Social Determinants of Aging Service Use and Home and Community-Based Service Availability: Do Childhood Disadvantage and Local Characteristics Matter?

How do individual and social factors come together to shape older adults’ access to and use of community-based services? In this dissertation, I examine how childhood disadvantage and local characteristics shape older adults’ likelihood of aging service use. I also explore rural-urban differences in the relationships between local characteristics and county-level aging and disability services and home health availability. Drawing from the Behavioral Model of Health Services Use, Cumulative Inequality Theory, and Political Economy of Aging theoretical perspectives, I use data from the Health and Retirement Study, the National Neighborhood Data Archive, and the American Community Survey to explore individual and social determinants of aging service use and home and community-based service (HCBS) availability. This dissertation is divided into three empirical chapters. In the first study, I investigate the relationship between childhood disadvantage and aging service use. I find that older adults who experienced poorer health and lower socioeconomic status in childhood are more likely to use any aging services. Later life health and functional status and social and socioeconomic factors partially explain how childhood disadvantage translates into increased levels of aging service use. I also find that the relationships between childhood disadvantage and aging service use differ by service type. In the second study, I examine the association between perceived and objective local characteristics and aging service use. I find lower levels of aging service use among older adults who live in more Republican counties, urban counties, and counties with higher poverty rates and larger shares of racial/ethnic minority residents, net of individual-level characteristics. In the third study, I explore how local characteristics are associated with HCBS availability in rural and urban areas. I find dramatic local variation in aging and disability services and home health establishments and employees across the country. I also find a number of rural-urban differences in the specific local characteristics associated with HCBS density. For example, aging and disability services establishment density is lower in urban counties that are more Republican and have larger shares of Hispanic or Black residents, but higher in rural counties with higher voter turnout and larger shares of Hispanic or Black residents. Taken together, these studies show that childhood disadvantage and local characteristics are important predictors of older adults’ community-based service access and use. My findings suggest opportunities for policymakers and aging service providers to improve equitable access to high-quality community-based services that support older adults’ health, independence, and quality of life. I suggest enhancing aging service providers’ capacity to identify and address older adults’ experiences of childhood disadvantage by screening for adverse childhood experiences and expanding the use of trauma-informed care practices. I also call for a multipronged policy approach to address local inequality in older adults’ community-based service access and use, including by strengthening federal funding for HCBS, developing equity-focused HCBS network adequacy standards, and supporting locally tailored approaches to build provider capacity and mitigate barriers to service access.