, eight categories emerged as antecedents for AIP included Physical environment, community services, elderly health, financial ability, transportation, socialization, information support, and technology. Most AIP studies (36%) were related to the environment[26] included the indoor and outdoor environment.[42] That determines the ability of the elderly for AIP or, conversely, their need for long-term care.[43] In addition to the importance of the physical environment, the fit between the elderly and the environment[44] also the age friendly environment is important.[44] After environment, services are important.[26] the service category in this study is related to both the existence of different services in the community and access to these services. Community services include wide range of services[35]; home care services, home delivery, transportation, day care centers, and health services.[45] These health services in the form of informal health care including family careers[39] and formal care by the community[35] are provided for AIP.[39] The elderly need financial ability and support to receive these services.[42,46] Technology also helps them in many dimensions: services, information, and communication for AIP.[46]

Consequences

The consequences of AIP were divided into two main categories: individual acceptance and community acceptance. AIP improves elderly health.[38,42] and functional competency[37,43] and reduces the risk of elderly mortality.[35,38] It also leads to the well-being and improvement of the quality of life of the elderly[38,47] and with cost-effective care[29,42] causes economic benefits. Finally, it makes elderly Acceptability. Also, by reducing residential care and reducing transfer to institutional centers such as nursing homes[35,38] being in line with community policies[26,30,42] causes community Acceptability.

Working definition of AIP

Following the analysis and comparison of data, the following working definition was provided to enter the fieldwork phase; AIP means the elderly living in their home and community independently, comfortably, and safely. The elderly spends aging in their home, which is their first priority and belong to it, while maintaining relationships with family, friends, and the community. Doing it depends on the elderly health, physical environment, financial ability, socialization, information support, and technology that will be accepted by the individual and society.

Field work phase

Participant characteristics

The elderly participants in the study included both males and females, 65–88 years old, with different levels of education [Table 3].

Table 3.

Characteristics of participants in work field phase

Participant Gender Age education Wilson Typology Interview duration (minutes)
P1 Female 70 Diploma Model case 60
P2 Male 74 Retired teacher Model case 70
P3 Male 79 Elementary school Contrary case 40
P4 Female 67 Associate Degree Model case 50
P5 Male 88 Under diploma Borderline case 53
P6 Female 65 Illiterate Model case 45
P7 Male 68 Under diploma Model case 64
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Attributes

According to the information of the interviewees, the attributes of AIP were finally placed in nine main categories. During this phase, eight categories emerged of the theoretical phase were approved, and a new category: Life routine continuity was also achieved, which is presented in the unlimited classification matrix [Table 4].

Table 4.

Matrix of categories emerged in theoretical and fieldwork phases

AIP Theoretical phase Fieldwork phase
Attributes independence Life routines continuity
environment Attachment
Maintain networks
Live in home and community
Safely
Comfortably
Non-institutionalization
First Preference
Antecedents Elderly health Predicting AIP antecedents
Financial ability
physical environment skilled workers
Transportation
Community services Age-appropriate activity
Socialization
information support Reliability of services
technology
Consequences Individual acceptance Maintaining social status
community acceptance
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Life routine continuity

According to the interviewees, life routine continuity means the continuity of life as before without disturbing the routines and normal plans of life. The elderly is separated from their homes and communities and placed in long-term care centers, disrupting their routine and life plan, activities and even their relationships are broken and changed. As one participant points:

“As long as you are at home, everything is the same as before. You can do the same programs every day and have the same communication, but when you go to a nursing home, everything changes and changes and you lose everything. And a new life is practically created.” (P2)

And another participant says, leaving home is like dying and losing normal life there:

“Why do you take us out of our home and send us to nursing home that same as dying and your life practically ends there, living is not the same as before and the normal life changes.” (P5)

Antecedents

In this phase, in addition to confirming the emerging antecedents in the theoretical phase, the “Predicting antecedents of AIP” emerge as a main category of antecedents. Based on interviews subcategories of “Predicting antecedents of AIP” include: health planning, forecasting of required services, financial planning, forecasting home modification, do not divide the inheritance, planning for communication, predicting activity for aging.

“In order to be able to live in my own house until end of life, I have already planned and prevented problems. If you do not have a suitable plan for your own aging, you will be dependent on others. You cannot live independently.” (P4)

As well as the “reliability of services” and “skilled workers” as subcategory of “community services” and “age-appropriate activity” as subcategory of “socialization” were emerged [Table 4]. For example, about the skilled workers and the reliability of services, a participant said:

“we hired another worker to help with things like bathing and cooking and elderly medicine, but he really could not be trusted at all … I got into a fight with him. he was not new but he did not any training on elderly care” (P1)

Consequences

In addition to confirming the findings of the theoretical phase as AIP Consequences, the only new finding of fieldwork phase was the preservation of social dignity, which is one of the main subcategory of individual acceptance [Table 4]. A participant as contrary case of Wilson typology who was in a nursing home said:

“Why is it like this here (nursing home) I do not feel at all useful here. I do not feel at all … I used to have a status and dignity as long as I lived in my own house, but now here …” (P3)

Final phase

Based on all the information obtained in the phase of field work are compared to the findings of the theoretical phase, and finally the concept of AIP was defined as: AIP is the first preference of elderly who spends aging in their own home that belong it safely, independently, and comfortably while they have a continuum in life routines and relationships with family and friends. For AIP, predicting AIP antecedents, elderly’s health, physical environment, financial ability, socialization, information support, and technology are necessary and leads to the elderly and the community acceptable.

Discussion

Following this research, it was found that AIP has been an important concept that has been emphasized as it leads to improving the quality of life, increasing their sense of independence, increasing their sense of security, and improving the general health of the elderly.[7,15] Especially during the last 30 years, policymakers and geriatricians have placed more emphasis on conceptualizing AIP as an achievable and valuable goal.[28] In 1980, AIP was first mentioned indirectly in studies, but then became a major part of studies in the 1990s and accelerated, and in the 2000s, the AIP studies increased and issues related to that like environment, services, health, and technology have been addressed.[26] However, AIP was still an ambiguous concept[10] and is relatively new in the science of geriatrics and has many meanings for it[28] and there is no unit definition.[37] The basic concepts of AIP are formed by connecting to a place. It was found that the first definitions for AIP refer to the elderly being in a familiar environment that includes their home and community.[37] For example, the definition of Rowles and Rothstein, who described AIP with place and place as a sense of belonging and security and physiological comfort or social inclusion, or Rothstein, who, by examining the meaning of home for the elderly, has discovered the place.[27] Thus, most studies and related fields, in their definition of AIP, have referred to the elderly remaining in their homes,[18,26,29,30,31,35,36] As mentioned, among the dimensions for AIP, most of the study topics focus on the place or home, and the main purpose of the AIP model is to keep the elderly in their home and thus prevent unnecessary admission to LTC setting. They can get the care they need at home and community.[18,48,49] Although the home or physical environment is very important and is a main part of AIP, but according to this study, there is practically no priority and precedence between the attributes and antecedents of AIP. All of them are necessary, only the prediction of the AIP antecedents was a step ahead of the other, so that the elderly had to anticipate aging from previous years and plan to stay at home. However, homes are not always a safe shelter and can become a source of conflict, especially when inadequate alternative care leads to AIP decision-making.[10] And according to Golant view, it is not the best option for elder who need LTC facilities, because bringing these cervices to home will cost them more.[50] Accordingly, staying home does not always mean AIP. Sometimes it means stuck in place, that is, as mentioned, the elderly cannot be transferred to residential setting to benefit from institutional care, therefore, they are forced to stay at home.[51,52] In order for staying to mean AIP, it must have the attributes mentioned in this study. In this regard, a study by Pani. KE in 2021 which is the latest similar study, and the dimensions related to AIP as: environment, social networks, support, technology and personal characteristics,[53] which partially confirms the dimensions obtained in this study.

Conclusion

AIP is in front of the aging in LTC settings, what has created this confrontation is independence. Independence means living independently and having the ability to choose in life.[10,28] Since AIP is preference by the majority of the elderly.[54,55,56] If the elderly and their needs are met in such a way that the elderly can stay at home, then they do not have to choose LTC settings. And thus stay away from the community.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Footnotes

1

Long term care.

2

home- and community-based services

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