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The aging Canadian population is becoming increasingly ethno-culturally diverse primarily due to immigration. This, together with research indicating increased likelihood of long-term residential care (LTRC) use at older ages and challenges in providing these services, prompt important questions about whether LTRC services are prepared to provide culturally responsive and competent care to immigrant and ethno-cultural minority older adults (EMOA). This ethnographic study, informed by a critical theoretical perspective, explored these questions from the perspectives of South Asian older adults (SAOAs) and their family caregivers (FCGs). In-depth interviews with 18 SAOAs in LTRC, assisted living and those at home, their FCGs, and seven key informants from LTRC and the South Asian (SA) community (n=43) were undertaken. These interviews, in addition to 220 hours of participant observation in two LTRC facilities, provided information regarding the needs, preferences, experiences and situation of SAOAs in LTRC as well as how SA families make decisions regarding the use of such services. A select review of provincial policy, residential care regulation, health authority and facility documents, exposed taken-for-granted assumptions in how care and services are provided and the sociopolitical context of LTRC provision. Study findings suggest that LTRC services are challenged to meet the needs of immigrant and EMOA and reflect unequal and inequitable care, illuminated by the differential impact of macro-policies and resource-constrained LTRC environments on SAOAs and their families and on the ability of existing LTRC services to provide person-centred care. This inequity in service provision has implications for immigrant and EMOA and their family members in light of findings that the decision to move to LTRC is essentially a (non) decision influenced by a range of social structural factors that interact to necessitate the move to LTRC. Study findings revealed the salience of socio-economic status and economic resources in particular, in the (non) decision for LTRC placement. The findings from this study along with demographic shifts in the aging Canadian population call for LTRC service providers and policy makers to actively prepare for increasing ethno-culturally diverse resident populations and point to the need for equity informed approaches to the care of older adults. / Graduate / 2022-03-31

Malgré des études prolifiques sur le bien-être et la détresse psychologique, peu d'études ont testé la relation entre ces domaines de la santé mentale. De plus, il y a peu de modèles de la santé mentale qui ont été validés auprès des personnes âgées. II est essentiel de comprendre la notion de santé mentale des personnes agées étant donné le nombre important que represents cette population. Obiectifs : L'objectif de cette étude était de tester un modèle de mesure de la santé mentale chez les Canadiennes et Canadiens agés. Une validation de construit a été realisée pour les échelles de mesures du bien-être et la détresse psychologique et l'hypothèse d'indépendance des deux dimensions a été examinée. Le modèle a été testé selon le sexe et l'âge. Méthodoloqie : Les données proviennent de L'Enquête sur la santé dans les collectivités canadiennes - Cycle 1.2 - Santé mentale et Bien-être de Statistique Canada (2002). Cette étude épidemiologique transversale a été realisée auprès de 37 000 canadiens vivant dans la communauté dont 8 000 personnes de 65 ans et plus. Les échelles de mesures incluent l'Echelle de mesure des manifestations de bien-être psychologique de Masse et al. et le K10, une mesure de détresse psychologique developpée par Kessler et al. Les modèles d'équations structurales ont été testés à l'aide de la version 8.71 de LISREL. Résultats : Le modèle 2-facteur était valide pour les hommes et les femmes ages de 55 - 74 et 75 et plus. Ses résultats sont en accord avec la littérature. L'échele du bien être besoin plus d'études de validation. Des échantillons plus grands des personnes âgées ont nécessaires pour valider l'étude étant donne les méthodes utilités.

The older lesbian, gay, and bisexual (LGB) population is often underrepresented in the current body of research and the needs of this population are not well understood. Most research with this population has focused on wealthy, gay men, creating a deficit in regard to our understanding of the lesbian and bisexual individuals in the population. The present study was designed to add to the body of research on same-sex attracted older adults, by assessing well-being and acceptance of sexual orientation within the population. This study filled gaps in our current understanding of this population and provided new data for the Gay Identity Questionnaire (GIQ) as well as normative data for this population on several measures of well-being. Additionally, it created an image of how older same-sex attracted adults view themselves and the needs that they perceive within their population. Same-sex attracted adults, age 50 and older, were recruited through an anonymous online survey (N = 327; Age M: 59 years old, SD = 6.96). Sexual identity development was assessed with the GIQ (Brady & Busse, 1994; Halpin & Allen, 2004), and psychological well-being was assessed via the Depression-Happiness Scale (Joseph & Lewis, 1993), Satisfaction with Life Scale (Pavot & Diener, 1993), UCLA Loneliness Scale (Russell, 1996), Rosenberg's Self Esteem Scale (Rosenberg, 1989), Interpersonal Support Evaluation List. Regression analysis showed that age was overall a significant predictor of all of the outcome measures, with higher age predicting better well-being scores. The GIQ was not a significant predictor in the final model. The implications of these results in regard to the usefulness of the GIQ as a research and clinical assessment tool are discussed, as well as suggestions for future research with this population. A descriptive analysis of results and participants comments is also provided, with an emphasis on different areas of need within the older LGB population.

This thesis portfolio examines attitudes to ageing in older adults, and explores the impact that attitudes to ageing have on mental health status and quality of life. Attitudes to ageing are becoming more widely measured in older adults, particularly with the ageing population but also due the recent development of the Attitudes to Ageing Questionnaire. There is growing evidence to suggest a relationship between attitudes to ageing and mental health status in older adults. However, no study has explored the association between attitudes to ageing and quality of life in older adults, incorporating the Attitudes to Ageing Questionnaire and the World Health Organisation Quality of Life measures. Firstly a systematic search of studies exploring the relationship between attitudes to ageing and mental health in older adults (≥55 years) was undertaken. All potentially relevant studies were screened against inclusion and exclusion criteria. Variables related to attitudes to ageing, ageism, age stereotypes, depression and anxiety were considered in this review. Twelve papers met inclusion criteria for the systematic review. The setting, culture and measures incorporated varied across the studies. A negative attitude to ageing was associated with poorer mental health status in older adults across all 12 studies. The second part of this portfolio was an international cross-sectional analysis of attitudes to ageing and quality of life in older adults (≥57 years). Correlation and regression analyses explored the relationship between attitudes to ageing and QOL and investigated the impact of socio-demographic variables, depression and attitudes to ageing on two quality of life measures. The two constructs were positively related; a more positive attitude to ageing was associated with a better quality of life. Further, positive attitudes to ageing was a significant predictor of a better QOL. The sample was then divided into two age groups (57-79 years and 80+ years) and attitudes to ageing and quality of life ratings were compared. Results revealed more negative ratings in attitudes to ageing and quality of life in the over 80 year old age group. Correlation and regression analyses were then explored across both age groups. More positive attitudes to ageing was a significant predictor of better quality of life across both age groups. Overall, the two studies in this thesis portfolio highlight the need to better recognise and target older adults’ negative attitudes to ageing. Appropriate psychological interventions could be provided to challenge negative attitudes and promote attitude change in an attempt to improve mental health difficulties and quality of life in older adults. Continued use of the Attitudes to Ageing Questionnaire and quality of life psychometric measures in clinical practice and research is encouraged.

Aims The overall aim of this thesis was to extend current knowledge about the prevalence of malnutrition, to identify possible risk factors for development of malnutrition, and to describe the consequences of malnutrition in relation to all-cause and cause-specific mortality among older adults admitted to hospital. Methods The prevalence of malnutrition was estimated in a cohort of 1771 older adults (≥65 years) who were admitted to a Swedish hospital during 2008–2009 (15 months) and screened for malnutrition using the Mini Nutritional Assessment (MNA) instrument. Possible risk factors for malnutrition were recorded during the hospital stay (Study I). Dietary intake 10 years earlier (in 1997) was collected for 725 of these older adults (Study II). All-cause (Study III) and cause-specific (Study IV) mortality were followed up after medians of 3.5 and 5.1 years, respectively, for 1767 of the participants. Results The prevalence of malnutrition was 9.4% while 55.1% were at risk of malnutrition. Risk factors for malnutrition was an overnight fast >11 hours, <4 eating episodes a day, and not cooking independently. In middle-aged and older adults with a body mass index <25 kg/m2 in 1997, the risk of malnutrition increased for each additional percentage point of energy from total, saturated and monounsaturated fat at follow-up after 10 years. Malnourished older adults had almost four times higher risk of death during follow-up, while those at risk of malnutrition had a 56% higher risk, compared to well-nourished. Furthermore, well-nourished older adults had consistently lower risk of death, regardless of the cause of death. Conclusions Only 35.5% of older adults admitted to hospital were well-nourished. The identified risk factors could be used in interventions aimed at preventing malnutrition. Normal-weight and underweight middle-aged and older adults should consider limiting the intake of total fat and/or improve the quality of the fat in the diet in order to decrease the risk of becoming malnourished later in life. Malnutrition and risk of malnutrition were associated with increased overall and cause-specific mortality. These relationships emphasize the need for nutritional screening to identify individuals who may require nutritional support in order to avoid preterm death.

The aim of the thesis was to investigate factors influencing ICT use by older-adults. A selection of psycho-social, socio-demographic and health determinants were investigated with Internet use. Data were collected through questionnaires (Studies I-III) and interviews (Study IV). Univariate and multivariate analyses were conducted, investigating Internet use as a dichotomous variable, with the aforementioned factors. The results indicated that psycho-social determinants did not affect older-adults’ Internet use (Study I). Scoring higher on the personality traits openness and extraversion did not affect whether the older adults started to use the Internet (Study II). However, well-being increased for some frail older-adults when using the tablet computer and connected to the Internet (Study IV). Some socio-demographic determinants affected Internet use. Being younger in age was a strong contributing factor in all four studies whether the older-adult would use the Internet. Higher education influenced Internet use (Study I & III), correlated with living in a rural or urban setting (Study III); yet education was not influencing whether they would start to use the Internet. Living alone was correlated with Internet use, especially if the older-adult lived in an urban setting (Study III). Functional disability and household economy did not affect Internet use. Finally, the health determinants on Internet use were quite strong. Normal cognitive functioning influenced whether older-adults would start to use the Internet (Study II). The older-adult living in an urban environment, would use the Internet if they had normal cognitive functioning (Study III). It was noted also from Study IV that the learning to use the Tablet PC and Skype took longer for older people and more repetition was needed. Being frail was a strong factor whether the older-adult would use the Internet. They would not want to learn or try to use the technology if they were too ill (Study IV). The findings show only a small increase (7.7%) in Internet use by older-adults over time. The indicators of non-use are: higher in age, lower educated, living alone or rurally, lower cognition and frailty. There are two different profiles of rural and urban Internet users. These determinants along with an understanding of the use of technology, and a good support system, are a few pillars in ICT adoption by older-adults. As ICT continues to develop as a means to provide better health care, it will be important to take into account the abovementioned indicators. In certain cases Internet use is not a given, which continues to exclude older-adults. Part of healthy aging is social participation; therefore being connected and included in the digital society is important. Alternative and not only one design solutions should be explored in health care and by organisations, so as to cater to the heterogeneity of the aging population.

Problem statement: As a result of the aging population, the number of people living with chronic disease has increased to almost 50% (CDC, 2004). Two of the main goals in treating patients with chronic diseases are to provide seamless care from setting to setting and prevent disability in the older adult. Many have proposed the use of electronic personal health record systems (PHRs) in the self-management process, but adoption remains low. The purpose of this research was to validate and test an explanatory model of the barriers and facilitators to older adults' adoption of personal health records for self-managing chronic illnesses. The long range goal of the research is to use the explanatory model to develop interventions that will maximize the facilitators and minimize the barriers to adoption. Methods: A preliminary attempt to capture the essential barriers and facilitators that predict adoption of PHRs among older adults with chronic illness was synthesized from the literature. In Phase One of the study, the model was integrated from existing literature and validated using a Delphi method. In Phase Two of the study, the model was pilot tested and refined for future investigations. Findings: The results of this study validated the Personal Health Records Adoption Model (PHRAM) and a preliminary instrument that measured barriers and facilitators to the adoption of PHRs in older adults who are self managing chronic illness. Additional findings indicate that while seniors are seeking options to manage their health and have expressed an interest in using Internet-based PHRs, they may require assistance to gain access to PHRs. Implications: The potential for PHRs to increase patient autonomy and reduce for disability and the resulting negative health consequences needs further investigation as we move into the next era of healthcare delivery. The results of this study provided the foundation for continued theoretically-based research in this area.

There has been a growing interest among policymakers in the potential role of physical activity (PA) as a strategy to mitigate the challenges associated with an aging population, specifically the potential pressures on the health care system presented by an increasing need and demand for long term management of chronic health conditions. In this dissertation, the relationship between PA and health service utilization among older adults and the role of PA in reducing health services utilization in this population is examined via two studies. Study 1: The purpose of Study 1 was to examine relationships between LTPA and health services utilization in a nationally representative sample of community-dwelling adults aged 50 years and older. Methods: This study involved a secondary analysis of data from the Cycle 3.1 of the Canadian Community Health Survey. The analysis was restricted to individuals aged 50 years and older, resulting in an unweighted sample of 56,652 adults (48%M; 52%F; mean age 63.5±10.2 years), stratified a priori into three age groups (50 – 64 years, 65 – 79 years, 80 years and older). Self-reported use of general physician (GP) services, specialist physician services and hospital services for the 12-month period prior to the survey were the outcomes of interest. The main independent variable of interest was self-reported LTPA for a 3-month period prior to the survey. A comprehensive set of predisposing, enabling, and health need factors associated with health services utilization were included as control variables in all analyses. Separate multiple logistic and negative binomial regression models were used to assess the association between LTPA and each dichotomous and count-based dependent variable, respectively. Bootstrap re-sampling procedures were applied in all regression analyses. Results In the 50-64 year age group, active individuals were 27% less likely to report any contact with a GP (OR=0.73; p<.001) and had 8% fewer GP consultations (IRR=0.92; p<.01) than their inactive counterparts. Among 65 to 79 year olds, active respondents were 18% less likely than their inactive counterparts to have had an overnight hospitalization in the previous 12 months (OR=0.82, p<.05). Across all age groups, higher levels of non-leisure physical activity was associated with lower health services utilization. Study 2: The purpose of Study 2 was to investigate the effects of a randomized community-based PA intervention (50+ in motion) on participants’ health service utilization and healthcare costs over a 5-year period. Methods: 50+ in motion was a randomized clinical trial comparing the effectiveness of a class-based (CB) and home-based (HB) exercise program for older adults with select chronic health conditions (hypertension, dyslipidemia, type 2 diabetes mellitus, osteoarthritis, overweight or obesity). Of the 172 participants randomized, 59 CB and 69 HB participants granted access to their administrative health data. Data pertaining to GP and specialist physician services utilization and costs as well as hospital services utilization and costs were obtained for all consenting participants from the Saskatchewan Ministry of Health for the year prior to enrolment in the 50+ in motion study through to 48-months post-randomization, for a total of 5-years of data. Independent variables including demographic characteristics, physical activity, sedentary behaviour, cardiovascular endurance, functional fitness, body composition, blood pressure, and self-reported physical and mental health status were collected directly from participants prior to randomization and then annually for 4 years. Longitudinal effects of the 50+ in motion intervention on health services utilization and healthcare costs were assessed using the generalized estimating equation (GEE) approach with covariates selected for inclusion based on methods of purposeful selection. Results: There were no significant differences in health services utilization or health care costs between the CB and HB interventions until the final year of the study when the HB group had 60% more GP visits than the CB group and were 89% less likely than the CB group to be frequent users of specialist services. There were no significant differences between the randomization groups in healthcare costs. Measures of functional fitness emphasizing lower body strength, endurance and power were more consistently associated with lower health services utilization than CV endurance, body composition or physical activity. Sedentary behavior was associated with higher hospital costs, independent of physical activity, functional fitness and health status. Overall Conclusion: Taken together, the two studies in this thesis address a significant gap in the Canadian literature and provide novel insights into the relationships between PA, health and health services utilization in older adults. While further research is needed to improve our understanding of the relationships between physical activity and sedentary behaviour, physical fitness, and health services utilization, the findings presented in this thesis suggest reducing sedentary behaviour and improving functional fitness in older adults may be as important as physical activity, if not more so, in terms of potential impact on health services utilization and health care costs. For health care professionals and policymakers at all levels, the findings highlight the advantages of a multi-pronged, interdisciplinary approach to the development of public health initiatives and interventions focused on increasing PA participation and functional fitness among older adults.