Consumer-directed Care Research Articles

Person-centred Australian residential aged care services: how well do actions match the claims?

AbstractRecent inquiries into residential aged care services, including the 2018–2019 Australian Royal Commission into Aged Care Quality and Safety, have informed revisions to the 2019 Australian Aged Care Quality Standards. Reforms to the Standards include a greater focus on person-centred services, consumer-directed care and authentic participation in decision-making on service provision by residents and their family members. In respect of person-centred services, the revised Standards reflect the four elements of the ‘Valuing, Individualised Care, Personal Perspective, Social Environment’ (or VIPS) framework for quality aged (social) care services in the United Kingdom. This qualitative study investigated whether the quality of services in a convenience sample of seven Australian aged care homes, which claimed to be person-centred, aligned with the four elements and 24 indicators of the VIPS framework. Data were obtained via semi-structured interviews with a volunteer sample of people associated with these seven aged care homes: 12 residents, 15 family members and 18 staff members in various roles. Data were analysed deductively with a priori reference to the 24 VIPS framework indicators, achieving data saturation for four common themes which indicated more person-centredness and ten common themes indicating less person-centredness. Only two of seven homes adhered to the four elements and 24 indicators of the VIPS framework across most service offerings. The remaining five homes offered some aspects of a person-centred service. The study findings provide insight to the factors which support and hamper the implementation of the VIPS-informed indicators of a person-centred aged care service and, therefore, what is needed to help meet person-centred requirements as outlined in the 2019 Australian Aged Care Quality Standards.

Consumer directed care aged care reforms in Australia since 2009: A retrospective policy analysis

In 2009, the Australian federal government used the projected rise in aged care expenditure and changing societal attitudes to justify the decision to overhaul the funding for aged healthcare services. A major feature of the reforms was the introduction of a consumer directed care (CDC) model. This followed the UK, Sweden, Canada and the USA who had already implemented CDC to some degree. The CDC model transferred aged care decisions from providers to consumers. This promised to create a competitive market system, resulting in decreased costs, increased quality and increased consumer satisfaction of aged healthcare services. Advocacy services were also reformed to address market failures. These changes were achieved by engaging key actors throughout the policy cycle, giving perceived legitimacy and transparency; and commissioning reviews with restricted scope and at calculated times, limiting their ability to produce negative criticism. In July 2018, the federal government gained full funding and responsibility for aged care with the support of key stakeholders and multiple reviews, yet with little objective data on the benefit of the reforms. This analysis highlights the power of the policymaking process in creating policies.

Multimorbidity, Consumer- Directed Care, and Drug-Related Harm.

People from developed countries around the world now routinely live into their 80s and beyond, and this is associated with a range of medical and societal challenges that must be addressed. It is relatively rare to encounter older people who are not affected by one or more chronic diseases, including conditions such as osteoarthritis, gastroesophageal reflux disease (GERD), hypertension, and depression. The concurrence of a number of medical and/or psychiatric conditions in the same patient has come to be referred to as multimorbidity, and it is a particularly familiar phenomenon observed by health care providers in settings such as the Emergency Department (ED), primary care practice, and long-term care facilities. Given that life expectancy continues to increase, and that there is considerable further investment in research for the development of new treatments, which will achieve adoption and be promoted to consumers, it is clear that multimorbidity is likely to be a driver for problems arising from medications that are vigorously promoted to consumers.

Promoting occupational therapy interventions in the Australian community aged care sector.

With the introduction of consumer-directed care in the Australian community aged care sector, there are more opportunities for occupational therapists to provide evidence-based services that meet consumer needs. There is also an increasing requirement for health professionals to promote their interventions to consumers. Particularly for the implementation of new programs within organisations. However, occupational therapists have historically neglected widely promoting the role of occupational therapy services for older people. This study examines the perceptions of occupational therapists and their managers in promoting their service; the Care of People in their Environment (COPE) Program. This study utilised a qualitative interpretative description; including 28 in-depth interviews. Purposeful sampling ensured a variety of occupational therapists from different health contexts. Thematic analysis captured key emergent themes related to promoting occupational therapy interventions and implementation. Many occupational therapists were apprehensive about promoting or selling their services and interventions. Greater levels of confidence in promoting the program were present when the program aligned with traditional models of service delivery and organisational processes. Occupational therapists described having limited opportunity to directly promote the program to consumers as community case managers were mostly the main contact at the organisation. There was limited consideration of promotion strategies and therefore limited enactment of strategies by organisations. Not-for-profit and non-government organisations recognise that the changed community aged care market provided new business opportunities. With changes in the Australian aged care system, occupational therapy has great opportunity to provide diverse, evidence-based interventions driven by the needs of consumers. Reframing the notion of 'selling', to empowering consumers to be more informed about their options, will allow occupational therapists to build confidence in their promotional skills. Promoting evidence-based programs will have positive outcomes for the visibility, professional identity and recognition of occupational therapy.

Vouchers and Consumer-Directed Care: Implications for Community Care Services in Hong Kong

Abstract There has been considerable interest in the concept of consumer-directed care (CDC) for ageing populations. One type of CDC employs vouchers that older people can use to procure a panel of social services that best fits their needs. The voucher-based strategy has been institutionalised in Hong Kong as the Community Care Service Voucher for the Elderly (CCSV). Using a qualitative, semi-structured interview method, researchers probed the experiences of two groups (twenty-six CCSV users and twenty-seven CCSV non-users) with the voucher programme between March 2014 and September 2015 during the first phase of CCSV. The interviews revealed a set of social and institutional supports needed to empower clients to effectively utilise the voucher. These supports (or forms of capital) were consistently present amongst active CCSV users and deficient amongst non-users. The research demonstrates that instituting a voucher does not, by itself, lead to optimised choices but, rather, that a network of institutional and social resources must be assembled in support of the voucher programme. In some instances, a case management approach may be needed, as older people (and family) need to combine different forms of institutional and social support to comprehend the voucher programme and utilise it for their particular needs.

Use of Alcohol in Long Term Care Settings: A Comparative Analysis of Personal Choice, Public Health Advice and the Law

Alcohol is one of the most widely available psychoactive substances globally. Many accept the risks associated with alcohol consumption for reasons such as social engagement and feelings of pleasure. Alcohol consumption in a nursing home (NH) setting highlights the moral and logistical challenges of balancing the need for a safe living and working environment with the dignity of risk (DoR) and personal autonomy of residents.This analysis explores public health, human rights, and legal frameworks in their approach to a NH resident's choice to drink alcohol. Key issues under the public health framework include the medical risks associated with alcohol consumption, whether residents with impaired cognitive functioning have the capacity to make a decision about alcohol consumption, and the practical and ethical implications of supplying alcohol to residents. Under a legal framework, NHs must consider the legal imperative to respect residents' rights, the possibility of liability in negligence, duties owed to employees, the existence of substitute decision-makers, and liquor licensing laws. Fundamental considerations under the human rights framework include the damaging psychological effects of risk-avoidance and the importance of inclusive risk assessment processes.Alcohol policies should incorporate elements from all 3 frameworks. There is limited data publicly available about alcohol policies in NHs. Further research is needed to establish current practice and to evaluate the merits and disadvantages of different policies. Establishing inclusive and thorough decision-making processes is key to achieving better consumer-directed care.

Navigating the marketisation of community aged care services in rural Australia

The aged care policies of many Organisation for Economic Co-operation and Development countries reflect free-market principles. In Australia, the recently introduced Consumer Directed Care programme centres on markets in which a range of organisations compete to provide services to community-living elders. As consumers, older people are allocated government funding with which they select and purchase items from their chosen service organisation. This article presents findings from a case study that explored the impacts of this programme on a group of rurally based, not-for-profit providers and consumers. The findings portray the challenges and advantages associated with providing and accessing services in limited rural markets.

Consumer expectations of self-managing aged home care packages in Australia.

This study investigated the expectations of older people who chose to participate in a self-management trial of home aged care packages conducted by COTA Australia. Empowerment theory is used to interpret the findings. All Australian home aged care support packages are delivered using a consumer directed care (CDC) model, and most are managed by an aged care provider. The COTA Australia trial gave older people the opportunity to self-manage their package and have more control over spending and less constraints on its use. This study examined three questions: (a) what motivated the older person, or an informal carer acting on their behalf, to participate in the self-managing trial; (b) what outcomes they expected (c) and what was their attitude towards risk. The trial was conducted over 9months in 2018-2019. Seven registered home aged care providers from six Australian states and territories recruited 103 consumers to the trial, with having an informal carer act on their behalf. Online questionnaires with consumers (n=103) and informal carers (n=66), and 18 semi-structured interviews showed that older consumers and their informal carers had high expectations that self-management would result in: increased choice and control and more flexible use of funds; lower administration fees and more money to spend on services and supports; improved relations with service providers and the opportunity to select support staff. Participants wanted clear information and guidelines and support from their provider. While wanting to have more control and be empowered, few respondents noted concerns about possible risks. This finding raises questions about consumers' awareness of risks that are documented in the literature, and it challenges providers to balance risk management with facilitating independence and autonomy.

Communication and Coordination Processes Supporting Integrated Transitional Care: Australian Healthcare Practitioners' Perspectives.

Introduction:Although a large body of research has identified effective models of transitional care, questions remain about the optimal translation of this knowledge into practice. In Australia, the introduction of a model of consumer-directed care uniquely challenges the practice of integrated care transitions for older adults. This study aimed to identify strengths and weaknesses in transitional care for older adults in an Australian setting by describing healthcare practitioners’ experiences of care provision.Methods:The study used a qualitative design in two phases: 1) semi-structured interviews, 2) one focus group. The setting comprised one public health network and five community services in urban Australia. In Phase 1, health practitioners across settings were interviewed about their experience of transitional care. Phase 2 sought feedback about the Phase 1 findings from different practitioners. All data were thematically analysed.Findings:In Phase 1), 48 healthcare practitioners were interviewed across multiple settings. Few participants were aware of the introduction of consumer-directed care in community aged care. Four main themes were identified: ‘Rapid and safe care transition’, ‘Discussing as a team’, ‘Questioning the discharge’, and ‘Engaging patients and carers’. In Phase 2), seven participants from different settings reviewed and endorsed the findings from Phase 1.Discussion and conclusions:Findings indicate that healthcare practitioners use a range of communication and coordination processes in optimising integrated transitional care. Although participants involved their patients in transitional care planning, most participants were unaware of the recent implementation of consumer-directed care. In contexts of community-based care shaped by multidisciplinary, sub-acute and CDC models, care integration must focus on improved communication with patients and carers to ascertain their needs and to support their increased responsibility in their care transitions.

Consumer experiences of home care packages.

The study aimed to explore consumers' experiences of receiving a home care package (HCP). Community engagement was used to recruit older people approved for a HCP. Data were collected through face-to-face interviews, and data analysis identified themes. Effective consumer-directed care depends on access to reliable information. Participants who reported satisfactory experiences had: (a) providers that charged reasonable fees; (b) case managers who delivered person-centred care; (c) support workers who were consistently assigned to them; (d) a family member for support and advocacy; and (5) ongoing community engagement. Consumer experience requires tighter regulation of providers and policy attention to fees and minimal standards of staff training. The policy of full cost recovery restricts consumers' access to local government services.

Understanding the work of case managers in Australian community aged care: a longitudinal time and motion study.

Objective The aim of this study was to quantify the work activities of community aged care case managers and assess changes following consumer-directed policy reforms. Methods A longitudinal, time and motion study was performed, with direct observation (n=339h) of case managers undertaking work in the office or in the community. We compared the distribution of proportions of time spent across seven broad work task categories during May-August 2014 (P1) and May-October 2016 (P2). Results Office time was primarily consumed by communication (43.7%) and documentation (33.3%) tasks. Documentation increased substantially from P1 to P2 (29.4% vs 37.0% respectively; P<0.001), with more time spent on the subtask of recording information (18.0% vs 24.5% respectively; P=0.039). Travel (45.9%) and communication (41.0%) accounted for most community time. Time in communication increased from P1 to P2 (37.3% vs 48.4% respectively; P=0.047), with more time allocated to client communication (14.6% vs 31.7%; P<0.001). Case managers spent 33.6% of community time in clients' homes (median 25.2min per client; 22.8 vs 30.1min in P1 and P2 respectively) and visited a median of two clients per day (3 vs 1 visits per day in P1 and P2 respectively). Conclusions This study provides the first quantification of task-time distribution among this workforce and how work patterns have changed during a time of significant policy reform and operational changes within the community aged care sector. What is known about the topic? Early qualitative studies gauging case managers' perceptions of the effect of consumer-directed care reforms on their work activities indicate an increase in time spent working directly with aged care clients. However, there is no existing quantitative evidence examining changes to case managers' work activities. What does this paper add? By capturing timed, multidimensional data, this study provides new quantitative evidence of how case managers distribute their time on work activities in office and community settings. Further, the results provide an indication of changes in work task-time distribution over a 2-year period when significant policy reforms and operational changes occurred. Amid a changing aged care landscape, how and with whom case managers spend their time was found to shift, with an increase in time spent recording information and communicating with clients identified. What are the implications for practitioners? This study demonstrates that direct observational studies provide important evidence of the ways in which policy and organisational changes affect community aged care case managers' work activities in practice. Triangulating this quantitative evidence with existing qualitative accounts of policy impact can further allow assessment of how complex reforms may affect everyday work. For policy makers and aged care organisations, such evidence can help discern whether policies and changes are having their desired effects, as well as providing insights as to why or why not.

Choice and quality in home-based and community-based aged care: insights from two rapid evidence reviews

AbstractAs consumer-directed care programmes become increasingly common in aged care provision, there is a heightened requirement for literature summarising the experience and perspectives of recipients. We conducted rapid evidence reviews on two components of consumer experience of home- and community-based aged care: (a) drivers of choice when looking for a service (Question 1 (Q1)); and (b) perceptions of quality of services (Question 2 (Q2)). We systematically searched MEDLINE and EMBASE databases, and conducted manual (non-systematic) searches of primary and grey literature (e.g. government reports) across CINAHL, Scopus, PsychINFO, and Web of Science, Trove and OpenGrey databases. Articles deemed eligible after abstract/full-text screening subsequently underwent risk-of-bias assessment to ensure their quality. The final included studies (Q1: N = 21; Q2: N = 19) comprised both quantitative and qualitative articles, which highlighted that consumer choices of services are driven by a combination of: desire for flexibility in service provision; optimising mobility; need for personal assistance, security and safety, interaction, and social/leisure activities; and to target and address previously unmet needs. Similarly, consumer perspectives of quality include control and autonomy, interpersonal interactions, flexibility of choice, and safety and affordability. Our reviews suggest that future model development should take into account consumers’ freedom to choose services in a flexible manner, and the value they place on interpersonal relationships and social interaction.

Resident perceptions of opportunity for communication and contribution to care planning in residential aged care.

Irrespective of age, communication is a tool of expression and a key daily activity meeting the human need for social interaction and connection. The introduction of consumer-directed care (CDC) emphasises the importance of communication to provide consumers with the opportunity to exercise choice over the care they receive. As consumer-directed care progresses, it is hypothesised that the feasibility of shared decision-making and care planning in residential aged care will be largely determined by the communication opportunities afforded to the residents. Therefore, the aim of this study was to explore resident perceptions of the opportunities they have to communicate, including the opportunity to express their care preferences and contribute opinions about their care. A qualitative inductive design was adopted. An individual interview format was used to gather the perspectives of 102 residents. Data were analysed using qualitative content analysis to generate themes illustrating patterns in participant views. Overall, residents desired increased involvement in their care planning and increased opportunity for more meaningful communication and social opportunities. Residents described the negative impact of the communication difficulties they face on their communication and the need for support and activities to be tailored to residents' individual communication needs. To facilitate resident participation in CDC and meet resident desire for increased social communication, further investment in resources to support resident-staff communication and accommodate residents' individual communication needs is required. By highlighting communication as a stand-alone activity and a priority of residents, the findings of this study raise the profile of communication and demonstrate the need for explicit allocation of care time and specialist services to support resident-staff communication and social communication in residential aged care. Such support must be tailored to meet residents' individual communication needs and be coupled with increased staff training in providing communication support. Without facilitating resident communication and increasing the opportunity to communicate, shared decision-making and care planning in residential aged care consistent with person-centred and consumer-directed models of care will be limited.

The happiness initiative: Changing organizational culture to make ‘brilliance’ mainstream in aged care

AbstractWith the ageing of the population, researchers are investigating the experiences of people living and working in residential aged care. Positive organizational scholarship in healthcare (POSH) and its focus on ‘brilliance’ has not been used as a lens for understanding or improving aged care, although the sector prioritizes person-centred, consumer-directed care. In this qualitative case study, through in-depth interviews, a focus group, and observations, we use a POSH lens to explore how forms of leadership, management structures, and human resource practices facilitate positive experiences for both staff and residents. A thematic data analysis identified the importance of authentic leadership in creating a client-centred organizational culture where ‘happiness’ is an explicit core value. Educating and recruiting staff that share this vision, alongside reflective engagement, rituals and symbols, enabled the building of a responsive care culture that facilitated acts of ‘brilliance’ in healthcare.

An early investigation of individual budget expenditures in the era of consumer-directed care.

To identify the key categories of consumer expenditures following the introduction of consumer-directed care (CDC) in the Australian community aged care sector. Income and expenditure data were extracted from monthly budget statements and categorised. Expenditures by category were examined by home care package level, length of time receiving CDC and socio-demographic characteristics. A total of 150 older people in receipt of CDC in South Australia and New South Wales were approached, of whom 95 (63%) consented to participate. Hours of formal care support received was a key driver of expenditure. On average, approximately 53% of total expenditure was allocated to care services, 20% to administration and 17% to case management. This study was undertaken during the initial stages of the transition to CDC. Further research should investigate the longer-term budgetary impacts of the transition to CDC for consumers and the sector.

Consumer directed care in residential aged care: an evaluation of a staff training program

Objectives: The advent of Consumer-Directed Care (CDC, or individualized care) in Residential Aged Care Facilities (RACFs, or residential care) will require a paradigm shift in service delivery. This article evaluated the six-session Resident at the Centre of Care (RCC) staff training program designed to equip staff to implement a CDC model of care among residents.Method: There were two experimental conditions: RCC training program alone, RCC training program plus support, and a ‘care as usual’ condition. Outcome measures were resident quality of life (QoL) and resident working relationships with staff at 3-month follow-up. At Time 1, 92 residents from RACFs participated in the program. The RCC is six sessions that focus on the development of staff skills in communicating with residents, as well as the organizational change and transformational leadership that is needed for the implementation of CDC.Results: There were significant improvements in resident QoL. There was no major difference between the RCC Program plus support condition compared to the RCC Program alone condition, but both were associated with more positive changes in resident QoL than the ‘care as usual’ condition.Conclusion: This study demonstrates that training staff in strategies to implement CDC in RACFs can lead to an improvement in the wellbeing of many residents, and that additional support to assist staff to implement the strategies may not be required to produce such improvements. Longer term follow-up is necessary to determine if the improvements in resident QoL are sustained.

Individualised funding and its implications for the skills and competencies required by disability support workers in Australia

ABSTRACT Within Australia, the National Disability Insurance Scheme (NDIS) has been heralded as one of the most significant social policy initiatives of recent times. The introduction of the NDIS follows similar moves towards individualised funding and consumer-directed care in the aged care sector. International evidence provides examples of the implications of individualised funding for workers within the social care sector; however, little attention has been paid to how the shift to individualised funding impacts on the skills and competencies required by disability support workers and in an Australian context. Our study aims to provide such an examination. We use qualitative data from in-depth interviews with key stakeholders including disability support workers; people with disability, and their families and carers; disability service providers; and training providers to investigate the impact of the NDIS on the skills and competencies required by disability support workers. Findings suggest that disability support workers require new skills to support choice and control, to be more customer-orientated and, to move from task-focused to person-centred care. As a consequence of these changes, the training of disability support workers is adapting to take account of these new skills and competencies.

A randomized controlled trial to evaluate the effectiveness of a staff training program to implement consumer directed care on resident quality of life in residential aged care

BackgroundResidential Aged Care Facilities (RACFs) are moving towards a Consumer Directed Care (CDC) model of care. There are limited examples of CDC in ageing research, and no evaluation of a comprehensive CDC intervention in residential care was located. This study will implement and evaluate a staff training program, Resident at the Center of Care (RCC), designed to facilitate and drive CDC in residential care.MethodsThe study will adopt a cluster randomized controlled design with 39 facilities randomly allocated to one of three conditions: delivery of the RCC program plus additional organizational support, delivery of the program without additional support, and care as usual. A total of 834 staff (22 in each facility, half senior, half general staff) as well as 744 residents (20 in each facility) will be recruited to participate in the study. The RCC program comprises five sessions spread over nine weeks: Session 1 clarifies CDC principles; Sessions 2 to 5 focus on skills to build and maintain working relationships with residents, as well as identifying organizational barriers and facilitators regarding the implementation of CDC. The primary outcome measure is resident quality of life. Secondary outcome measures are resident measures of choice and control, the working relationship between resident and staff; staff reports of transformational leadership, job satisfaction, intention to quit, experience of CDC, work role stress, organizational climate, and organizational readiness for change. All measures will be completed at four time points: pre-intervention, 3-months, 6-months, and 12-month follow-up. Primary analyses will be conducted on an intention to treat basis. Outcomes for the three conditions will be compared with multilevel linear regression modelling.DiscussionThe RCC program is designed to improve the knowledge and skills of staff and encourage transformational leadership and organizational change that supports implementation of CDC. The overarching goal is to improve the quality of life and care of older people living in residential care.Trial registrationACTRN12618000779279; Registered 9 May 2018 with the Australian and New Zealand Clinical Trials Registry (ANZCTR; http://www.anzctr.org.au/).

The emerging role of Financial Counsellors in supporting Older Persons in financial hardship and with management of Consumer‐directed Care packages within Australia

AbstractThe role of financial counsellors as providers of information, support and advocacy for those in financial difficulty is a well established mechanism in the mainstream welfare landscape in Australia. In general, the role of financial counsellors is in helping people alleviate or resolve their financial difficulties through improvement of their financial literacy. It is recognised as an important component of policy responses to assist low‐income households and individuals in financial stress. The use of financial counsellors for older persons (i.e., those aged 65+ years), however, appears to be underutilised. Financial hardship and abuse of older persons within our community are becoming key issues as the population of Australia “ages”. Existing evidence also suggests that service providers alone do not have adequate skills to address these issues. This paper firstly examines the development of financial counselling in Australia. It then examines the newly emerging role of financial counselling in supporting older persons in addressing barriers to financial literacy and then in navigating the complex landscape of aged care service provision. The current financialisation, marketisation and complexities of consumer‐directed care are identified as key contextual factors. The paper will then discuss an evaluation study of the provision of financial counselling to the older person population designed to support financial hardship and navigation of the complex aged care services system. The findings of the paper are based on an evaluation of the Financial Consumer Rights Council (FCRC), Victoria: Dignity and Debt Financial Difficulty and Getting Older initiative. This pilot initiative included older persons from both community‐based and aged care residential facilities in one regional area of Victoria. The initiative, conducted over 2016, was designed to assess the effectiveness of one‐on‐one financial counselling sessions with older persons that provided consumer advocacy and information about support services and entitlements (including hardship protections) associated with ageing. The evaluation found that the provision of financial counselling to the older person population could be a key mechanism in improving overall financial literacy, avoiding periods of financial hardship and in maintaining financial well‐being, quality of life and positive ageing. Findings also demonstrated a need for an expanded outreach financial counselling model to better service older persons in more isolated living environments and/or with mobility impairments living in the community, and the potential to situate offices of financial counsellors within medical centres (a space often visited by the ageing population), to co‐situate financial health check‐ups as an overall element of health and well‐being. As such, financial counselling was viewed as well placed to support older persons in improvement of financial literacy and in supporting navigation of the increasingly complex marketised and consumer‐directed care (CDC) landscape of aged care service provision in Australia.

Anticipated Engagement in a Village Organization for Aging in Place

Although older adults prefer maintaining residence independently in the community as they grow older it is not always possible due to impairments, isolation, and changing health needs. Villages, an emerging consumer-directed care model providing social engagement and services, support aging in place. To be viable organizations villages must attract and enroll sufficient numbers of members. This study examined factors associated with older adults anticipated engagement as a village member. Using a cross-sectional survey design community residing older adults (N = 193) identified predisposing, enabling, and need factors associated with anticipated engagement. Participants rated anticipated engagement between “Slightly Unlikely” and “Likely” (Mean = 2.71, SD = 1.31). A model including predisposing and enabling factors produced the best overall fit [−2 Log likelihood = 246.514, χ2(8) = 20.414, p. = .008] correctly classifying 61.1% of cases and explaining 13.4% of the variance according to the Nagelkerke R2 statistic. Older adults who engage in preventative health behaviors may be predisposed to joining a village as well as those who are already engaging in supportive acts of neighboring. Villages might consider these factors in designing outreach and service programing. Future research should identify how factors such as income and personal health practices contribute to interest in village membership.