Developing an In-depth Understanding of Elderly Adult’s Vulnerability to Climate Change

Developing an In-depth Understanding of Elderly Adult’s Vulnerability to Climate Change Abstract Purpose of Study Recent reports highlight the vulnerability of elderly adults to climate change, yet limited research has focused on this topic. To address this, the purpose of this study was to develop an in-depth understanding of elderly adult’s vulnerability to climate change within the context of a specific community. Design and Methods A case study methodology utilizing a community-based action research approach was employed to engage elderly participants living in Bridgeport, CT, in exploring their vulnerability to current and predicted climate stressors with a focus on extreme heat, flooding and storms, and air pollution. Results This research identifies personal characteristics that interact with contextual factors to influence elderly adult’s vulnerability to climate change. Personal characteristics include health, economic, and social considerations. Contextual factors include the adequacy of emergency preparedness measures, transportation resources, and coping and recovery resources. As a result of the interplay of these characteristics and factors, predicted climate changes could have serious consequences for Bridgeport’s elderly adults. Implications This research provides a contextualized and detailed illustration of how climate change could overwhelm elderly adult’s adaptive capacity and highlights the need for support services to provide safeguards. The issues and concerns raised may bear similarities to other locations, especially urban settings facing similar climate stressors with similar socioeconomic conditions. The findings suggest a need for further research to improve our understanding and serve as the basis for collaborative adaptation planning that engages elderly communities with local governments and a broad coalition of partners to keep elders safe. Advocacy, Analysis—mixed methods, Assessment of conditions/people, Disparities (health, racial), Health care policy, Public policy, Social services In comparison with the general population, some groups within society are more vulnerable to climate change and will bear a disproportionate burden of its impacts (IPCC, 2007). The IPCC (2007) defines vulnerability as a function of three characteristics: Exposure: the character, rate, and magnitude of climate change to which a system, individual, or population is exposed. Sensitivity: the sensitivity or susceptibility to damage from those changes. Adaptive capacity: the capacity to adjust to changes in climate in order to moderate potential damage, take advantage of opportunities, or cope with consequences. The uneven distribution of climate impacts is rooted in varying levels of vulnerability to climate change among individuals and groups. In this understanding, exposure to climatic stressors is exacerbated by increased sensitivity to those impacts and decreased capacity to adapt. For human populations, both sensitivity to climate impacts and adaptive capacity are influenced by economic, social, geographic, demographic, cultural, institutional, governance, and environmental factors. As a result, vulnerability is associated with inequalities expressed through varying levels of wealth, education, disability, access to resources, health status, gender, and age, as well as marginalization and cultural characteristics. The interplay of these factors determines what is referred to as an individual’s or group’s relative level of “social vulnerability” by influencing their ability to prepare for, cope with, and recover from climate stressors (Lynn, MacKendrick, & Donoghue, 2011). In recent reports and papers, elderly adults (65 years and older) have been one group recognized as having a heightened vulnerability to climate change (Bunker et al., 2016; IPCC, 2014; Melillo et al., 2014). Historical precedence demonstrates older adults often bear the brunt of impacts associated with extreme weather and researchers in a variety of fields, including public health, disaster management, and gerontology, have examined the vulnerability of elders to climate-related stressors (Eldar, 1992; Fernandez, Byard, Lin, Benson, & Barbera, 2002; Ngo, 2001). To apply this understanding to the context of climate change in the United States, Gamble and colleagues (2013) prepared a thorough literature review drawing from peer-reviewed papers, government reports, and demographic and health data. They note the most threatening climate stressors facing elderly adults include heat waves, hurricanes, flooding, droughts, poor air quality, and infectious diseases. Contributing to elderly individuals’ sensitivity, Gamble and colleagues highlight factors associated with advancing age, including respiratory impairments, impairments associated with diabetes, cardiovascular and thermoregulatory impairments, and heat sensitivity. They describe the importance of socioeconomic factors including income level, access to health and social services, educational level, and adequacy of infrastructure. As determinants of adaptive capacity, the authors highlight the importance of functional limitations, economic status, living situation, human and social capital, and communication technology and other infrastructure. Although the review by Gamble and colleagues provides a valuable contribution to our understanding, scientists have, as yet, devoted little attention to conducting research on the vulnerability of elderly adults within the context of climate change. Our current understanding has been drawn largely from research into older adults’ historical vulnerability to climate stressors outside of the context of climate change. Gamble and her coauthors’ review begins to connect the theoretical dots by contextualizing historical research within the framework of current climate predictions, but there has been little research focused on the novel impacts of climate change. Notable exceptions include research by Bunker and colleagues (2016) and Carter and colleagues (2016). Bunker and colleagues (2016) conducted a meta-analysis examining the implications of predicted temperature changes on elderly adults, finding that even a 1 °C increase can affect mortality and morbidity of elderly adults. Focusing on the Nordic Region, Carter and colleagues (2016) incorporated vulnerability indicators into an online mapping tool that served to raise awareness of elderly adult’s vulnerability and inform planning. Additional research is needed to understand how predicted changes in the frequency and intensity of multiple interacting stressors may affect the elders in a range of geographic locations. Our understanding could also benefit from research into factors that contribute to the elders’ adaptive capacity. Although Gamble and colleagues devote attention to this and offer an important contribution, their analysis highlights factors that limit adaptive capacity. To complement this understanding, it would be beneficial to explore adaptive resources that elders can and do employ to prepare for, cope with, or recover from a variety of climate stressors. In his 2014 book, Protecting Seniors Against Environmental Disasters, Michael Greenberg highlights the limited understanding of how elderly adults react before, during, and after natural hazards as “the most glaring gap in our knowledge.” This information would enable us to build on the elders’ existing approaches and resources to design effective adaptation strategies. Finally, our understanding could benefit from increased attention to elders’ perspectives on climate change. Cornell’s (2015) research with older adults in Australia demonstrates the value of incorporating elders’ perspectives in the context of emergency preparedness, but such inclusive approaches are rare. Most research on elders’ vulnerability views them as research subjects and focuses on determining possible causes of their vulnerability (Al-Rousan, Rubenstein, & Wallace, 2014; Cornell, Cusack, & Arbon, 2012; Gamble et al., 2013). Little research has sought to incorporate the perspectives of elders with regard to climate change or involve them as active participants in the research. As a result of our limited understanding of the elders’ concerns, we risk developing adaptation strategies that do not address elder-specific needs. To address these gaps in our understanding, this article presents the results of a participatory inquiry involving members of the elderly community of Bridgeport, CT, in examining their vulnerability to extreme weather and predicted climate changes. This research considers the vulnerability of elderly adults within the unique context of climate change, including an emphasis on adaptive strategies and resources that elderly adults currently employ. In doing so, it draws directly from the experiences and perspectives of the elderly participants and seeks to share their understanding and concerns. Design and Methods This research was undertaken in partnership with the Department on Aging in Bridgeport, CT, to engage the city’s elderly community in a participatory investigation into their vulnerability to climate change. To ensure that the research incorporated the perspective and experience of the elderly community of Bridgeport, the process was guided by principles of community-based action research: upholding a spirit of cooperation and equity, examining issues within their context, recognizing the validity of multiple ways of knowing, and fostering action to address issues of community concern (Stringer, 2007). The elderly participants were included as voluntary partners throughout the research process, helping determine the focus of the inquiry, contributing to the design and execution of the data collection and analysis, and reviewing and amending the findings. The research followed the main steps employed in a vulnerability assessment, including identifying relevant climate stressors, examining current vulnerability to those stressors, and extrapolating future vulnerability based on predicted climate changes and adaptive capacity. This approach bears close resemblance to Ford and Smit’s (2004) research that drew on local knowledge to conduct place-specific case studies assessing the vulnerability of indigenous Arctic communities to climate change. Although Ford and Smit used this approach to assess the vulnerability of entire vulnerable communities, the current research utilized a similar approach to assess the vulnerability of a specific vulnerable group within the larger community. The assessment relied on qualitative data gathered through participatory meetings followed by quantitative data gathered through a Likert scale survey. The city of Bridgeport is an advantageous location for this research for multiple reasons. Located in southwestern Connecticut along Long Island Sound, Bridgeport has a large and diverse elderly population with 16,000 residents aged 65 or older encompassing a breadth of socioeconomic conditions and ethnic backgrounds (U.S. Census Bureau, 2012; Figure 1). Over the coming century, the elderly community of Bridgeport is predicted to experience multiple climatic stressors including: Figure 1. View largeDownload slide Map showing the location of Bridgeport, CT. Base map prepared by the State of Connecticut Department of Energy and Environmental Protection (2013). Figure 1. View largeDownload slide Map showing the location of Bridgeport, CT. Base map prepared by the State of Connecticut Department of Energy and Environmental Protection (2013). increasing average temperatures of between 3 °F and 10 °F, a doubling of days over 90 °F, sea level rise of 1–4 feet, a doubling of high precipitation events, and increasing air pollution and allergens. (Melillo et al., 2014) In addition, the elderly community’s previous experience with related climate stressors serves as effective precedents in assessing vulnerabilities and coping capacities. In considering their vulnerability, the research engaged elderly participants in investigating five questions: How are elderly residents of Bridgeport currently affected by climate-related stressors? What factors contribute to their vulnerability to those stressors? What strategies do they currently employ to prepare for, cope with, and recover from the impacts of those climate-related stressors? How will climate change alter their experience dealing with climate-related stressors? What are their most pressing concerns in relation to their vulnerability to climate change? This research was conducted in two phases. The initial phase consisted of two participatory meetings open to the elderly community of Bridgeport wherein the participants considered their vulnerability to climate change and collaborated with the lead researcher to develop a research instrument in the form of a survey to examine elders’ concerns over climate change. The second phase of the research consisted of administration of the survey to a different sample of older adults. The participatory meetings were held at Bridgeport’s main senior center. Demographic data were collected from meeting participants via surveys to ensure a diverse representation of the city’s population was included. The first meeting began with a presentation about historical and predicted climate trends in Bridgeport focusing on temperature and extreme heat, flooding and storms, and air pollution and allergens. Following the presentation, participants divided into working groups to answer research questions one through four in the context of a specific climate stressor; either extreme heat, flooding and storms, or air pollutants and allergens. In their discussions, each group utilized antecedent and consequence mapping to identify potential factors affecting their vulnerability (Stringer, 2007). A summary document of the discussions was shared with participants at the second meeting. Participants offered feedback, which was incorporated into the findings. Participants then reviewed recent climate predictions for Bridgeport and discussed how their vulnerability to each stressor might change. The results of this discussion were reviewed by the participants and their feedback was incorporated. Focusing on the fifth research question, the participants collaborated with the lead researcher on developing a Likert scale survey to allow elderly community members to rank their level of concern over 31 factors that could contribute to their vulnerability. These factors were based on the discussions during the two meetings and supplemented by issues raised in the scientific literature. The Likert scale had five points ranging from “unconcerned” to “very concerned.” For the second phase of the research, the survey was distributed in English and Spanish through organizations that engage with the elderly community. This approach was decided based on the participants’ recommendation and in an effort to reach a diverse representation of Bridgeport’s elderly adults. Demographic data were collected from a random subset of one in five survey respondents to ensure that surveys results reflected Bridgeport’s elderly adults. Survey results were analyzed to note respondents’ average level of concern over each factor. In addition, the number of highly concerned responses (responses of a four or five) was totaled for each question. Results Phase 1: Participatory Meetings Sample Fifty-five residents of Bridgeport who were age 65 or older participated in the two vulnerability assessment meetings. They comprised a diverse representation of Bridgeport’s elderly community (Table 1). Furthermore, as the participants considered their vulnerability to climate change, they made a concerted effort to consider how their fellow elderly community members not in attendance might be affected. Table 1. Demographic Comparison of Vulnerability Assessment Meeting Participants With General Elderly Population of Bridgeport Category Elderly population in Bridgeport Meeting participants (n = 55) Survey respondents (n = 35a) Age (average) 74.2 73.8 75.3 Age by cohort (%)  65–74 n/a 60 51.4  75–84 n/a 24 25.7  85+ n/a 16 22.9 Gender (%)  Female 60.8 78.1 77.1  Male 39.2 11.9 22.9 Race (%)  Asian 2.8 1.8 2.9  Black or African American 28.3 61.8 54.3  White 63.3 25.5 28.6  Other 5.6 10.9 14.3 Hispanic or Latino (%) 22.1 16.7 23.5 Living alone (%) 59.9 49 51.4 Educational attainment (%)  Less than a high school degree 41.3 37.7 42.9  High school degree or equivalent 34.1 41.5 37.1  Some college/associates degree 14.6 15.1 11.4  Bachelors degree or higher 10.1 5.6 8.6 Living with a disability (%) 41 56.6 52.9 Primary language (%)  English n/a 84.6 77.1  Spanish n/a 9.1 14.3  Greek n/a 1.8 2.9  Portuguese n/a 3.6 2.9  Chinese n/a 1.8 2.9 Speak English less than very well (%) 29 10.9 17.1 Employment (%)  Full or part time 15.9 13.5 14.3  Unemployed or retired 84.1 86.5 85.7 Household income (%)  Less than $10,000 n/a 58.7 55.2  $10,000–$20,000 n/a 26.1 17.2  $20,000–$40,000 n/a 13 20.7  $40,000+ n/a 4.3 6.9 Housing status (%)  Owner occupied 55.6 40 63.3  Renter occupied 44.4 60 36.7 Category Elderly population in Bridgeport Meeting participants (n = 55) Survey respondents (n = 35a) Age (average) 74.2 73.8 75.3 Age by cohort (%)  65–74 n/a 60 51.4  75–84 n/a 24 25.7  85+ n/a 16 22.9 Gender (%)  Female 60.8 78.1 77.1  Male 39.2 11.9 22.9 Race (%)  Asian 2.8 1.8 2.9  Black or African American 28.3 61.8 54.3  White 63.3 25.5 28.6  Other 5.6 10.9 14.3 Hispanic or Latino (%) 22.1 16.7 23.5 Living alone (%) 59.9 49 51.4 Educational attainment (%)  Less than a high school degree 41.3 37.7 42.9  High school degree or equivalent 34.1 41.5 37.1  Some college/associates degree 14.6 15.1 11.4  Bachelors degree or higher 10.1 5.6 8.6 Living with a disability (%) 41 56.6 52.9 Primary language (%)  English n/a 84.6 77.1  Spanish n/a 9.1 14.3  Greek n/a 1.8 2.9  Portuguese n/a 3.6 2.9  Chinese n/a 1.8 2.9 Speak English less than very well (%) 29 10.9 17.1 Employment (%)  Full or part time 15.9 13.5 14.3  Unemployed or retired 84.1 86.5 85.7 Household income (%)  Less than $10,000 n/a 58.7 55.2  $10,000–$20,000 n/a 26.1 17.2  $20,000–$40,000 n/a 13 20.7  $40,000+ n/a 4.3 6.9 Housing status (%)  Owner occupied 55.6 40 63.3  Renter occupied 44.4 60 36.7 Note: n/a = not applicable. Data for the general elderly population in Bridgeport are taken from the U.S. Census Bureau’s American Community Survey (2012). aThe 35 survey respondents represent a subset comprising 21% of the 164 total survey respondents. View Large Table 1. Demographic Comparison of Vulnerability Assessment Meeting Participants With General Elderly Population of Bridgeport Category Elderly population in Bridgeport Meeting participants (n = 55) Survey respondents (n = 35a) Age (average) 74.2 73.8 75.3 Age by cohort (%)  65–74 n/a 60 51.4  75–84 n/a 24 25.7  85+ n/a 16 22.9 Gender (%)  Female 60.8 78.1 77.1  Male 39.2 11.9 22.9 Race (%)  Asian 2.8 1.8 2.9  Black or African American 28.3 61.8 54.3  White 63.3 25.5 28.6  Other 5.6 10.9 14.3 Hispanic or Latino (%) 22.1 16.7 23.5 Living alone (%) 59.9 49 51.4 Educational attainment (%)  Less than a high school degree 41.3 37.7 42.9  High school degree or equivalent 34.1 41.5 37.1  Some college/associates degree 14.6 15.1 11.4  Bachelors degree or higher 10.1 5.6 8.6 Living with a disability (%) 41 56.6 52.9 Primary language (%)  English n/a 84.6 77.1  Spanish n/a 9.1 14.3  Greek n/a 1.8 2.9  Portuguese n/a 3.6 2.9  Chinese n/a 1.8 2.9 Speak English less than very well (%) 29 10.9 17.1 Employment (%)  Full or part time 15.9 13.5 14.3  Unemployed or retired 84.1 86.5 85.7 Household income (%)  Less than $10,000 n/a 58.7 55.2  $10,000–$20,000 n/a 26.1 17.2  $20,000–$40,000 n/a 13 20.7  $40,000+ n/a 4.3 6.9 Housing status (%)  Owner occupied 55.6 40 63.3  Renter occupied 44.4 60 36.7 Category Elderly population in Bridgeport Meeting participants (n = 55) Survey respondents (n = 35a) Age (average) 74.2 73.8 75.3 Age by cohort (%)  65–74 n/a 60 51.4  75–84 n/a 24 25.7  85+ n/a 16 22.9 Gender (%)  Female 60.8 78.1 77.1  Male 39.2 11.9 22.9 Race (%)  Asian 2.8 1.8 2.9  Black or African American 28.3 61.8 54.3  White 63.3 25.5 28.6  Other 5.6 10.9 14.3 Hispanic or Latino (%) 22.1 16.7 23.5 Living alone (%) 59.9 49 51.4 Educational attainment (%)  Less than a high school degree 41.3 37.7 42.9  High school degree or equivalent 34.1 41.5 37.1  Some college/associates degree 14.6 15.1 11.4  Bachelors degree or higher 10.1 5.6 8.6 Living with a disability (%) 41 56.6 52.9 Primary language (%)  English n/a 84.6 77.1  Spanish n/a 9.1 14.3  Greek n/a 1.8 2.9  Portuguese n/a 3.6 2.9  Chinese n/a 1.8 2.9 Speak English less than very well (%) 29 10.9 17.1 Employment (%)  Full or part time 15.9 13.5 14.3  Unemployed or retired 84.1 86.5 85.7 Household income (%)  Less than $10,000 n/a 58.7 55.2  $10,000–$20,000 n/a 26.1 17.2  $20,000–$40,000 n/a 13 20.7  $40,000+ n/a 4.3 6.9 Housing status (%)  Owner occupied 55.6 40 63.3  Renter occupied 44.4 60 36.7 Note: n/a = not applicable. Data for the general elderly population in Bridgeport are taken from the U.S. Census Bureau’s American Community Survey (2012). aThe 35 survey respondents represent a subset comprising 21% of the 164 total survey respondents. View Large Current Impacts Participants described multiple ways in which they and their fellow elderly community members are currently affected by extreme heat, air pollution, and flooding and storms. As a result of extreme heat and elevated air pollution, participants noted physical ailments including general pain and discomfort, difficulty breathing, and difficulty sleeping. Participants experienced psychological impacts including anxiety, depression, and irritability. In more severe cases, participants described illness and hospitalization following extreme heat and high levels of air pollution. Participants explained how these events can serve to trap elders in their homes, leading to isolation and difficulty accessing needed resources or services, including groceries, medicine, or medical treatments. As one participant stated, “If it gets too hot, I just have to stay inside my house and can’t go out.” Participants noted that storms and flooding could lead to physical injury followed by a prolonged and difficult recovery process. In addition, if electricity goes out as a result of a storm, elders could be unable to run needed medical equipment, heat or cool their homes, cook, or refrigerate food. Loss of electricity could also result in the spoilage of medication, such as insulin, that requires refrigeration. Elders dependent on an elevator or stair lift could become trapped in their home. Participants described challenges traveling to get medications and medical treatments, as well as running errands during or following a storm. They explained the effects of storms and flooding can make it difficult for caregivers to access elders during and following storms or flooding. In addition, participants described ways that storms and flooding can result in damage to their property, with floods filling basements with water, and high winds damaging roofing or siding and bringing down limbs on their yard or house. They explained how these impacts in turn can have health impacts. For example, sewage overflow and mold contamination following flooding can make elders’ homes unsafe and result in illness if left untreated. Finally, participants noted challenges coping with trauma and stress following storms and flooding. Current Vulnerability Participants identified a number of personal characteristics and contextual factors that contribute to their vulnerability to these stressors. Personal characteristics Participants noted a variety of personal characteristics that contributed to their vulnerability to climate change. Among the most influential, they highlighted chronic health conditions prevalent among elderly adults that can increase their sensitivity to climate change by causing adverse reactions to climate-related stressors. Participants noted adverse reactions to high temperatures worsened by diabetes. They described how conditions including asthma, lung infection, and chronic obstructive pulmonary disease can lead to severe reactions to air pollution. Living with a disability was highlighted as an important factor potentially reducing adaptive capacity. As an example, participants described how traveling to a cooling center or shelter in a heat wave or storm can be extremely difficult for individuals confined to a wheelchair. They noted how challenges with traveling can be exacerbated in emergency situations. Participants described how Alzheimer’s and other cognitive impairments can present challenges throughout the hazard life cycle, making it difficult for elders to receive and comprehend warnings, take needed steps to protect themselves, and navigate potentially complex recovery processes. They highlighted that poor hearing can make it difficult for elders to hear or comprehend warnings associated with extreme weather and climate-related stressors. They described how impairments and diseases can make elderly individuals dependent on the support of caregivers, leaving them at heightened risk during events such as storms or flooding that can prevent caregivers from gaining access to them. Participants highlighted living by oneself as contributing to the vulnerability of some elderly adults. Participants suggested that these individuals might be less likely to receive important warnings or instructions regarding climate-related stressors. Isolated elders with a limited ability to use communication technology could be at even greater risk of failing to receive warnings. Participants noted how isolated elders may lack the social support network to help them respond to emergency situations. Participants voiced concern that these elders may not have the support needed to recover from illness, injury, trauma, or property damage. As one participant commented, “If there is a big storm, I don’t have any living relatives to come check on me and see if I need help.” Participants identified a number of ways that lack of employment and living on a low or fixed income can reduce adaptive capacity. As a result, elders may lack the money needed to gather emergency supplies and make preparations to be able to safely take shelter at home in a storm or other emergency. They may also be unable to pay for alternative shelter in an emergency or conduct repairs or clean up after a storm or flood. In the context of extreme heat and air pollution, financial limitations can prevent elderly individuals from purchasing and running air conditioning or dehumidifiers. Economic limitations can also make receiving needed medical treatment or medication following an injury or illness more challenging. In addition to highlighting challenges associated with low income, participants observed that individuals with a limited command of the English language can face difficulties receiving warnings of impending severe weather, taking steps to protect themselves, and receiving needed support as part of the recovery process. Participants noted that minority status and a lack of formal educational attainment could also pose challenges, but these characteristics were not discussed in depth by the group. Contextual factors Participants highlighted four contextual factors that can enhance or limit the adaptive capacity of elderly adults. These contextual factors are as follows: adequacy of transportation resources, effectiveness of public warning mechanisms, availability of resources to promote safe shelter, and adequacy of resources to aid in coping and recovery. Adequacy of transportation resources.  Participants noted that adequate transportation resources are vital for elderly individuals to gather resources to prepare for climate-related stressors, seek safe shelter away from home, and access resources and services to aid in their recovery. Many of the personal characteristics described previously, including certain disabilities, diminished sensory awareness, and financial limitations, can make it difficult for elderly individuals to drive or own a car. As a result, many elderly adults are dependent on public transportation for meeting these needs. Even for individuals who can normally drive, inclement weather and flooding during severe storms may make them unable to drive or uncomfortable doing so, causing them to seek alternative transportation. As a result, participants explained their vulnerability to climate-related stressors depended in part on the availability of transportation options to bring them from their home to grocery stores, shelters, cooling centers, clinics, and hospitals. Given the limited financial resources of many elders, participants noted these options have to be inexpensive. They highlighted that transportation options must accommodate and support individuals with a variety of disabilities and people who need to bring specialized medical equipment or supplies. Finally, they highlighted that elders need to be aware of transportation resources and how to access them. Effectiveness of warning mechanisms. Participants noted it is important for elders to receive adequate warning of upcoming climate-related stressors so that they can protect themselves. Again, personal characteristics, including social isolation, cognitive impairments, diminished sensory awareness, and a lack of technological fluency, make it difficult for governments or other support organizations to provide elders with adequate warning. It is even more difficult to reach elders with limited English-speaking ability. To overcome these challenges, participants noted it is important for warnings to be distributed using appropriate technology to reach older adults, with information relevant to the elders, and be communicated clearly in a manner that will be understandable to elders with a variety of cognitive and sensory capacities. Considering appropriate technology for distributing warnings, participants suggested they preferred to be contacted by telephone or in person. Availability of resources to promote safe shelter. Participants noted the importance of having access to safe shelter during extreme weather or other climate-related stressors. They explained this could include making their home safe, either through home repairs to weather storms or through purchasing and running air conditioning in a heat wave or period of elevated air pollution. Financial limitations can make this challenging for many elders and prohibit them from paying for alternate shelter in an emergency. As a result, participants highlighted the importance of having emergency shelters and cooling centers available. They noted that shelters and cooling centers need to be able to accommodate elders with special needs and that elders need to be aware of their location. This is not always the case, as one participant commented, “I have no idea where they are or what to bring.” In addition, participants highlighted the importance of having adequate transportation resources to bring elders to shelters or cooling centers. Adequacy of resources to aid in coping and recovery. The participating elders noted the importance of resources to aid in coping and recovery. They described how financial limitations, disabilities, and chronic medical conditions can make it difficult for elders to travel to or afford needed medical treatments or medications. Elders with these conditions could have difficulty accomplishing essential tasks during or following a climate-related stressor. These conditions can make it difficult for elders to undertake or pay for home repairs or clean up after storms. Elders highlighted the importance of support in these diverse aspects of coping and recovery. As with the other factors, they noted that elders need to be aware of resources and accessing them needs to be simple enough for them to navigate. Current Adaptive Strategies and Resources Participants shared a number of adaptive strategies and resources they currently employ to prepare for, cope with, and recover from extreme weather and other climate-related stressors. In the context of extreme heat and air pollution, they explained how they often remain indoors at home, but noted this can lead to ongoing isolation and prohibit elderly individuals from running important errands to obtain medical treatments and groceries. Some participants described closing their windows and running air conditioning, but added this presents an additional expense that many elders cannot afford. One participant compellingly explained, “It sets a double standard, where those who can afford it can protect themselves, but those who can’t, especially those living alone and on a fixed income, are more at risk.” During periods of extreme heat, participants highlighted additional ways they modify their behavior, including dressing light, drinking extra fluids, taking cool showers, closing blinds, and eating light foods. In the context of air pollution, some participants noted they use breathing machines, which again makes it difficult for them to travel and run errands. Finally, as a result of extreme heat and air pollution, participants explained they sometimes need to travel to the hospital for treatments. When this occurs, participants described it can be physically difficult to travel, financially burdensome, and overly time consuming. In the context of flooding and storms, some elders mentioned needing to seek shelter in a hotel if they felt their home was or might become unsafe. They noted this was an expensive option that was challenging or unavailable for many elders given their limited economic resources. Other participants described staying with friends and family during or following a storm if their home might be unsafe or was damaged. Again, participants explained this would not be an option for isolated elders lacking a local social support network. Finally, following floods and storms, participants described how they were often incapable of undertaking the needed cleanup or repairs and had to pay for those services. Participants highlighted the challenges of paying for this added expense. Potential Impacts of Predicted Climate Changes on Elderly Adult’s Vulnerability Participants described two primary ways their vulnerability may be affected by predicted changes in extreme heat, flooding and storms, and air pollution and allergens. First, previously unaffected or little affected elders may be underprepared to cope with the increasing intensity of climate stressors. Second, the increasing intensity of climate stressors coupled with an increase in frequency could overwhelm the adaptive capacity of some elderly individuals. Currently, some elders may be largely unaffected by climate-related stressors. As climate change progresses, however, these individuals may begin to be adversely affected and find themselves unprepared and without any coping experience. The lack of preparedness and coping strategies could heighten their vulnerability. For example, an older adult’s basement may have never flooded previously, but increases in heavy precipitation events could result in severe flooding causing damage to the residence. As another example, an older adult who has been previously unaffected by high-temperature days may find herself experiencing heat related illnesses as the intensity of heat waves increases. In both cases, the individuals could lack important information and strategies and, as a result, could face significant challenges coping with and recovering from these novel impacts. Even elders previously affected by certain climate-related stressors may find their adaptive strategies insufficient to protect themselves from predicted changes. Participants suggested that even small changes in the intensity of climate-related stressors can have a significant impact on some elders. As one elder shared, “Even a difference of a couple degrees in temperature can be a big deal to me.” Participants noted, in both cases, the risk to elders could be increased if they underestimate the severity of future extreme weather events. They suggested that elderly individuals may base their decision making about how to prepare for future events on previous experience. If certain climate stressors increase in intensity, it could result in elders underpreparing for more severe events, thereby putting themselves more at risk. Even if elders perceived the risks they face as severe and wished to protect themselves, climate change could overwhelm their adaptive capacity. As participants described, the adaptive capacity of many elders can be limited by factors including a lack of financial resources, social isolation, health conditions and disabilities, and marginalization. As was illustrated in the descriptions of adaptive strategies elderly adults currently employ, many of their approaches can have secondary impacts that further draw down their existing adaptive capacity. If elders are forced to employ these adaptive strategies to a greater degree, the secondary impacts could exhaust their economic, physical, mental, and social resources. This is exemplified by one participant’s concern, “Sure I could run my AC more, but that costs more money that I don’t have, so where am I going to get the money from?” In addition, climate stressors will not be changing in isolation, but predictions contend that extreme heat, flooding and storms, and air pollution will increase in concert. Even if individuals were able to muster the resources to safeguard themselves from increases in one stressor, concurrent increases in other stressors may prove overwhelming. For example, if the previously quoted participant could find the financial resources to run additional air conditioning to cope with increasing temperatures, concurrent increases in home repair costs from more severe storms may be more than she could afford. Phase 2: Survey Results Sample A total of 164 elders completed the survey and, although not a random sample, demographic data collected from a random subset of one in five respondents demonstrates that the survey reached a diverse representation of Bridgeport’s elderly community (Table 1). The demographic data also show that the survey reached segments of the elderly population with characteristics, such as living alone or on a low income, that may put them at heightened risk to climate-related stressors. Respondent Concerns The survey results highlight the respondents’ generally high level of concern over climate-related stressors (Table 2). Respondents ranked 14 of the 31 questions as an average of three or above, and more than 30% of respondents ranked 23 of the 31 questions as high concerns (four or five on the Likert scale). Some of the respondents’ most pressing concerns focused on receiving adequate warning. This included concerns over not receiving warnings or receiving warnings that do not have enough information or are hard to understand. Respondents also expressed heightened concern over factors related to shelter, including concerns over the safety of their homes, difficulties getting to shelters, the safety and comfort of shelters, and their abundance. In addition, respondents ranked issues related to getting assistance and the recovery process as particularly concerning. These included concerns over traveling to the hospital both during and following climate-related stressors, getting food and supplies, doing essential activities while electricity is out, coping with trauma and stress, and conducting repairs and clean up following a storm or flood. Table 2. Survey Results Showing Respondents’ Average Level of Concern Over Various Issues Associated With Extreme Weather and Percentage of Respondents Ranking Each Issue as a High Concern (n = 164) Issue Average level of concern % Highly concerned Receiving adequate warning  Will not receive warning 3.58 50  Warning will not have enough info 3.74 62  Warning will be hard to understand 3.48 51  Warning will not be in my language 1.97 18 Staying safe at home  My house is unsafe and cannot afford to fix 3.29 47  Cannot afford to run AC in heat wave 2.76 36   Cannot afford to run AC in air pollution 2.67 35 Having adequate transportation resources  Lack of public transportation where I live 2.49 29  Lack of ride sharing where I live 2.89 39  Public transport is too expensive 2.46 26  Can not afford transportation in emergency 2.54 27  It is physically difficult for me to travel 2.29 19  It is hard to travel because of equip needs or medicine 2.07 16 Finding safe shelter  Do not know where shelter is located 2.92 39  Hard for me to get to shelter 3.01 46  Shelters are unsafe 3.14 44  Shelters are uncomfortable 3.08 40  There are not enough shelters 3.45 57  Hard for me to stay in shelter because of equip needs or medicine 2.48 28 Getting needed assistance  No one will check on me during or after extreme weather 2.90 30  Do not know emergency numbers 2.86 38  Will not be able to leave my building if power is out 2.19 19  Will be difficult for caregivers to reach me in storm 2.65 32  Will be difficult to get to hospital or get medicine during or after extreme weather 3.08 43  Will be difficult to get food and supplies during or after extreme weather 3.25 47  If electricity is out, will be difficult to do essential activities 3.45 51 Having resource to aid in recovery  Difficult to cope with trauma and stress 3.05 36  Difficult to travel to hospital for treatment if injured or sickened 3.27 47  Difficult to afford medication or treatment if injured or sickened 2.93 34  Will not have needed support to do daily tasks if injured or sickened 2.94 32  Difficult to do clean up or repairs to property 3.19 47 Issue Average level of concern % Highly concerned Receiving adequate warning  Will not receive warning 3.58 50  Warning will not have enough info 3.74 62  Warning will be hard to understand 3.48 51  Warning will not be in my language 1.97 18 Staying safe at home  My house is unsafe and cannot afford to fix 3.29 47  Cannot afford to run AC in heat wave 2.76 36   Cannot afford to run AC in air pollution 2.67 35 Having adequate transportation resources  Lack of public transportation where I live 2.49 29  Lack of ride sharing where I live 2.89 39  Public transport is too expensive 2.46 26  Can not afford transportation in emergency 2.54 27  It is physically difficult for me to travel 2.29 19  It is hard to travel because of equip needs or medicine 2.07 16 Finding safe shelter  Do not know where shelter is located 2.92 39  Hard for me to get to shelter 3.01 46  Shelters are unsafe 3.14 44  Shelters are uncomfortable 3.08 40  There are not enough shelters 3.45 57  Hard for me to stay in shelter because of equip needs or medicine 2.48 28 Getting needed assistance  No one will check on me during or after extreme weather 2.90 30  Do not know emergency numbers 2.86 38  Will not be able to leave my building if power is out 2.19 19  Will be difficult for caregivers to reach me in storm 2.65 32  Will be difficult to get to hospital or get medicine during or after extreme weather 3.08 43  Will be difficult to get food and supplies during or after extreme weather 3.25 47  If electricity is out, will be difficult to do essential activities 3.45 51 Having resource to aid in recovery  Difficult to cope with trauma and stress 3.05 36  Difficult to travel to hospital for treatment if injured or sickened 3.27 47  Difficult to afford medication or treatment if injured or sickened 2.93 34  Will not have needed support to do daily tasks if injured or sickened 2.94 32  Difficult to do clean up or repairs to property 3.19 47 Note: For Likert scale, 1 = unconcerned and 5 = very concerned. For % highly concerned, a ranking of a 4 or 5 is considered a high level of concern. View Large Table 2. Survey Results Showing Respondents’ Average Level of Concern Over Various Issues Associated With Extreme Weather and Percentage of Respondents Ranking Each Issue as a High Concern (n = 164) Issue Average level of concern % Highly concerned Receiving adequate warning  Will not receive warning 3.58 50  Warning will not have enough info 3.74 62  Warning will be hard to understand 3.48 51  Warning will not be in my language 1.97 18 Staying safe at home  My house is unsafe and cannot afford to fix 3.29 47  Cannot afford to run AC in heat wave 2.76 36   Cannot afford to run AC in air pollution 2.67 35 Having adequate transportation resources  Lack of public transportation where I live 2.49 29  Lack of ride sharing where I live 2.89 39  Public transport is too expensive 2.46 26  Can not afford transportation in emergency 2.54 27  It is physically difficult for me to travel 2.29 19  It is hard to travel because of equip needs or medicine 2.07 16 Finding safe shelter  Do not know where shelter is located 2.92 39  Hard for me to get to shelter 3.01 46  Shelters are unsafe 3.14 44  Shelters are uncomfortable 3.08 40  There are not enough shelters 3.45 57  Hard for me to stay in shelter because of equip needs or medicine 2.48 28 Getting needed assistance  No one will check on me during or after extreme weather 2.90 30  Do not know emergency numbers 2.86 38  Will not be able to leave my building if power is out 2.19 19  Will be difficult for caregivers to reach me in storm 2.65 32  Will be difficult to get to hospital or get medicine during or after extreme weather 3.08 43  Will be difficult to get food and supplies during or after extreme weather 3.25 47  If electricity is out, will be difficult to do essential activities 3.45 51 Having resource to aid in recovery  Difficult to cope with trauma and stress 3.05 36  Difficult to travel to hospital for treatment if injured or sickened 3.27 47  Difficult to afford medication or treatment if injured or sickened 2.93 34  Will not have needed support to do daily tasks if injured or sickened 2.94 32  Difficult to do clean up or repairs to property 3.19 47 Issue Average level of concern % Highly concerned Receiving adequate warning  Will not receive warning 3.58 50  Warning will not have enough info 3.74 62  Warning will be hard to understand 3.48 51  Warning will not be in my language 1.97 18 Staying safe at home  My house is unsafe and cannot afford to fix 3.29 47  Cannot afford to run AC in heat wave 2.76 36   Cannot afford to run AC in air pollution 2.67 35 Having adequate transportation resources  Lack of public transportation where I live 2.49 29  Lack of ride sharing where I live 2.89 39  Public transport is too expensive 2.46 26  Can not afford transportation in emergency 2.54 27  It is physically difficult for me to travel 2.29 19  It is hard to travel because of equip needs or medicine 2.07 16 Finding safe shelter  Do not know where shelter is located 2.92 39  Hard for me to get to shelter 3.01 46  Shelters are unsafe 3.14 44  Shelters are uncomfortable 3.08 40  There are not enough shelters 3.45 57  Hard for me to stay in shelter because of equip needs or medicine 2.48 28 Getting needed assistance  No one will check on me during or after extreme weather 2.90 30  Do not know emergency numbers 2.86 38  Will not be able to leave my building if power is out 2.19 19  Will be difficult for caregivers to reach me in storm 2.65 32  Will be difficult to get to hospital or get medicine during or after extreme weather 3.08 43  Will be difficult to get food and supplies during or after extreme weather 3.25 47  If electricity is out, will be difficult to do essential activities 3.45 51 Having resource to aid in recovery  Difficult to cope with trauma and stress 3.05 36  Difficult to travel to hospital for treatment if injured or sickened 3.27 47  Difficult to afford medication or treatment if injured or sickened 2.93 34  Will not have needed support to do daily tasks if injured or sickened 2.94 32  Difficult to do clean up or repairs to property 3.19 47 Note: For Likert scale, 1 = unconcerned and 5 = very concerned. For % highly concerned, a ranking of a 4 or 5 is considered a high level of concern. View Large Discussion This study of the elderly community of Bridgeport, CT, provides an in-depth exploration of the numerous and potentially serious ways elders are affected by climate-related stressors including extreme heat, air pollution, and flooding and storms. It illustrates how these impacts can be experienced in a range of ways including physical injury, anxiety, stress, social isolation, financial hardship, and damage to physical property. It shows how even relatively minor impacts often overlooked in the broader literature on disasters and elderly adults can present significant challenges to some elders. For example, a downed limb in an elder’s yard following a storm could cause emotional stress, physical injury, or financial hardship. This study demonstrates how multiple personal characteristics associated with advancing age serve to increase their vulnerability. The participants’ description of factors contributing to their current vulnerability, including chronic health conditions, physical and cognitive disabilities, social isolation, and economic limitations, echoes findings from other studies on the vulnerability of elderly adults to climate stressors (for comparison, see Eldar, 1992; Fernandez et al., 2002; Gamble et al., 2013; Ngo, 2001). The relevance of the participants’ assessment is also evidenced by demographic data of Bridgeport’s elderly adults. For example, as of 2012, 41% of Bridgeport’s elderly adults lived with a disability, 59.9% lived alone, 84.1% were unemployed or retired, and 17.3% lived below the poverty line (U.S. Census Bureau, 2012). Given these high percentages, substantial portions of the elderly community of Bridgeport are likely to have one or multiple personal characteristic heightening their vulnerability. Factors associated with marginalization were less prominent in the participants’ discussion, but may also contribute to their vulnerability. Gamble and colleagues (2013) identified minority status, little formal education, and low-income levels as aspects of marginalization potentially putting elders at risk. Given the significant percentages of Bridgeport’s elders with these demographic characteristics (Table 1), it seems likely that marginalization could contribute to the vulnerability of a substantial fraction of the elderly community. Participants may have been hesitant to explore this potentially sensitive subject matter at an open meeting and alternative research approaches, such as individual interviews, may be needed to explore these aspects in depth. The personal characteristics identified can vary greatly from one elder to the next and advancing age is not in itself a determinant of vulnerability. For those elders, however, who are more vulnerable as a result of these characteristics, there may be little they can do at the individual level to protect themselves and predicted climate changes could overwhelm their limited capacity to adapt. This is especially worrisome as many of the participating elders’ current adaptation strategies had negative secondary impacts or restrictions limiting their effectiveness. As a result, contextual factors, including the effectiveness of warning mechanisms, adequacy of public transportation, availability of resources to promote safe shelter, and adequacy of resources to aid in coping and recovery, will be vital in keeping elders safe. The participants’ descriptions of these factors may be of value to those developing adaptation strategies. For example, when considering warning mechanisms, participants requested to be contacted on the phone or in person. This suggests a need to employ automated phone warnings and to mobilize community organizations when reaching out to elderly individuals. As another example, participants continually stressed the importance of resources being affordable, easily accessible for elders, and effectively promoted among elders to generate widespread awareness. To design adaptation measures that meet the needs of older adults, it is also important to understand which contextual factors they are most concerned about. In the context of the current research, the survey allowed elders to rate their relative level of concern over a range of factors. The survey illustrated elders’ generally high level of concern and the broad nature of those concerns. It also points toward those factors elders felt were most worrisome, such as concerns over not receiving warnings or of warnings having inadequate information. Although it is important to note the most prominent concerns, it is also important to pay attention to concerns that might be held by specific subgroups within the elderly community. As the meeting participants discussed, vulnerability is affected by personal characteristics that vary greatly among elders. Certain subgroups within the community many have concerns based on unique aspects of their vulnerability. For example, concerns over not receiving warnings in a language you understand only affect elderly individuals who do not speak English or speak it poorly. Although this subgroup only represents 29% of the city’s total elderly population, and so their concern will not be shared generally, it is an important factor contributing to the vulnerability of those individuals. This relatively low level of overall concern but high level of concern within a specific subgroup is seen in the survey results, with concern over warnings not being in an individual’s language ranking a 1.97 overall, but with 18% of respondents ranking this as a high concern. Although not shared by the larger community, their concern deserves due consideration by government agencies and other organizations working to support older adults. Such a perspective presents the survey results in an additional light, as all 31 questions were ranked as high concerns by over 15% of respondents. A limitation of this aspect of the research is that only one in five survey respondents provided demographic data and so the demographic composition of the respondents is not known with the same precision as with the meeting participants. Demographic data were collected from a subset to reduce the effort required by elders filling out the survey, but in future research, the benefits of establishing a complete demographic profile may outweigh this consideration. Despite this limitation, the clear indication from the survey of a generally high level of concern spreading over diverse issues warrants consideration. It is interesting to note that there are programs in Bridgeport to address some of the concerns raised in the study but that elderly individuals were often unaware of them or how to utilize them (T. Jones, Public Health Emergency Preparedness Director with the City of Bridgeport, personal communication, April 27, 2015). Accordingly, the vulnerability of some elderly adults in Bridgeport may not be due to a lack of programs but due to poor awareness of available resources and a lack of emergency preparedness. This echoes the findings of a survey conducted by Al-Rousan and colleagues (2014) investigating elderly adult’s preparedness for natural disasters. Sampling elderly individuals across the United States, this study found two thirds of respondents did not have an emergency preparedness plan and were largely unaware of emergency resources. Furthermore, one third did not have basic food, water, and medical supplies in case of an emergency. These insights support the assertion by Gamble and colleagues (2013) that education and outreach should be important aspects of adaptation efforts targeted at elders. Within this context, an important question for Bridgeport and potentially for other locations will be not only how to develop additional programs to protect elders, but how to conduct the outreach and education efforts to raise awareness of existing resources and to enhance preparedness. Different approaches may be needed to reach elders with diverse backgrounds and characteristics and elders who are reluctant to acknowledge their own vulnerabilities may be particularly resistant to engaging in preparedness and planning activities. Although this study is limited to one location, aspects of this elderly community’s vulnerability may be applicable to other locations, especially other cities facing similar climate stressors and with similar socioeconomic characteristics among the elderly population. Given the multiple characteristics associated with aging that can serve to increase sensitivity and reduce adaptive capacity, it is possible that in other locations contextual factors will also play an important role safeguarding elders from the impacts of climate change. In addition, given the diverse socioeconomic and health characteristics that influence the vulnerability of older adults generally, it is possible that other communities might also hold a broad range of concerns regarding their vulnerability. Further studies in additional communities are needed to determine the degree of variability between sites and which facets of this study are transferable under different circumstances. This research could aid in developing vulnerability indicators capable of mapping the vulnerability of elders to climate change. Although this would fill a key gap highlighted by Gamble and colleagues (2013) in our ability to keep elders safe, it is important that indicator-based assessments do not preclude participatory processes that give voice to the local concerns. This research is also limited in its focus on the vulnerability of elderly individuals living independently. Elders in managed care facilities will likely have a different experience of climate-related stressors and the nature of their vulnerability could be dissimilar. Further research is needed to investigate vulnerability within this context. This study offers two resources to aid in future research: an adaptable framework for conducting participatory vulnerability assessments and a survey instrument for assessing individual and community concerns. The participatory assessment and survey instrument, however, have only been employed in this study. Both approaches should be considered works in progress and in need of ongoing refinement. For future applications, practitioners should expect to tailor them to site-specific conditions. Through ongoing application and refinement, these resources may be developed into generally applicable assessment tools. Conclusion Climate change poses a significant risk to older adults. With their first hand experience of climate stressors, elders’ insights into their own vulnerability could be of great help in efforts to keep them safe. This study illustrates the serious impacts climate change could have on elders, the importance of community level support, and the value of incorporating elders’ knowledge, perspective, and experience into vulnerability assessments. This study also presents two resources to aid in future research: an adaptable participatory framework for examining the vulnerability of elderly communities and a survey instrument to assess elders’ concerns. Through additional research, especially research integrating elders as participants, we can develop detailed understandings of the factors that increase or reduce their vulnerability in different contexts and better understand elders’ concerns. These understandings provide a basis for adaptation planning that can bring elderly communities together with local governments and a coalition of partners to help keep elders safe in a time of climate change. References Al-Rousan T. M. Rubenstein L. M. , & Wallace R. B . ( 2014 ). Preparedness for natural disasters among older US adults: A nationwide survey . American Journal of Public Health , 104 , 506 – 511 . doi: 10.2105/AJPH.2013.301559 Google Scholar CrossRef Search ADS PubMed Bunker A. Wildenhain J. Vandenbergh A. Henschke N. Rocklöv J. Hajat S. , & Sauerborn R . ( 2016 ). Effects of air temperature on climate-sensitive mortality and morbidity outcomes in the elderly: A systematic review and meta-analysis of epidemiological evidence . EBioMedicine , 6 , 258 – 268 . doi: 10.1016/j.ebiom.2016.02.034 Google Scholar CrossRef Search ADS PubMed Carter T. R. Fronzek S. Inkinen A. Lahtinen I. Lahtinen M. Mela H. , … Terama E . ( 2016 ). Characterising vulnerability of the elderly to climate change in the Nordic region . Regional Environmental Change , 16 , 43 – 58 . doi: 10.1007/s10113-014-0688-7 Google Scholar CrossRef Search ADS Cornell V . ( 2015 ). What do older people’s life experiences tell us about emergency preparedness ? The Australian Journal of Emergency Management , 30 , 27 . Cornell V. Cusack L. , & Arbon P . ( 2012 ). Older people and disaster preparedness: A literature review . The Australian Journal of Emergency Management , 27 , 49 . Eldar R . ( 1992 ). The needs of elderly persons in natural disasters: Observations and recommendations . Disasters , 16 , 355 – 358 . doi: 10.1111/j.1467–7717.1992.tb00416.x Google Scholar CrossRef Search ADS Fernandez L. S. Byard D. Lin C. C. Benson S. , & Barbera J. A . ( 2002 ). Frail elderly as disaster victims: Emergency management strategies . Prehospital and Disaster Medicine , 17 , 67 – 74 . doi: 10.1017/S1049023X00000200 Google Scholar CrossRef Search ADS PubMed Ford J. D. , & Smit B . ( 2004 ). A framework for assessing the vulnerability of communities in the Canadian Arctic to risks associated with climate change . Arctic , 57 , 389 – 400 . doi: 10.14430/arctic516 Google Scholar CrossRef Search ADS Gamble J. L. Hurley B. J. Schultz P. A. Jaglom W. S. Krishnan N. , & Harris M . ( 2013 ). Climate change and older Americans: State of the science . Environmental Health Perspectives , 121 , 15 – 22 . doi: 10.1289/ehp.1205223 Google Scholar CrossRef Search ADS PubMed Greenberg M. R . ( 2014 ). Protecting seniors against environmental disasters: From hazards and vulnerability to prevention and resilience . London, UK : Routledge . IPCC . ( 2007 ). Fourth assessment report, climate change . Geneva, Switzerland : UNEP . IPCC . ( 2014 ). Climate Change 2014: Impacts, adaptation, and vulnerability . Geneva, Switzerland : UNEP . Lynn K. MacKendrick K. , & Donoghue E. M . ( 2011 ). Social vulnerability and climate change: Synthesis of literature . Portland, OR : US Department of Agriculture, Forest Service, Pacific Northwest Research Station . Melillo J. M. Richmond T. C. , & Yohe G. W . (Eds.). ( 2014 ). Climate change impacts in the United States: The Third National Climate Assessment . Washington DC : U.S. Global Change Research Program . Ngo E. B . ( 2001 ). When disasters and age collide: Reviewing vulnerability of the elderly . Natural Hazards Review , 2 , 80 – 89 . doi: 10.1061/(ASCE)1527-6988(2001)2:2(80) Google Scholar CrossRef Search ADS State of Connecticut Department of Energy and Environmental Protection . ( 2013 ). Connecticut and vicinity state boundary polygon . Retrieved from http://pubs.usgs.gov/of/2012/1103/data/basemaps/shoreline/ct_vicinity_geo.gif Stringer E. T . ( 2007 ). Action research . Thousand Oaks, CA : Sage . U.S. Census Bureau . ( 2012 ). American communities survey . Washington, DC : U.S. Census Bureau . © The Author(s) 2017. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png The Gerontologist Oxford University Press

Developing an In-depth Understanding of Elderly Adult’s Vulnerability to Climate Change

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© The Author(s) 2017. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.
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Abstract

Abstract Purpose of Study Recent reports highlight the vulnerability of elderly adults to climate change, yet limited research has focused on this topic. To address this, the purpose of this study was to develop an in-depth understanding of elderly adult’s vulnerability to climate change within the context of a specific community. Design and Methods A case study methodology utilizing a community-based action research approach was employed to engage elderly participants living in Bridgeport, CT, in exploring their vulnerability to current and predicted climate stressors with a focus on extreme heat, flooding and storms, and air pollution. Results This research identifies personal characteristics that interact with contextual factors to influence elderly adult’s vulnerability to climate change. Personal characteristics include health, economic, and social considerations. Contextual factors include the adequacy of emergency preparedness measures, transportation resources, and coping and recovery resources. As a result of the interplay of these characteristics and factors, predicted climate changes could have serious consequences for Bridgeport’s elderly adults. Implications This research provides a contextualized and detailed illustration of how climate change could overwhelm elderly adult’s adaptive capacity and highlights the need for support services to provide safeguards. The issues and concerns raised may bear similarities to other locations, especially urban settings facing similar climate stressors with similar socioeconomic conditions. The findings suggest a need for further research to improve our understanding and serve as the basis for collaborative adaptation planning that engages elderly communities with local governments and a broad coalition of partners to keep elders safe. Advocacy, Analysis—mixed methods, Assessment of conditions/people, Disparities (health, racial), Health care policy, Public policy, Social services In comparison with the general population, some groups within society are more vulnerable to climate change and will bear a disproportionate burden of its impacts (IPCC, 2007). The IPCC (2007) defines vulnerability as a function of three characteristics: Exposure: the character, rate, and magnitude of climate change to which a system, individual, or population is exposed. Sensitivity: the sensitivity or susceptibility to damage from those changes. Adaptive capacity: the capacity to adjust to changes in climate in order to moderate potential damage, take advantage of opportunities, or cope with consequences. The uneven distribution of climate impacts is rooted in varying levels of vulnerability to climate change among individuals and groups. In this understanding, exposure to climatic stressors is exacerbated by increased sensitivity to those impacts and decreased capacity to adapt. For human populations, both sensitivity to climate impacts and adaptive capacity are influenced by economic, social, geographic, demographic, cultural, institutional, governance, and environmental factors. As a result, vulnerability is associated with inequalities expressed through varying levels of wealth, education, disability, access to resources, health status, gender, and age, as well as marginalization and cultural characteristics. The interplay of these factors determines what is referred to as an individual’s or group’s relative level of “social vulnerability” by influencing their ability to prepare for, cope with, and recover from climate stressors (Lynn, MacKendrick, & Donoghue, 2011). In recent reports and papers, elderly adults (65 years and older) have been one group recognized as having a heightened vulnerability to climate change (Bunker et al., 2016; IPCC, 2014; Melillo et al., 2014). Historical precedence demonstrates older adults often bear the brunt of impacts associated with extreme weather and researchers in a variety of fields, including public health, disaster management, and gerontology, have examined the vulnerability of elders to climate-related stressors (Eldar, 1992; Fernandez, Byard, Lin, Benson, & Barbera, 2002; Ngo, 2001). To apply this understanding to the context of climate change in the United States, Gamble and colleagues (2013) prepared a thorough literature review drawing from peer-reviewed papers, government reports, and demographic and health data. They note the most threatening climate stressors facing elderly adults include heat waves, hurricanes, flooding, droughts, poor air quality, and infectious diseases. Contributing to elderly individuals’ sensitivity, Gamble and colleagues highlight factors associated with advancing age, including respiratory impairments, impairments associated with diabetes, cardiovascular and thermoregulatory impairments, and heat sensitivity. They describe the importance of socioeconomic factors including income level, access to health and social services, educational level, and adequacy of infrastructure. As determinants of adaptive capacity, the authors highlight the importance of functional limitations, economic status, living situation, human and social capital, and communication technology and other infrastructure. Although the review by Gamble and colleagues provides a valuable contribution to our understanding, scientists have, as yet, devoted little attention to conducting research on the vulnerability of elderly adults within the context of climate change. Our current understanding has been drawn largely from research into older adults’ historical vulnerability to climate stressors outside of the context of climate change. Gamble and her coauthors’ review begins to connect the theoretical dots by contextualizing historical research within the framework of current climate predictions, but there has been little research focused on the novel impacts of climate change. Notable exceptions include research by Bunker and colleagues (2016) and Carter and colleagues (2016). Bunker and colleagues (2016) conducted a meta-analysis examining the implications of predicted temperature changes on elderly adults, finding that even a 1 °C increase can affect mortality and morbidity of elderly adults. Focusing on the Nordic Region, Carter and colleagues (2016) incorporated vulnerability indicators into an online mapping tool that served to raise awareness of elderly adult’s vulnerability and inform planning. Additional research is needed to understand how predicted changes in the frequency and intensity of multiple interacting stressors may affect the elders in a range of geographic locations. Our understanding could also benefit from research into factors that contribute to the elders’ adaptive capacity. Although Gamble and colleagues devote attention to this and offer an important contribution, their analysis highlights factors that limit adaptive capacity. To complement this understanding, it would be beneficial to explore adaptive resources that elders can and do employ to prepare for, cope with, or recover from a variety of climate stressors. In his 2014 book, Protecting Seniors Against Environmental Disasters, Michael Greenberg highlights the limited understanding of how elderly adults react before, during, and after natural hazards as “the most glaring gap in our knowledge.” This information would enable us to build on the elders’ existing approaches and resources to design effective adaptation strategies. Finally, our understanding could benefit from increased attention to elders’ perspectives on climate change. Cornell’s (2015) research with older adults in Australia demonstrates the value of incorporating elders’ perspectives in the context of emergency preparedness, but such inclusive approaches are rare. Most research on elders’ vulnerability views them as research subjects and focuses on determining possible causes of their vulnerability (Al-Rousan, Rubenstein, & Wallace, 2014; Cornell, Cusack, & Arbon, 2012; Gamble et al., 2013). Little research has sought to incorporate the perspectives of elders with regard to climate change or involve them as active participants in the research. As a result of our limited understanding of the elders’ concerns, we risk developing adaptation strategies that do not address elder-specific needs. To address these gaps in our understanding, this article presents the results of a participatory inquiry involving members of the elderly community of Bridgeport, CT, in examining their vulnerability to extreme weather and predicted climate changes. This research considers the vulnerability of elderly adults within the unique context of climate change, including an emphasis on adaptive strategies and resources that elderly adults currently employ. In doing so, it draws directly from the experiences and perspectives of the elderly participants and seeks to share their understanding and concerns. Design and Methods This research was undertaken in partnership with the Department on Aging in Bridgeport, CT, to engage the city’s elderly community in a participatory investigation into their vulnerability to climate change. To ensure that the research incorporated the perspective and experience of the elderly community of Bridgeport, the process was guided by principles of community-based action research: upholding a spirit of cooperation and equity, examining issues within their context, recognizing the validity of multiple ways of knowing, and fostering action to address issues of community concern (Stringer, 2007). The elderly participants were included as voluntary partners throughout the research process, helping determine the focus of the inquiry, contributing to the design and execution of the data collection and analysis, and reviewing and amending the findings. The research followed the main steps employed in a vulnerability assessment, including identifying relevant climate stressors, examining current vulnerability to those stressors, and extrapolating future vulnerability based on predicted climate changes and adaptive capacity. This approach bears close resemblance to Ford and Smit’s (2004) research that drew on local knowledge to conduct place-specific case studies assessing the vulnerability of indigenous Arctic communities to climate change. Although Ford and Smit used this approach to assess the vulnerability of entire vulnerable communities, the current research utilized a similar approach to assess the vulnerability of a specific vulnerable group within the larger community. The assessment relied on qualitative data gathered through participatory meetings followed by quantitative data gathered through a Likert scale survey. The city of Bridgeport is an advantageous location for this research for multiple reasons. Located in southwestern Connecticut along Long Island Sound, Bridgeport has a large and diverse elderly population with 16,000 residents aged 65 or older encompassing a breadth of socioeconomic conditions and ethnic backgrounds (U.S. Census Bureau, 2012; Figure 1). Over the coming century, the elderly community of Bridgeport is predicted to experience multiple climatic stressors including: Figure 1. View largeDownload slide Map showing the location of Bridgeport, CT. Base map prepared by the State of Connecticut Department of Energy and Environmental Protection (2013). Figure 1. View largeDownload slide Map showing the location of Bridgeport, CT. Base map prepared by the State of Connecticut Department of Energy and Environmental Protection (2013). increasing average temperatures of between 3 °F and 10 °F, a doubling of days over 90 °F, sea level rise of 1–4 feet, a doubling of high precipitation events, and increasing air pollution and allergens. (Melillo et al., 2014) In addition, the elderly community’s previous experience with related climate stressors serves as effective precedents in assessing vulnerabilities and coping capacities. In considering their vulnerability, the research engaged elderly participants in investigating five questions: How are elderly residents of Bridgeport currently affected by climate-related stressors? What factors contribute to their vulnerability to those stressors? What strategies do they currently employ to prepare for, cope with, and recover from the impacts of those climate-related stressors? How will climate change alter their experience dealing with climate-related stressors? What are their most pressing concerns in relation to their vulnerability to climate change? This research was conducted in two phases. The initial phase consisted of two participatory meetings open to the elderly community of Bridgeport wherein the participants considered their vulnerability to climate change and collaborated with the lead researcher to develop a research instrument in the form of a survey to examine elders’ concerns over climate change. The second phase of the research consisted of administration of the survey to a different sample of older adults. The participatory meetings were held at Bridgeport’s main senior center. Demographic data were collected from meeting participants via surveys to ensure a diverse representation of the city’s population was included. The first meeting began with a presentation about historical and predicted climate trends in Bridgeport focusing on temperature and extreme heat, flooding and storms, and air pollution and allergens. Following the presentation, participants divided into working groups to answer research questions one through four in the context of a specific climate stressor; either extreme heat, flooding and storms, or air pollutants and allergens. In their discussions, each group utilized antecedent and consequence mapping to identify potential factors affecting their vulnerability (Stringer, 2007). A summary document of the discussions was shared with participants at the second meeting. Participants offered feedback, which was incorporated into the findings. Participants then reviewed recent climate predictions for Bridgeport and discussed how their vulnerability to each stressor might change. The results of this discussion were reviewed by the participants and their feedback was incorporated. Focusing on the fifth research question, the participants collaborated with the lead researcher on developing a Likert scale survey to allow elderly community members to rank their level of concern over 31 factors that could contribute to their vulnerability. These factors were based on the discussions during the two meetings and supplemented by issues raised in the scientific literature. The Likert scale had five points ranging from “unconcerned” to “very concerned.” For the second phase of the research, the survey was distributed in English and Spanish through organizations that engage with the elderly community. This approach was decided based on the participants’ recommendation and in an effort to reach a diverse representation of Bridgeport’s elderly adults. Demographic data were collected from a random subset of one in five survey respondents to ensure that surveys results reflected Bridgeport’s elderly adults. Survey results were analyzed to note respondents’ average level of concern over each factor. In addition, the number of highly concerned responses (responses of a four or five) was totaled for each question. Results Phase 1: Participatory Meetings Sample Fifty-five residents of Bridgeport who were age 65 or older participated in the two vulnerability assessment meetings. They comprised a diverse representation of Bridgeport’s elderly community (Table 1). Furthermore, as the participants considered their vulnerability to climate change, they made a concerted effort to consider how their fellow elderly community members not in attendance might be affected. Table 1. Demographic Comparison of Vulnerability Assessment Meeting Participants With General Elderly Population of Bridgeport Category Elderly population in Bridgeport Meeting participants (n = 55) Survey respondents (n = 35a) Age (average) 74.2 73.8 75.3 Age by cohort (%)  65–74 n/a 60 51.4  75–84 n/a 24 25.7  85+ n/a 16 22.9 Gender (%)  Female 60.8 78.1 77.1  Male 39.2 11.9 22.9 Race (%)  Asian 2.8 1.8 2.9  Black or African American 28.3 61.8 54.3  White 63.3 25.5 28.6  Other 5.6 10.9 14.3 Hispanic or Latino (%) 22.1 16.7 23.5 Living alone (%) 59.9 49 51.4 Educational attainment (%)  Less than a high school degree 41.3 37.7 42.9  High school degree or equivalent 34.1 41.5 37.1  Some college/associates degree 14.6 15.1 11.4  Bachelors degree or higher 10.1 5.6 8.6 Living with a disability (%) 41 56.6 52.9 Primary language (%)  English n/a 84.6 77.1  Spanish n/a 9.1 14.3  Greek n/a 1.8 2.9  Portuguese n/a 3.6 2.9  Chinese n/a 1.8 2.9 Speak English less than very well (%) 29 10.9 17.1 Employment (%)  Full or part time 15.9 13.5 14.3  Unemployed or retired 84.1 86.5 85.7 Household income (%)  Less than $10,000 n/a 58.7 55.2  $10,000–$20,000 n/a 26.1 17.2  $20,000–$40,000 n/a 13 20.7  $40,000+ n/a 4.3 6.9 Housing status (%)  Owner occupied 55.6 40 63.3  Renter occupied 44.4 60 36.7 Category Elderly population in Bridgeport Meeting participants (n = 55) Survey respondents (n = 35a) Age (average) 74.2 73.8 75.3 Age by cohort (%)  65–74 n/a 60 51.4  75–84 n/a 24 25.7  85+ n/a 16 22.9 Gender (%)  Female 60.8 78.1 77.1  Male 39.2 11.9 22.9 Race (%)  Asian 2.8 1.8 2.9  Black or African American 28.3 61.8 54.3  White 63.3 25.5 28.6  Other 5.6 10.9 14.3 Hispanic or Latino (%) 22.1 16.7 23.5 Living alone (%) 59.9 49 51.4 Educational attainment (%)  Less than a high school degree 41.3 37.7 42.9  High school degree or equivalent 34.1 41.5 37.1  Some college/associates degree 14.6 15.1 11.4  Bachelors degree or higher 10.1 5.6 8.6 Living with a disability (%) 41 56.6 52.9 Primary language (%)  English n/a 84.6 77.1  Spanish n/a 9.1 14.3  Greek n/a 1.8 2.9  Portuguese n/a 3.6 2.9  Chinese n/a 1.8 2.9 Speak English less than very well (%) 29 10.9 17.1 Employment (%)  Full or part time 15.9 13.5 14.3  Unemployed or retired 84.1 86.5 85.7 Household income (%)  Less than $10,000 n/a 58.7 55.2  $10,000–$20,000 n/a 26.1 17.2  $20,000–$40,000 n/a 13 20.7  $40,000+ n/a 4.3 6.9 Housing status (%)  Owner occupied 55.6 40 63.3  Renter occupied 44.4 60 36.7 Note: n/a = not applicable. Data for the general elderly population in Bridgeport are taken from the U.S. Census Bureau’s American Community Survey (2012). aThe 35 survey respondents represent a subset comprising 21% of the 164 total survey respondents. View Large Table 1. Demographic Comparison of Vulnerability Assessment Meeting Participants With General Elderly Population of Bridgeport Category Elderly population in Bridgeport Meeting participants (n = 55) Survey respondents (n = 35a) Age (average) 74.2 73.8 75.3 Age by cohort (%)  65–74 n/a 60 51.4  75–84 n/a 24 25.7  85+ n/a 16 22.9 Gender (%)  Female 60.8 78.1 77.1  Male 39.2 11.9 22.9 Race (%)  Asian 2.8 1.8 2.9  Black or African American 28.3 61.8 54.3  White 63.3 25.5 28.6  Other 5.6 10.9 14.3 Hispanic or Latino (%) 22.1 16.7 23.5 Living alone (%) 59.9 49 51.4 Educational attainment (%)  Less than a high school degree 41.3 37.7 42.9  High school degree or equivalent 34.1 41.5 37.1  Some college/associates degree 14.6 15.1 11.4  Bachelors degree or higher 10.1 5.6 8.6 Living with a disability (%) 41 56.6 52.9 Primary language (%)  English n/a 84.6 77.1  Spanish n/a 9.1 14.3  Greek n/a 1.8 2.9  Portuguese n/a 3.6 2.9  Chinese n/a 1.8 2.9 Speak English less than very well (%) 29 10.9 17.1 Employment (%)  Full or part time 15.9 13.5 14.3  Unemployed or retired 84.1 86.5 85.7 Household income (%)  Less than $10,000 n/a 58.7 55.2  $10,000–$20,000 n/a 26.1 17.2  $20,000–$40,000 n/a 13 20.7  $40,000+ n/a 4.3 6.9 Housing status (%)  Owner occupied 55.6 40 63.3  Renter occupied 44.4 60 36.7 Category Elderly population in Bridgeport Meeting participants (n = 55) Survey respondents (n = 35a) Age (average) 74.2 73.8 75.3 Age by cohort (%)  65–74 n/a 60 51.4  75–84 n/a 24 25.7  85+ n/a 16 22.9 Gender (%)  Female 60.8 78.1 77.1  Male 39.2 11.9 22.9 Race (%)  Asian 2.8 1.8 2.9  Black or African American 28.3 61.8 54.3  White 63.3 25.5 28.6  Other 5.6 10.9 14.3 Hispanic or Latino (%) 22.1 16.7 23.5 Living alone (%) 59.9 49 51.4 Educational attainment (%)  Less than a high school degree 41.3 37.7 42.9  High school degree or equivalent 34.1 41.5 37.1  Some college/associates degree 14.6 15.1 11.4  Bachelors degree or higher 10.1 5.6 8.6 Living with a disability (%) 41 56.6 52.9 Primary language (%)  English n/a 84.6 77.1  Spanish n/a 9.1 14.3  Greek n/a 1.8 2.9  Portuguese n/a 3.6 2.9  Chinese n/a 1.8 2.9 Speak English less than very well (%) 29 10.9 17.1 Employment (%)  Full or part time 15.9 13.5 14.3  Unemployed or retired 84.1 86.5 85.7 Household income (%)  Less than $10,000 n/a 58.7 55.2  $10,000–$20,000 n/a 26.1 17.2  $20,000–$40,000 n/a 13 20.7  $40,000+ n/a 4.3 6.9 Housing status (%)  Owner occupied 55.6 40 63.3  Renter occupied 44.4 60 36.7 Note: n/a = not applicable. Data for the general elderly population in Bridgeport are taken from the U.S. Census Bureau’s American Community Survey (2012). aThe 35 survey respondents represent a subset comprising 21% of the 164 total survey respondents. View Large Current Impacts Participants described multiple ways in which they and their fellow elderly community members are currently affected by extreme heat, air pollution, and flooding and storms. As a result of extreme heat and elevated air pollution, participants noted physical ailments including general pain and discomfort, difficulty breathing, and difficulty sleeping. Participants experienced psychological impacts including anxiety, depression, and irritability. In more severe cases, participants described illness and hospitalization following extreme heat and high levels of air pollution. Participants explained how these events can serve to trap elders in their homes, leading to isolation and difficulty accessing needed resources or services, including groceries, medicine, or medical treatments. As one participant stated, “If it gets too hot, I just have to stay inside my house and can’t go out.” Participants noted that storms and flooding could lead to physical injury followed by a prolonged and difficult recovery process. In addition, if electricity goes out as a result of a storm, elders could be unable to run needed medical equipment, heat or cool their homes, cook, or refrigerate food. Loss of electricity could also result in the spoilage of medication, such as insulin, that requires refrigeration. Elders dependent on an elevator or stair lift could become trapped in their home. Participants described challenges traveling to get medications and medical treatments, as well as running errands during or following a storm. They explained the effects of storms and flooding can make it difficult for caregivers to access elders during and following storms or flooding. In addition, participants described ways that storms and flooding can result in damage to their property, with floods filling basements with water, and high winds damaging roofing or siding and bringing down limbs on their yard or house. They explained how these impacts in turn can have health impacts. For example, sewage overflow and mold contamination following flooding can make elders’ homes unsafe and result in illness if left untreated. Finally, participants noted challenges coping with trauma and stress following storms and flooding. Current Vulnerability Participants identified a number of personal characteristics and contextual factors that contribute to their vulnerability to these stressors. Personal characteristics Participants noted a variety of personal characteristics that contributed to their vulnerability to climate change. Among the most influential, they highlighted chronic health conditions prevalent among elderly adults that can increase their sensitivity to climate change by causing adverse reactions to climate-related stressors. Participants noted adverse reactions to high temperatures worsened by diabetes. They described how conditions including asthma, lung infection, and chronic obstructive pulmonary disease can lead to severe reactions to air pollution. Living with a disability was highlighted as an important factor potentially reducing adaptive capacity. As an example, participants described how traveling to a cooling center or shelter in a heat wave or storm can be extremely difficult for individuals confined to a wheelchair. They noted how challenges with traveling can be exacerbated in emergency situations. Participants described how Alzheimer’s and other cognitive impairments can present challenges throughout the hazard life cycle, making it difficult for elders to receive and comprehend warnings, take needed steps to protect themselves, and navigate potentially complex recovery processes. They highlighted that poor hearing can make it difficult for elders to hear or comprehend warnings associated with extreme weather and climate-related stressors. They described how impairments and diseases can make elderly individuals dependent on the support of caregivers, leaving them at heightened risk during events such as storms or flooding that can prevent caregivers from gaining access to them. Participants highlighted living by oneself as contributing to the vulnerability of some elderly adults. Participants suggested that these individuals might be less likely to receive important warnings or instructions regarding climate-related stressors. Isolated elders with a limited ability to use communication technology could be at even greater risk of failing to receive warnings. Participants noted how isolated elders may lack the social support network to help them respond to emergency situations. Participants voiced concern that these elders may not have the support needed to recover from illness, injury, trauma, or property damage. As one participant commented, “If there is a big storm, I don’t have any living relatives to come check on me and see if I need help.” Participants identified a number of ways that lack of employment and living on a low or fixed income can reduce adaptive capacity. As a result, elders may lack the money needed to gather emergency supplies and make preparations to be able to safely take shelter at home in a storm or other emergency. They may also be unable to pay for alternative shelter in an emergency or conduct repairs or clean up after a storm or flood. In the context of extreme heat and air pollution, financial limitations can prevent elderly individuals from purchasing and running air conditioning or dehumidifiers. Economic limitations can also make receiving needed medical treatment or medication following an injury or illness more challenging. In addition to highlighting challenges associated with low income, participants observed that individuals with a limited command of the English language can face difficulties receiving warnings of impending severe weather, taking steps to protect themselves, and receiving needed support as part of the recovery process. Participants noted that minority status and a lack of formal educational attainment could also pose challenges, but these characteristics were not discussed in depth by the group. Contextual factors Participants highlighted four contextual factors that can enhance or limit the adaptive capacity of elderly adults. These contextual factors are as follows: adequacy of transportation resources, effectiveness of public warning mechanisms, availability of resources to promote safe shelter, and adequacy of resources to aid in coping and recovery. Adequacy of transportation resources.  Participants noted that adequate transportation resources are vital for elderly individuals to gather resources to prepare for climate-related stressors, seek safe shelter away from home, and access resources and services to aid in their recovery. Many of the personal characteristics described previously, including certain disabilities, diminished sensory awareness, and financial limitations, can make it difficult for elderly individuals to drive or own a car. As a result, many elderly adults are dependent on public transportation for meeting these needs. Even for individuals who can normally drive, inclement weather and flooding during severe storms may make them unable to drive or uncomfortable doing so, causing them to seek alternative transportation. As a result, participants explained their vulnerability to climate-related stressors depended in part on the availability of transportation options to bring them from their home to grocery stores, shelters, cooling centers, clinics, and hospitals. Given the limited financial resources of many elders, participants noted these options have to be inexpensive. They highlighted that transportation options must accommodate and support individuals with a variety of disabilities and people who need to bring specialized medical equipment or supplies. Finally, they highlighted that elders need to be aware of transportation resources and how to access them. Effectiveness of warning mechanisms. Participants noted it is important for elders to receive adequate warning of upcoming climate-related stressors so that they can protect themselves. Again, personal characteristics, including social isolation, cognitive impairments, diminished sensory awareness, and a lack of technological fluency, make it difficult for governments or other support organizations to provide elders with adequate warning. It is even more difficult to reach elders with limited English-speaking ability. To overcome these challenges, participants noted it is important for warnings to be distributed using appropriate technology to reach older adults, with information relevant to the elders, and be communicated clearly in a manner that will be understandable to elders with a variety of cognitive and sensory capacities. Considering appropriate technology for distributing warnings, participants suggested they preferred to be contacted by telephone or in person. Availability of resources to promote safe shelter. Participants noted the importance of having access to safe shelter during extreme weather or other climate-related stressors. They explained this could include making their home safe, either through home repairs to weather storms or through purchasing and running air conditioning in a heat wave or period of elevated air pollution. Financial limitations can make this challenging for many elders and prohibit them from paying for alternate shelter in an emergency. As a result, participants highlighted the importance of having emergency shelters and cooling centers available. They noted that shelters and cooling centers need to be able to accommodate elders with special needs and that elders need to be aware of their location. This is not always the case, as one participant commented, “I have no idea where they are or what to bring.” In addition, participants highlighted the importance of having adequate transportation resources to bring elders to shelters or cooling centers. Adequacy of resources to aid in coping and recovery. The participating elders noted the importance of resources to aid in coping and recovery. They described how financial limitations, disabilities, and chronic medical conditions can make it difficult for elders to travel to or afford needed medical treatments or medications. Elders with these conditions could have difficulty accomplishing essential tasks during or following a climate-related stressor. These conditions can make it difficult for elders to undertake or pay for home repairs or clean up after storms. Elders highlighted the importance of support in these diverse aspects of coping and recovery. As with the other factors, they noted that elders need to be aware of resources and accessing them needs to be simple enough for them to navigate. Current Adaptive Strategies and Resources Participants shared a number of adaptive strategies and resources they currently employ to prepare for, cope with, and recover from extreme weather and other climate-related stressors. In the context of extreme heat and air pollution, they explained how they often remain indoors at home, but noted this can lead to ongoing isolation and prohibit elderly individuals from running important errands to obtain medical treatments and groceries. Some participants described closing their windows and running air conditioning, but added this presents an additional expense that many elders cannot afford. One participant compellingly explained, “It sets a double standard, where those who can afford it can protect themselves, but those who can’t, especially those living alone and on a fixed income, are more at risk.” During periods of extreme heat, participants highlighted additional ways they modify their behavior, including dressing light, drinking extra fluids, taking cool showers, closing blinds, and eating light foods. In the context of air pollution, some participants noted they use breathing machines, which again makes it difficult for them to travel and run errands. Finally, as a result of extreme heat and air pollution, participants explained they sometimes need to travel to the hospital for treatments. When this occurs, participants described it can be physically difficult to travel, financially burdensome, and overly time consuming. In the context of flooding and storms, some elders mentioned needing to seek shelter in a hotel if they felt their home was or might become unsafe. They noted this was an expensive option that was challenging or unavailable for many elders given their limited economic resources. Other participants described staying with friends and family during or following a storm if their home might be unsafe or was damaged. Again, participants explained this would not be an option for isolated elders lacking a local social support network. Finally, following floods and storms, participants described how they were often incapable of undertaking the needed cleanup or repairs and had to pay for those services. Participants highlighted the challenges of paying for this added expense. Potential Impacts of Predicted Climate Changes on Elderly Adult’s Vulnerability Participants described two primary ways their vulnerability may be affected by predicted changes in extreme heat, flooding and storms, and air pollution and allergens. First, previously unaffected or little affected elders may be underprepared to cope with the increasing intensity of climate stressors. Second, the increasing intensity of climate stressors coupled with an increase in frequency could overwhelm the adaptive capacity of some elderly individuals. Currently, some elders may be largely unaffected by climate-related stressors. As climate change progresses, however, these individuals may begin to be adversely affected and find themselves unprepared and without any coping experience. The lack of preparedness and coping strategies could heighten their vulnerability. For example, an older adult’s basement may have never flooded previously, but increases in heavy precipitation events could result in severe flooding causing damage to the residence. As another example, an older adult who has been previously unaffected by high-temperature days may find herself experiencing heat related illnesses as the intensity of heat waves increases. In both cases, the individuals could lack important information and strategies and, as a result, could face significant challenges coping with and recovering from these novel impacts. Even elders previously affected by certain climate-related stressors may find their adaptive strategies insufficient to protect themselves from predicted changes. Participants suggested that even small changes in the intensity of climate-related stressors can have a significant impact on some elders. As one elder shared, “Even a difference of a couple degrees in temperature can be a big deal to me.” Participants noted, in both cases, the risk to elders could be increased if they underestimate the severity of future extreme weather events. They suggested that elderly individuals may base their decision making about how to prepare for future events on previous experience. If certain climate stressors increase in intensity, it could result in elders underpreparing for more severe events, thereby putting themselves more at risk. Even if elders perceived the risks they face as severe and wished to protect themselves, climate change could overwhelm their adaptive capacity. As participants described, the adaptive capacity of many elders can be limited by factors including a lack of financial resources, social isolation, health conditions and disabilities, and marginalization. As was illustrated in the descriptions of adaptive strategies elderly adults currently employ, many of their approaches can have secondary impacts that further draw down their existing adaptive capacity. If elders are forced to employ these adaptive strategies to a greater degree, the secondary impacts could exhaust their economic, physical, mental, and social resources. This is exemplified by one participant’s concern, “Sure I could run my AC more, but that costs more money that I don’t have, so where am I going to get the money from?” In addition, climate stressors will not be changing in isolation, but predictions contend that extreme heat, flooding and storms, and air pollution will increase in concert. Even if individuals were able to muster the resources to safeguard themselves from increases in one stressor, concurrent increases in other stressors may prove overwhelming. For example, if the previously quoted participant could find the financial resources to run additional air conditioning to cope with increasing temperatures, concurrent increases in home repair costs from more severe storms may be more than she could afford. Phase 2: Survey Results Sample A total of 164 elders completed the survey and, although not a random sample, demographic data collected from a random subset of one in five respondents demonstrates that the survey reached a diverse representation of Bridgeport’s elderly community (Table 1). The demographic data also show that the survey reached segments of the elderly population with characteristics, such as living alone or on a low income, that may put them at heightened risk to climate-related stressors. Respondent Concerns The survey results highlight the respondents’ generally high level of concern over climate-related stressors (Table 2). Respondents ranked 14 of the 31 questions as an average of three or above, and more than 30% of respondents ranked 23 of the 31 questions as high concerns (four or five on the Likert scale). Some of the respondents’ most pressing concerns focused on receiving adequate warning. This included concerns over not receiving warnings or receiving warnings that do not have enough information or are hard to understand. Respondents also expressed heightened concern over factors related to shelter, including concerns over the safety of their homes, difficulties getting to shelters, the safety and comfort of shelters, and their abundance. In addition, respondents ranked issues related to getting assistance and the recovery process as particularly concerning. These included concerns over traveling to the hospital both during and following climate-related stressors, getting food and supplies, doing essential activities while electricity is out, coping with trauma and stress, and conducting repairs and clean up following a storm or flood. Table 2. Survey Results Showing Respondents’ Average Level of Concern Over Various Issues Associated With Extreme Weather and Percentage of Respondents Ranking Each Issue as a High Concern (n = 164) Issue Average level of concern % Highly concerned Receiving adequate warning  Will not receive warning 3.58 50  Warning will not have enough info 3.74 62  Warning will be hard to understand 3.48 51  Warning will not be in my language 1.97 18 Staying safe at home  My house is unsafe and cannot afford to fix 3.29 47  Cannot afford to run AC in heat wave 2.76 36   Cannot afford to run AC in air pollution 2.67 35 Having adequate transportation resources  Lack of public transportation where I live 2.49 29  Lack of ride sharing where I live 2.89 39  Public transport is too expensive 2.46 26  Can not afford transportation in emergency 2.54 27  It is physically difficult for me to travel 2.29 19  It is hard to travel because of equip needs or medicine 2.07 16 Finding safe shelter  Do not know where shelter is located 2.92 39  Hard for me to get to shelter 3.01 46  Shelters are unsafe 3.14 44  Shelters are uncomfortable 3.08 40  There are not enough shelters 3.45 57  Hard for me to stay in shelter because of equip needs or medicine 2.48 28 Getting needed assistance  No one will check on me during or after extreme weather 2.90 30  Do not know emergency numbers 2.86 38  Will not be able to leave my building if power is out 2.19 19  Will be difficult for caregivers to reach me in storm 2.65 32  Will be difficult to get to hospital or get medicine during or after extreme weather 3.08 43  Will be difficult to get food and supplies during or after extreme weather 3.25 47  If electricity is out, will be difficult to do essential activities 3.45 51 Having resource to aid in recovery  Difficult to cope with trauma and stress 3.05 36  Difficult to travel to hospital for treatment if injured or sickened 3.27 47  Difficult to afford medication or treatment if injured or sickened 2.93 34  Will not have needed support to do daily tasks if injured or sickened 2.94 32  Difficult to do clean up or repairs to property 3.19 47 Issue Average level of concern % Highly concerned Receiving adequate warning  Will not receive warning 3.58 50  Warning will not have enough info 3.74 62  Warning will be hard to understand 3.48 51  Warning will not be in my language 1.97 18 Staying safe at home  My house is unsafe and cannot afford to fix 3.29 47  Cannot afford to run AC in heat wave 2.76 36   Cannot afford to run AC in air pollution 2.67 35 Having adequate transportation resources  Lack of public transportation where I live 2.49 29  Lack of ride sharing where I live 2.89 39  Public transport is too expensive 2.46 26  Can not afford transportation in emergency 2.54 27  It is physically difficult for me to travel 2.29 19  It is hard to travel because of equip needs or medicine 2.07 16 Finding safe shelter  Do not know where shelter is located 2.92 39  Hard for me to get to shelter 3.01 46  Shelters are unsafe 3.14 44  Shelters are uncomfortable 3.08 40  There are not enough shelters 3.45 57  Hard for me to stay in shelter because of equip needs or medicine 2.48 28 Getting needed assistance  No one will check on me during or after extreme weather 2.90 30  Do not know emergency numbers 2.86 38  Will not be able to leave my building if power is out 2.19 19  Will be difficult for caregivers to reach me in storm 2.65 32  Will be difficult to get to hospital or get medicine during or after extreme weather 3.08 43  Will be difficult to get food and supplies during or after extreme weather 3.25 47  If electricity is out, will be difficult to do essential activities 3.45 51 Having resource to aid in recovery  Difficult to cope with trauma and stress 3.05 36  Difficult to travel to hospital for treatment if injured or sickened 3.27 47  Difficult to afford medication or treatment if injured or sickened 2.93 34  Will not have needed support to do daily tasks if injured or sickened 2.94 32  Difficult to do clean up or repairs to property 3.19 47 Note: For Likert scale, 1 = unconcerned and 5 = very concerned. For % highly concerned, a ranking of a 4 or 5 is considered a high level of concern. View Large Table 2. Survey Results Showing Respondents’ Average Level of Concern Over Various Issues Associated With Extreme Weather and Percentage of Respondents Ranking Each Issue as a High Concern (n = 164) Issue Average level of concern % Highly concerned Receiving adequate warning  Will not receive warning 3.58 50  Warning will not have enough info 3.74 62  Warning will be hard to understand 3.48 51  Warning will not be in my language 1.97 18 Staying safe at home  My house is unsafe and cannot afford to fix 3.29 47  Cannot afford to run AC in heat wave 2.76 36   Cannot afford to run AC in air pollution 2.67 35 Having adequate transportation resources  Lack of public transportation where I live 2.49 29  Lack of ride sharing where I live 2.89 39  Public transport is too expensive 2.46 26  Can not afford transportation in emergency 2.54 27  It is physically difficult for me to travel 2.29 19  It is hard to travel because of equip needs or medicine 2.07 16 Finding safe shelter  Do not know where shelter is located 2.92 39  Hard for me to get to shelter 3.01 46  Shelters are unsafe 3.14 44  Shelters are uncomfortable 3.08 40  There are not enough shelters 3.45 57  Hard for me to stay in shelter because of equip needs or medicine 2.48 28 Getting needed assistance  No one will check on me during or after extreme weather 2.90 30  Do not know emergency numbers 2.86 38  Will not be able to leave my building if power is out 2.19 19  Will be difficult for caregivers to reach me in storm 2.65 32  Will be difficult to get to hospital or get medicine during or after extreme weather 3.08 43  Will be difficult to get food and supplies during or after extreme weather 3.25 47  If electricity is out, will be difficult to do essential activities 3.45 51 Having resource to aid in recovery  Difficult to cope with trauma and stress 3.05 36  Difficult to travel to hospital for treatment if injured or sickened 3.27 47  Difficult to afford medication or treatment if injured or sickened 2.93 34  Will not have needed support to do daily tasks if injured or sickened 2.94 32  Difficult to do clean up or repairs to property 3.19 47 Issue Average level of concern % Highly concerned Receiving adequate warning  Will not receive warning 3.58 50  Warning will not have enough info 3.74 62  Warning will be hard to understand 3.48 51  Warning will not be in my language 1.97 18 Staying safe at home  My house is unsafe and cannot afford to fix 3.29 47  Cannot afford to run AC in heat wave 2.76 36   Cannot afford to run AC in air pollution 2.67 35 Having adequate transportation resources  Lack of public transportation where I live 2.49 29  Lack of ride sharing where I live 2.89 39  Public transport is too expensive 2.46 26  Can not afford transportation in emergency 2.54 27  It is physically difficult for me to travel 2.29 19  It is hard to travel because of equip needs or medicine 2.07 16 Finding safe shelter  Do not know where shelter is located 2.92 39  Hard for me to get to shelter 3.01 46  Shelters are unsafe 3.14 44  Shelters are uncomfortable 3.08 40  There are not enough shelters 3.45 57  Hard for me to stay in shelter because of equip needs or medicine 2.48 28 Getting needed assistance  No one will check on me during or after extreme weather 2.90 30  Do not know emergency numbers 2.86 38  Will not be able to leave my building if power is out 2.19 19  Will be difficult for caregivers to reach me in storm 2.65 32  Will be difficult to get to hospital or get medicine during or after extreme weather 3.08 43  Will be difficult to get food and supplies during or after extreme weather 3.25 47  If electricity is out, will be difficult to do essential activities 3.45 51 Having resource to aid in recovery  Difficult to cope with trauma and stress 3.05 36  Difficult to travel to hospital for treatment if injured or sickened 3.27 47  Difficult to afford medication or treatment if injured or sickened 2.93 34  Will not have needed support to do daily tasks if injured or sickened 2.94 32  Difficult to do clean up or repairs to property 3.19 47 Note: For Likert scale, 1 = unconcerned and 5 = very concerned. For % highly concerned, a ranking of a 4 or 5 is considered a high level of concern. View Large Discussion This study of the elderly community of Bridgeport, CT, provides an in-depth exploration of the numerous and potentially serious ways elders are affected by climate-related stressors including extreme heat, air pollution, and flooding and storms. It illustrates how these impacts can be experienced in a range of ways including physical injury, anxiety, stress, social isolation, financial hardship, and damage to physical property. It shows how even relatively minor impacts often overlooked in the broader literature on disasters and elderly adults can present significant challenges to some elders. For example, a downed limb in an elder’s yard following a storm could cause emotional stress, physical injury, or financial hardship. This study demonstrates how multiple personal characteristics associated with advancing age serve to increase their vulnerability. The participants’ description of factors contributing to their current vulnerability, including chronic health conditions, physical and cognitive disabilities, social isolation, and economic limitations, echoes findings from other studies on the vulnerability of elderly adults to climate stressors (for comparison, see Eldar, 1992; Fernandez et al., 2002; Gamble et al., 2013; Ngo, 2001). The relevance of the participants’ assessment is also evidenced by demographic data of Bridgeport’s elderly adults. For example, as of 2012, 41% of Bridgeport’s elderly adults lived with a disability, 59.9% lived alone, 84.1% were unemployed or retired, and 17.3% lived below the poverty line (U.S. Census Bureau, 2012). Given these high percentages, substantial portions of the elderly community of Bridgeport are likely to have one or multiple personal characteristic heightening their vulnerability. Factors associated with marginalization were less prominent in the participants’ discussion, but may also contribute to their vulnerability. Gamble and colleagues (2013) identified minority status, little formal education, and low-income levels as aspects of marginalization potentially putting elders at risk. Given the significant percentages of Bridgeport’s elders with these demographic characteristics (Table 1), it seems likely that marginalization could contribute to the vulnerability of a substantial fraction of the elderly community. Participants may have been hesitant to explore this potentially sensitive subject matter at an open meeting and alternative research approaches, such as individual interviews, may be needed to explore these aspects in depth. The personal characteristics identified can vary greatly from one elder to the next and advancing age is not in itself a determinant of vulnerability. For those elders, however, who are more vulnerable as a result of these characteristics, there may be little they can do at the individual level to protect themselves and predicted climate changes could overwhelm their limited capacity to adapt. This is especially worrisome as many of the participating elders’ current adaptation strategies had negative secondary impacts or restrictions limiting their effectiveness. As a result, contextual factors, including the effectiveness of warning mechanisms, adequacy of public transportation, availability of resources to promote safe shelter, and adequacy of resources to aid in coping and recovery, will be vital in keeping elders safe. The participants’ descriptions of these factors may be of value to those developing adaptation strategies. For example, when considering warning mechanisms, participants requested to be contacted on the phone or in person. This suggests a need to employ automated phone warnings and to mobilize community organizations when reaching out to elderly individuals. As another example, participants continually stressed the importance of resources being affordable, easily accessible for elders, and effectively promoted among elders to generate widespread awareness. To design adaptation measures that meet the needs of older adults, it is also important to understand which contextual factors they are most concerned about. In the context of the current research, the survey allowed elders to rate their relative level of concern over a range of factors. The survey illustrated elders’ generally high level of concern and the broad nature of those concerns. It also points toward those factors elders felt were most worrisome, such as concerns over not receiving warnings or of warnings having inadequate information. Although it is important to note the most prominent concerns, it is also important to pay attention to concerns that might be held by specific subgroups within the elderly community. As the meeting participants discussed, vulnerability is affected by personal characteristics that vary greatly among elders. Certain subgroups within the community many have concerns based on unique aspects of their vulnerability. For example, concerns over not receiving warnings in a language you understand only affect elderly individuals who do not speak English or speak it poorly. Although this subgroup only represents 29% of the city’s total elderly population, and so their concern will not be shared generally, it is an important factor contributing to the vulnerability of those individuals. This relatively low level of overall concern but high level of concern within a specific subgroup is seen in the survey results, with concern over warnings not being in an individual’s language ranking a 1.97 overall, but with 18% of respondents ranking this as a high concern. Although not shared by the larger community, their concern deserves due consideration by government agencies and other organizations working to support older adults. Such a perspective presents the survey results in an additional light, as all 31 questions were ranked as high concerns by over 15% of respondents. A limitation of this aspect of the research is that only one in five survey respondents provided demographic data and so the demographic composition of the respondents is not known with the same precision as with the meeting participants. Demographic data were collected from a subset to reduce the effort required by elders filling out the survey, but in future research, the benefits of establishing a complete demographic profile may outweigh this consideration. Despite this limitation, the clear indication from the survey of a generally high level of concern spreading over diverse issues warrants consideration. It is interesting to note that there are programs in Bridgeport to address some of the concerns raised in the study but that elderly individuals were often unaware of them or how to utilize them (T. Jones, Public Health Emergency Preparedness Director with the City of Bridgeport, personal communication, April 27, 2015). Accordingly, the vulnerability of some elderly adults in Bridgeport may not be due to a lack of programs but due to poor awareness of available resources and a lack of emergency preparedness. This echoes the findings of a survey conducted by Al-Rousan and colleagues (2014) investigating elderly adult’s preparedness for natural disasters. Sampling elderly individuals across the United States, this study found two thirds of respondents did not have an emergency preparedness plan and were largely unaware of emergency resources. Furthermore, one third did not have basic food, water, and medical supplies in case of an emergency. These insights support the assertion by Gamble and colleagues (2013) that education and outreach should be important aspects of adaptation efforts targeted at elders. Within this context, an important question for Bridgeport and potentially for other locations will be not only how to develop additional programs to protect elders, but how to conduct the outreach and education efforts to raise awareness of existing resources and to enhance preparedness. Different approaches may be needed to reach elders with diverse backgrounds and characteristics and elders who are reluctant to acknowledge their own vulnerabilities may be particularly resistant to engaging in preparedness and planning activities. Although this study is limited to one location, aspects of this elderly community’s vulnerability may be applicable to other locations, especially other cities facing similar climate stressors and with similar socioeconomic characteristics among the elderly population. Given the multiple characteristics associated with aging that can serve to increase sensitivity and reduce adaptive capacity, it is possible that in other locations contextual factors will also play an important role safeguarding elders from the impacts of climate change. In addition, given the diverse socioeconomic and health characteristics that influence the vulnerability of older adults generally, it is possible that other communities might also hold a broad range of concerns regarding their vulnerability. Further studies in additional communities are needed to determine the degree of variability between sites and which facets of this study are transferable under different circumstances. This research could aid in developing vulnerability indicators capable of mapping the vulnerability of elders to climate change. Although this would fill a key gap highlighted by Gamble and colleagues (2013) in our ability to keep elders safe, it is important that indicator-based assessments do not preclude participatory processes that give voice to the local concerns. This research is also limited in its focus on the vulnerability of elderly individuals living independently. Elders in managed care facilities will likely have a different experience of climate-related stressors and the nature of their vulnerability could be dissimilar. Further research is needed to investigate vulnerability within this context. This study offers two resources to aid in future research: an adaptable framework for conducting participatory vulnerability assessments and a survey instrument for assessing individual and community concerns. The participatory assessment and survey instrument, however, have only been employed in this study. Both approaches should be considered works in progress and in need of ongoing refinement. For future applications, practitioners should expect to tailor them to site-specific conditions. Through ongoing application and refinement, these resources may be developed into generally applicable assessment tools. Conclusion Climate change poses a significant risk to older adults. With their first hand experience of climate stressors, elders’ insights into their own vulnerability could be of great help in efforts to keep them safe. This study illustrates the serious impacts climate change could have on elders, the importance of community level support, and the value of incorporating elders’ knowledge, perspective, and experience into vulnerability assessments. This study also presents two resources to aid in future research: an adaptable participatory framework for examining the vulnerability of elderly communities and a survey instrument to assess elders’ concerns. Through additional research, especially research integrating elders as participants, we can develop detailed understandings of the factors that increase or reduce their vulnerability in different contexts and better understand elders’ concerns. These understandings provide a basis for adaptation planning that can bring elderly communities together with local governments and a coalition of partners to help keep elders safe in a time of climate change. References Al-Rousan T. M. Rubenstein L. M. , & Wallace R. B . ( 2014 ). Preparedness for natural disasters among older US adults: A nationwide survey . American Journal of Public Health , 104 , 506 – 511 . doi: 10.2105/AJPH.2013.301559 Google Scholar CrossRef Search ADS PubMed Bunker A. Wildenhain J. Vandenbergh A. Henschke N. Rocklöv J. Hajat S. , & Sauerborn R . ( 2016 ). Effects of air temperature on climate-sensitive mortality and morbidity outcomes in the elderly: A systematic review and meta-analysis of epidemiological evidence . EBioMedicine , 6 , 258 – 268 . doi: 10.1016/j.ebiom.2016.02.034 Google Scholar CrossRef Search ADS PubMed Carter T. R. Fronzek S. Inkinen A. Lahtinen I. Lahtinen M. Mela H. , … Terama E . ( 2016 ). 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Washington, DC : U.S. Census Bureau . © The Author(s) 2017. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

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The GerontologistOxford University Press

Published: Feb 3, 2017

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