• Download the Final Report (PDF)
• Download the Project Brief (PDF)
• Read "The experience of transportation to visit a Nursing home resident: a case study" published in the May 2020 issue of Social Work in Health Care

Older adults who live in nursing homes are at an increased risk for depression and anxiety, and research has shown that social connections and family support are key factors that positively impact their mental health. However, research also suggests that one of the primary barriers to maintaining those relationships, and enabling family members to visit residents, is transportation.

NITC dissertation fellow Vivian J. Miller, a recent graduate of the University of Texas at Arlington’s School of Social Work, made this issue the focus of her doctoral research, "Transportation, Social Support by Family Visitation, and Depression of Older Adult Nursing Home Residents: A Mixed-Methods Study." Miller had previously worked with older adults as a social worker in a nursing home, in addition to her personal experience with her own family members, and was aware of the challenges involved in ensuring their quality of life. She had seen firsthand the importance of social relationships and frequent contact with family members who didn't live in the facility. 

"It's important to look at the resident as a community member, rather than someone who only lives within the confines of the nursing home. They're aren't just a resident of that facility; they are still a member of the larger community," Miller said. 

Her dissertation examined the transportation barriers of family members in the community visiting their loved ones in long-term care nursing homes. Miller also looked at the relationships between transportation – in terms of travel time, travel cost, transportation disadvantage, and the perceived value of its importance – and depressive symptoms of residents in nursing homes. Results highlight the mediating role of social support in mitigating depression.

TRAVEL BARRIERS TO VISITATION

Miller collected data at 11 nursing home sites in three cities: Arlington, Fort Worth, and Weatherford, Texas. She surveyed 65 pairs of a nursing home resident and one of their family members (a total of 130 respondents), and then conducted in-depth follow-up interviews with 11 family members of residents. These case studies uncovered rich, in-depth experiences of family visiting residents. Miller chose people from both "extremes": those with family members who visited multiple times per day, and those whose families weren't able to visit as frequently. Car accessibility was an issue already described in existing literature, but going beyond that, Miller's interviews found that the difficulties weren't limited to the cost & time of transportation itself. Seven primary themes emerged: 

1. Car access – For family members with car access, visitation was frequent. Overall, car ownership coupled with travel time was found to be a strong influencer of consistent visitation.
2. Alternative modes – A number of family members relied on non-car modes of transportation, and this was found to limit visits. Across the three communities involved in this study, just one – Fort Worth– offered public transportation as an option. One resident’s wife stated that her "greatest challenge was just getting a ride."
3. Flexibility – Those family members that had car access were able to visit on short notice if the need arose, and many found that their flexibility was due to this transportation option.
4. Travel time – Family reported negative aspects of travel time, regardless of the mode. 
5. Actual cost – The actual cost of traveling to the nursing home to visit a loved one (e.g. gasoline, car payments, transit fares) was found to be a significant contributor that prohibited transportation. The daughter of one resident said, "I have a job. But it's not enough money for me to make trips like that, so I haven't really been able to go down there and see my mom."
6. Collateral cost – Related costs such as lodging and meals. 
7. Health and Mobility – A few family members shared that they have their own pressing health and mobility challenges which directly relate to their experiences with transportation access, in turn linked to their visitation. 

Some family members shared that while it is hard to visit due to travel time, they would increase visitation if the circumstances were different. The results of the inability to visit led to fractured, strained relationships between family and residents. 

AN INTERDISCIPLINARY SOLUTION

At UTA, Miller worked as a research assistant on various transportation equity and social justice projects with professors Noelle Fields, Courtney Cronley and Stephen Mattingly. These NITC researchers at UTA had already been pioneering an interdisciplinary approach to tackling issues at the intersection of transportation and social work.

"I think that only with true interdisciplinary approaches can these complex problems be solved. As a social worker, we're often tasked with advocating for those that don't have a voice and also helping to navigate these complex systems. One recommendation that emerged from this project was for social workers in nursing homes to work with the community on solving transportation issues – working with a local transit system, providing subsidies, vouchers, things like that," Miller said.

In partnership with social workers and allied health care professionals, transportation planners ought to continue to explore innovative transportation assessments that include at-risk, marginalized, and isolated populations, such as residents in nursing homes and older adults.

OPPORTUNITIES FOR FUTURE RESEARCH

As the population within the United States, and worldwide, continues to age at a rapid pace, researchers across disciplines will need to continue to explore new ways to improve the overall quality-of-life for community-members. This research has significant implications for future studies. The role of transportation is critical to connect community members for both social opportunities and relationship maintenance. It is also imperative for job development and engagement in daily activities.

Miller graduated from UTA with her Ph.D. in social work and has now accepted a tenure-track position as Assistant Professor in Social Work in the Department of Human Services at Bowling Green State University. Her research agenda continues to be embedded in the local community on topics related to transportation among isolated, low-income older adults. Follow Vivian Miller on Twitter to learn more, or read her 2018 NITC Student Spotlight interview.

This research was funded by a Dissertation Fellowship from the National Institute for Transportation and Communities.

RELATED RESEARCH

To learn more about this and other NITC research, sign up for our monthly research newsletter.

• Life-Space Mobility and Aging in Place
• Social Equity in Transit: Toward social and environmental justice in transportation
• Travel to Food: Transportation Barriers for the Food Insecure in Tampa Bay

The National Institute for Transportation and Communities (NITC) is one of seven U.S. Department of Transportation national university transportation centers. NITC is a program of the Transportation Research and Education Center (TREC) at Portland State University. This PSU-led research partnership also includes the Oregon Institute of Technology, University of Arizona, University of Oregon, University of Texas at Arlington and University of Utah. We pursue our theme — improving mobility of people and goods to build strong communities — through research, education and technology transfer.