This article aims to increase the understanding of older adults’ participation with home-based service providers. It is critical to ensure that home-based services promote older adults’ ability to live in their own homes, and to participate in daily life and society as long as possible. Exploring older adults’ experiences with participation in home-based service delivery is essential for development and delivery of high-quality services that support older adults’ participation. Older adults with a variety of age-related physical impairments and frequency of home-based services were interviewed. The data was collected by in-depth face-to-face interviews in the older adults’ homes. A constant comparative method inspired by constructivist grounded theory was applied to analyze the data. The study highlights the importance of understanding emotional and intellectual aspects of older adults’ participation, and to recognize their strategies for balancing agency in everyday life.
There is an increasing focus on activity and participation for older adults due to the active and healthy ageing policy frameworks (Ervik and Helgøy 2005; Rechel et al. 2009; WHO 2002). An important goal is to support older adults' possibilities and capacity to live in their own homes as long as possible, and to participate in daily life and society. Policy and research relating to disability issues like equal rights to participate in society has to a large extent addressed people with functional limitations at working age. The majority of people living with functional limitations are older, and thus calls for broadening policy and research of disability issues to include this group (Johansson 2008). As the ageing population grows, the number of older adults living in place and depending on home-based services will increase (WHO 2004). Studies of older adults with reduced capacity and functional decline have found relationships between participation and increased duration of life, less illness and deferral of further functional decline (Avlund et al. 2004; Ritsatakis 2008; Visser et al. 2002).
Several studies have found that depending on home-based services in old age may represent barriers to participation (Lyttle and Ryan 2010; McGarry 2009; Vik, Nyård, and Lilja 2007). Encounters with staff and the service system may represent barriers to control and self-determination in everyday life (Ellefsen 2002; Vik, Nyård, and Lilja 2007). Other studies indicate that home-based services are given as passive help and that there is a need to explore factors promoting participation in older recipients of home-based services (Vabø 2007; Witsø, Eide, and Vik 2011). Knowledge of how older adults perceive and experience participation when living in place and depending on home-based services is limited, and needs to be further explored. More knowledge about how home-based services influence older peoples’ participation in daily life will increase the possibility of designing services that facilitate their participation.
Participation in service delivery has frequently been understood as user involvement, co-determination, empowerment and involvement in decision-making (Adams 2008; Eldh, Ekman, and Ehnfors 2010; Kemshall and Littlechild 2000; Willumsen 2005). Moreover, perspectives on participation range from a strong focus on civil rights for all at a societal level (Shakespeare 2004; WHO 2002) to an individual level, with a focus on participation in nursing care (Larsson et al. 2007; Sahlsten et al. 2005), participation as autonomy (Cardol, Jong, and Ward 2002) and agency (Vik et al. 2008). The World Health Organization defines participation as engagement in life situations (WHO 2001). Accordingly, the concept of participation has various meanings and different levels. In this article, the focus is on participation in service delivery.
Several studies concerning older home-based service recipients' participation in everyday life have taken the perspective of the professionals (McGarry 2009; McWilliam et al. 2001; Vik 2011; Vik and Eide 2012a, 2012b; Witsø, Eide, and Vik 2011). In a study of Witsø, Eide, and Vik (2011), professionals understood older adults' participation in service delivery as ‘being included and taking part in decision-making’, ‘socializing during service delivery’ and ‘collaboration in keeping up or regaining functions’. According to the professionals, a prominent need in the older adults was social participation with the service providers. Other studies have focused on relational aspects (McGarry 2009; Olsson and Ingvad 2001; Sahlsten et al. 2005, 2008; Wreder 2008) and interpersonal skills (Belcher et al. 2006), and the impact on participation in interaction between professionals and older adults. Olsson and Ingvad (2001) showed that service providers were likely to experience the relational climate with the older service recipients with a higher degree of emotion than the service recipients. This finding was explained as an expression of a wish for a warm and close relationship and a desire to be kind, loving, appreciated and confirmed as competent. McGarry (2009) found that care interactions between service providers and older adults often are disempowering. Other studies emphasize continuity of care and time as key for professionals to facilitate and enhance participation in older home-based service recipients (Olsson and Ingvad 2001; Vik 2011; Vik and Eide 2012a, 2012b). Recent studies have found that older adults in the context of living in place and receiving home-based services emphasize family, friends and neighbours as important for participation and facilitating participation in everyday life (Witsø, Eide, and Vik 2012; Witsø, Vik, and Ytterhus 2012). Still, little is known about how older adults experience participation in the interface with home-based services. In order to address this gap in knowledge an important step is to study how older adults perceive participation as collaboration with service providers.
A strong emphasis among professionals on their own role in the older adults' lives may possibly contribute to a recipient role and passivity in the older adults. Accordingly, a possible discrepancy between the professionals and the older adults' perspectives of participation in service delivery may represent a barrier to older adults' participation. Professionals in home-based services need knowledge about older adults' understanding of participation in everyday life in general and in the context of receiving home-based services in special, in order to promote and facilitate their activity and participation. The current study is part of a broader study on professional service providers' and elderly persons’ perspectives on participation. The specific aim of this article is to explore and illuminate how older adults perceive and experience participation with service providers in their everyday life. Their understandings of participation in everyday life in general are reported elsewhere (Witsø, Vik, and Ytterhus 2012).
A purposeful sampling strategy, an approach seeking participants who are relevant to the research question, in accordance with Charmaz (2006) was applied. The sampling strategy was based upon findings in studies included in the larger project (Witsø, Eide, and Vik 2011, 2012; Witsø, Vik, and Ytterhus 2012) and the on-going analysis in the present study (Charmaz 2006). Findings in the first study (Witsø, Eide, and Vik 2011) showed, for example, that service providers perceived older adults generally as passively waiting for service providers to come, being in need of social participation with service providers and that service providers represented barriers to older adults' participation in everyday life. The second study (Witsø, Eide, and Vik 2012) included a survey among older adults with low to moderate needs of home-based services. An interesting finding from this study was that older adults' satisfaction with participation in everyday life activities showed no correlation with frequency of home-based service delivery. Consequently, for the present study, and in order to gain rich data and explore previous findings, it became apparent that the sample should vary in living accommodations, social situations, level of age-related physical impairments and health problems (see Table 1). It became apparent after the first five interviews that it was necessary to reach older adults with little informal social support and older adults feeling lonely, in order to capture a broader picture of aspects affecting older adults' participation with service providers. Thus far, the participants had not placed great emphasis on the social aspects of participation with service providers. Therefore, preliminary theoretical categories at that stage, including older adults' balancing agency, the content of their values and their interaction and socializing with service providers became necessary to explore further.
|Participants||Age||Impairments||Habitationa||Walking aid/device||Home-based services||Care intensityb|
|1||Anne (F)||79||Hip operated, stiffness||Single-unit dwelling, alone||Rollator inside/outside, wheelchair for transportation outside||Bathing/shower, on/off with support/medical stockings, getting rid of garbage, fetching post/mail, cleaning, safety alarm||Middle|
|2||Peter (M)||86||Chronic pain in neck and shoulders, stiffness||Single flat in assisted-living block, alone||Rollator when shopping||Home nursing care (×1), cleaning, safety alarm||Low|
|3||Christine (F)||76||Dizziness, frequent faller||Single flat in senior housing block, alone||Rollator inside/wheel chair outside||Home nursing care (×4), personal care, inspection call, cleaning, safety alarm||High|
|4||Tor (M)||72||Neurological disease||Single flat in senior housing block, alone||Rollator outside||Home nursing care (×2), inspection call, cleaning, safety alarm||Middle|
|5||Mary (F)||82||Hip-operated, knee-operated, pain||Single flat in assisted living block, alone||Rollator inside/outside||Switch on/off the stove, private cleaning, safety alarm||Low|
|6||Elisabeth (F)||84||Hip-fracture operated, visually impaired||Single flat in block, alone||Rollator inside/outside||On/off with support/medical stockings, private cleaning, safety alarm||Low|
|7||Carla (F)||85||Brittle bones||Single unit dwelling, alone||Rollator inside, wheelchair outside||Home nursing care (×4), personal care, fetching post/mail, meals on wheels, cleaning, safety alarm||High|
|8||Marianne (F)||72||Visually impaired, reduced walking ability||Single unit dwelling, with husband||Rollator inside/outside||Personal care (×2), physiotherapy (×4 per week), private cleaning, safety alarm||Middle|
|9||Ingrid (F)||89||Dizziness, fatigue||Single flat in joint senior ownership, alone||Rollator on hold||Home nursing care (×1), safety alarm||Low|
|10||Lisa (F)||87||Neurological disease, frequent faller||Single unit dwelling, alone||Rollator inside/outside||Personal care (×2), cleaning, meals on wheels, preparing breakfast/lunch, physiotherapy (×2 per week), safety alarm||Middle|
Ten interviews were accomplished (see Table 1). The participants lived in a city of 170,000 inhabitants in Norway, and were able and willing to talk about how they perceived participation with the service providers in everyday life. The interviews took place in the older adults' homes in autumn and early winter 2011. Participants were initially contacted by a municipal service provider, and they were contacted and interviewed by the first author after giving their written consent. The interviews were recorded and transcribed verbatim. The informants have been given altered names in the text.
The older adults received defined home-based services, mostly related to the facilitation of everyday life routines, that is, getting help to shower, getting dressed, preparing meals, receiving medicines, fetching the post and short inspection calls to assess the older adults' condition during the day. Semi-structured interviews were used to gather the data, including open-ended questions. Examples of questions were: What kind of services do you receive (including follow up questions of when, how often, why and by whom)? How do you experience service delivery? Could you tell about a typical setting when you receive services? What happens? How do you experience your participation with the service providers?
After the tenth interview, the data were considered to have reached the saturation point (Charmaz 2006). Charmaz's (2006) approach to a constant comparative method was applied to illuminate the older adults' meanings, experiences and conditions influencing participation in their everyday life with the service providers. After the tenth interview, no information emerged that provided new theoretical insight into the properties of the categories in the study, and data collection ended at this point. This decision was additionally supported by findings in another study in the larger project (Witsø, Eide, and Vik 2012).
The data was analyzed by applying a constant comparative method as described by Charmaz (2006), including a process of initial and focused coding, and by writing memos. Initial coding is characterised by line-by-line or segment-by-segment coding, establishing analytic directions by separating data into actions, categories and processes, by discovering patterns and contrasts in the data and by staying close to the language used by the participants. Examples of initial coding were ‘being polite is a mutual responsibility’, ‘expecting and claiming respectful behaviour’, ‘being grateful’, ‘being irritated at repeated delays’, ‘being realistic’, ‘being indulgent’, ‘feeling security’, ‘staying alert’, ‘enjoying diversity among service providers' and ‘small-talking’. By comparing initial codes and each interview with each other, the initial coding process resulted in preliminary focused codes. Focused coding requires decisions about which initial codes that make most analytic sense to categorise the data most completely and incisively. A refining process included comparison of data with data, preliminary focused codes with focused codes and with the memos and data material as a whole. The initial and focused coding process resulted in two final categories. The first category was labelled, ‘Balancing agency – a process of giving, taking and letting go’. Examples of preliminary focused codes embraced by this category were taking part in service delivery, being indulgent and flexible, acting and being treated with dignity, balancing control and accepting the being in need of home-based services. The second category, ‘Socialising with the service providers', included the following examples of preliminary focused codes, being connected to society, socialising with the service providers and experiencing security.
The last step identified a core category, describing older adults' participation with the service providers as taking home-based services into everyday life. (see Table 2).
The core category represented the older adults' process of acting on changing capacity in everyday life and was characterized by emotional and intellectual aspects of participation. Emotional aspects refer to the feelings evoked by receiving services and participation with the service providers, that is, feeling gratitude, general contentedness, humour, or annoyance. Intellectual aspects of participation included the ways in which the older adults handled the feelings evoked by participation with the service providers, that is, ways of staying rational, and how they planned and reflected on their participation with the service providers, in order to keep control and dignity in everyday life.
This category and its subcategories illuminate the older adults' strategies for balancing agency as the process of giving, taking and letting go, and represent different dimensions of how they upheld flexibility and control when encountering the service providers. One dimension of the category as a whole was the older adults' expressions of emotional aspects of participation, such as gratefulness and being positively astonished by the variety of services being attainable, and contentedness with both services and the service providers. Anne (79) said: ‘just to imagine having such a department, which one also can trust, it's fantastic’, and Mary (82) said: ‘Not in my wildest dreams could I imagine how much help it's possible to get’.
However, the older adults not only expressed gratitude and contentedness, but also certain expectations in the interface with service providers. The analysis identified the subcategories; expecting joint responsibility for appropriate service delivery, being understanding and indulgent and making one's mark, presenting the characteristics of the category ‘balancing agency – a process of giving, taking and letting go’. The subcategories included the older adults' expectations and their own role in encounters with the service providers in order to take the services into their everyday life.
The older adults expected appropriateness and skill in accomplishment of services, which also represented the older adults' main expectation for receiving services in the first place. Marianne (72) said, ‘I expect them to do what they come for (--) to help me stay clean and be accurate about it’. The expectations referred to the importance and role of services, most of all being a facilitating part of everyday life, making it possible to fend for oneself in place, and upholding personal values such as well-being and dignity, that is, staying clean, in Marianne's case. In the process of taking the home-based services into everyday life, participants expected the service providers to be aware of their signals during service delivery, but they did not want them to passively wait for instructions. On the contrary, they valued the service providers' initiative and appreciated confidence in carrying through the routines of service delivery. It contributed to integration of the services in everyday life and experience of safety and control.
Tor (72) said: ‘I find it excellent when they get on and around by themselves. It's really ok, because worst of all is when the service provider comes in and just stands there … “now, what was it you needed help for, again?”’
The older adults emphasised their own role and behaviour, and influence on service delivery. One aspect of expecting joint responsibility for appropriate service delivery included taking responsibility and acting with civility themselves.
Ingrid (89) said: ‘Appropriate service delivery depends on how you behave, yourself, your own attitude’.
Furthermore, the older adults did not look at themselves as passive recipients of services, but described how they gave directions to the service providers in a polite way during service delivery.
Anne (79) said: ‘(--) and if they forget to dry my feet I just lift up my legs to them. (--) I don't have to say much, it just works that way by itself (--), and then I kindly ask them to put on my trousers and my bra’.
Another aspect of expecting joint responsibility for appropriate service delivery was collaboration to keep up the older adults' independence in daily life activities. This collaboration was mainly related to having time to accomplish the activity independently.
Tor (72) said: ‘They contribute to my independence by just waiting a little so that I can try to get up from bed on my own’.
The older adults differentiated between the service system on one side, and the service providers on the other side. The older adults understood that the home-based service system is under organizational pressure and expressed its shortcomings such as delays and the use of temporary employment, increasing the number of different people executing services. The main reaction to this as expressed by Marianne (72):
Another aspect of being understanding and indulgent was expressed by sympathising with and forgiving the service providers relating their shortcomings and great work load. Even repeated delays that could be experienced as physically unpleasant and unworthy, that is, when waiting for help to reach the toilet, were met with understanding. The older adults were also aware of the fact that their older neighbours could be in need of urgent help, which contributed to the understanding. Tor (72) said:
One just has to take it as it comes and those who are present, and from time to time there's a flu epidemic or something of the kind, and then they have to hire temporary staff (--), but mostly they are all good.
The older adults were well aware of the demarcation of services, and found that the service providers were very focused on accomplishing their task. The older adults reflected on reasons for service providers' focus on accomplishing tasks, relating it to directions and regulations of the service system. Lisa (87) said:
(–) repeated urgent cases, that's the worst situation. You know, there are all kinds of accidents in this house, people fall out of their beds and the like, but of course, that's those peoples’ workday, they do their best.
The older adults considered the advantages and disadvantages of possible directives in order to have services carried through flexibly and to keep up their own dignity in service delivery. Furthermore, the reflections exemplified in this subcategory were expressions of intellectual aspects and strategies of participation.
Maybe they don't think that I can do a lot myself (laughs) (--) this morning I had already cleaned myself thoroughly when the service provider came (laughs). I told her so, and that I was expecting a visitor. When is she coming, she asked. At eleven o'clock, I answered. You really have a lot of time to shower then, she said. Very well, you'll just have to do it, then, I said. So today, I'm really clean, actually scrubbed (laughs). I assume that they want to know that I am clean. But it was really good to have my back washed, too (--) so it doesn't matter really, I get it the way I want, anyway, and it's good to be a little bit coddled with, too.
The older adults saw home-based services as a barrier to their participation in some situations, and there were limits for how understanding and indulgent they wanted to be. When the older adults experienced their dignity being violated, they made their mark about it.
Examples of frustrating situations that participants mentioned included service providers' lack of specific skills needed to carry through services, and lack of initiative or lack of punctuality. These examples represented a contrast to making home-based services a natural part of everyday life. Lisa (87) said:
A lack of punctuality evoked emotional aspects of participation like feeling annoyance or disrespect and was the main example that provoked participants. Interestingly, the older adults did not see a lack of punctuality as a general barrier to everyday life activities. However, delays represented a barrier for participation for those who depended on services before they could leave the house or join dated activities.
On Saturdays I go shopping with my son, between eleven and twelve o'clock. I want the service providers to come before eleven, then – yes! If they don't come in time, then they prevent me from getting to the shops with him. If the time gets half past ten, then I call them and ask if it takes long before they get here.
Even though the older adults shared the understanding of the service providers as meaning well in service delivery, they expressed that the service providers' intentions sometimes could be seen as a lack of tactfulness. If the older adults' dignity was threatened by their good intentions, participants rejected the service providers' suggestions in order to uphold control.
In summary, both emotional and intellectual aspects of participation were involved. The category included the participants' understandings, meanings of and strategies for participation related to receiving services and the organization of services.
(–) when they came this morning they asked if they should change the bedclothes. They have asked about that several times, and I said that without special circumstances it isn't necessary to change more often than once a month … take it easy! It's so neat and without a spot, so …
This category covers dimensions of social participation beyond receiving predefined home-based services. An aspect of integrating home-based services into the older adults' everyday life was variations of social participation with the service providers, which reached beyond the demarcated services the older adults received. Both subcategories, small talking in the passing by and being a part of society refer to a sense of belonging in the world.
The older adults attached greatest importance to the services outlined, but they also emphasized the small-talk dimension of service delivery. The participants did not want or expect the service providers to stay long, and social participation was mostly related to family like children, grandchildren, siblings, and friends and neighbours. However, they enjoyed small-talk with the service providers on topics such as the weather, headings in the newspapers, children or grandchildren or plans for the day, at an everyday level of social interaction. Participation as small-talk was nevertheless related to basic human needs and social roles like enjoying the feeling and exchange of kindness, civilities, cheer and being confirmed and recognized as a human being.
Marianne (72) said:
It was additionally important for the older adults that the service providers enjoyed coming to them. The feelings evoked by the social interaction could be seen as emotional aspects of participation.
They are so cheerful and friendly, they have good manners (--), and they tell me about their kids and then I tell about my great-grandchild and show them a picture of her, and they like that. We talk about all sorts of things. I like that, because that's the way I'm used to behave in everyday life.
Christine (72) said: ‘We talk about ordinary things (--), joke with each other (--). I have always liked a good joke, and they say they can joke with me. (--) They say they like coming to me’.
The older adults did not expect the service providers to sit down for coffee, but an aspect of the small talk dimension was showing hospitality by offering the service providers a pastille or a chocolate on their way out.
The participants related their social participation to family, neighbours and friends, not the service providers. However, the service system represented diversities of gender, cultural backgrounds and ages in the service providers. This diversity represented access to the wider society, and the older adults found this interesting. Encountering the service providers also gave them access to present themselves and their own experiences.
Ingrid (89) said:
The older adults put great emphasis on the security alarm that linked them to society by creating a feeling of security for contact and getting help if and when they needed it.
Sometimes I tell the young nurses about the war, and during the war. I think they have something to learn from it (--). I have talked a lot with refugees and migrant workers, because there are quite a few migrant workers coming, and I find it extremely interesting. There are some Danish workers, but they are almost like us, you know, and Swedes. There are some differences there, but altogether people are people.
Peter (86) said: ‘it represents a sense of security, you know – then I know that I get in contact when I need it’. However, participants were anxious not to misuse the security alarm, and it was used only when the older adults felt they really needed to, that is, after a fall. Not wanting to misuse the security alarm was related to the values of fending for oneself and keeping up one's dignity and pride as a human being. The older adults' feelings related to linking to society also represented intellectual and emotional aspects of participation.
In summary, the older adults' participation with the service providers comprised a process of taking them into everyday life and balancing agency in order to preserve control and to live life approximately as usual. The older adults held onto the person they were, and interacted with the service providers by giving and taking, and they marked their limits within their possibilities in a situation of receiving home-based services. The findings identified participation with the service providers as a process of balancing agency reflecting the older adults' different strategies for participation with the service providers, and reflecting their integrated and well established values, expressing their personalities and self-presentation. The older adults regarded interaction and receiving services as a mutual responsibility of giving, taking and letting go, a process depending on values, such as mutual flexibility, understanding and indulgence, but at the same time having and marking their limits for understanding and thus preserving integrity. Furthermore, the older adults' participation in service delivery included social participation as small talk with the service providers, representing different dimensions of belonging and linking to society.
The purpose of this study was to illuminate and understand the experiences of older adults' participation with service providers in everyday life. The older adults adapted to the situation by accepting the needs of home-based services on one side and acted upon the changing capacity and encounters with the service providers on the other. Overall, our findings are in line with the theoretical perspective of Rowles and Ravdal (2002), who argued that older adults actively create new meanings as circumstances change.
A main finding in the present study was that the participants were content with the service system and the service providers. Although other studies have found the same tendency (Bailey 2007; Dale et al. 2010, 2011), this finding is interesting because of recent findings that service providers' experience themselves and the service system as barriers to older adults' participation in everyday life (Vik 2011; Vik and Eide 2012a; Witsø, Eide, and Vik 2011). Being content could be explained by the older adults' wish not to be a burden to the service providers, their acknowledgement and appreciation of the service providers doing their best in a stressful working day, or fearing that complaints about services or service delivery could lead to sanctions or reduced quality of services. Furthermore, the older adults in the present study were actually positively astonished by the variety and access to services. This aspect of being content could be explained as a reaction to how services tend to be focused negatively in media, as insufficient, unworthy treatment, system faults and accidents in service delivery (Huseby and Paulsen 2009). However, expressions of being content could also represent ways of presenting oneself as a person, that is, expressions of being active and still going strong. The older adults, that is, did not regard themselves as passive recipients of the services, but viewed and acted upon service delivery as a mutual responsibility between the service providers and themselves. We believe the finding of being content in the present study could also represent an expression of the older adults' values, and form a basis and motivation for their strategies in balancing agency and represent a contrast to a role as passive recipient or victim.
Nevertheless, it is critical to see the older adults' expression of being content in relation to their expressions of home-based services as representing barriers to their participation.
Interestingly, our study found that the older adults differentiated between the service system on one side and the individuals working in the system on the other side. When they experienced barriers to participation, it was mostly related to shortcomings of the service system, not the individuals working in the system. In recent studies, the service system is also experienced as a barrier for giving sufficient services by the professionals (Vik 2011; Vik and Eide 2012a; Witsø, Eide and Vik 2012). Thus, studies have found that service providers strive to give better and more services than the service system demands to feel that, their work is professional and sufficient (Rønning 2004; Vik and Eide 2012b). Hence, a possible explanation to our finding is that when the participants took in the service providers' efforts and workload, it contributed to feeling sympathy for them. The older adults and the service providers could possibly also share experiences of shortcomings of the system level, which again could create a sense of community. Taken together, these aspects could contribute to the older adults' understanding and indulgence.
Another main finding is that, in order to fend for themselves, the older adults took the service providers into their everyday life, accepting the need for support in daily life. Other studies have found that older adults are very concerned with managing and governing daily life without support in order to keep a basis for spontaneity and freedom (Dunér and Nordström 2005; Haak et al. 2007; Vik et al. 2008). A study by Haak et al. (2007) showed that older adults becoming dependent on home-based services experienced being in the hands of others, in the sense of being without control of how, when and with whom to perform different activities in the service delivery. Receiving home-based services is also associated with interactions crossing the intimate sphere and contexts of privacy; that is, when being helped with getting out of bed in the bedroom or feminine or masculine hygiene in the bathroom, representing contexts where dignity is at risk (Lerø 2006). Another study found that older adults feared that receiving home-based services included having people poking around their homes, observing their private lives and thus influencing their control negatively (Dunér and Nordström 2005). However, in the present study, accepting the need for home-based services could be seen in the light of the theory of selective optimisation with compensation, and as a compensation strategy and new means of compensation for changing capacity (Baltes and Carstensen 1996) in order to fend for oneself and preserve freedom, control and dignity. It could be that the older adults had come to terms with their loss of functioning over time, and thus adapted to changing capacity. Another explanation could be that the participants expected themselves being worthy and in a position deserving services, accomplished in ways preserving their dignity, after having contributed to the welfare system and society by working and paying taxes during a long life. Taken together, our findings indicate that the participants had taken home-based services into everyday life on their own premises, indicating that the older adults experienced to preserve control of their situation to a certain extent. This finding is interesting when taking into consideration that older adults may adopt and adapt to a picture of home-based services presented and criticized as increasingly medically oriented, being based on effectiveness and at the sacrifice of preventive work, rehabilitation, social and practical services (Brevik 2010; Rønning 2004). Integrating home-based services on one's own premises, could thus be experienced as a main task in everyday life. Consequently, the processes of participation as balancing agency and socializing in the interface with service providers could represent ways of selective optimization of accomplishing this task (Baltes and Baltes 1990). However, in order to integrate home-based services on one's own premises, and as a possible consequence, other needs could be de-emphasized.
Another interesting finding in this study is that social interaction with the service providers was considered subordinate to the practical and physical support the older adults received to facilitate their everyday life. A recent study of service providers' perspectives on older home-based service recipients' participation by Witsø, Eide, and Vik (2011) found that service providers considered social participation with the service providers among the most important needs in older home-based service recipients. However, a study among older adults with low levels of home-based service needs showed no correlation between the participants' satisfaction with participation in everyday life activities and frequency of home-based service delivery (Witsø, Eide, and Vik 2012). Taken together with the findings in the present study this may indicate that professionals can overestimate their own role in service delivery. Nevertheless, several studies have emphasized older adults' needs of physical touch the establishment of personal, close and continuous relationships as crucial in service delivery and preventing loneliness in older adults living in place (Bailey 2007; Olsson and Ingvad 2001). Interestingly, the older adults in this study did not find the large number of different people serving them as a problem, as long as they knew what to do and how to do it in a skilled way when they arrived. On the contrary, they said the variety offered them a connection to the larger society. Hence, and although social participation with the service providers was subordinate to practical and personal support in everyday life activities, there is good reason to dwell upon its specific meanings and functions. The small-talk dimension of participation as social interaction has previously been recognized as chatting about everyday matters and being treated as any normal human being to older adults when receiving services in place (Vik, Nygård, and Lilja 2009). In the present study, small talk with a variety of people with different cultural backgrounds, dialects and age – a characteristic of the service system – gave older adults opportunities to uphold a well-known and familiar kind of ordinary everyday conversation. Album (1994) described this dimension as the contentless meaningful chat that is important for our recognition and self-esteem. Such social interaction should not be underestimated. On one side, there may not be a solid argument in favour of an overestimation of one's own professional role in the social life of older adults. It may cause more and unnecessary stress and the feeling of insufficiency in the service providers. On the other side, this point does not excuse professionals' responsibility for the quality of service delivery. It is important that service providers and home-based services recognize and understand the meaning and importance of this dimension of social interaction, what it gives and what it takes, and facilitate it.
This study took place in Norway, and the experiences of the participants were related to home-based services within the Nordic welfare system. Although generalisation to other populations is not the aim of qualitative research (Patton 2002), the traits identified in this study should be relevant for older people receiving home-based services and professionals within home-based service systems in general. However, a study limitation may be that the study included only a small number of participants that were interviewed only once. Follow up interviews and observations of interaction between older adults and home-based service staff could have given more information about participation in service delivery. However, the findings concerning how older adults tend to be satisfied with services are supported by other studies (Bailey 2007; Dale et al. 2010, 2011). In that respect, our findings may illuminate and give more nuances to the content of participation in older adults when depending on home-based services. The present study did not find that different dwelling conditions or organisation of home-based services in relation to dwelling influenced older adults' experiences or expectations of participation in the interface with service providers. However, it is possible that in larger samples, factors like different dwelling conditions and organisation of home-based services in relation to that is, assisted-living housing versus single unit housing, can influence on older adults' experiences of accessibility and consequently on their participation with service providers. Evaluative aspects of participation with service providers like choice, importance and satisfaction should therefore be investigated in future studies.
To support participation in older adults depending on home-based services, it is of importance to recognize the complexity of dignity and pride, the multiple expressions of and strategies of being and staying worthy. Participation as social interaction with the service providers was considered as subordinate practical and physical support. Hence, it is important to pay attention to and not overstate the role of service providers in the older adults' lives. Depending on home-based services may represent a process of keeping up agency and representing a variety of strategies for keeping up meaningful participation and dignity in everyday life. In order to understand the meanings and experiences, and facilitate participation, professionals must show interest in the intellectual and emotional aspects of older adults' participation, representing their feelings, reflections and rationale related to their strategies for participation.
The authors would like to thank the older adults for willingly sharing their time and experiences with us, the Norwegian Research Council for financial support for this study and the priority programme ‘Participation’ at Sør-Trøndelag University College for both professional and technical support.
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