A series of focus groups was carried out to explore the feasibility of involving family and friends in assisting problem older drivers limit or stop unsafe driving. Results have been used to formulate solutions and interventions, and can be used in the future to develop themes and messages for a comprehensive, cohesive, and consistent social marketing campaign for driving safety.
The focus group technique represents a small group dynamics approach to social and other types of marketing research. Typically, eight to twelve specifically recruited participants (screened according to defined client specifications) are engaged in a roundtable discussion directed by an experienced moderator. This type of interactive environment encourages involvement among participants. Ideas and motivations are often uncovered which do not typically surface through conventional survey methods.
The focus group interview seeks to develop insight and direction rather than definitive or precise measures. Because of the size of the panels and screened recruitment employed, it should be clearly understood that the work is exploratory in nature. The findings must be regarded in relationship to the literature review and be considered directive for future quantitative study. Findings cannot be projected to make predictions about a larger population. Focus groups are conducted for the purpose of qualitative insight, such as gaining an understanding of the categories of thought, attitudes, and behaviors about specific issues; understanding reasons why people hold certain opinions or behave the way they do; and obtaining language target groups use to talk about issues for later use in communications to those targets, including information materials and quantitative survey questions.
Six focus groups with a total of 50 participants were conducted in St. Louis, Missouri, and Akron, Ohio, during May and July 1996. In St. Louis, two groups were conducted among female family and one among male family members concerned about an older driver. An additional group was conducted among professionals who work with atrisk older drivers and family and were serving as faculty at the International Symposium on Alzheimer's Disease and Driving sponsored by the Washington University School of Medicine.
In St. Louis, groups among female family members were divided into those whose family member had stopped driving and those whose family member was currently driving. Group participants were selected for their concern about an older driver with whom they have a close relationship; the older driver either still drove or stopped driving within the past 2 years; and the older driver had functional limitations caused by Alzheimer's disease or other dementia; vision disorder due to macular degeneration, cataracts, glaucoma or other vision impairment; or other condition, such as arthritis, diabetes, heart disease, stroke, etc., that may impair his/her ability to drive safely. Participants displayed a range in age from under 25 to over 80, martial status, relationship to the older driver (although most were spouses or adult children) living arrangements with the older driver, ethnicity, education, and number and ages of children.
In Akron, one group consisted of females who were concerned about an older driver and the other among a similar group of males. All participants were over age 55 with most over the age of 70. Most said they were concerned about a friend, but many were concerned about a sister, brotherinlaw, or other peer group relative.
Discussions concentrated on issues related to the feasibility of family and friends intervening on behalf of an older driver to assist that atrisk individual in modifying or stopping driving. Panelists were encouraged to share their stories and experiences related to unsafe older drivers, to relate interventions they had tried or would consider trying in this endeavor, and to evaluate these interventions for broader use among others who are concerned.
After introductions, family and friend panelists first discussed their concerns about a specific older driver with accounts and anecdotes about problem driving situations and outcomes and awareness of related medical conditions. Next these panelists discussed their involvement, if any; the involvement of professionals; barriers panelists faced in assisting the unsafe older driver to modify or stop driving; the resources the panelists used, if any, to assist them in getting the unsafe older driver to make safe driving decisions; and perceived transportation alternatives to driving for older adults.
In Missouri, family panelists were then shown a summary of the (then) pending Missouri state legislation for reporting impaired drivers, asked to rate their approval, and discussed their reasons for approval or disapproval of this legislation. In Akron groups, the discussions among friends focused on issues of reporting. Finally, panelists discussed their perceptions of the role family and friends may play in helping unsafe older drivers, what resources families and friends of unsafe older drivers need to help in the situation, and where to expect to find those resources.
The focus group among professionals in St. Louis followed a similar pattern. Group objectives centered on obtaining an understanding of the perceptions professionals have regarding the role of family and friends in assisting atrisk older drivers make safe driving decisions including:
How families become aware of the problem
Barriers to family involvement
Ascertaining the role of professionals in assisting older drivers, family and friends who may need interventions for driving modification and cessation.
Professionals were asked to consider and discuss how they perceive the problem of family/friend intervention; how professionals come in contact with family members; how professionals overcome barriers to family involvement; what resources they use; and unmet needs among families, friends, and professionals for helping atrisk older drivers and involving family members.
Focus Group Objectives
Specific focus group objectives were as follows:
Obtain an understanding of the characteristics of family and friends who might help a problem older driver modify or cease his/her driving.
Evaluate levels of awareness and observation of functional limitations that lead to problem driving.
Explore perceptions of current and potential ways family/friends may identify older adults who have problems driving safely.
Assess the ability of family/friends to help older people modify their driving on their own without legal procedures.
Investigate barriers to and motivations for family and friends regulating/reporting in their relationships with older drivers, such as levels of family functioning, and ability to make decisions regarding older family members; ability of friends or peers to keep older drivers from driving unsafely.
Explore issues and concerns including fear among family and friends about meddling in older drivers' private lives; loss of mobility through driving cessation of spouse and perceived presence of transportation alternatives to support mobility.
Assess the use of support groups such as health care professionals, driving assessment clinics, social service agencies, police, courts, and volunteer programs to assist older drivers.
Determine levels of knowledge regarding state reporting procedures and requirements and willingness to report to a variety of authorities: DMV, physician, and others who may assist in driving intervention.
Determine how state reporting procedures encourage or hinder family/friends reporting, including concerns that the state will inform who reported the older driver.
Identify the conditions under which family and friends would be likely to intervene to improve the driving decisions an older driver makes.
Summary of Focus Group Findings
Characteristics of Those Who Intervene
Those most likely to intervene to help the problem older driver modify or stop driving are those with strongest concern and caring for the older drivergenerally the same individuals who are likely to become caregivers or decisionmakers for care giving. Interventionists are most likely to be a spouse, or an adult child of an older driver. This suggests that a marketing campaign targeted to these family members, without alienating other relatives or friends, would be most successful.Awareness and Observation of Functional Limitations
Virtually all family members and friends are able to recognize unsafe driving behavior among the elderly of their concern. While many family and friends associate unsafe driving with specific medical conditions, many others do not do so. The common denominator for discussing impairments is functional, rather than related to a specific medical condition or diagnosis. Further, relatives seem to recognize signs of impairments well before a triggering incident or medical diagnosis occurs. Some individuals are faced with family members who refuse to go to a physician. This suggests that marketing materials should address areas of functional impairment, including early signs of medical conditions that would impair driving performance, and how to recognizeThe signs. Identification of AtRisk Driving
Family and friends characterize unsafe driving among older adults as forgetfulness, confusion, bad judgment, and/or not following the rules of the road; inability to see where they are going; and aggressive driving. Indicators of unsafe driving situations are an accident; new dents and dings on the older driver's car; neighbors, friends or others calling family members about the driving problem; police calling family members about the driving problem; and the family member or friend observing the unsafe driving while a passenger. Although most family and friends report a change from relatively safer driving to unsafe driving, a few noted unsafe driving over much of the family member's lifetime.
Specific patterns of unsafe driving family and friends mention include: driving too slow on the expressway, drives too fast and he'll drive right up on a car; weaves in and out of lanes; car parked in the yard; straddled the line frequently; slowed down for green lights; stopping for green lights; failed to stop for red lights; ignoring red lights; won't use turn signals; didn't look when backed out, didn't use the mirrors; couldn't find the gas pedal; couldn't find the brake. Interestingly, family members, friends, and professionals agree that unsafe older drivers also have noticeable impairments in the performance of other daily activities.
These findings suggest that family and friends could be encouraged through social marketing to look for signs of unsafe driving, along with other indicators of functional impairments, to recommend that the elder undergo a driving assessment by qualified personnel. Findings also suggest that geriatric assessment clinics and social service agencies that often deal with caregivers should consider establishing driving assessment clinics to assist older adults and families in making safe driving decisions.
Ability of Family Members and Friends to Intervene
A number of family members and friends had tried to intervene to get the problem older driver to modify their unsafe driving behavior or stop driving. Most who had success in intervening did so on their own, generally by removing the car keys and/or the car. Only a few had the support of a physician. None had the support of the police or DMV, although a some had tried and still others would have liked these authorities to have helped.
Although interventionists wanted and expected the support of physicians, the police, DMV, and lawmakers in their intervention attempts, this support was often lacking. Physicians did not always agree with family members about the seriousness of the problem. Given the lack of social norms about driving cessation and the strength of cultural norms for independence and mobility, the police and DMV officials often missed opportunities to intervene in the interest of public safety. This suggests that physicians, police, and others in a position to protect public safety, need to be informed about:
Levels of Family Functioning and Caregiving: Motivations and Barriers to Intervention
How to recognize impaired drivers
Assist family members in their interventions
Support legal efforts to get unsafe drivers off the roads
Advocate for public safety when independence and mobility become a threat to others.
Although intervention is difficult, at best, for those who intervened or potentially will, it appears that those who intervene are generally able to cope with most family interactions and relationships. This ability to cope, along with a strong concern for safety and feelings of responsibility, appears to provide interventionists with the motivations they need to intervene. Only a few would not be able to intervene. In these instances, the family member or friend does not define unsafe driving as serious enough for intervention at this time or is not able to cope with the perceived consequences of intervention and driving cessation. Conflicts over the perceived role reversal with the child guiding the parent and guilt in intervention; dependence by the older driver for rides; and being too busy to provide rides served as barriers to intervention.
These findings suggest that a social marketing campaign to remove unsafe drivers from the roads may help some of those less able to cope with an elder's impairments. Findings also suggest that social service agencies may increase their client base through outreach efforts to assist families and older adults early in the impairment process when the elder is still driving. Additional opportunities exist for transportation providers to target older adults who may be transitioning to driving cessation.Fear of Meddling
Fear of meddling appears to be a minor concern among family and friends. Most family members said they want to be told by friends, neighbors, coworkers, or others about an older relative's unsafe driving; most agepeers said they want to tell family members. Few family and friends said they would not tell the atrisk older driver, his/her family, or authorities about the elder's unsafe driving because they did not stick their nose in someone else's business. Only one relativea daughterinlawexpressed the belief that she is not a close enough relative to intervene and consequently left that task to her husband and his sister. A number of friends discussed their intervention on behalf of others, not all of which resulted in success. A few family members spoke negatively about nonrelatives who could have intervened but chose not to.Alternative Transportation
Many panelists were aware of alternative transportation, including public fixed route and demand responsive bus services, the Metro Link train service in St. Louis, church and organization services, and taxi cabs. Most panelists said they would encourage their older relative to use these alternatives, especially if the services met their travel needs. Some perceived current services to be inadequate to meet those needs. A few panelists said they or the older family member use these alternatives. A few others said they would not let their older relatives use public transportation. Most agreed that public policy initiatives should improve transportation alternatives so that older adults now and in the future will be able to give up driving more readily with the knowledge that they will remain independent and mobile.
These findings suggest that family and friends of atrisk older drivers should be targeted as well as older adults for support of alternative transportation services. Further, availability of transportation alternatives should be included in local social marketing campaigns.Use of Community Supports
Many panelists mentioned going to their physician for help. Because a number of panelists were recruited with the assistance of the Alzheimer's Association using their client base, it is not surprising that the most frequently cited community organization resource in St. Louis is the Alzheimer's Association. While this agency provides support for driving cessation for older adults as well as family members, it appears that unsafe driving may not be the primary reason family members first go to this agency for help. However, family members find a great deal of support at this agency through attending support groups and getting information related to the disease, and ideas for intervention. Generally, those affiliated with the Alzheimer's Association mentioned contacting the police or DMV for help. No one mentioned using another social service agency for help in driving cessation. Only one family member mentioned going to a driving assessment clinic. She and her husband went to a driving clinic 5 years earlier, when her husband, the atrisk older driver, perceived he was experiencing memory loss. He continued to go periodically for testing. No one mentioned being aware of or going to a volunteer organization for assistance in intervention. Further, professionals believed that there were few resources for older drivers and families related to safe driving decisions. Professionals also documented their unmet needs for information and education tools for themselves and for distribution to family members and atrisk older drivers.
These findings suggest that the physician is the most frequent contact for issues related to safe driving. Given the reluctance of many physicians to get involved with families and issues of driving cessation, the social marketing campaign must include and target healthcare personnel. Other community resources, such as social service agencies, police, and courts, should be included as well. Findings also indicate that volunteer groups that support safe driving decisions may be particularly valuable, provided these are guided and facilitated by qualified personnel. Ideally, community resources should have the ability to refer family and friends to a regional driving assessment clinic.Knowledge of State Reporting Procedures
Most panelists in Missouri and Ohio do not appear to have a good knowledge of reporting possibilities. Those who had tried to report for a retest or license revocation knew they could not report. Except for those affiliated with the Alzheimer's Association, most St. Louis panelists were unaware of then-pending legislation that would permit reporting in Missouri.Willingness to Report
About twothirds of panelists said they would be willing to report a problem older driver. Several had tried to report to the DMV for retesting and/or inquire about procedures for getting a license revoked. With no reporting regulations in Missouri and Ohio at that time, attempts to notify state authorities did not result in positive action. A number had also tried to enlist the help of the physician. While a few had success, others did not.
The remaining third of family and friends who hesitated to report focus their concerns on:
Reporting as a last resort, to be used when all else has failed
Anonymity and confidentiality for the reporter
Older driver not yet bad enough and knowing when unsafe driving is really bad
Revenge and retribution
Reporting leading directly to license revocation without a hearing or retest.
Focus group findings indicated a willingness to report among family members, especially when their own interventions have not succeeded. Results also suggest that issues of anonymity and confidentiality, while a barrier to a few, may be overcome through regulations that negate perceptions of possible revenge by the problem older driver. Development and institution of reporting regulations may coincide with that of the social marketing campaign to enhance awareness and knowledge among state residents.Conditions Conducive to Intervention
Family and friends are likely to intervene under the following conditions:
They believe the older driver is in imminent danger to themselves and others on the road
They believe they have a responsibility for and to the older person
They will be the primary or secondary caregiver
They are able to make decisions for the elder's good, over the elder's objections
They are able to overcome any feelings of disrespect or guilt
They have the support or at least the tacit approval of other family members
They are willing to provide or secure transportation when the older driver stops driving
They perceive alternative transportation exists
They attend support groups dealing with functional disabilities and/or caregiving
They have the support of the physician, law enforcement personnel, and the DMV for reporting and retesting.
These findings suggest that family and friends most likely to intervene feel both a social responsibility (for public safety) as well as a responsibility in caring for the problem older driver. Those who intervene are themselves able to make decisions and belong to families who are also capable of decisionmaking. They also are willing to engage in increased caregiving through providing some or all of the unsafe older drivers' travel needs. The presence of alternative transportation is a factor for some in their intervention, as is participation in a support group.
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