The baby boom generation is moving slowly but certainly through the working years and on towards their old age. The implications for health and social care are at the forefront of public awareness and policy debate, and there is concern about the ability of seniors and governments to finance the boomers’ retirement. Gerontologists have played, and continue to play, an important role in preparing for an aging population by providing the research evidence that change is needed. In particular, as this special issue will demonstrate, gerontologists focus on (1) describing the current experience of middle-aged and older adults (i.e., the context), (2) developing and evaluating new models of care (i.e., the practice), (3) making projections about the future of an aging population based on current trends, and (4) advocating for policy solutions to improve the care of an aging population (i.e., the policy).
This special issue of the Canadian Journal on Aging presents research results in caring for an aging population by researchers affiliated with the multidisciplinary research program Social and Economic Dimensions of an Aging Population (SEDAP-II). The major funding for SEDAP-II has been provided by the Social Sciences and Humanities Research Council of Canada under the terms of its Major Collaborative Research Initiative competition.Footnote 1 It involves 46 academics from 14 universities in Canada and 3 universities abroad.
SEDAP-II is concerned with how population aging will affect the labour force and the economy. Articles presented in this special issue can be roughly divided into four sections: (1) four articles address the future needs of an aging population by describing the current context of aging and making future projections, (2) two articles address the current context of two diverse groups of care givers, (3) two articles address the relationship between home care providers and care recipients, and (4) two articles describe and evaluate a falls intervention effort for an “at risk” group of seniors receiving home care services.
Addressing the Future Needs of an Aging Population
Maintaining independence is a goal that older adults have rated as integral to their quality of life. While most seniors living at home report their overall health as good, the vast majority report at least one chronic condition diagnosed by a health professional. Some chronic diseases are more likely than others to lead to disability, and the type of disability experienced is related to the disease. Disabilities that limit everyday activities can have a profound impact on seniors’ lives including their mobility, agility, ability to do activities of daily living, leisure activities, and overall psychological well-being. With the aging of the Canadian population, the number of people with chronic diseases will increase dramatically, resulting in higher costs to the health care system and a greater strain on the home health and social care system as well as on informal caregivers.
In the first article that addresses the future needs of an aging population, “Chronic Health Conditions: Changing Prevalence in an Aging Population and Some Implications for the Delivery of Health Services”, Frank Denton and Byron Spencer document how the population-wide prevalence rates for a set of chronic conditions dramatically increase over the next quarter century in consequence of projected changes in age distribution. If the number of conditions were to be maintained, the authors’ projection indicates that health care requirements would grow more rapidly than the population – more than twice as rapidly in the case of hospital stays. However, Denton and Spencer demonstrate that if there were a hypothetical reduction in the number of chronic conditions per capita, it would have a significant impact on the use of health care resources and result in substantial savings. Their results have policy and practice implications for promoting healthy aging.
Significant regional variations exist both in relation to the availability of health services and funding among rural communities. Indeed, both publicly subsidized and privately accessed services have typically been characterized as “limited” in rural areas when compared to urban centers. This in part may be attributed to how home and health care are funded – typically according to the population size, leaving small communities with often-meager financial resources compounded by a shortage of health care professionals within the community. In addition, rural communities are generally “older” than their urban counterparts.
The second article on the future needs of an aging population is “Does Geography Matter? The Health Service Use and Unmet Healthcare Needs of Older Canadians”. In it, James Ted McDonald and Heather Conde examine, through the 2002-03 Canadian Community Health Care Survey, whether the use of basic health services and the incidence of unmet health care needs by older Canadians vary across Canada’s urban and rural areas. The authors are driven by the question of whether rural residents are likely to face greater barriers to obtaining health care than their urban counterparts. On the one hand, they find that a number of important measures of health service use (i.e., visits to a GP, to a specialist, and to a dentist) are lower among older Canadians living in rural areas than among those living in urban areas. On the other hand, no differences in hospital nights or unmet health care needs were found, a result suggesting that for rural residents the perception of needs may be related to the lack of health care services in their area. In terms of policy and practice, the authors’ results further highlight the need for health care services in rural areas and for policy initiatives to stress the importance of access to timely and preventive health care for people in rural areas.
We have done the basic research on seniors’ financial well-being in retirement in Canada. We know the distribution of income in retirement, the sources of income, and we have identified the groups of seniors living at or below the poverty line. A question that has been debated by policy makers and financial planners is, How much do seniors need to finance their retirement? In their article addressing the theme of an aging population’s needs, “The Costs of Basic Needs for the Canadian Elderly”, Bonnie Jeanne MacDonald, Doug Andrews, and Robert Brown determine the after-tax income required to finance basic needs, including health care, for Canadian seniors living in different circumstances in five major cities across Canada. Their study establishes that basic expenses vary enormously depending on the life circumstances of seniors and that the total living costs for an elderly person is near or even higher than that for a non-elderly adult living in similar circumstances, which is opposite to the more popular conclusion that seniors need less income than their working counterparts. The authors further argue that combined maximum Old age Security and Guaranteed Income Supplement benefits are not sufficient to meet the cost of basic needs for low-income seniors who rent their shelter and rely on public transportation. They conclude that individual circumstances, rather than retirement status per se, are the primary drivers in determining the costs of basic needs. In terms of policy and practice, the authors suggest that seniors and financial planners do not blindly rely on fixed replacement ratio or universal level of income when projecting the level of finances needed to retire.
The percentage of older adults in Canada is expected to increase dramatically in the next two decades. Of older adults receiving care, about half receive all their care from family and friends, and there has been a shift towards increasing reliance on family care providers, away from institutions and the formal care system. In the last article addressing the needs of an aging population, “What Will the Family Composition of Older Persons Be Like Tomorrow? A Comparison of Canada and France”, Joëlle Gaymu and colleagues argue that comparisons to France are of interest because French society has had a head start in terms of population aging, and in fewer than 30 years, the proportion of older people in Canada will be similar to that of France. Canada can look to France and other European countries to assess their policy responses to challenges of managing population aging. Using the LifePaths longitudinal microsimulation model, the authors demonstrate how changes in the age structure, sex ratio, marital status, and proportion of people who do not have a surviving child will transform the family network of older people in both structure and number in Canada and in France. While they note country differences, they demonstrate that, on the one hand, over the next 25 years the pool of potential family carers consisting of spouses and children will increase from the effect of the baby boom generation. On the other hand, the population most dependent on formal care, with no potential support from a child or a spouse, will also increase, and the shortage of family carers is likely to become more acute after 2030, due to changes in different family compositions. Policy and programs in both countries, the authors argue, will need to prepare for a greater number of elderly spouses providing care, and in Canada, a significant increase in the number that will rely on formal services should be of concern.
Diverse Groups of Caregivers
Extensive research on caregiving describes the caregivers, assessing their contribution in terms of both savings to the health care system and the quality of care that is provided. This research also examines the caregivers’ health, and their need for respite. One focus of research has been on the stress and burden experienced by caregivers, although there is some research that speaks to the “rewards” of caregiving. The second set of articles fleshes out the experiences, perceptions, and needs of two distinct groups of caregivers. Lori Campbell describes the experiences of sons who are providing care to an aging parent in “Sons Who Care: Exploring the Male Experience in Filial Caregiving”. She seeks to identify the ways in which their understanding of caregiving is the same or different based on marital status and co-residence. Her analysis is organized around six themes including (1) “because it is family”, (2) “close or closer with care”, (3) “a mixture of emotions”, (4) “caregiving as a gradual process”, and (5) “identity as a caring son:personal growth” “and change through caregiving”. Despite differences manifested by their social context, she shows that sons do have a strong commitment to and concern for their parents. She describes, in particular, the central commitment made by never-married, co-resident sons – most of whom did not work full-time – to the care of their parent and the implication this caregiving experience has for their future financial security.
Karen Kobayashi and Laura Funk, in “Of the Family Tree: Congruence on Filial Obligation between Older Parents and Adult Children in Japanese Canadian Families,” explore generational differences in filial obligation among older parents and adult children in post-immigrant Japanese Canadian families. They use their interviews with 100 parent-child dyads in British Columbia to explore the now classic intergenerational stake hypothesis that maintains that parents and children have different expectations and understandings of the filial relationship as a result of developmental differences in their concerns or “stakes”. The authors’ analysis leads them to challenge this hypothesis because the majority of parent-child dyads indicate overall agreement in filial obligation under different social contexts (i.e., variations in parent’s gender, marital status, and parent’s health). Their study points to the enduring form of solidarity in Japanese Canadian families, but they caution that governments should not use the assumption of family solidarity and support as an excuse to offload responsibility for care to older adults onto families.
Home Care Providers and Caregivers
Home care is the fastest-growing segment of the health care sector in Canada. The third set of articles examines issues faced by home support workers in providing care to clients and expands our knowledge of the experiences of formal caregivers. Joanie Sims-Gould and Anne Martin-Matthews in “Strategies Used by Home Support Workers in the Delivery of Care to Elderly Clients” use data from interviews with 118 home support workers in British Columbia to examine a conceptual model that locates home support worker, elderly client, and family member at the intersection of the public and private spheres framed by their social, spatial, temporal, and organizational features. Their analysis informs and extends our understanding of the job experiences of home support workers.
Despite the fact that the Canadian health care sector increasingly relies on immigrant care workers in home and long-term care in Canada, very little is known about the workers’ experiences and their relations with clients. The article by Ivy Lynn Bourgeault and colleagues, “Relations between Immigrant Care Workers and Older Persons in Long-Term Care”, seeks to examine the relations that immigrant care workers have with their older clients. The authors’ analysis reveals important insights with regards to how differences in ethnic or racial background, cultural differences, and language barriers between home care workers and their clients complicate relationships. This is further compounded by the shortage of staff, heavy workloads, and the general neglect of older adult care. The article ends with a discussion of policy implications including the need for special, culturally sensitive educational programs for both immigrant care workers and families and caregivers, and the need for further consideration of matching immigrant care workers and older adult clients with similar backgrounds.
Canada is a leader in evidence-based medicine, and we are developing best-practice guidelines in providing care for older adults. Accordingly, we complete this special supplement with two articles by Maureen Markel-Reid and colleagues that present the results of a multifactorial and interdisciplinary team approach to falls prevention for older home care clients. The first article, “A Cross-Sectional Study of the Prevalence, Correlates, and Costs of Falls in Older Home Care Clients at Risk of Falling”, reports the results at baseline from a randomized controlled trial of 109 people aged 75 and over, of which 71 per cent had reported a fall in the previous six months. The major contributions of the study are that it focuses on both falls and near-falls (slips and trips), and it measures the use and costs of the full range of health services. The study report reveals the multifactorial nature of falls and identifies multiple interacting risk factors, some of which are modifiable. The second article, “The Effects and Costs of a Multifactorial and Interdisciplinary Team Approach to Falls Prevention for Older Home Care Clients ‘At Risk’ for Falling: A Randomized Control Trial”, reports the results of the intervention – a six-month multifactorial and evidence-based prevention strategy involving an interdisciplinary team. The study results provide evidence that screening, followed by targeted interventions aimed at multiple factors and provided by an interdisciplinary team, result in improvements in health-related quality of life, reduction of falls for some types of seniors, and a reduction in slips and trips at no additional health care costs. Study results support the literature regarding best-practice guidelines for providing falls prevention to older people at risk of falls and conclude with recommendations for home care policy makers, agencies, and funders to ensure an interdisciplinary approach to falls prevention.
Much of public policy in Canada is concerned with the implications of the population’s aging. Recognition is growing that policies and programs will have to change to deal with the projected growth in the number and proportion of older adults. Research will play an important role by describing the current experience of middle-aged and older adults (i.e., the context), developing and evaluating new models of care (i.e., the practice), making projections about the future of an aging population based on current trends, and advocating for policy solutions to improve the care of an aging population (i.e., the policy). The research articles presented here provide information and suggestions to help policy makers and planners prepare the way ahead, but much more information is needed if we are to meet the needs of our aging population.
There is an assumption that Canada’s long-term care system will dramatically change in the future to provide better quality of care to older adults both in their own homes and in nursing homes. It is argued that the baby boomers are a very different generation than their parents and that they will demand changes to health and community care. They will want to age at home with health and community care support services to assist them. Further, if they are no longer able to live independently or if they wish a change in residence, they will demand affordable alternative housing to meet their needs. They will expect nursing homes to provide high-quality care including stimulating recreational activities, good food, opportunities for physical exercise, and rehabilitation. If this assumption is true, we ask, why are the baby boomers not more vocal in demanding changes to the care system for their parents, some of whom are currently receiving care or will be in need of care in the very near future? After all, when the baby boomers reach the point in their lives where they need services to maintain independence, it may be too late to effect the changes they need. The time is now! As researchers and educators, we have a moral responsibility to engage in using our knowledge and expertise to inform practice and policy debate to improve both the quality of care and the quality of life of our older population.