Introduction
The concept of ageing in place has a long history in policy and research literature and refers to ‘staying in your own home and community as you get older’ (Government of British Columbia 2025). Rogers et al. (Reference Rogers, Ramadhani and Harris2020) also add the element of independence in their definition of ageing in place: ‘one’s journey to maintain independence in one’s place of residence as well as to participate in one’s community’ (p. 1). While the Federal/Provincial/Territorial (FPT) Ministers Responsible for Seniors Forum (2012) includes health services and social supports that ensure the safety and independence of older adults in their definition of ‘ageing in place’, others use ‘ageing in the right place’ to indicate that older adults’ setting or living environment must be appropriate to their personal needs, preferences, lifestyles and vulnerabilities (Canham et al. Reference Canham, Weldrick, Sussman, Walsh and Mahmood2022; Narushima and Kawabata Reference Narushima and Kawabata2020).
Health services and social supports are both important to rural ageing in place where older adults take a more holistic approach in prioritizing social and cognitive aspects alongside physical ones (Bascu et al. Reference Bascu, Jeffery, Abonyi, Johnson, Novik, Martz and Oosman2014). There are disparities in health-care access and outcomes for rural older adults owing to limited health-care infrastructure, fewer care providers and longer travel distances to access appropriate and timely care (Hansen et al. Reference Hansen, Newbold, Scott, Vrkljan, Grenier, Huang, Skinner, Winterton and Walsh2021; Hulko et al. Reference Hulko, Mirza and Seeley2021; Mirza and Hulko Reference Mirza and Hulko2022; Mirza et al. Reference Mirza, Brown and Hulko2022). However, ageing in place rurally is not solely dependent on health-care services; local human resources to assist with transportation, housekeeping and social engagement are of equal importance (Carver et al. Reference Carver, Beamish, Phillips and Villeneuve2018).
Rural older adults are often viewed homogenously despite being positioned as marginalized owing to their geographic location or (lack of) proximity to large urban centres. Other aspects of their social location such as poverty and gender are overlooked, however (Keating et al. Reference Keating, Swindle and Fletcher2011). An exception is Ryser and Halseth’s (Reference Ryser and Halseth2011) research on low-income older women living alone in rural areas, the findings of which have been confirmed in subsequent research showing that gender, income and living situation (continue to) impact rural older adults’ ability to age in place (Ferris et al. Reference Ferris, Glicksman and Kleban2016; Narushima and Kawabata Reference Narushima and Kawabata2020). Gender, income and living situation are all known social determinants of health (SDH) for rural older adults.
Raphael (Reference Raphael2016) defines SDH as ‘the economic and social conditions that shape the health of individuals, communities and jurisdictions as a whole’ (p. 3). The World Health Organization’s (WHO Reference World Health Organization2025) more expansive and socio-political definition refers to SDH as ‘the conditions in which people are born, grow, live, work and age, and the wider forces that shape the conditions of daily life...[which] include economic policies and systems, development agendas, social norms, social policies and political systems’ (para. 2-3). Peace, a stable ecosystem, sustainable resources, social justice and equity were part of the WHO’s 1986 listing of ‘the fundamental conditions and resources for health’ (WHO, n.d., para. 4), alongside other SDH that remain in lists today: shelter, education, food and income.
Service providers increasingly recognize that socio-political forces and economic systems negatively impact service users’ health (Bourgois et al. Reference Bourgois, Holmes, Sue and Quesada2017). As a result, newer conceptualizations of SDH append ‘related inequalities’ (Islam Reference Islam2019) or ‘structural determinants of health’ (Bourgois et al. Reference Bourgois, Holmes, Sue and Quesada2017) to more explicitly reference the unequal distribution of social factors that determine health and the role and influence of public policy and systems of oppression such as racism and colonialism. Indigenous determinants of health also go ‘beyond the social’ to encompass geographic, economic, historical, narrative and genealogical and structural determinants, all of which are impacted by ongoing colonialism (De Leeuw et al. Reference De Leeuw, Lindsay, Greenwood, In Greenwood, de Leeuw and Lindsay2018, p. xxiii). While definitions of SDH are fairly similar, with the WHO definition being the most often cited, there are variations in the actual lists or enumerations of SDH in policy documents and research literature.
The most commonly identified determinants across global (i.e., WHO) and Canadian models are housing and physical environment, income and poverty, education, social inclusion/exclusion and supports, employment and working conditions, access to health services and early childhood development (Greenwood et al. Reference Greenwood, De Leeuw, Stout, Larstone and Sutherland2022; Health Canada 2020; Loppie and Wien Reference Loppie and Wien2022; Raphael Reference Raphael2016; Raphael et al. Reference Raphael, Bryant, Mikkonen and Raphael2020; WHO 2022). Gender is not an SDH for the WHO, but rather a cross-cutting theme. Several SDH are identified by some of these models and not others, namely, disability, geography, food (in)security, culture/language, race/racism, Indigenous ancestry, biology, healthy behaviours and structural conflict/globalization. Ageing or later life is not recognized as an SDH at all, seemingly as this stage of the lifecourse is viewed as the outcome of past experiences rather than a determinant of future ones. Known SDH such as those enumerated already play different roles in later life experiences, including based on urban or rural residence, with the pace and experience of ageing varying considerably.
Background
To better support ageing in place, provincial health authorities in British Columbia (BC), Canada, initiated a restructuring of their primary and community care services in 2015 and called this ‘repositioning’, mandating the five regional health authorities (Island, Vancouver Coastal, Fraser, Interior, Northern) to take action within the next year. The goal was to reduce hospital visits and delay transitions to long-term care through strengthening the ability of older adults to live independently for longer (BC MOH 2014). From their informal consultations with family carers and service providers, Interior Health (IH) identified SDH as a key theme, stressing that ‘social determinants of health such as housing, food security, limited financial resources, transportation and social connectedness need to be addressed and mitigated’ (IH 2015, p. 3). Further, IH (2015) recognized that SDH need to be addressed at all levels – local, regional, provincial and national (p. 18).
Interior Health’s quality improvement exercise involved mainly service providers and care partners (in urban areas) and overlooked service users living in rural communities. Hence, our team of researchers and health-care partners conducted research with a socio-culturally and geographically diverse population of older residents to inform IH’s restructuring initiative (Hulko et al. Reference Hulko, Mirza and Seeley2021). There are 54 First Nation communities and 16 Métis chartered communities in the IH region and a greater proportion of Indigenous people (8.8 per cent) than the provincial average (6 per cent) (Medical Health Officer Report on the Health of the Population 2019, p. 7). In contrast, only 5.6 per cent of the IH population are visible minorities compared to 33.3 per cent for the province; of the 5.6 per cent, the largest group is South Asian (30.8 per cent) (Medical Health Officer Report on the Health of the Population 2019, p. 7).
British Columbia is Canada’s Western-most province and the Central Interior region lies in the lower middle of the province, far from either a coast or a border. The upper half of the province is covered by Northern Health and the remaining four regional health authorities cover the southern half of the province; of these four, IH is the largest and covers the southeastern portion of the province. Home to over 789,000 people, this large geographic area (215,000 km2) has an average population density of 3.5 people per km2 (Medical Health Officer Report on the Health of the Population 2019, p. 7). British Columbia’s Central Interior maintains a strong presence in the resource and agriculture sectors, complemented by manufacturing, services and a thriving tourism industry (Province of British Columbia 2024).
Theoretical framework
Critical gerontology guided the design and operationalization of this study as it directs us to consider the political-economic context of care, which includes SDH, and treats older adults as a diverse, heterogeneous group with expertise to share and agency to enact (Biggs et al. Reference Biggs, Estes and Phillipson2003; Hulko et al. Reference Hulko, Brotman, Stern and Ferrer2020). The positionality of the researchers is important in critical gerontology; our research team was made up of three White Anglo-Canadian women, two of whom identify as queer, and one racialized (South Asian) man. We were all involved in data collection and analysis, yet only two of us were involved in interpretation of the SDH data and manuscript writing. Our advisory committee – made up of IH practitioners and decision makers including Indigenous representation – assisted with research design, participant recruitment and interpretation of findings.
A critical perspective on rural ageing moves away from biomedical perspectives, while focusing on rural complexities and the older adults who experience them across the continuum of care (Poulin et al. Reference Poulin, Skinner and Hanlon2020). A goal of our research was to identify the SDH for community-dwelling older adults in BC’s Central Interior region, and determine the ways in which primary and community care restructuring could address them. Our understanding of SDH and which specific ones to focus on was informed by both leading experts (Raphael Reference Raphael2016) and our regional health system’s articulation (IH 2015).
Research questions
We present data gathered as part of a larger mixed-methods triangulation study (Creswell and Creswell Reference Creswell and Creswell2018) on older adults’ views on the repositioning of primary and community care (Hulko et al. Reference Hulko, Mirza and Seeley2021). The quantitative and qualitive data we gathered simultaneously allowed us to identify the SDH for community-dwelling older adults and describe how the ongoing restructuring might address these SDH. The research questions (RQs) for our analysis of these SDH data were:
1. What are the SDH for community-dwelling older adults in the Interior of BC?
2. In what ways are SDH related to older adults’ views on primary and community care?
3. How might this restructuring address the SDH of older adults in the Interior?
Methods
Sampling and recruitment
Older adults from one small city (urban) and nine surrounding rural towns (two rural and seven small rural)Footnote 1 were recruited in 2016 for this study through IH (home and community care, walk-in clinics), older adult advocacy and/or peer support groups, weekly or monthly gatherings of older adults (e.g., Elders’ luncheons, Soup’s On) and local seniors’ centres. We were particularly interested in older adults living with complex chronic disease (CCD), ‘a condition involving multiple morbidities that requires the attention of multiple healthcare providers or facilities and possibly community (home)-based care’ (Sevick et al. Reference Sevick, Trauth, Ling, Anderson, Piatt, Kilbourne and Goodman2007, p. 438). To increase representation and/or to diversify our sample, we made repeat visits to three of the ten communities (one rural and two small rural) and arranged for a Punjabi interpreter for an additional focus group at a Sikh temple (urban). Three of the focus groups were with Indigenous Elders, including one in a remote First Nations community (small rural) to which we were invited, and two housing complexes (one urban, one rural) for Indigenous Elders. Our repeat efforts to hold a focus group with older sexual and gender minorities (urban) were unsuccessful and only one participant disclosed their sexual minority status.
Data collection and analysis
All participants provided informed consent and completed a demographic questionnaire before participating in an interview or focus group. Focus groups allowed us to generate a great deal of information in a short period of time (i.e. one visit to the community) and individual interviews suited those reluctant to express their views in front of others; for example, the majority of those who took part in interviews were women, including the participant who identified as a sexual minority. The 15 focus groups we held comprised 2 to 10 participants (median of 5) and lasted between 44 minutes and 2 hours 37 minutes. The nine interviews were conducted in person, often at the same venue as the focus groups (except for one by phone) and averaged 30 minutes in length. The same interview guide was used for individual interviews and focus groups and included a specific question about SDH. After asking about how the repositioning of primary and community care will impact them and their community, we inquired: We are interested in the social factors we asked you about earlier in the socio-demographic questionnaire (age, gender, Indigenous ancestry, ethnocultural background, sexual and/or gender minority, chronic health conditions, income and living situation). How might the repositioning address these factors? What about your situation in particular? Focus groups and interviews were audio-taped and sent to a professional transcriber. Field notes were taken by research assistants to assist with analysis and focused on the setting and non-verbal cues.
Demographic data were entered into SPSS to calculate descriptive statistics and correlations (Pearson’s chi-square). Participants had been asked to select one of three chronic health condition categories: none, one, two or more. This allowed us to determine how many were living with CCD (two or more chronic health conditions) as well as examine the relationship of income to CCD and observe any difference in income brackets and CCD between the racialized and non-racialized participants. We also examined the relationship of gender to living situation, type of residence and income.
For interview and focus group data, we used NVivo 10 to inductively code all the data, consistent with content analysis (Hsieh and Shannon Reference Hsieh and Shannon2005). This allowed us to identify and analyze the relevant SDH and their intersections. First, we separated out the SDH data from the larger dataset (Hulko et al. Reference Hulko, Mirza and Seeley2021), using only data coded as SDH, and analyzed these in more depth. This was a combination of inductive (i.e. open coding of transcripts) and deductive (i.e. answers to the social factors question, comparison to SDH models) analysis. As our demographic questionnaire (see Appendix 1) included some open-ended questions, we had to categorize these data. This included ‘living situation’, which we coded using IH’s categorizations of living situation (with whom one lives) and type of residence (including degree of formal support); this allowed us to ‘quantitize’ these data, that is, calculate frequencies (Sandelowski et al. Reference Sandelowski, Voils and Knafl2009). Specifically, we did content analysis of qualitative data and then added up (quantitized) our qualitative codes (Nzabonimpa Reference Nzabonimpa2018, p. 2). This analytical process involved seeking out other SDH models (Global, Canadian, Indigenous) and using these models to search for additional determinants in our dataset. We then compared our list (Box) to create Table 5 and interpret our findings.
To ensure rigour, we collected data through multiple means until we reached saturation, analyzed data individually and collectively, engaged in regular peer debriefing (researchers and community-based researcher), returned to participating communities to share preliminary findings as a form of member checking and created an audit trail (e.g. field notes, meeting minutes, memos in NVivo). We also merged our quantitative and qualitative results to describe the relevant SDH more fully (numerically and thematically) and substantiate our conclusions.
Results
Description of sample
Of the 83 participants, 61 lived in rural (10.8 per cent) and small rural (62.7 per cent) towns and 22 (26.5 per cent) lived in the small city. The average age of participants was 75 years (range of 62–89 years); 56 were cisgender women, 27 were cisgender men and none identified as trans, two-spirit or non-binary; 1 woman identified as bisexual; and 13 identified as Indigenous and 7 as Sikh, making racialized participants 24.1 per cent. Forty-four participants had CCD, which we operationalized as the presence of two or more chronic health conditions (Table 1); the main conditions reported were diabetes, arthritis, chronic obstructive pulmonary disease (COPD), heart disease (hypertension and stroke), mental illness (depression), dementia and osteoporosis.
Table 1. Chronic health conditions
As Table 2 shows, there were differences in living situation, type of residence and income based on gender. For those participants who declared their income (n = 75), the majority were in the under $30,000/year bracket, while very few participants reported an income of over $45,000/year. More women than men reported living on low income (69 per cent versus 31 per cent). Gender differences also were seen in living situation: 64 per cent of the women and 48 per cent of the men lived alone and a greater number of women (16 per cent) than men (7 per cent) resided in assisted living or group homes.
Table 2. Characteristics by gender
We found that 45 per cent of the 20 racialized participants (Indigenous and Sikh) lived on less than $15,000 per year (70 per cent for Indigenous and 28.6 per cent for Sikh), whereas only 19 per cent of the 63 Caucasian participants were in this income bracket; and CCD was more prevalent amongst the Indigenous (61.5 per cent) than the non-Indigenous participants (51.4 per cent). The correlation between Indigenous ancestry and income was significant (p = 0.023), while that between Indigenous ancestry and CCD was not (p = 0.79). There was no relationship between gender and CCD (p = 0.822) based on self-reporting of chronic health conditions (Table 3).
Table 3. Statistical tests
* Based on Pearson’s chi-square test.
Relevant social determinants of health
In terms of our first RQ, the relevant SDH were income, living situation (alone and in private dwelling with no home support), living rurally, Indigenous ancestry, ethno-racial minority status, gender and transportation. The multifaceted nature of transportation as an issue for rural-dwelling older adults is addressed in a companion article (Mirza and Hulko Reference Mirza and Hulko2022), thus not elaborated upon here. We added ageing/seniors, food security, connections, disability, sexual orientation and gender expression to our preliminary list of SDH after searching our data for these specific determinants which appear in other models. However, only ageing/seniors was prominent in our analysis, likely explained by the fact that all participants were older adults. Seven SDH were key for older adults living in small cities and rural communities (Box); these are not listed in order of significance.
SDH for older adults in small cities and rural communities
1. Income
2. Living situation – alone and in private dwelling with no home support
3. Living rurally
4. Indigenous ancestry
5. Ethno-racial minority status
6. Gender
7. Transportation
Impact of SDH on primary and community care
In discussing the relationship of SDH to primary and community care in a small city and surrounding rural communities (RQ2), participants interrelated multiple SDHs. For example, the quote from which our title is derived highlights not only income but also transportation and support/connections:
I think most of it comes down to the SDH … I think we have a whole bunch of information and a whole bunch of tools and treatments, but it’s the things like transportation and money and supports and people to help and connections [that] I think are the ones that are really hindering the effectiveness of that health care. (Small Rural [SR] 1, Focus Group [FG] 2)
The interrelating of various SDH seen in this quote was not uncommon. Thus, in the sections that follow, we address each SDH (see Box) separately and in relation to the others with which they intersect.
SDH 1 – Income: ‘and if you haven’t got the money, I guess you just don’t go’
Income was the most predominant SDH in our dataset as it intersected with more SDHs than any other single determinant and had the most coded references (66). The lower an older adult’s income, the more chronic health conditions they had (Table 4). For the 75 participants who declared an income, those receiving <$15,000 (n = 20) or $15,000–29,999 (n = 28) had two or more chronic health conditions (i.e. were living with CCD). In contrast, those with an income of $30,000 or more (n = 27) had only one chronic health condition.
Table 4. Relationships of income categories with chronic health conditions
Participants spoke of the injustice of having to pay for health care, and distrust of the system owing to service costs: ‘The system has downloaded a lot of costs to the sector that can least afford it’ (SR3, FG1). Some of the costs mentioned were private home care, housekeeping, medications – ‘$175 per month on pills’; ‘over $12,000 per year, my prescriptions alone. Never mind the insulin I had to take, before’ (SR4, FG1) – eye exams, dental care and therapy – ‘And there are no therapists, except if you spend money. You have to be in a higher bracket to pay private fees to go to a therapist, physiotherapist, to do specific work on a specific condition’ (SR5, FG2).
An Indigenous Elder from a rural community explained that First Nations Elders may forgo treatment owing to upfront costs or lack of reimbursement:
I don’t know if I’m supposed to pay up front; we are Status native Indians and we are supposed to have our medical, yet you go in and see the eye doctor and you end up paying 50 or 60 dollars to get your eyes examined. And you don’t get reimbursed for it and yet you’re supposed to have your medical covered for eyes, teeth and … [chuckling] … your medical bills … And if you haven’t got the money, I guess you just don’t go. (Rural [R] 1, Interview [Int] 2)
An older woman in a small rural town spoke not only of their own low income – ‘my little miserable salary’ – but also of the much higher incomes of their neighbours – ‘retired teachers or retired bureaucrats of some kind [whose] pensions are adequate’ – as well as their friends living in ‘beautiful [care] homes in urban (U) … that cost them $3,000.00, $2,500.00 to $3,000.00 a month’. They noted that they ‘wouldn’t have that kind of money to go’ should they need to move to a care home and cannot hire people to help them stay at home as ‘you need your funds for looking after your house and things’ (SR3, Int 2). Another older woman living alone on a low income shared that she had no choice but to take on the arduous and time-consuming task of washing her floors owing to the high cost of private assistance and lack of government support in the form of home care.
I’ve tried to get home care for me, for my legs, ‘cause I can’t wash my floors. It’s 85 to 100 dollars an hour to get someone to come in and clean your floors. Like, I don’t have any family, I don’t have anybody up here to do my floors. I did my floors the other day, it took me three days, sitting in my chair with a mop and it’s a lousy job …. But yeah, I’m on limited income, I make less than $20 grand a year, I can’t afford that kind of money [for home care]. (SR2, FG)
This section indicates the varied ways in which older adults experience financial constraints which impact their ability to age in place and access to primary and community care, including their living situations.
SDH 2 – Living situation: ‘they can just plunk you in with someone who may not want you’
Two aspects of living situation were significant: living alone and living in a private dwelling with no home support. Living alone is one of IH’s six categories for living situation (Table 2) and was the one the majority (59 per cent) of the participant responses matched and spoke about when referring to their living situation or that of others. The majority (83 per cent) of participant responses fell into the category of private home/apartment with no home support, one of IH’s five categories for type of residence, and again this was predominant in the focus groups and interviews. Similar to the previous SDH (income), living situation was related to other SDHs, including gender, income and transportation.
For those living alone, access to informal help and support or its absence was of greatest concern, with one participant questioning ‘Who is to help you at home?’ and then explaining why some older adults might not have familial support:
You don’t have your daughter or your son or that, because maybe they are already in their 70s and have had a heart attack … or they are on drugs or they are there [and] you can’t [rely on them], you know, let’s get real, there’s grandchildren and they can’t come to you. So, there’s a gap right there of finding help and staying in the home. (R2, FG)
Another participant spoke of living alone and getting up at night, knowing that ‘the people below me, they hear me right above the bedroom and if I get up and I fall, they can phone for an ambulance’. They further described their neighbours as ‘really helpful around the house; they clean up the yard because I can’t get out and do it’ (U, FG2). Also raised was the lack of choice about where to go if family were available, regardless of the strength or quality of the relationship: ‘Interior Health figures they can just plunk you in with someone [who is a family member] who may not want you, but then I can see, there’s lots of people who it wouldn’t work for’ (SR2, Int).
Concerns about living in a multigenerational household were also expressed, with consideration given to the impact on both the older adult and their adult children and/or teenage grandchildren:
Well, there’s this stay with family or this or that. I think nowadays they might be hard pressed to find families that want them to stay with them and then it would be that ‘would they want them to?’ I get along with my daughter just fine, but it’s like, I don’t want to live in her house, you know and then you got the grandkids who are teenagers who will be getting older, rather than younger, but still, it’s like, do they want [their grandparent there]? … And then I know other people who build in a basement suite and they only live with their kids, so I suppose it’s a personal type thing, but … I wouldn’t be able to stand my mother living in my house. I don’t care how many nurses and doctors you send in to do whatever. (SR2, Int)
As seen, the presence of family members may not be desired and may not signify support. One Indigenous Elder grieved her lost independence after a family member unexpectedly moved in with her:
Well, I used to live by myself for a long time until my son came and moved in. He just moved in with me, he didn’t say he was moving in … He just came for supper and didn’t leave. But it was hard for me for quite a while to get used to him being there. I was used to being by myself and doing everything by myself. (SR1, FG1)
Living alone requires not only the support of others in the home but also being able to leave the home to ensure that basic needs can be met – if one no longer drives or finds it unsafe to drive:
How independent can I be? So, I stay in an apartment and I can’t drive and I can’t, you know I can’t really walk too far and we’ve got, well don’t know what your winters are like, but if they are like [city in Northern BC], they can be pretty severe. And you know, then am I confined to the house, you know? I probably can get my kids to get my groceries and stuff, but what about other people who are not in, you know, who don’t have access to somebody that drives. (SR7, Int)
Nutrition can be a concern for people who live alone and have food, but are ‘scared to eat because [they are] alone all the time’. Gesturing to another Indigenous Elder, this participant said, ‘She’s scared to eat alone because she chokes, even drinking water and that’s why she’s losing so much weight’ and suggested there should be ‘someplace or something where they can watch her, where she can eat, because she likes eating’ (R1, Int2). In addition to the challenges faced by those living alone, the concerns related to living rurally add another layer of complexity.
SDH 3 – Living rurally: ‘you’re definitely a second-class citizen’
Long-term care was a topic frequently brought up in rural communities where options are limited or non-existent; thus, calls for ‘more residential care so people aren’t farmed out so far and wide’ (SR1, FG1) were common. This contributed to feeling like ‘You’re definitely a second-class citizen’ (SR3, FG1). If there is a long-term care home in the community, then there is likely a waitlist and, while waiting, older adults may be living in a mobile home without hot water:
We’ve got our names in … to get into the old age home since we moved here in March and they said that we really do need to get in there because there’s stairs here and we live in what’s called a fifth wheel, so it’s like camping to me … There’s no space here, the tub is small, we have hot water problems, you know, so like I heat the kettle for hot water. (SR1, Int 2)
Home care was also a concern for participants who complained about a chronic shortage of workers and stressed that ‘rural health care is not mini-urban’ (SR3, FG1). Rural older adults used to limitations in health-care services, expressed resignedly ‘so we live with it’ (SR5, FG1). At the same time, they called attention to the fact that ‘we can’t all live in the city’ (SR1, FG2), suggesting the need for a reallocation of services to rural areas.
Living rurally intersected with age, disability and transportation in that living rurally was thought to become more difficult the older one gets and mobility to be a challenge owing to disability and/or limited transportation options. Disability in this sense was about age-associated impairments rather than ageing with a disability.
SDH 4 – Indigenous ancestry: ‘if only you could go out in the bush and hunt Ensure’
The quantitative data on Indigenous ancestry showed that more Indigenous than non-Indigenous participants had two or more chronic health conditions and they also had lower income, neither of which was the case for the Sikh participants. One non-Indigenous participant stated, ‘it’s all a question of money’ (SR3, Int2) and an Indigenous Elder similarly commented, ‘if only you could go out in the bush and hunt Ensure’ [a nutrition supplement recommended to Elders by First Nations Health] (SR1, FG2).
The qualitative data revealed a strong awareness of the inequities experienced by Indigenous peoples, with one Indigenous Elder contrasting the theft of their resources with the withholding of a simple medication: ‘all the minerals they take out of BC, like the logs, the gold and everything and you know, they never gave the Natives a cent out of that [resource extraction]. ‘Cause the billions and billions and billions of dollars, but we ask for an Aspirin and they say “No. You’ve already used your supply”’ (SR1, FG2).
Non-Indigenous older adults spoke of Indigenous Elders in relation to primary and community care in both negative and positive ways. For example, one non-Indigenous older adult expressed the belief that ‘sometimes they have better medical than we do’ (SR3, Int2), while another stated that ‘so far as accessing Interior Health, they face the same challenges [such] as how do you get to a doctor’ (SR5, FG1). A non-Indigenous older woman claimed that ‘natives don’t have to pay for their medications’, yet immediately questioned the veracity of her statement and acknowledged that she would not want to be in the position of those who get free medication: ‘You just hear stories and of course neither do people on assisted living or welfare or whatever you call it, they don’t have to pay for that stuff [medications]. I don’t want to be in their position either’ (SR4, FG1).
Expressions of support and understanding were also heard, often referencing inclusion: ‘we have to make an attempt to be inclusive and that means that whatever background those individuals have come from, we try to nurture and support that, so that health care is actually a help’ (SR4, FG1). This extended to the design of care homes and the type of care offered within:
Some of the traditional methods of healing or dealing with mental issues will be different than what we European North Americans traditionally deal with. And I think we would really have to be cognizant if we create a facility, that if there is one room or two rooms or whatever that have a specific First Nations motif or a culture or however we approach that to make sure that it is inclusive. If it doesn’t get used, that doesn’t mean we are wrong, it means that we are just extending our hand and trying to be inclusive. Otherwise, it is always going to be them over there [indicating the river], we over here. (SR4, FG1)
Some older adults – particularly those living rurally – expressed compassion for Indigenous Elders and recognized the need for inclusive and culturally appropriate health care. Misunderstandings about benefits were also evident in the responses of non-Indigenous older adults with there being a stark contrast between perceptions of fairness and/or injustice on the part of Indigenous Elders and non-Indigenous older adults.
SDH 5 – Ethno-racial minority status: ‘as long as somebody can speak the language’
The quantitative data showed that – unlike the Indigenous participants – the Sikh participants (28.6 per cent) did not have lower income than their Caucasian counterparts (19 per cent) nor did the Sikh participants discuss income as an SDH like the Indigenous Elders did. Another contrast between these two groups was that some of the Sikh older adults viewed primary and community care positively. As the interpreter summarized, rather than translating word for word the participant’s response, ‘so, he is saying that he feels that Canada is number one and he really appreciates the services that he gets, because whether you are poor, rich, you are treated equally and you have the same access to services and nobody dies of hunger here as compared to other countries’ (U, FG4).
Both language and culture were priorities for Sikh older adults, with participants stating ‘there are not enough Indian doctors’ and stressing that ‘they should have more Punjabi people speaking Punjabi’ (U, FG4). Most of the participants ‘take family member[s] to go to doctor. Family member, no problem’ (U, FG4). At the same time, family members serving as interpreters was not ideal, as one Sikh older woman described:
I tell you the problem, like if I can’t speak English, I take somebody, a family member and he can’t speak good English or he’s not very good in English. So, he will go with me, but he can’t make everything I want [understood], he can’t make the doctor understand what I want, what I have inside, so if there’s some professional people, they [can] explain what the problem is. (U, Int)
Instead of relying on family members to accompany a Sikh older adult to an appointment to translate for them or having a translator on-site, Sikh older adults felt it important that staff at the new Seniors Health and Wellness Centre (SHWC) – an outcome of primary and community care restructuring – speak their language. This was the priority for them and what would encourage them to access the SHWC, as the interpreter summarized: ‘it would only be convenient if somebody could speak their language there. Better than getting a translator and stuff to go with them. So, they could take the bus and go there by themselves … Whether it’s a male or a female [care provider], they don’t care, as long as somebody can speak the language’ (U, FG4). As this quote indicates, gender was not important for the Sikh older adults.
SDH 6 – Gender: ‘nobody really even seems to care’
As mentioned earlier, gender was related to income, with participants discussing the ways in which (heterosexual) women’s traditional roles as wives and mothers impacted their earning ability, which was compounded by the death of their husbands.
In [care complex], when I was there, people were paying $6,000 and $7,000 a month just to stay in a residence. I mean there are very few of us in that category because many, many of us were stay home moms, so we don’t have that ability to pay for that, so you more or less have to stay in your home if that’s the case. (SR1, FG1)
An additional element was the lack of information provided to women on government support available to them after their husbands died, including survivor benefits:
When the women came into our nursing home, a lot of them they have never worked … their husbands die, they are 70 or 80 years old and nobody even tells them that they need to sign some papers so that they can get the income. They’ve never worked … they have tried to live on nothing because the man has had the income and it’s, you know, they pay his way in the nursing home, but she doesn’t have enough to live on at home and nobody really even seems to care. (SR7, Int)
Building on this, adult children not being able to assist their widowed mothers was referenced by another participant: ‘And how do these people cope? Because the woman who has stayed home to look after her children, they are not going to be there always, they’re gone, their husband’s gone and here she is. And she’s probably in good health until she is about 65 or 70 and then, Bingo. There’s nobody there, you know’ (SR2, FG). As these quotes demonstrate, participants mostly talked about others rather than themselves, despite being older women.
Addressing SDH through restructuring: ‘we got to come together’
When asked about the ways restructuring could address SDH (RQ3), participants suggested specific SDH and their intersections and spoke to health-care providers needing to understand ageing and older adults:
I woke up and wished I had a doctor that I could tell him all of my little aches and pains, but you wouldn’t dare do if you were going to your doctor and she can say well this one [health concern] isn’t serious, don’t worry about it anymore and this one we better check up. But, it would be to a doctor that understands how seniors feel and how they worry about their health. So, I think that if there were some doctors that understood seniors. (SR3, FG1)
Participants generally believed that the government should provide more resources (financial support, equipment, affordable home care or housekeeping) to enable older adults to remain at home. In terms of transportation and rurality, participants recommended increasing home support and services that travel to rural communities. Health care and health-care providers were urged to build on community-led initiatives and supports and align with older adults wanting to maintain community. Several participants desired inclusive community meetings, with one suggesting that IH should increase opportunities for Indigenous and non-Indigenous older adults to come together:
The last meeting that was held here in April, I don’t recall seeing too many First Nations people there. Now, they also are involved because it is one community and they do have their concerns and I think they do have their own group of people that sort of work with the youth and whatever other critical factors are going on. So, somehow pulling us together [in] a community meeting. (SR4, FG1)
In addition to Indigenizing health care or making health care more culturally inclusive, Indigenous Elders called for their own community members to come together more, to support one another. As one participant, ‘considered an Elder in the community’, said:
Come on, sit down, let’s talk. Let’s have a cup of tea. Let’s have a meal. Let’s be together. Because this is where we live. This is when we live, when we are together. We live to support one another. We care for one another. We share with one another, right? To provide strength, guidance, love, but we got to come together. This is what happens when we come together. (U, FG3)
In contrast, Sikh older adults were generally grateful for the health services they received – in comparison to their country of origin – and only stressed that addressing ‘language is a must’ (U, FG4). Moreover, a female participant referred to gender, Indigenous ancestry and sexual orientation in calling for restructuring to ensure equal treatment: ‘Well, it [restructuring] would help a person, me a woman and the Natives and a person who is of same sex, gender or whatever it’s called, homosexual, lesbian, yeah, if they needed the help, they should get it’ (SR3, Int). This quote powerfully summarizes the intersections of social categories evident in our dataset and showcases the optimism with which some participants envisioned the restructuring of primary and community care and its potential to enable them to age in place.
Discussion
In the results section earlier, we presented our findings related to each of our three research questions, starting with the SDH for community-dwelling older adults in BC’s interior (Box), how these SDH relate to older adults’ views on primary and community care (SDH 1–7) and the ways restructuring might address SDH for older adults in BC’s interior. The seven SDH we identified are compared with those found in global, national, Indigenous and local models, which include between 8 and 14 SDH domains (Table 5). Four appear in all models: housing and physical environment, income and poverty, education and social inclusion/exclusion and supports. Five other domains appear in nearly all models: early childhood development, food (in)security, (un)employment and working conditions, access to health services and culture/language. While early life is identified as a key determinant, ageing or later life is not and disability rarely appears. An Indigenous SDH framework is similar to both the WHO (2022) and the Health Canada (2020) models, though it adds geo-physical environments, highlights language as part of culture, refers to poverty and social status alongside income and positions colonialism or coloniality as the primary determinant. The only models that, like ours, include determinants related to geography and Indigenous ancestry/colonialism are those by Raphael (Reference Raphael2016) and Raphael et al. (Reference Raphael, Bryant, Mikkonen and Raphael2020) and Indigenous scholars (Greenwood et al. Reference Greenwood, De Leeuw, Stout, Larstone and Sutherland2022; Loppie and Wien Reference Loppie and Wien2022).
Table 5. Social determinants of health models/frameworks
* Race/racism was added in 2018/2019 when Aboriginal status was removed.
** Five other SDHs (food security, connections, sexual orientation and gender expression, disability and ageing/seniors) were discussed by some participants, but were not the main SDHs for our sample.
Some of the SDH contained in other models, such as food (in)security, education, social inclusion/exclusion and supports, were not relevant to and/or addressed by participants in our study as our research was focused on health care, specifically primary and community care. Similarly, employment and working conditions is unlikely to be an SDH for older adults with an average age of 75 years.
Income was the most predominant SDH and intersected with all others except for ethno-racial minority status, which was unsurprising as income appears in all SDH models (Table 5), along with housing and physical environment, which we refer to as living situation. Our categorization of living situation data was based on with whom people live and whether they received support, not only type of housing. For older adults, important components of ‘space’ are who shares the home (family members, pets, friends, care providers; living or visiting there) and the home atmosphere (sense of safety, independence, participation). While these aspects of the home environment (space) are of key relevance to ageing in place (FPT Ministers Responsible for Seniors Forum 2012; Rogers et al. Reference Rogers, Ramadhani and Harris2020), they are overlooked in SDH models that reference housing and/or physical environment and do not address ageing or later life. Hence, as critical gerontologists we use ‘living situation’, rather than housing and/or physical environment.
‘Space’ is commonly paired with ‘place’ in environmental and geographical gerontology (Peace Reference Peace2022; Rogers et al. Reference Rogers, Ramadhani and Harris2020), with the latter referring to the community or geographic location in which the space is located. In our research, place is encapsulated by ‘living rurally’, an aspect of ageing in place often overlooked in SDH models. Rural residents experienced different challenges than urban dwellers, including limited access to health services and transportation options. These factors are known to impact one’s ability to age in place (Hansen et al. Reference Hansen, Newbold, Scott, Vrkljan, Grenier, Huang, Skinner, Winterton and Walsh2021). Further, the ways in which SDH (e.g. transportation) impacted older adults living rurally were distinct. The concept of ‘transport poverty’ captures this robust linkage between limited transportation options and lack of access to health and other essential services (Kiss Reference Kiss2022; Stjernborg and Svensson Reference Stjernborg and Svensson2024). Transport poverty is an apt description for what the older adults in our study were experiencing for, as Kiss (Reference Kiss2022) notes, ‘it is intertwined with social vulnerabilities, such as low income, old age or disabilities and with regional disadvantages’ (p. 2). Although IH was aware of the significance of transportation as an SDH at the outset of their repositioning, they did not consult with rural older adults. Our research found transportation to be linked to social vulnerabilities, with the latter more pronounced for those living rurally (Mirza and Hulko Reference Mirza and Hulko2022). Attention to transportation as an SDH – or transport poverty – is needed and will likely require locating services in rural communities and changing the structure of health-care funding so that rural residents are not underserved or treated as ‘second class citizens’.
Our study shows that Indigenous ancestry and ethno-racial minority status – as SDH – manifested differently. Income was predominant as an SDH for the Indigenous participants based on both quantitative and qualitative data, yet was not for Sikh participants. Some Sikh participants expressed gratitude to the government and contentment with primary and community care services in comparison to their country of origin. This made us realize that grouping Indigenous and racialized participants under labels such as BIPOC (Black, Indigenous and People of Colour) homogenizes their unique health-care experiences. This highlights the importance of collecting both quantitative and qualitative data and comparing the results to appreciate the heterogeneity that exists among BIPOC.
Despite the majority of the participants being older women, when gender was discussed in terms of SDHs, participants tended to refer to others (e.g. older women living alone), rather than themselves. They may have been envisioning their own futures or discussing their own situation by referring to a third person. Gender in relation to being an older man was not discussed, supporting early theorizations of men as ‘the invisible gendered subject’ (Whitehead Reference Whitehead2001). Calasanti et al.’s (Reference Calasanti, Pietilä, King and Ojala2022) work with older men shows that ‘respondents may struggle to find concrete referents for a topic not often discussed in daily life’ (p. 4). This likely happened in our study with respect to gender and sexual orientation.
While ageing/later life was not identified as an SDH, it was discussed by the participants and in a way that reinforced the biomedicalization of ageing (Estes and Binney Reference Estes and Binney1989), a discursive phenomenon critical gerontologists contest (Hanlon and Poulin Reference Hanlon, Poulin, Skinner, Winterton and Walsh2020; Hulko et al. Reference Hulko, Brotman, Stern and Ferrer2020). That is, medical conditions and impairments were discussed by participants as part of ageing/later life, not as disability per se. Older adults did not identify themselves as persons with disabilities, despite using mobility aids and medical devices, which can be seen as a challenge to the successful ageing narrative which positions those with poor health or physical limitations as incapable of ageing well (Pruchno and Carr Reference Pruchno and Carr2017). Such an ability of older adults to overcome physical limitations is more appropriately termed resilience or resistance than successful ageing (Hulko et al. Reference Hulko, Brotman, Stern and Ferrer2020).
Participants in our study strongly advocated for working together with one another and with IH. This was based on concern for others, which came across strongly through discussion of most SDHs except ethno-cultural minority status. Concern for ethno-cultural/racial groups other than Indigenous people was not mentioned despite people of Asian origin composing 19.3 per cent of the Canadian population (Statistics Canada 2023) and South Asians (e.g. Sikh) being a sizeable (3 per cent) presence in BC’s Central Interior and 35 per cent of visible minorities (Statistics Canada 2017). Despite this, the extent to which the outcomes of repositioning will serve equity-seeking older adults, including those living rurally, and address their concerns/priorities remains a question to be investigated.
Strengths and limitations
The strengths of our study include the number of participating communities, size and composition of the sample, including the high number of men (32.5 per cent) and racialized participants (24.1 per cent), and voices of service users being the priority rather than those of care partners and service providers. Other strengths were the long-standing partnership with IH decision makers and practitioners to ensure research relevance and timely mobilization of study findings, use of mixed methods and interdisciplinary expertise and commitment to critical gerontological research and practice of our research team. One way we overcame the potential limitation of our Punjabi interpreter summarizing the Sikh participants’ responses rather than translating word for word is that the second author understands Punjabi and was able to verify the accuracy.
In terms of limitations, using IH’s schemata to categorize our living situation data as with whom one lives and the type of dwelling they reside in did not allow for complexities such as living in mobile homes, having to care for a spouse, living with an adult child who does not provide support or having familial support nearby. We did not ask about marital status or immigration status; however, both demographic characteristics were referenced in the interviews and focus groups. As income data is notoriously difficult to acquire, we used income brackets to decrease item non-response (Yan Reference Yan2021), which affected our ability to draw conclusions about the impact of income on other SDH.
The main SDHs were those discussed by our sample; however, other SDHs like racism and sexual orientation might have been more predominant if our sample had included more sexual and/or gender minority participants and Black and Asian older adults, for example. While the majority of our sample was living with CCD and observed using medical equipment (e.g. walkers, wheelchairs, canes, oxygen therapy) and/or being assisted by companions during the focus groups and interviews, disability was rarely discussed, which may have been an artefact of our interview questions in which we did not ask about disability in addition to CCD. This was an oversight.
Conclusions and implications for policy and practice
In this study, we focused on service users facing the most disparities or identified as ‘priority populations’, that is, ‘frail elderly’ and rural and First Nation communities. Moreover, BC MOH (2014) did not identify ethno-cultural communities or low-income people as priority populations despite these groups being recognized as ‘more likely to experience poor health and suffer from chronic conditions’ alongside Indigenous peoples and ‘frail’ seniors (Longhurst and Cohen Reference Longhurst and Cohen2019, p. 1). Given this, it is important for BC’s MOH to focus on older adults from ethno-cultural and low-income backgrounds in addition to those who are Indigenous and/or have CCD, particularly as late life immigration is predicted to ensure population ageing continues past 2030 (Statistics Canada 2022). Further, as older adults may not associate CCD with disability, researchers and practitioners should name disability separately from CCD (Goering Reference Goering2015) or ‘frailty’ to ensure accurate and complete assessments.
The results of our study challenge not only contemporary SDH models that overlook key SDH for older adults and rural residents but also the perceived homogeneity of rural ageing and BIPOC. By highlighting the views of both Indigenous Elders and Sikh older adults – populations minimally included in ageing research – we showcase the diverse experiences of older Canadians and expand gerontological narratives on ageing and health care. Our findings challenge the homogenization of BIPOC experiences in the literature as we confirmed income as a significant SDH for Indigenous participants yet revealed that Sikh participants did not see income as a major issue. This offers new insight into different socio-economic realities within BC’s interior, particularly for older South Asians, which has not been addressed in the literature. Further, we highlight a positive reception of health care by Sikh participants, a view that contrasts markedly with the more complex relationship Indigenous communities have with the health-care system owing to historical and contemporary trauma (De Leeuw et al. Reference De Leeuw, Lindsay, Greenwood, In Greenwood, de Leeuw and Lindsay2018; Hulko et al. Reference Hulko, Brotman, Stern and Ferrer2020).
In addition to these general points, our conceptualization of living situation adds an important social dimension to ageing and health care, which was underexplored in the literature within the context of health-care restructuring. We also discuss transport poverty and, in doing so, provide a new approach to understanding how transportation barriers intersect with social vulnerabilities in rural populations. These are not exclusive to South Asian and Indigenous participants, however.
To address the lack of inclusion of ageing/later life in SDH models and disassociate ageing from illness and disability, early childhood development or childhood experiences could be changed to ‘ageing and development across the lifecourse’. In addition, transportation and living rurally need to be included in SDH models as they directly impact older adults. Housing and physical environment could be expanded or changed to better reflect the importance of space and place in line with articulations of ageing in the right place (Canham et al. Reference Canham, Weldrick, Sussman, Walsh and Mahmood2022). Who shares the space with the older adult, if anyone, and what social supports are attached to this space are important considerations in addressing SDH and enabling ageing in place.
Health-care practitioners and policy professionals need to understand that SDH are all interrelated and one cannot be tackled without considering the others. It is imperative that policy/decision makers at all levels of government and across sites and sectors of health and social care include in their restructuring initiatives actual commitments and concrete plans to address SDH, especially income, living situation, living rurally, transportation and their intersections. This includes changing funding models so rural communities get their fair share and ensuring that age-friendly planning tables at the municipal level are inclusive of rural and remote older adults. Future research should seek to determine the outcomes of the restructuring of primary and community care, taking into consideration the priorities identified by older adults (Hulko et al. Reference Hulko, Mirza and Seeley2021) and the evidence presented here on the role that SDH play in accessing primary and community care to support ageing in place.
Acknowledgements
Lori Seeley, co-investigator on ROAR; Liz Brown, community-based researcher, for assistance with data collection, preparation and analysis (coding); Katlyn Mellett, BSW practicum student, for assistance with manuscript preparation; numerous community groups and seniors’ organizations that promoted our research and provided space for focus groups and interviews; and all the older adults who took part in ROAR and advocated for change.
Author contributions
Both authors contributed equally to the conceptualization, data collection, analysis and interpretation of the research reported herein, with the second author taking responsibility for the preparation and analysis of the quantitative data and the first author doing so for the qualitative data. Both authors contributed to the writing of this manuscript with the first author being responsible for ∼60 per cent and the second ∼40 per cent.
Financial support
This work was supported by Interior Health [grant number IHRGC_2016-11] and Michael Smith Health Research BC [grant number 16817]. Neither Interior Health nor Michael Smith Health Research BC played a role in the design, execution, analysis and interpretation of data or the writing of this study. Interior Health played a nominal role in the design, execution and interpretation of data in that one of the co-investigators worked for Interior Health in a leadership position, as did advisory committee members; none of their contributions were subject to oversight by Interior Health, however, and Interior Health played no role in the writing of this study.
Competing interests
The authors declare none.
Ethical standards
This work was approved by the research ethics boards of Thompson Rivers University and Interior Health.
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