Aging People, Aging Places: Experiences, Opportunities, and Challenges of Growing Older in Canada 9781447352570

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Aging People, Aging Places: Experiences, Opportunities, and Challenges of Growing Older in Canada
 9781447352570

Table of contents :
Front cover
Title Page
Copyright Page
Table of Contents
List of figures and tables
Notes on contributors
Introduction
Part I: Urban
1. Aging in urban Canada
2. ‘An accessible route is always the longest’: older adults’ experience of their urban environment captured by user led audits and photovoice
3. Urban community vignette
4. Walking in the city: seniors’ experience in Canada and France
5. Urban practitioner vignette
Part II: Suburban
6. Aging in suburban Canada
7. An age-friendly city? LGBTQ and frail older adults
8. Suburban community vignette
9. New micro-mobilities and aging in the suburbs
10. Suburban practitioner vignette
Part III: Rural
11. Aging in rural Canada
12. A profile of the rural and remote older population
13. Rural community vignette
14. Supports and limitations of aging in a rural place for women aged 85 and older
15. Rural practitioner vignette
Part IV: Indigenous
16. Aging in Indigenous Canada
17. Pursuing pathways to care: dementia and aging in Indigenous communities
18. Indigenous community vignette
19. Métis older adults and the negotiation of nativeness
20. Indigenous practitioner vignette
Conclusion
Index
Back cover

Citation preview

AGING PEOPLE, AGING PLACES EXPERIENCES, OPPORTUNITIES, AND CHALLENGES OF GROWING OLDER IN CANADA EDITED BY MAXWELL HARTT, SAMANTHA BIGLIERI, MARK W. ROSENBERG, AND SARAH E. NELSON

AGING PEOPLE, AGING PLACES Experiences, Opportunities, and Challenges of Growing Older in Canada Edited by Maxwell Hartt, Samantha Biglieri, Mark W. Rosenberg, and Sarah E. Nelson

First published in Great Britain in 2021 by Policy Press, an imprint of Bristol University Press University of Bristol 1-9 Old Park Hill Bristol BS2 8BB UK t: +44 (0)117 954 5940 e: [email protected] Details of international sales and distribution partners are available at policy.bristoluniversitypress.co.uk © Bristol University Press 2021 British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library ISBN 978-1-4473-5256-3 hardcover ISBN 978-1-4473-5259-4 ePub ISBN 978-1-4473-5257-0 ePdf The right of Maxwell Hartt, Samantha Biglieri, Mark W. Rosenberg, and Sarah E. Nelson to be identified as editors of this work has been asserted by them in accordance with the Copyright, Designs and Patents Act 1988. All rights reserved: no part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise without the prior permission of Bristol University Press. Every reasonable effort has been made to obtain permission to reproduce copyrighted material. If, however, anyone knows of an oversight, please contact the publisher. The statements and opinions contained within this publication are solely those of the editors and contributors and not of the University of Bristol or Bristol University Press. The University of Bristol and Bristol University Press disclaim responsibility for any injury to persons or property resulting from any material published in this publication. Bristol University Press and Policy Press work to counter discrimination on grounds of gender, race, disability, age and sexuality. Cover design: Robin Hawes Front cover image: iStock 1175874694 Bristol University Press and Policy Press use environmentally responsible print partners. Printed in Great Britain by CPI Group (UK) Ltd, Croydon, CR0 4YY

Contents List of figures and tables Notes on contributors

v vii

Introduction 1 Maxwell Hartt and Samantha Biglieri PART I Urban 1 Aging in urban Canada Samantha Biglieri, Maxwell Hartt, and Natalie S. Channer

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2

‘An accessible route is always the longest’: older adults’ experience of their urban environment captured by user-led audits and photovoice Atiya Mahmood and Delphine Labbé

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3

Urban community vignette Lillian Wells

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4

Walking in the city: seniors’ experience in Canada and France Marie-Soleil Cloutier and Florence Huguenin-Richard

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5

Urban practitioner vignette Marianne Wilkat and Barry Pendergast, with Natalie S. Channer

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PART II Suburban 6 Aging in suburban Canada Maxwell Hartt, Natalie S. Channer, and Samantha Biglieri

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An age-friendly city? LGBTQ and frail older adults Lindsay Herman, Ryan Walker, and Mark W. Rosenberg

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8

Suburban community vignette Candace Skrapek and Elliot Paus Jenssen

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New micro-mobilities and aging in the suburbs Jennifer Dean and Edward Donato

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10

Suburban practitioner vignette Chris Kawalec with Madison Empey-Salisbury

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PART III Rural 11 Aging in rural Canada Natalie S. Channer, Samantha Biglieri, and Maxwell Hartt

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12

A profile of the rural and remote older population Mark W. Rosenberg

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13

Rural community vignette Della Webster and Sylvia Humphries

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Supports and limitations of aging in a rural place for women aged 85 and older Olive Bryanton, Lori E. Weeks, and William Montelpare

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Rural practitioner vignette John Whalley

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PART IV Indigenous 16 Aging in Indigenous Canada Sarah E. Nelson

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Pursuing pathways to care: dementia and aging in 205 Indigenous communities Carrie Bourassa, Mackenzie Jardine, Danette Starblanket, Sebastian Lefebvre, Marlin Legare, Dana Hickey, Jessica Dieter, Betty McKenna, Gail Boehme, and Nicole Akan

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Indigenous community vignette Larry McDermott

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Métis older adults and the negotiation of nativeness John Lewis

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Indigenous practitioner vignette Connie Paul

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Conclusion 247 Mark W. Rosenberg Index

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List of figures and tables

Figures 1.1 2.1 4.1 4.2

4.3 6.1 9.1 9.2 9.3 11.1 14.1 14.2 16.1

Canada’s urban population by region and age Examples of pictures from each community and for each theme Study area and walkability audit results Examples of street features increasing (a, b, d, f) or decreasing (c, e) the walkability audit index in Montréal and Lille Tracking paths for pedestrians in Lomme-Lambersart and Wazemmes Canada’s suburban population by region and age E-bike models used in the study E-trike pedestrian interaction on multi-use trails E-bike rider at a busy intersection along a multi-use trail Canada’s rural population by region and age Making baby quilts Sharing pictures and stories Proportion of the population aged 14 and under and 65 and over by Indigenous identity

16 31 55 61

63 82 121 125 126 142 178 182 198

Tables Int.1 Age-friendly domains and a selection of key factors 1.1 Number of Canadian urban residents by age, low income, immigrant neighbourhood, and foreign language neighbourhood 4.1 The MAPISE walkability audit dimensions, indicators and characteristics per street segment and crossing 4.2 Proportion of street segments according to their walkability audit results 4.3 Differences in proportion between tracking paths and audit street segments according to their walkability results in Lomme-Lambersart and Wazemmes 6.1 Number of Canadian suburban residents by age, low income, immigrant neighbourhood and foreign language neighbourhood

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5 17

56 59 65

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11.1 Number of Canadian rural residents by age, low income, immigrant neighbourhood, and foreign language neighbourhood 14.1 Participant profiles (n=10)

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177

Notes on contributors (Cree, Bear Clan) Nicole Akan is a member of the Muskowekwan First Nation. She is the current Community Research Assistant for the All Nations’ Healing Hospital Health Services. Previously employed by Morning Star Lodge and CBC Saskatchewan where she has gained valuable experience in leadership, finance, and relationship building in community. Samantha Biglieri is an Assistant Professor in the School of Urban and Regional Planning at Ryerson University, a practising planner, and Past President of the Toronto Council on Aging. Samantha’s work on age- and dementia-inclusive urban planning and housing has been featured in academic/industry publications, international conferences, podcasts, and on CBC Radio. Gail Boehme is the Executive Director of the All Nations’ Healing Hospital and File Hills Qu’Appelle Tribal Council Health Services. Carrie Bourassa is the Scientific Director of the CIHR Institute of Indigenous Peoples’ Health and a Professor in the Department of Community Health and Epidemiology at the University of Saskatchewan. She is also the Principal Investigator for the Canada Foundation for Innovation funded Morning Star Lodge. Olive Bryanton is a researcher in the Department of Health Sciences at the University of Prince Edward Island. She co-chairs the PEI Government Seniors Health & Wellness Implemental Council, is the Atlantic representative on AGE-WELL Older Adults and Caregiver Advisory Committee and is actively involved in other panCanadian projects. Natalie S. Channer is a master’s student in the School of Geographical Sciences at the University of Bristol. She completed her BA in Human Geography at Cardiff University in 2020. She worked as a Research Assistant on the Aging People, Aging Places project throughout the summer of 2019. Marie-Soleil Cloutier is a health geographer and Professor of Urban Studies at Institut national de la recherche scientifique, Québec.

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She is the Director of the Pedestrian and Urban Space Laboratory (LAPS), where her research interests include the impact of the built environment on pedestrian road safety and road risk perception. Jennifer Dean is an Associate Professor in the School of Planning at the University of Waterloo where she teaches and conducts research on healthy and inclusive communities. Jennifer holds degrees in Geography (PhD, McMaster University; MA, University of Toronto) and Women’s Studies and Geography (BA, University of Toronto Mississauga). Jessica Dieter is from Okanese First Nation in Treaty 4 Territory. An employee of the FHQ Tribal Council, she has filled various roles revolving around First Nation health and education. Through research and front-line work, she has engaged in work with birthing, youth, and adults – especially Elders. Edward Donato is a recent graduate from the Master of Arts program at the School of Planning at the University of Waterloo. He also holds an Honours BA in Geography from McMaster University. Edward’s expertise is in active transportation and health, sustainable public transportation, and older adult mobility. Madison Empey-Salisbury is in her final year of undergraduate studies at the University of Waterloo working towards her Bachelor of Environmental Studies in Planning. Her interests lie primarily in transportation planning, which is reflected in her previous research experience in active transportation. Maxwell Hartt is an Assistant Professor in the Department of Geography and Planning at Queen’s University. He holds a PhD in Planning from the University of Waterloo. Maxwell leads the Ageing Suburban Nations project funded by the British Academy and is a Co‑Investigator on the ESRC-funded Double Ageing project. Lindsay Herman completed her MA in Geography and BA (Hons) in Regional and Urban Planning at the University of Saskatchewan. She now works as a marketing manager in the health and fitness industry. Dana Hickey is an Anishinaabe researcher from Dokis First Nation in Ontario, Canada. Dana recently defended a Master of Indigenous Relations thesis at Laurentian University. Dana’s research interests have

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been focused on power imbalances that have social implications, such as health inequities in Canada. Florence Huguenin-Richard is a Lecturer in Geography at the Sorbonne University in France. Her research examines mobility, walkability, and pedestrian safety, with a focus on the place of older adults, children, and young people in living spaces. Sylvia Humphries is a retired secondary school math teacher with an interest in outdoor education, canoeing, and community building. Sylvia is a Senior Goodwill Ambassador for Charlotte County, New Brunswick, a co-coordinator of the Town of Saint Andrews Community Garden and the chair of the Vibrant Communities Charlotte County (VCCC) Board. Mackenzie Jardine is a Métis woman of Métis Nation Saskatchewan and a student in the University of Saskatchewan’s School of Medicine. Her career goal is to help create a representative workforce of Indigenous people within the healthcare system and to contribute to eliminating the health inequities experienced by Indigenous people. Chris Kawalec is the Community Development Program Manager at the City of Peterborough. Chris has an undergraduate degree in Geography from McMaster University and a Master’s in City Planning from the University of Manitoba. Chris was one of the key leaders instrumental to the implementation and success of Peterborough’s Age-Friendly Community Action Plan. Delphine Labbé is an Assistant Professor at the University of Illinois at Chicago. Her research focuses on promoting full participation of people with disabilities of all ages by better understanding the person–environment interaction and using participatory action research to co-create interventions with key stakeholders to develop inclusive communities. Sebastien Lefebvre is a Research Assistant at the Morning Star Lodge, an Indigenous community-based health research lab spearheaded by Dr. Carrie Bourassa. As an ally, Sebastien brought data analysis and mentoring skills to the lab which were put to use in the development of Indigenous-based data analysis methods.

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Marlin Legare works as a Research Assistant for Morning Star Lodge in Regina, Saskatchewan. He is also a Citizen of the Métis Nation who is directly involved as a research lead for community-based Indigenous health projects in partnership with the File Hills Qu’Appelle Tribal Council in Fort Qu’Appelle, Saskatchewan. John Lewis is a Citizen of the Métis Nation of Ontario and Professor in the School of Planning at the University of Waterloo. He has worked as a community planner and consultant for municipal and First Nations governments and as a researcher for the Ontario Ministry of Seniors’ Affairs. Atiya Mahmood is an Associate Professor in the Gerontology Department at Simon Fraser University. Her training is in environmental gerontology and her research focuses on health and built environments for older adults with a specific interest in neighbourhood environments, mobility, active living, and pro-social behaviour/social engagement of diverse groups of older adults in community-based and supportive housing. Larry McDermott is a member of Shabot Obaadjiwan First Nation, an Algonquin nation in what is now eastern Ontario, and is part of the Indigenous Advisory Group and Indigenous Elders’ Circle of the Law Society of Ontario. He holds an Honorary Doctor of Laws from the University of Guelph and is the executive director of Plenty Canada. Elder Betty McKenna is Anishnabae from the Shoal River Band #366 who, with her husband Ken, has had three children. She is an Elder for First Nations and Métis education at the Regina Public School Board, and a lecturer of Indigenous Health Studies in social work and biology. William Montelpare is the Margaret and Wallace McCain Chair in Human Development and Health at the University of Prince Edward Island. As the scientific lead for the Primary and Integrated Healthcare Innovation Network, he is developing health and wellness opportunities for Islanders across the age spectrum. Sarah E. Nelson is an Assistant Professor in the Department of Geography and Geology at the University of Nebraska at Omaha. Her research interests span health equity, community-based research, and health services for older populations. Her current research is a

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collaborative project on how older Algonquin knowledge holders interact with oral histories, and how this impacts both older individuals and community health. Connie Paul has worked for 30 years as a nurse and now works at the Snuneymuxw First Nation Health Centre in Nanaimo on what is now called Vancouver Island, British Columbia. Elliot Paus Jenssen is a retired social worker and a member of the Age-Friendly Saskatoon Initiative Steering Committee. In retirement, Elliot has continued to work with a range of community volunteer activities that focus primarily on promoting positive aging and creating a better quality of life for Saskatoon’s older adults. Barry Pendergast is the President of the Oakridge Virtual Seniors Village project, which in three years has rapidly grown to 100  members. While the majority are physically and mentally fit, new funding is anticipated to cover a four-year program to expand the group and progressively reach the most vulnerable. Mark W. Rosenberg is a Professor in the Department of Geography and Planning and cross-appointed in the Department of Public Health Sciences at Queen’s University. He is the Tier  1 Canada Research Chair in Aging, Health and Development. Publications from his research can be found in the leading journals of geography, gerontology, social science, and medicine. Candace Skrapek is a retired registered nurse educator and Co-Chair of the Age-Friendly Saskatoon Initiative. In retirement, Candace has continued to utilize her past education, experience, and expertise in a range of community volunteer activities that focus primarily on promoting positive aging and creating a better quality of life for Saskatoon’s older adults. Danette Starblanket is from the Star Blanket Cree Nation and is nearing completion of her PhD at the University of Saskatchewan. Danette is an instructor at the First Nations University of Canada and research co-lead at the Morning Star Lodge, an Indigenous-based research lab. Ryan Walker is a Professor of Geography and Planning at the University of Saskatchewan, Saskatoon, Canada, and past-Chair of its

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regional and urban planning program. He has degrees from Queen’s University at Kingston (PhD), University of Waterloo (MA), and University of Lethbridge (BA). Della Webster is a retired school administrator/university supervisor who is involved in the Age-Friendly Initiative with the Greenwich Local Service District in New Brunswick. She has worked closely with the Wellness Branch of the Province of New Brunswick to implement various programs for seniors, such as Healthy Chefs. Lori E. Weeks is an Associate Professor in the School of Nursing at Dalhousie University where she is a member of the Healthy Populations Institute, the Centre for Transformative Nursing, and Health Research and the JBI Centre of Excellence. She also holds a scientific appointment with the Nova Scotia Health Authority. Lilian Wells is professor emerita, Factor-Inwentash Faculty of Social Work University of Toronto. Her research and teaching includes aging, health and disability, empowerment practice, organizational change, and long-term care. She was a founding member of the Toronto Council on Aging and currently is President of the Ontario Association of Councils of Aging. John Whalley is the Vice President of Business and Finance at New Dawn Enterprises Limited in Sydney, Nova Scotia. From 1997 to 2015, he was the Economic Development Manager for the Cape Breton Regional Municipality. He holds an honours BA and a MA in Economics from Dalhousie University. Marianne Wilkat has volunteered her entire adult life. She has been working on affordable/accessible housing for seniors for almost 15  years. In 2005 she received The Alberta Centennial Medal in recognition of outstanding service to the people and province of Alberta.

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Introduction Maxwell Hartt and Samantha Biglieri Our world is growing older. As birth rates continue to drop, and younger residents and recent immigrants congregate in a small number of global cities, the demographic geography of Western nations has become increasing uneven (Townshend and Walker, 2015). While it is important to celebrate the fact that people are living longer and healthier, such changes in population also challenge the viability of economic and healthcare systems (Nefs et  al, 2013). Canada’s demographic shift is particularly significant as Canada is home to the world’s largest proportion of ‘baby boomers’ – those born between 1947 and 1966 (Foot, 1999). As the baby boomers reach and pass retirement age, Canada’s population pyramid will become increasingly top-heavy. The shift is already well underway. As of 2015, Canadians aged 65 years and older have outnumbered children aged 0 to 14 years (Statistics Canada, 2015). The aging of the population has called into question how prepared national, provincial, and local governments are to support the needs of the heterogeneous older adult population. Though national- and provincial-level planning on macro-level issues like pensions and healthcare is commonplace, these debates neglect how policies play out on the ground in the complex and varied regional milieu of a large nation like Canada (Hodge, 2008). Recent research has shown a ubiquitous increase in older adult populations across Canadian municipalities (Hartt and Biglieri, 2018). Of course, an increase in the older adult population is not problematic in its own right. More concerning is that the Canadian cities expected to age the most are also the least likely to have begun any age-friendly planning (Hartt and Biglieri, 2018). In order to prepare for this demographic shift, we need a better understanding of the local implications of aging and the built environment’s impact on the health and wellbeing of older adults. The importance of the local environment is reflected in the overwhelming desire of older adults to maintain their independence as they age, often expressed as the desire to age in place (Hodge, 2008). As people age, they are increasingly likely to experience some kind of impairment (physical, sensory, or cognitive) or reduced mobility (Myers et al, 2005). This reduced ability means that an individual is

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more likely to be impacted by barriers in his or her local environment (Lawton, 1982). In fact, 70% of our aging process is determined by external factors, as research has shown that genetic factors account for less than 30% (Vaupel et  al, 2003; Wahl and Oswald, 2010). Older adults’ independence, sense of dignity, and overall quality of life often manifest at the community level (Thomas and Blanchard, 2009; Plouffe and Kalache, 2010). Furthermore, older adults are more likely than any other age group to spend time in their immediate neighbourhoods (Kerr et  al, 2012). Therefore, it follows that the local community becomes an ideal space for intervention. The need for additional research on local experiences of aging has also been highlighted by policymakers. The Chief Public Health Officer of Canada (2017) emphasized the need to focus more research on the built environment’s impacts on health – specifically, the importance of encouraging physical activity, promoting healthy food options, and supporting mental wellness, especially for vulnerable populations like older adults. The Improving Health By Design Report by the Chief Medical Officers of Health in the Greater Toronto and Hamilton Area (2014) called on public health policymakers and planners to encourage the creation of walkable mixed-use neighbourhoods as a way to combat chronic disease and encourage active transportation, and identified older adults as more vulnerable when in automobiledependent neighbourhoods. In order to live well as we age, a combination of individual factors (such as income, health status, and housing) and community-level factors (such as access to transportation, community supports, and housing) must come together to support people in everyday activities (Lawton and Nahemow, 1973; Carlsson, 2002; Scheidt and Windley, 2006). This fundamental combination of individual and community is reflected in the title and organization of this book: Aging People, Aging Places. Throughout this text, a wide range of contributors from across Canada demonstrate how community-level factors can be the difference between enabling and disabling older adults. And in doing so, shed light on the debates and discussions needed to help Canadians age better. In this introduction, we first outline the underlying rationale and overarching objectives of the book. Next, we unpack the idea of the ‘local’ context and explain how we perceive it. From there, we provide an overview and critique of the World Health Organization’s (WHO) Age-Friendly City (AFC) model in order to provide some foundational context for the chapters to come. Finally, we outline the structure of the rest of the book.

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Rationale, objectives, and ‘local’ aging Canada is changing. Economically, socially, environmentally, and culturally, the aging of the population and the rural-(sub)urban shift are fundamentally changing Canada. We believe that big changes require big questions and big discussions. However, these questions and discussions often overlook a key spatial component. Despite the growing acknowledgement of the importance of the local municipal and neighbourhood context, much of the aging literature remains either focused on national- and provincial-level issues, such as pensions and healthcare systems, or individual geriatric care. Similarly, programs and courses focused on aging at Canadian universities are overwhelmingly housed in health science or sociology. This book aims to not only fill the disciplinary and geographic gap in the aging literature by focusing on the local, but also to generate a wider, more inclusive, discussion on aging in Canadian communities. Unencumbered by disciplinary boundaries or town-and-gown silos, this book embraces debates from a range of disciplines, public and private actors, and individual community members. Together, we highlight the diversity of challenges, opportunities, and policies influencing and being influenced by Canada’s aging population to help shed light on two fundamental questions: How well do the places we live in support the health and wellbeing of older adults? And what can be done to make it better? One of the unique and important contributions of this book is our explicit focus on aging at the local level across Canada. But in a vast, multifaceted country spanning almost 10 million square kilometres, what is ‘local’? To us, local is the geographic representation of a person’s day-to-day life. It is their commute, their social network, their cultural space, their familiar territory. Local is the rich intertwined spatial tapestry of economic, social, environmental, and cultural that defines everyday experiences. And it is an inherently relative concept. One person may view an entire metropolitan area as their local environment, whereas another may limit their conception of local to a few streets or even a single building. In addition to its relative size or extent, an individual’s local environment is also defined by its built form. And in Canada, the local built environment can vary considerably. Living in a rural community like Petit Étang, Nova Scotia, brings a different set of local opportunities and challenges than living on Queen Street West in Toronto, Ontario, or suburban Richmond, British Columbia. While there is no correct or optimal conception of local, it does influence how we live our life – especially as we age.

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In this book, we aspire to capture the breadth of local Canadian experiences. From the very first conversations that led to this book’s creation, we have been intent on recognizing and celebrating the diversity of the Canadian aging experience. As such, the book covers a wide range of Canadian people and places. Canada’s aging population is far from homogeneous and we felt it was important to reflect and celebrate that diversity within these pages – from recent immigrants to Indigenous peoples, and older adults of varying abilities and identities. We are thrilled that this book not only includes research on a wide range of older adults, but it incorporates a wide range academic, practitioner, and older adult voices authoring the chapters, case studies, and personal vignettes. Similarly, we wanted to ensure geographic breadth to capture the Canadian aging experience. As you read through the book, you will be transported from urban metropolises to rural towns, from Nova Scotia to British Columbia. No matter whereabouts you are in Canada, the local environment is a key component of aging well. The importance of examination and intervention at the local level has been reflected in the WHO’s policy push for AFCs. The WHO recognizes that, as we grow older, our physical and relational environment plays an increasingly significant role in our quality of life (WHO, 2017). The AFC policy movement has been developing momentum around the globe for over ten years and is a foundational conceptual and practical element of the aging discourse. Therefore, before delving into the remainder of the book, we will first provide a summary of the AFC history and framework, its practical application, and relevant critiques and recommendations.

The promise and limitations of AFCs The AFC movement is based on the recognition that: (1) the world’s population is aging (with the number of older adults to be the highest in human history), (2) it is the local level of government that can make some of the most tangible impacts on older adults’ everyday lives, and (3) our cities were not made for older adults. The AFC policy movement began in the early 2000s with focus group research in megacities, regional centres, and small towns all over the world (led by Canadian Louise Plouffe and Brazilian Alexandre Kalache for the WHO). The focus groups included 1,485 participants over the age of 60, 250 caregivers, and 515 service providers from 33 countries (WHO, 2007). The objective of the WHO’s research agenda was to determine the areas of everyday life that impact the lives of older adults and how they could be improved by a local government. The

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Introduction

WHO was and remains the largest global supporter of the original research and the movement as it continues today, hosting the global Age-Friendly Network, and numerous resources for local, provincial, and national governments interested in the framework. The team from the WHO, working with partners across the globe, developed the Age-Friendly City Framework with 77  factors nested within eight domains (WHO, 2007). The eight domains and a selection of key factors can be found in Table Int.1. Two key facets of the AFC framework are its holistic nature (encompassing nearly every Table Int.1: Age-friendly domains and a selection of key factors Social Participation

Accessible opportunities Affordable activities Range of opportunities Awareness of activities and events

Civic Participation and Employment

Volunteering options for older people Better employment options/opportunities Accommodate older workers/volunteers Encouraging civic participation

Community Support and Health Services

Accessible care Wide range of healthcare services Aging well services Homecare

Transportation

Availability Affordability Reliability and frequency Travel destinations

Communication and Information

Widespread distribution The right information at the right time Will someone speak to me? Age-friendly formats and design

Respect and Social Inclusion

Respect and disrespectful behaviour Ageism and ignorance Intergenerational interactions Place within community

Housing

Affordability Essential services Design Modifications

Outdoor Spaces and Buildings

Pleasant and clean environment Importance of green spaces Somewhere to rest Age-friendly pavements

Source: WHO, 2007

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action a local government can undertake), and its flexibility (which allows the framework to be place-based and context-specific to the needs of older adults in a particular locale). As part of the AFC framework, the WHO also developed a systematic process through which a municipality, anywhere in the world, could officially be branded a WHO-recognized Age-Friendly City. In order to receive the WHO’s seal of approval, municipalities would have to demonstrate that they had: 1. Completed a background study/needs review of the older adults in their community based on the eight domains (eg  reviewing census data, cataloguing existing services and supports for older adults, etc); 2. Conducted public engagement with older adults in their community about issues to be solved in regard to the eight domains (eg hosting a town hall, open house or creating an advisory group); 3. Developed an Age-Friendly Plan that is context specific (based on the previous two steps) and includes the eight pillars; 4. Received endorsement from the municipal government and received a signature of commitment from the municipality’s Mayor. Once these four steps were completed, the WHO would declare the city ‘Age-Friendly’, send an official letter to the municipality, and add the city to the AFC list on its website. Municipalities all over the world have completed this process, receiving official status from the WHO, including a number of Canadian municipalities. Once AFC status has been granted, municipalities are required to renew this process every three years in order to continue to be considered WHO Age-Friendly. While the AFC movement has gained traction over the past decade, especially in raising public consciousness to the needs of older adults in our cities and towns and the need to plan for them, there are a few critiques of the movement. First, in its focus on municipal issues, scholars have argued that the AFC framework ignores macroscale issues that greatly affect the everyday lives of older adults – neoliberalization, austerity policies, and global market forces (Plouffe and Kalache, 2010; Buffel and Phillipson, 2016). Macro-level dynamics can affect affordability (eg housing, food, personal supports, etc), erode social safety nets with the privatization or downloading of services, and reduce public pension plans (or fail to increase them to keep pace with inflation), which can all lead to greater inequalities. These issues have

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Introduction

a particularly strong impact on older adults as they are more likely to require additional supports and services as they age and are often living on fixed incomes. As the AFC model focuses on the municipal level, it does not tend to engage with these larger issues, as they are more likely to be impacted by larger levels of government with greater taxation powers. Canada provides an apt example of the disconnect between government powers. In Canada, healthcare is a provincial responsibility and many of the homecare-related services are administered by this level of government. Of course, an important part of an AFC model is access to health and social care services. However, AFC policies are created by the local level of government, not provincial. This means that even the best AFC policy put forward by a city would not be able to meaningfully change health/social care investment and policy beyond advocating to provincial governments. There are also critiques of the AFC model in terms of how it speaks about older adults, and how the policy presents itself as apolitical. The AFC model can be considered paternalistic in its orientation. Activists have begun to use terms like ‘age-inclusive’ and to assert the rights of older adults to access the places they live and to be supported living at home. Further, the model is problematic in how it depoliticizes the issue of a lack of services and supports for older adults. Building a few benches (one of the common built environment recommendations) is AFC appropriate, but bigger questions of why homecare has been defunded in Canada are not. Furthermore, Dalmer (2019) highlights that AFC policies neglect the role of family/friend support networks, in addition to inaccurately framing aging-in-place as a problem of choice. Another main critique of AFCs has to do with implementation of the policy. There are a number of issues stemming from its voluntary nature (and thus being susceptible to political interest and available funding) as well as the necessary continued involvement of older adults in the plan’s creation, implementation, and evaluation. AFCs are meant to be ongoing processes for municipalities in the sense that they are not only done once but considered living documents. However, many municipalities in Canada have not engaged with the process at all. Our own work on Ontario’s municipalities found that uptake was mixed (Hartt and Biglieri, 2018). In fact, we found that municipalities with the greatest proportion of older adults were the least likely to have completed any form of AFC planning. We speculate that this discrepancy could be due to differences in voluntary policy and budgets, funding, and leadership.

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Voluntary policy, budget, and funding An AFC Plan is voluntary in Ontario and most other provinces. Municipalities are not required by law to create and review AFC plans. This is in contrast to a municipality’s land use plan – called an Official Plan – which is required to be reviewed every ten years. As a result, AFC Plans are susceptible to the politics of the day, as well as the budget available for their creation, maintenance, and execution of the goals/activities outlined. For municipalities where the lives of older adults are an important issue, politicians might choose to invest more heavily in their Age-Friendly Plans and goals/actions, and the same is true for disinvestment, or for a politician to pay lip service to a plan without allocating any part of the city budget behind it. It is also highly possible for an AFC Plan to ‘sit on a shelf ’ without concrete actions, responsible departments, and funding to implement those actions. Funding is a crucial element of AFCs. In Ontario, the Liberal Provincial government of the late 2010s began offering municipalities small grants to undertake AFC planning. This led to a number of municipalities beginning this process, however in the absence of continued funding, many municipalities have stopped moving forward with their plans. Differences in leadership Differences in political leadership can make or break an AFC Plan. Because AFC Plans often rely heavily on volunteers, it can be difficult to create or maintain interest, engagement, and progress. That being said, many municipalities have been able to sustain progress by incorporating a number of diverse strategies. For instance, the City of Toronto created a massive voluntary network to support their AFC Plan, including city departments, other levels of government, universities, hospitals, and non-profit/private entities that serve and speak for older adults in the city (called the Toronto Seniors Strategy Accountability Table). The continued success of this Accountability Table has led to changes within the local level of government, and consolidation of services that serve seniors into one department at the city. Other success stories of leadership include municipalities like Peterborough (Chapter 10) and Calgary (Chapter 5). In all, the AFC model has been incredibly successful. It has given municipalities around the world a flexible framework and the opportunity to meaningfully engage with the older adults who live

8

Introduction

in their community. The centrality of community engagement is something to be celebrated, as it implores municipalities to actually talk to older adults, instead of relying on proxies. However, as the aforementioned critiques highlight, there is still work to be done. In order to advance the AFC movement, Age-Friendly Plans should be a by-law requirement for local municipalities and funding should be guaranteed from higher levels of government (for AFC Plan creation, implementation, and evaluation). Regional, provincial, and national Age-Friendly Plans should be integrated to ensure inter-governmental co-operation, and to address issues that affect older adults that cannot be tackled at a municipal level (eg social security, health/social care). Coalitions with other groups should be built to organize and develop macro-scale policies to support funding for affordable housing, and to provide support and guidance to ensure people are afforded their rights (eg tenants rights’ associations, disabled folks, new immigrants). In the remainder of this book, we explore and unpack these, and related, challenges and opportunities of aging people and places all across Canada.

Book structure The book is divided into an introduction, conclusion, and four major parts: urban, suburban, rural, and Indigenous. The four parts represent distinct built and cultural environments within the Canadian landscape – each with its own unique opportunities and challenges for an aging population. Although not a singular place type, the fourth part is included as Indigenous peoples are a unique and fundamental part of Canadian culture, and therefore, of the Canadian aging experience. The relationship between Indigenous peoples and places in Canada cuts across the urban, suburban, and rural, as well as reserves. Due to the diverse and historical ties to place, and potentially heightened vulnerabilities, the multi-dimensional relationship between Indigenous aging and place requires in-depth and targeted study. Each of the four parts include an overview, two research-based articles, one community member vignette, and one practitioner vignette. Using a consistent template, part overviews present key debates, statistics, and maps pertaining to the current and projected future state of aging, and opportunities and challenges unique to the respective built environment. Research articles present novel conceptual arguments alongside empirical analysis to help us better understand lived experiences of aging across Canadian communities. Community member vignettes allow a range of older adults to share

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Aging People, Aging Places

their own experiences, as well as their views on the challenges and opportunities of aging in their respective environments. In their vignettes the practitioners present their community as a short case study. They highlight key statistics, policies, initiatives, and challenges from the perspective of their position within local government or stakeholder organization. The conclusion synthesizes the four major parts and highlights the comparative aspects of local level aging in the Canadian context, provides policy recommendations, and highlights opportunities for future research. References Buffel, T. and Phillipson, C. (2016) ‘Can global cities be “age-friendly cities”? Urban development and ageing populations’, Cities, 55: 94–100. Carlsson, G. (2002) ‘Catching the bus in old age: methodological aspects of accessibility assessments in public transport’. Doctoral thesis, Lund University, Sweden. Chief Medical Officers of Health in the GTHA (2014) ‘Improving Health by Design in the Greater Toronto-Hamilton Area Report’. Toronto. Available at: https://www.peelregion.ca/health/resources/ healthbydesign/pdf/moh-report.pdf. Chief Public Health Officer of Canada (2017) ‘The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2018: Designing Healthy Living’. Ottawa, ON. Available at: https://www. canada.ca/en/public-health/services/publications/chief-publichealth-officer-reports-state-public-health-canada/2017-designinghealthy-living.html. Dalmer, N. (2019) ‘A logic of choice: Problematizing the documentary reality of Canadian aging in place policies’, Journal of Aging Studies, 48: 40–9. Foot, D.K. (1999).Boom, Bust & Echo 2000: Profiting from the Demographic Shift in the New Millennium (2nd edn), Toronto: Stoddart. Hartt, M. and Biglieri, S. (2018) ‘Prepared for the silver tsunami? An examination of municipal old-age dependency and age-friendly policy in Ontario, Canada’, Journal of Urban Affairs, 40(5): 625–38. Hodge, G. (2008) The Geography of Aging: Preparing Communities for the Surge in Seniors. Montréal and Kingston: McGill-Queen’s University Press. Kerr, J., Rosenberg, D., and Frank, L. (2012) ‘The role of the built environment in healthy aging: community design, physical activity, and health among older adults’, Journal of Planning Literature, 27(1): 43–60.

10

Introduction

Lawton, M.P. (1982) ‘Competence, environmental press, and the adaptation of older people’, in P. Windley and T. Byerts (eds) Aging and the Environment: Theoretical Approaches. New York: Springer, pp 43–60. Lawton, M.P. and Nahemow, L. (1973) ‘Ecology and the aging process’, in C. Eisdorfer and M.P. Lawton (eds) Psychology of Adult Development and Aging. Washington, DC: American Psychological Association, pp 619–74. Myers, A.M., Cyarto, E.V., and Blanchard, R. (2005) ‘Challenges in quantifying mobility in frail older adults’, European Review of Aging and Physical Activity, 2(1): 3–21. Nefs, M., Alves, S., Zasada, I., and Haase, D. (2013) ‘Shrinking cities as retirement cities? Opportunities for shrinking cities as green living environments for older individuals’, Environment and Planning  A, 45(6): 1455–73. Plouffe, L. and Kalache, A. (2010) ‘Towards global age-friendly cities: determining urban features that promote active aging’, Journal of Urban Health, 87(5): 733–9. Scheidt, R.J. and Windley, P.G. (2006) ‘Environmental gerontology: progress in the post-Lawton era’, in J.E. Birren, K.W. Schaie, R.P. Abeles, M. Gatz, and T.A. Salthouse (eds) Handbook of Psychology of Aging. Boston, MA: Elsevier Academic Press, pp 105–25. Statistics Canada (2015) ‘Canada’s population estimates: Age and sex, July 1, 2015’, The Daily, 29 September. Ottawa, ON. Available at: http://www.statcan.gc.ca/daily-quotidien/150929/dq150929b-eng. htm. Thomas, B.W.H. and Blanchard, J.M. (2009) ‘Moving beyond place: aging in community’, Journal of the American Society on Aging, 33(2): 12–17. Townshend, I. and Walker, R. (2015) ‘Life course and lifestyle changes: urban change through the lens of demography’, in P. Filion, M. Moos, T. Vinodrai, and R. Walker (eds) Canadian Cities in Transition: Perspectives for an Urban Age (5th  edn), Don Mills, ON: Oxford University Press. Vaupel, J.W., Carey, J.R., and Christensen, K. (2003) ‘Aging. It’s never too late’, Science, 301(5640): 1679–81. Wahl, H.-W. and Oswald, F. (2010) ‘Environmental perspectives on aging’, in D. Dannefer, and C. Phillipson (eds) International Handbook of Social Gerontology. London, UK: Sage, pp 111–24. WHO (World Health Organization) (2007) Global Age-Friendly Cities: A Guide. Geneva: WHO Press. WHO (World Health Organization) (2017) Towards an Age-Friendly World. Geneva: WHO Press.

11

PART I

Urban

1

Aging in urban Canada Samantha Biglieri, Maxwell Hartt, and Natalie S. Channer In this overview chapter, we call upon data from Statistics Canada and the academic literature to present some stylized facts and figures regarding urban older adults and a synthesis of the challenges and opportunities of aging in urban environments. This chapter serves to provide (1)  a snapshot of Canadian urban demographic trends, (2) an overview of the state-of-the-art thinking on urban aging, and (3) contextual framing for the in-depth research chapters and vignettes that make up the urban part of this book. Canada is predominantly a nation of rural spaces. By land area, urban locations occupy only 0.25% of Canada’s 9.9 million square kilometres. However, urbanization is quickly changing the national landscape. While Canada’s urban areas are growing steadily, they are simultaneously driving considerable suburban growth in their periphery. As we note in Chapter 6, Canada is a suburban nation. And those huge suburbs are growing around Canada’s urban centres. The three largest metropolitan areas (which include both urban and suburban areas), Toronto, Montréal, and Vancouver, are home to more than a third of all Canadians, with a combined population of 12.5 million (Statistics Canada, 2019). For many, urban Canada evokes images of these three iconic cities. Big, bustling conurbations with dense downtowns, skyscrapers, and expensive housing. But like suburban and rural areas, urban regions can take a variety of shapes and forms. Although there is no one perfect definition of ‘urban’, we adopt the following operational definition in order to provide a generalized overview of urban demographic trends in Canada: urban areas are dissemination areas (as defined by Statistics Canada) with a population density of 5,000 or more people per square kilometre, or areas with a population density of 1,000 to 5,000 people per square kilometre where fewer than 60% of population commutes by car (Channer et al, 2020). Using data from the Statistics Canada (2019) population estimates, we found that 5.3 million of Canada’s roughly 35 million people live

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Aging People, Aging Places

in urban areas. Of those 5.3 million, approximately 800,000 are aged 65 and over. Across Canada, the number of residents aged 65 and over is growing, and urban settings are no exception. Proportionally, 15% of Canada’s urban population are aged 65 and over, lower than suburban (17%) and rural (18%) locations. Looking at the older urban population by province (Figure 1.1), we can see that the largest proportion reside in Ontario. In fact, Ontario is home to nearly half of Canada’s older urban population (46%) and total urban population (48%). In Québec, urban residents are proportionally overrepresented as 29% of urban Canadians aged 65 and over reside there, yet Québec houses 25% of Canada’s urban population. Both British Columbia and the Prairies provinces (Manitoba, Saskatchewan, and Alberta) also have slightly higher proportions of older urban residents. Urban Canada is significantly more ethnically heterogeneous than its rural and suburban counterparts. Table  1.1 shows that 27% of Figure 1.1: Canada’s urban population by region and age Older (65+) Working (25–64) Young (0–24) 4,500,000 4,000,000

Urban population

3,500,000 3,000,000 2,500,000 2,000,000 1,500,000 1,000,000 500,000 0

Older (65+)

Atlantic

Québec

Ontario

17,730

377,005

583,590

Prairies 87,695

British Territories Columbia 215,505

1,909

Working (25–64)

69,425 1,203,725 2,347,990

455,180

800,160

7,530

Young (0–24)

34,215

227,125

326,570

4,480

588,485 1,211,590

Source: Statistics Canada, 2019

16

Aging in urban Canada Table 1.1: Number of Canadian urban residents by age, low income, immigrant neighbourhood, and foreign language neighbourhood Number of Canadian urban residents 65+ 85+ 65+ Low income 85+ Low income Total 1,282,615 268,892 197,445 42,140  91,759  55,040 Immigrant neighbourhoods 390,610 14,232  78,936  47,855 Foreign-language neighbourhoods 344,410 12,093 Source: Statistics Canada, 2019

urban Canadians aged 65 and over live in neighbourhoods where the principal language is neither English nor French – a complete contrast to rural regions that have only 1%. Urban Canada’s ethnic diversity is also denoted by the fact that 30% of older Canadians live in majority immigrant neighbourhoods. Older adults who live in majority immigrant neighbourhoods may be more vulnerable to consequences of social isolation from infrastructural barriers (Syed et al, 2017). Furthermore, of these older Canadians living in immigrant neighbourhoods, 34% of them are living on low incomes (defined by Statistics Canada’s after-tax low-income measure) and this proportion remains roughly the same for the cohort aged 85 and over. More broadly, across all types of neighbourhoods in urban Canada, one fifth of the older adult population are living on low incomes. Income inequality is a much more pronounced risk in urban areas where 21% of older Canadians live on low incomes, compared to 14% in rural areas. Other key debates in urban aging centre around the extent to which policy for infrastructure, transportation, and housing can serve the older generation. Urban environments have many structural opportunities to support age-friendly communities, including existing public transport systems, larger bureaucracies, and a stronger non-governmental organization presence. However, there are also limitations to such large and developed urban locations, such as incorporating diversity and scale into decision making. In the rest of this chapter, we summarize existing research on aging in Canadian urban communities and further unpack the challenges and benefits of urban aging.

Challenges to aging well in urban Canada Urban Canada’s older adult diversity requires a range of policies and facilities that reflect the heterogeneity of the population. Such policy considerations impact older adults’ mobility in urban areas,

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Aging People, Aging Places

their housing provision, healthcare service allocation, and accessible transportation options. Transportation policies in an aging society should emphasize how transport systems can best accommodate the requirements of a growing and increasingly diverse group of older Canadians. Recounting her own experience in Toronto in Chapter 3, Lillian Wells provides an important reminder that lived experiences differ and ‘age is just a number’. Diversity should be considered in transportation policy in a variety of ways including: infrastructure accessibility (eg installing elevators at subway stations, providing barrier-free access to buses and rail transit, installing wide, non-slip sidewalks, safe intersections, and implementing city-wide snow clearance from pavements), provision of alternative mobility options (eg public and paratransit services, active transportation) and licensing of older drivers in view of road safety (Ruben et  al, 2010). In Chapter 2, Atiya Mahmood and Delphine Labbé examine barriers encountered by older mobility device users in Vancouver and argue that planners and policymakers need to take a broader look at inclusion and participation. Focusing on piecemeal remedies such as curb cuts and sidewalk extensions is not enough. Mobility options and road safety licence renewal (such as age-based licensing in Ontario for older urban residents) should recognize the importance of automobility among the population while acknowledging the need for alternatives to private car use to meet mobility demands. Active travel and public transportation are important options for older adults with a wide range of physical, cognitive, and social benefits. However, many older adults, even in urban areas, prefer and rely on automobile use. Mercado and Páez (2009) found that in Hamilton, Ontario, the expected decline in distance travelled as residents age is more pronounced for car driving compared to car passenger and bus transport methods. Older Canadians also tend, on average, to drive the same distance as long as they keep their driving ability intact. This is a challenge for age-friendly policy as dedicated drivers risk a radically heightened vulnerability once they lose their driving licence. Planning practitioners and decision makers need to enable older adults to be mobile through better land use and transportation policy in order to maintain and extend their quality of life. To accomplish this, a combination of walkable neighbourhoods and suitable transportation provision are needed to overcome individual barriers to mobility. In order to provide for Canada’s older urban citizens, there is a need to go beyond traditional policy focus and consider the increased heterogeneity of the older population in regard to lifestyle, mobility, resources, infrastructure, and health (Mercado and Páez, 2009).

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Aging in urban Canada

Another element of aging policy that demands inclusivity is housing. Policymakers face the challenge of catering to a diverse mix of older Canadians and need to consider issues of low income, mobility, and cultural diversity. With more than a fifth of urban older adults living on a low income, it is unsurprising that affordability is the greatest challenge for housing older Canadians (Weeks and Leblanc, 2010). Clark (2005) found that 18% of Canadian older adults have problems with housing affordability. Affordability is a much greater issue for vulnerable older adults than for the general older adult population, especially those living on fixed incomes, and without pensions or assets (like owning property for instance) (Weeks and Leblanc, 2010). Furthermore, a majority of older adults live in single-detached housing, which can become unsuitable and inaccessible for older adults. For instance, stairs and designs that do not accommodate mobility devices, as well as grounds that they can no longer maintain. While urban centres are more likely to include apartment options, accessible features are not mandatory in residential buildings units – meaning that most of these housing options are still inaccessible or require significant investment to retrofit. In addition to affordability, suitability poses a major challenge. Housing provision for older adults needs to be accessible, available, safe, and culturally appropriate. Older adults who have immigrated to urban locations in Canada may have different housing concerns than the Canadian-born population. In their study of housing experiences of South Asian immigrant older adults in Edmonton, Ng et al (2019) found that, unlike Canadian-born older adults, it was a rarity for South Asian immigrants to live alone and that living with extended families was the most common living arrangement. However, housing has typically been built for the so-called traditional nuclear family in a single-detached dwelling, as opposed to multi-unit dwelling options that would accommodate these needs – the ‘missing middle housing’ (eg duplexes, triplexes, and low-rise apartments). Racialized and immigrant older adults also face more systemic barriers than their Caucasian and Canadian-born counterparts – for instance limited social supports, lower socio-economic status, and negative health outcomes, as well as being more at risk of social isolation and loneliness (Vang et al, 2017; Salma and Salami, 2019). With 30% of Canada’s older adult population being immigrants (Statistics Canada, 2017), and most of them living in urban areas, these systemic barriers indicate clearly that a one-size-fits-all approach to aging in place cannot be inclusive for Canada’s diverse population.

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Aging People, Aging Places

Urban locations also have unique healthcare challenges for older adults. These can range from lengthy waiting times for services (which can cause further health deterioration), to transportation and accessibility barriers to healthcare centres. Haggerty et al (2014) found that urban older adults tend, on average, to struggle more with distances to healthcare facilities to receive treatment than rural residents. They also concluded that added distance often results in people using closer emergency services for primary care, which is more costly for healthcare providers. Older adults tend to have strong preferences to obtain care from a familiar healthcare provider – one who is aware of their medical history and personal context – which can be less likely to occur in urban environments with a greater population density. While there is a higher concentration of care services for people living with dementia in urban centres, research comparing Ottawa, Calgary, and Edmonton suggested that ‘access to particular services at the time when they require it may depend on the specific centre that they reside in’ (Tam-Tham et al, 2016, p 8). Again, urban areas pose more significant challenges as a result of having a greater scale, as well as needing to plan for a wide diversity of individuals and coordinate organizations through policy and programming. Finally, in terms of overall municipal age-friendly policy, research in Manitoba found that larger cities take longer to implement projects, encounter substantial bureaucracy and face coordination challenges between departments. Further, due to the scale, community engagement is more difficult when compared with smaller communities where everyone knows each other and already works together (Menec et al, 2014).

Opportunities to age well in urban Canada Despite the aforementioned challenges for older Canadians, urban environments also offer unique opportunities to support aging in place. The physical scale of urban locations provides infrastructural advantages through increased services and larger transportation systems. As urban areas have such a diverse population, there is also scope for a wider range of services and community supports (Beatty and Berdahl, 2011; Novek and Menec, 2014). Spatially, urban environments are better equipped to provide services for older adults at a closer proximity than other, especially rural, neighbourhoods. Levasseur et al (2015) found that most urban older adults in Québec had access to services and amenities located within a five-minute walk of their dwelling. They found that increased social participation was associated with greater

20

Aging in urban Canada

proximity to neighbourhood resources – emphasizing the important relationship between the socio-spatial. Richard et al (2008) found that accessible urban walking environments and suitable transportation services in Montréal correlated with frequency of use and significantly increased social participation. In Chapter 4, Marie-Soleil Cloutier and Florence Huguenin-Richard compare older adult urban walking experiences in Montréal and Lille, France. They found that older adults did indeed have different behaviours and decision-making habits when walking in cities compared to younger pedestrians. Furthermore, their research highlights the importance of exclusive pedestrian space to provide visibility and freedom of movement. The more walkable a neighbourhood is (ie the presence of accessible walking infrastructure and amenities within 400–800m distances), the more potential there is for increased social interaction and connection for older adults (Richard et al, 2008; Ferreira et al, 2016). Urban areas are more likely to be walkable, with a mix of uses and easy access to transportation and amenities, as well as providing easier access to one’s social network (ie family, friends, neighbours). These factors produce higher levels of physical activity in older adults – they are up to three times as likely to meet Canada’s physical activity guidelines than their suburban counterparts (Winters et al, 2015). Physical activity is integral to a better quality of life, and the main protective factor against Alzheimer’s, Parkinson’s, and cognitive decline (Kerr et al, 2012; Paillard et al, 2015; Hirsch et al, 2017; Stubbs et al, 2017). These factors also promote greater food security for older adults (Chung et al, 2011), and can lead to reduced social isolation, the building of social capital, and a sense of independence and dignity (Leyden, 2003; Levasseaur et al, 2015). Finally access to amenities like ‘third places’ (eg coffee shops, libraries, parks, etc) has been identified as important for the social health of older adults (Oldenburg, 1989; Alidoust et al, 2018). As well as infrastructural advantages, urban locations generally have higher levels of healthcare provision and an increased variety of services to offer older adults. Urban neighbourhoods often offer walk-in clinics, a rarity in rural areas, which provide more care options without advance notice. A broader variety of services that provide better support influence healthcare satisfaction, which is higher in urban areas, as only 36% of urban residents reported unmet care needs compared to 52% or rural residents (Haggerty et  al, 2014). More efficient access to healthcare is assisted by organizational mechanisms including car-sharing arrangements, more frequent interactions with physicians, walk-in services, and a greater availability of local care alternatives (Forbes et al, 2006; Gamble et al, 2011).

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Aging People, Aging Places

Another major benefit to urban aging communities is the increased presence of non-profit organizations and resources available to support them. In Chapter 5, Marianne Wilkat and Barry Pendergast share their experiences supporting the older adult community in Calgary through the Calgary Aging in Place Co-Operative and the Oakridge Seniors’ Association. Urban non-profit organizations like these have the potential to facilitate a variety of affiliations and collaborations with external bodies that can improve their services, reach, and help foster community partnerships. Increased connectivity and greater numbers of volunteers are more likely to be available in urban settings. Non-profit sustainable initiatives that improve older adults’ quality of life in a variety of ways can be supported by cross-sector collaborations, systematic municipal involvement, and community champions in urban neighbourhoods (Russell et  al, 2019). Such supportive collaborations can provide urban aging non-governmental organizations with sponsorships, event spaces, promotion assistance, volunteers, and media guidance. The larger networks and available resources that are associated with urban locations may encourage the growth of supportive projects for older adults. That being said, the resultant complexity from so many organizations and programs can lead to confusion about what exists in a community for an individual older adult and could lead to difficulty navigating such a complex system. Altogether, while urban areas may have infrastructure (eg walkable neighbourhoods, transportation, healthcare services) as well as the funding capacity to facilitate a wider breadth of age-friendly initiatives than their suburban or rural counterparts, their success still relies heavily on political leadership, investment, commitment, and advocacy to building a city that is truly age-inclusive. References Alidoust, S., Bosman, C., and Holden, G. (2018) ‘Planning for healthy ageing: how the use of third places contributes to the social health of older populations’, Ageing & Society, 39(7): 1–26. Beatty, B. and Berdahl, L. (2011) ‘Health care and aboriginal seniors in urban Canada: helping a neglected class’, International Indigenous Policy Journal, 2(1): 1–16. Channer, N.S., Hartt, M., and Biglieri, S. (2020) ‘Aging-in-place and the spatial distribution of older adult vulnerability in Canada’, Applied Geography, 125.

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Chung, W.T., Gallo, W.T., Giunta, N., Canavan, M.E., Parikh, N.S., and Fahs, M.C. (2011) ‘Linking neighbourhood characteristics to food insecurity in older adults: the role of perceived safety, social cohesion, and walkability’, Journal of Urban Health: Bulletin of the New York Academy of Medicine, 89(3): 407–18. Clark, W. (2005) ‘What do seniors spend on housing?’, Canadian Social Trends, 78: 2–7. Ferreira, I.A., Johansson, M., Sternudd, C., and Fornara, F. (2016) ‘Transport walking in urban neighbourhoods—impact of perceived neighbourhood qualities and emotional relationship’, Landscape and Urban Planning, 150: 60–9. Forbes, D., Morgan, D., and Janzen, B. (2006) ‘Rural and urban Canadians with dementia: use of health care services’, Canadian Journal on Aging, 25(3): 321–30. Gamble, J., Eurich, D., Ezekowitz, J., Kaul, P., Quan, H., and McAlister, F. (2011) ‘Patterns of care and outcomes differ for urban versus rural patients with newly diagnosed heart failure, even in a universal healthcare system’, Journal of the American Heart Association, 4(3): 317–23. Haggerty, J., Roberge, D., Levesque, J., Gauthier, J., and Loignon, C. (2014) ‘An exploration of rural–urban differences in healthcareseeking trajectories: implications for measures of accessibility’, Health and Place, 28: 92–8. Hirsch, J.A., Winters, M., Clarke, P.J., Ste-Marie, N., and McKay, H.A. (2017) ‘The influence of walkability on broader mobility for Canadian middle-aged and older adults: an examination of Walk Score™ and the Mobility Over Varied Environments Scale (MOVES)’, Preventive Medicine, 95: S60–S67. Kerr, J., Rosenberg, D., and Frank, L. (2012) ‘The role of the built environment in healthy aging: Community design, physical activity, and health among older adults’, Journal of Planning Literature, 27(1): 43–60. Levasseur, M., Cohen, A., Dubois, M., Genereux, M., Richard, L., Therrien, F., and Payette, H. (2015) ‘Environmental factors associated with social participation of older adults living in metropolitan, urban, and rural areas: the NuAge study’, American Journal of Public Health, 105(8): 1718–25. Leyden, K.M. (2003) ‘Social capital and the built environment: the importance of walkable neighbourhoods’, American Journal of Public Health, 93(9): 1546–51.

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Menec, V., Novek, S., Veselyuk, D., and McArthur, J. (2014) ‘Lessons learned from a Canadian province-wide age-friendly initiative: the age-friendly Manitoba initiative’, Journal of Aging & Social Policy, 26(1): 33–51. Mercado, R. and Páez, A. (2009) ‘Determinants of distance travelled with a focus on the elderly: a multilevel analysis in the Hamilton CMA, Canada’, Journal of Transport Geography, 17(1): 65–76. Ng, C., Northcott, H., and Abu-Laban, S. (2019) ‘Housing and living arrangements of South Asian immigrant seniors in Edmonton, Alberta’, Canadian Journal on Aging, 3(3): 185–94. Novek, S. and Menec, V. (2014) ‘Older adults’ perceptions of agefriendly communities in Canada: a photovoice study’, Aging and Society, 34(6): 1052–72. Oldenburg, R. (1989) The Great Good Place: Cafés, Coffee Shops, Community Centers, Beauty Parlors, General Stores, Bars, Hangouts, and How They Get You through the Day. New York: Paragon House. Paillard, T., Rolland, Y., and de Souto Barreto, P. (2015) ‘Protective effects of physical exercise in Alzheimer’s disease and Parkinson’s disease: a narrative review’, Journal of Clinical Neurology 11(3): 212–19. Richard, L., Gauvin, L., Gosselin, L., and Laforest, S. (2008) ‘Staying connected: neighbourhood correlates of social participation among older adults living in an urban environment in Montréal, Québec’, Health Promotion International, 24(1): 46–57. Ruben, M., Páez, A., and Newbold, B. (2010) ‘Transport policy and the provision of mobility options in an aging society: a case study of Ontario, Canada’, Journal of Transport Geography, 18(5): 649–61. Russell, E., Skinner, M., and Fowler, K. (2019) ‘Emergent challenges and opportunities to sustaining age-friendly initiatives: qualitative findings from a Canadian age-friendly funding program’, Journal of Aging and Social Policy, 1–20. Available at: https://doi.org/10.1080/ 08959420.2019.1636595. Salma, J. and Salami, B. (2019) ‘“Growing old is not for the weak of heart”: social isolation and loneliness in Muslim immigrant older adults in Canada’, Health & Social Care in the Community, 28(2): 615–23. Statistics Canada (2017) ‘Immigration and ethnocultural diversity: key results from the 2016 census’. Available at: https://www150. statc an.gc.ca/n1/en/daily-quotidien/171025/dq171025b-eng. pdf?st=ixKYOblv. Statistics Canada (2019) ‘Population estimates on July 1, by age and sex. Table 17-10-0005-01’, Ottawa, Statistics Canada. Available at: https:// www150.statcan.gc.ca/t1/tbl1/en/tv.action?pid=1710000501.

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Stubbs, B., Chen, L.J., Chang, C.Y., Sun, W.J., and Ku, P.W. (2017) ‘Accelerometer-assessed light physical activity is protective of future cognitive ability: a longitudinal study among community dwelling older adults’, Experimental Gerontology, 91: 104–9. Syed, M., McDonald, L., Smirle, C., Lau, K., Mirza, R., and Hitzig, S. (2017) ‘Social isolation in Chinese older adults: scoping review for age-friendly community planning’, Canadian Journal on Aging, 36(2): 223–45. Tam-Tham, H., Nettel-Aguirre, A., Silvius, J., Dalziel, W., Garcia, L., Molnar, F., and Drummond, N. (2016) ‘Provision of dementiarelated services in Canada: a comparative study’, BMC Health Services Research, 16(1): 184. Vang, Z.M., Sigouin, J., Flenon, A., and Gagnon, A. (2017) ‘Are immigrants healthier than native-born Canadians? A systematic review of the healthy immigrant effect in Canada’, Ethnicity & Health, 22(3): 209–41. Weeks, L. and Leblanc, K. (2010) ‘Housing concerns of vulnerable older Canadians’, Canadian Journal on Aging, 29(3): 333–47. Winters, M., Voss, C., Ashe, M.C., Gutteridge, K., Mckay, H., and Sims-Gould, J. (2015) ‘Where do they go and how do they get there? Older adults’ travel behaviour in a highly walkable environment’, Social Science & Medicine, 133: 304–12.

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‘An accessible route is always the longest’: older adults’ experience of their urban environment captured by user-led audits and photovoice Atiya Mahmood and Delphine Labbé

According to propositions of the ecological model of aging (Lawton and Nahemow, 1973), the environment plays a significant role in outcomes for older persons experiencing a decline in competence, such as limitations in their cognitive and physical functioning. Other scholars have also noted that the immediate home and neighbourhood environments become increasingly important for older adults, as they are less likely to be working or have the ability to access a variety of locations in the urban environment (Glass and Balfour, 2003). As a result of health issues faced in advanced age, very old people tend to decrease their action range and spend large portions of the day at home and the ‘immediate outdoor environment’ (Oswald et al, 2010, p 238). Research showed that the physical environment close to home (two to three city blocks) has a strong relationship with mobility and social participation among older adults, especially those with mobility disability (Clarke et al, 2011; Williams and Willmott, 2012; Chaudhury et al, 2016). Lack of accessibility in urban neighbourhoods due to poorly designed public spaces may prevent older adults from fully participating in society. Multiple studies have documented the influence of environmental factors on the mobility and social participation of older adults and people with disabilities (Rosso et  al, 2011; Hanson et  al, 2013; Bigonnesse et al, 2018). For instance, Rosso and colleagues (2011) proposed that within the built environment, transportation systems (eg  traffic-related street characteristics or walking paths), landuse patterns (eg density, proximity of amenities), and urban design (eg aesthetics or neighbourhood decay) affected the mobility of older

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adults. Another recent review of the literature (Bigonnesse et  al, 2018) has highlighted that proximity and accessibility of destinations facilitated mobility for mobility device (MD) users, while sidewalks and street conditions, poorly designed or absent crosswalks, and traffic congestion were barriers to the neighbourhood environment. However, although empirical research in this area is growing, there is limited knowledge about which barriers or facilitators foster or deter mobility and social participation in the neighbourhood physical and social environment by older adults using MD (Botticello et al, 2014; Clarke, 2014; Harris et al, 2015). This chapter presents the results of neighbourhood builtenvironment audits and photo elicitation from a study conducted in the Greater Vancouver Area in British Columbia (BC) to explore the barriers and facilitators encountered by older MD users.

Methods Photovoice and environmental audits were the two participatory methods used in a mixed-method study entitled ‘Enabling Mobility And Participation among those with Disabilities (dEMAND)’. The dEMAND study was conducted in two provinces in Canada: BC and Québec. In BC, three cities/municipalities were included: Vancouver, North Vancouver, and New Westminster. This research was conducted as part of a multi-phase and multi-site study titled the Canadian Disability Participation Project. Photovoice For the photovoice data collection, the participants took pictures or videos of the mobility- and participation-related barriers and facilitators they encountered in their daily life over a two-week period. For each picture, they noted the location and reason for taking that picture. Individual interviews were then conducted with participants to discuss their most significant photographs, followed by focus group sessions with some participants to identify common themes from the pictures. The interviews and the focus groups data were analysed using an inductive thematic analysis approach (Braun and Clarke, 2006). Photographs and their associated quotes were grouped under identified themes, based on the focus group themes. A photo exhibit was developed that showcased pictures from the three cities around the themes. This exhibit was presented in community outreach events with different urban stakeholders.

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‘Stakeholders’ walkability/wheelability audit in neighbourhood’ – SWAN An easy-to-use neighbourhood environmental audit tool designed for older adults and persons with mobility called ‘Stakeholders’ Walkability/ Wheelability Audit in Neighbourhood’ (SWAN) was used in this study. SWAN allowed participants to evaluate both objective and subjective features that affect their mobility and social participation within their neighbourhoods (Mahmood et al, 2019). The tool consisted of objective and subjective items across five domains: functionality, safety, appearance and maintenance, land use and supportive features, and social aspects. In this research, we used Forsyth’s (2015) summary of walkability, which includes dimensions such as being traversable (eg allow to go from one path to the other), compact (eg short distance between destination), safe, usable (eg  sidewalks and crosswalks are in good condition), and supporting social interaction and physical activity for all pedestrians, including older adult or person with a disability. Based on the same dimensions, we defined wheelability as the extent to which the environment supports the ability to move around for a person who uses an MD with wheels (eg manual wheelchair or scooter). Three community forums (one in each city) were held to discuss the SWAN preliminary findings with participants and key stakeholders, such as urban planners and advocacy groups. Complementarity of the approaches The photovoice method and the SWAN audits complemented each other. They both focused on the assessment of the environmental barriers and facilitators; however, in photovoice, the participants captured that through photography of their daily lives, and in the SWAN audits, they conducted a structured assessment of specific sections of their neighbourhoods. The SWAN provided both objective and subjective quantitative data on the environmental features in the participants’ local neighbourhoods, while the photovoice pictures and interviews provided more contextual subjective qualitative information. Comparison of data from both sources helped to demonstrate complementarity and convergence of data (Farmer et al, 2006); sometimes the same barriers or facilitators were emphasized by both sources, while at other times, each shed light on different aspects of the environment. These data jointly provided an in-depth and nuanced information on salient social and physical environmental features that impact the mobility and inclusion of older MD users.

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Findings and discussion This chapter covers findings based on data collection with by 52 participants (20 men, 32 women) of which 11 completed both data collection methods, 20 did the photovoice only, and 21 did the environmental audits only. The average age of the participants was 61.8 years old. They all used some type of MD (powered and manual wheelchairs, scooters, walkers, or canes). Combining the photovoice and the SWAN data, four overarching themes emerged that were central to understanding the experience of mobility and social participation of older MD users in their urban environments. These themes were: En route, Destination, Continuum of Accessibility, and Agency. Figure 2.1 presents examples that illustrate each theme from the three communities. Findings for each theme are presented and discussed in the following section. Theme 1: En route The first theme entitled ‘En route’ emerged from both data sources and covered the usability and safety aspects of the physical path leading to a destination. This theme included both barriers and facilitators in the pedestrian environment (or public right of way), such as sidewalks, crosswalks, curb cuts, traffic signals, and lighting. The aspect of maintenance, such as unrepaired cracks and bumps on the sidewalks were also covered in the ‘En route’ theme. In the photovoice method, participants captured pictures of narrow sidewalks that did not allow two people to walk or wheel side by side and forced them to stop when someone wanted to cross. They also captured uneven or slippery sidewalk surfaces. The participants photographed curb cuts quite often to showcase both functional and safety issues such as steep slopes, misalignment with the crosswalks or absence of curb cuts. As one 85-year-old woman explained, ‘Some places […] the curbs are difficult to get over […] even though you use the cane you just don’t have the spring in your step anymore and trying to get from one side of the curb to the other side of the curb, especially if it’s grass or something uneven, it takes a little bit of, you know, mental determination to get through.’ Regarding traffic signals and street crossings, the most salient issue was the position of the pedestrian-activated buttons. Several photographs

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‘An accessible route is always the longest’ Figure 2.1: Examples of pictures from each community and for each theme

Theme 1. En route Well paved, wide and smooth pathways

Theme 2. Destination Stairs to access the park

Theme 3. Continuum of accessibility Construction blocking the sidewalk

Theme 4. Agency Painting of access to ramp was requested by the participant

showed these buttons in hard-to-reach locations or putting the person in an unsafe position. This is particularly important in Vancouver, as most crossings are pedestrian-controlled unlike those in other large Canadian cities. The participants also identified positive characteristics in their communities that made their daily journeys easier and safer. They photographed wide sidewalks and curb cuts that were smooth and had a gradual slope. The pictures of these facilitators were mostly taken in Vancouver, and less so in the other two communities. The theme of ‘En route’ was covered in the functionality domain in the SWAN tool, which includes features of the crosswalks and sidewalks including curb ramps/cuts, sidewalk obstructions and

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physical condition of both the street and sidewalk. One of the primary barriers observed in all three municipalities was related to the directionality of the curb cut not being aligned with the street crossing. The street crossings were equipped with visual or auditory pedestrian signals, however, less than half of them provided enough time to safely cross the street. Similar to the photovoice data, one of the main barriers noted on the sidewalks was the lack of maintenance, that is, the presence of bumpy and slippery material posing safety hazards. Additionally, permanent obstructions on the sidewalks and streets, such as trees, lamp posts, or fire hydrants, were noted as creating a break in the path, often needing excessive rerouting. The safety domain of the SWAN also captured data on the ‘En route’ theme. It covered features including direction of traffic, the smoothness of street pavement, or buffer space between sidewalk and the street. Sharing the road with cyclists and drivers was noted as problematic, as it made the participants feel unsafe with traffic around them. The audits demonstrated that less than half of the drivers on the audited streets maintained speed limits and under 40% of the cyclists were perceived as adhering to street rules and paying attention to pedestrians. Only a few audited segments had designated bike lane, which could explain this conflicting situation. Participants also rated the overall maintenance and aesthetics of the street segments including appearance of buildings, maintenance of the paths and streets, open spaces, and street furniture. Only half of the segments had public open spaces and well-maintained greenery, presence of accessible street furniture and streetlights. The environmental features discussed under this theme, such as curb cuts, crosswalks or traffic signals, were all identified as essential for mobility in a recent scoping review (Bigonnesse et  al, 2018). Urban planners and decision makers should continue working on reducing those barriers to mobility in order to promote older adults’ social integration, which is critical for their health and quality of life (Courtin and Knapp, 2017). Literature has shown that older adults with greater mobility limitations are more likely to have lower levels of participation in activities that bolster social connectedness and identity than those with better mobility (Rosso et al, 2011). An important aspect reflected in this theme was that usability and safety were two central and intertwined urban design features that impact mobility of older adults. The participants wanted to move about in their community easily and safely. Falls and accidents resulted in reduced quality of life for older adults and severe injuries lead to high healthcare consumption and costs (Hartholt et al, 2011). Thus, proper

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maintenance of the sidewalk and crosswalk infrastructure needs to be carefully considered in urban design policies. Moreover, this issue was present across the three communities assessed by the participants highlighting the universality of this problem of upkeep of the quality of the pedestrian realm to ensure inclusion for older adults living with mobility challenges. The city planners and decision makers in city councils should consider maintenance as one of the priorities that needs to be an integral part of their annual budget to ensure usable and safe pedestrian infrastructure for all their citizens. Theme 2: Destination This theme was related to accessibility issues in public places, such as plazas and parks, as well as the transition spaces from outdoors to indoors in terms of public or private buildings. This theme was addressed differently in the photovoice and the SWAN audit. During the photovoice interviews, the participants mostly talked about barriers they encountered in transition spaces of public buildings, shops, and services. For instance, they took pictures of parking areas that were not well connected to the public buildings or did not have ramps to get from the parking to main entrance. A few older adults also captured problems accessing main entrance because of stairs, lack of adequate wayfinding signage, or unsafe pathways in front of buildings such as public libraries or highly used tourist areas. As reported by one female MD user, using a powered wheelchair, ‘The design of [the convention centre] is horrible. They put the signs where you can’t read them! […] We had to walk a few blocks […] to find an elevator, but even the elevator pointed to different areas and didn’t have the right signage on it. Then for the elevator, we had to get accessed [through] a door that wasn’t accessible…’ Regarding stores and services, the presence of stairs and the absence of automatic or push-button doors were the main barriers that were photographed. The participants also took pictures of parks, most often to show paths with unusable surfaces (eg gravel, rocks, grass) limiting their ability to enjoy the entire space. However, some recently designed parks and recreation areas were chosen to illustrate examples of inclusive and accessible design. One participant explained about a new green urban space: ‘Beautiful view. It’s awesome. As far as that’s brand new, there’s no issues with gravel or ground surface or bumpiness.’

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The environmental design features that fall under this theme were covered in the land use and supportive features as well as social aspects domains of the SWAN. On the one hand, the land use and supportive features domain contained items regarding the presence and accessibility of amenities and services such as benches and public toilets, as well as grocery shops, restaurants, and places of worship. Very limited numbers of amenities and services on the audited segments were noted as accessible. The objective scores in all three cities were low in this domain and across all categories, revealing lack of accessible entrances to shops, inaccessible transit stops, and inadequate outdoor furniture as predominant barriers. On the other hand, the social aspects domain included items about the availability of places to gather and support social connections and subjective data on the overall friendliness of people. Participants noted that there were positive social interactions on the streets, and people appeared friendly (eg smiled and/or talked to others). However, less than a third of the audited segments contained accessible spaces supporting opportunities for social connections. The transition spaces were problematic because often they were not part of the public realm, that is, they were the responsibility of the building or store owner, or it was not always clear who had responsibility for those spaces. Moreover, despite the fact that these access areas were part of building codes, they often had minimal standards (Larkin et al, 2015). Parking access also came out as creating barriers and has been identified as an important environmental feature for mobility in previous studies (Evcil, 2009). As many older adults rely on cars (either as drivers or passengers) (Lord et al, 2011), it is important to continue to reinforce the need to make access to parking safe and usable. Parking accessibility could make a difference between an older adult going out to do their daily activities or becoming reliant on someone else, and consequently not going out at all. The SWAN data, and to a lesser extent the photovoice findings, demonstrated that accessible spaces for socialization are not sufficiently available for older adults. This is particularly alarming as study after study has shown that older adults, especially those with mobility limitations, experience higher levels of social isolation than other people (Courtin and Knapp, 2017) with severe consequences for their health and quality of life. Further, it is important to provide them access to outdoor accessible spaces such as parks and public places to facilitate contact with nature (Ryan et  al, 2010) and foster connectedness to their community (Novek and Menec, 2014). Considering that social dimension of accessibility, urban stakeholders could for instance develop guidelines

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or information handouts for local businesses to inform them about why and how to assure access for older adults. Moreover, they should think about how the different public spaces in their city such as parks or plazas need to be connected to the pedestrian networks to allow older adults with mobility limitations to take advantage of them. Theme 3: Continuum of accessibility The theme ‘Continuum of accessibility’ focused on temporal fluctuations of accessibility with circadian and seasonal variations, as well as due to conflicting social practices or inappropriate usage of the public realm or streetscape. This theme was extensively addressed in photovoice for all three communities. The participants reported how visibility at night was essential for their mobility. Many took pictures of areas that were easy to navigate during the day but became inaccessible and unsafe at dark. As a male scooter user mentioned: ‘This is the public square […] Well, on a dark, rainy night […] If you came out [from the main door] on a wheelchair or a scooter, … and you could go right off that jump there… [and], if your vision is poor, you could be in trouble.’ Another issue was the leaves that cover sidewalks, crosswalks, or curb cuts in fall and winter, making the path slippery and often hiding the condition of the pathways – creating unsafe situations. Regarding conflicting social practices, the most-reported elements were construction (eg closed sidewalks) or ineffective positioning of signage, followed by placement of sandwich boards in the middle of sidewalks by shopkeepers. However, helpful actions of people were also identified as compensating sometimes for the lack of accessibility within the built environment. For instance, some storekeepers would make extra effort to accommodate their older clients using MD and the participants felt it created accessibility and inclusion in a different way. Finally, this theme also included pictures of environmental features that were originally well designed but became inaccessible because of improper usage. For instance, one female participant, using a manual wheelchair, explained about a path near her house: ‘So that picture has a very nice, wide sidewalk, one of the few where you can walk side-by-side two people in a wheelchair. The challenge with this one is there are often bicycles using it. There is paved bike lanes on the street that are wide [but] cyclists don’t often get off the pedestrian route onto the bike route, so they are infringing

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on pedestrian areas. So what could have been a friendly pedestrian barrier-free path it is now challenged with having to navigate bicycles.’ This conflict between users’ needs also happened with drivers. The SWAN tool covered seasonal variations in the functionality and safety domains highlighting the upkeep of infrastructure during inclement weather conditions (eg snow and rain). The audits also captured information on safety of walking or wheeling at night, including issues of the adequacy of lighting. Participants’ objective audit scores showed that 50–70% felt safe to walk or wheel alone. Many participants also planned their day and routes in advance, so that they would avoid being out too late in dark areas. As was the case for photovoice, temporary obstacles (eg, garbage and recycling bins, parked vehicles, road construction) were noted in the audits. The participants explained how the lack of enforcement of regulations concerning temporary obstructions resulted in barriers that increased the time of travel or created disruption in their mobility network. In terms of social practices, there were also some issues noted, such as storeowners not only putting up sandwich boards for advertisements, but also littering and blocking off the sidewalks with their merchandise. This theme highlighted how accessibility is not a fixed set of built environmental features, but it is rather a complex and fluctuant concept. This is why it is important to understand the embodied experience of older adults with mobility limitations in order to integrate those nuances into the design and planning of our communities (Imrie, 2013). This type of experience-based knowledge offers comprehensive insights about the qualities of the environment that go beyond the minimum codes and standards (Heylighen et al, 2017) and should be included in the planning process from the beginning (Boys, 2014). This theme also underlined that inclusive design for all has a large social dimension. People’s behaviour and attitudes can make an environment less accessible, or on the contrary compensate for the lack of physical accessibility (Hästbacka et al, 2016). This highlights the importance of raising awareness among the general public about norms and rules that lead to development of inclusive environments. The urban decision makers could also think about how their communications with the older adults are being managed, if the information is easily accessible, and if their staff are trained to interact with different types of population. For instance, in Vancouver, the staff at the 3-1-1 Contact Centre could be informed about the accessibility features and services of the city. Furthermore, central to this is the matter of educating both

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the general public and staff on how small changes in habits of all road users can go a long way to assure that everyone, especially those with age and mobility related challenges, has the opportunity to engage in meaningful activities within their communities. Theme 4: Agency This theme highlighted the agency of the older MD users in negotiating or changing their environment. It covered the modifications participants have requested from their city planners and the potential solutions they would like to see implemented. It also covered the changes in their own behaviour or habits in their daily lives. ‘Potential solution’ emerged frequently in the interview and focus group transcripts of the photovoice participants, resulting in the creation of this theme, which illustrated the older MD users’ expression of agency. The pictures showed environmental features similar to the other themes, but the reasons behind taking those pictures were different. These were taken by the participants to show what they did to make temporary or permanent changes in the environments of their daily paths, or how they changed their own actions to deal with problematic features. For instance, one powered wheelchair users indicated, ‘So this picture is actually a positive thing, and it sort of something I like to brag a little bit about. This is a ramp outside my bank and this yellow is a relatively new feature because… This ramp is the best way to get down into the bank for somebody in a wheelchair but there was a white line before and somebody would park right in front of the ramp so I was stuck. I went and talked to the bank and they did something, I guess it’s sort of named after me, haha.’ The other types of actions participants took were to complain to their city council, talk to service owners, discover new paths to reach their destination, or be assertive when there was obstruction in the path. Participants from the three communities shared pictures of the changes they asked for or would like to see happen. In the SWAN, agency was not directly covered by any of the domains. However, disparities between the subjective rating and the objective score was found in all five domains and across all three communities, suggesting that the older MD users had modified (consciously or unconsciously) their perceptions of their environment to facilitate

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their daily lives. While the absence of several physical environmental features in the neighbourhood, such as curb cuts, well-maintained sidewalks, and adequate traffic signal timing led to a low objective score, this did not necessarily lead the participants to giving a lower subjective rating of their neighbourhood. For example, the average audit score for the Land Use and Support Features domain was 25%, compared to a subjective rating of 68%. Further analysis of qualitative secondary observations data and community forum transcripts revealed the ability of MD users to adapt to their challenging surroundings. The difference between the objective scores and subjective ratings raised important questions on the highly personal relationships older adults, especially those with mobility challenges, have with their neighbourhood environment, and the ways in which they adapted to these challenges. This theme showed that older adults were not passive actors in terms of interaction with their environment. They actively tried to shape their environment to fit their needs, but also their needs and preferences affected and changed their perceptions of their environments. Gibson argued in his theory of affordances (1979) that users will assess how the environment will support or limit the behaviour or activities they want to accomplish in an environment at a specific time, and in turn, these assessments will influence the perception of the environment. Moreover, the findings demonstrated that subjective data often provide insights about the embodied and daily experiences of people in their environment, which is still not well understood and is often ignored (Jackson, 2003; Winter et  al, 2016). For example, if older adults wanted to go to certain restaurants in their community, they might choose one that did not have accessible entryways, but as they had built relationships with the staff at those establishments, they felt supported and welcome in these spaces. They subjectively assessed these places as being supportive of the activities they wanted to accomplish. While making planning decisions, urban planners and municipal city staff should recognize this agency of older MD users and their needs and experiences (Lid, 2016; Winter et  al, 2016). Indeed, it has been shown that public participation that emphasizes learning and sharing experiences lead to the design of better-quality urban spaces (Ismail and Said, 2015). All the cities involved in the project had advisory committees comprised of people with disabilities and older adults, which were regularly consulted. In addition, cities could develop platforms (online or in person) that would allow the public to regularly share their inputs to inform prioritization, accessibility, and inclusion in the cities.

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Conclusion A major strength of this study was the collection of both objective and subjective data, allowing participants to better communicate their mobility experiences. By combining two complementary approaches and tools, it allowed us to get a deeper understanding of the mobility and social participation barriers and facilitators in the physical and social neighbourhood environment. With population aging and the increasing longevity phenomenon we cannot keep overlooking these issues. Municipal officials and city planners should not just focus on piecemeal remedies of curb cuts and sidewalk extensions, but take a broader look at inclusion and participation by bringing a universal or inclusive design lens into the planning process (Imrie, 2012). These findings reinforce what other researchers (eg Stafford and Baldwin, 2018) have advocated for street and sidewalk gradient/slope, shelter, climate protection, crosswalk placement and curb design, pedestrian safety, places to meet and socialize, places to rest, to be incorporated in transportation and urban design standards and legislation. To be truly inclusive of people of different ages and abilities, it is not only the design of the urban built environment that needs adjustment, but also the scheduling and prioritization of maintenance and upkeep of these environments. This has to be accompanied by guidelines on how bylaws around accessibility are enforced. Additionally, there needs to be training and education to raise awareness of the private/business sector use public infrastructure, and how this may result in blocking and creating a burden on older adult pedestrians, especially those who use mobility devices (eg their use of sandwich boards for advertisement and seating on sidewalks obstruct the path of mobility). A priority of this study was to include participants in the research process. In the SWAN, the older adults conducted the audits (as opposed to researchers), and they chose the audit segments themselves. In the photovoice process, the participants identified the pictures representing the themes they wished to highlight and also chose pictures that best represented their mobility experience. Similar types of participatory processes in recent research, especially where persons with higher vulnerability were part of the research process, have helped to highlight the ableist approach to planning and design of urban neighbourhoods and the built environment (Winter et al, 2014, 2016; King et al, 2016; Tuckett et al, 2018). Engaging participants as ‘citizen scientists’, that is, as contributors or co-creators in the research process, increases citizen engagement and advocacy, and potentially leads to removal of barriers to mobility in communities (King et al, 2016;

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Winter et al, 2016). This type of participatory research is a powerful method that enables older adults as citizen scientists to vocalize and advocate for pedestrian infrastructure that provides them choice and opportunity to move about safely and effortlessly in their city. This study demonstrates the pivotal need for and value of inclusion of diverse perspectives, especially those most affected by poor urban design, to better inform policy, planning, and design interventions that are spatially and socially just for all ages and abilities. Funding and acknowledgement The research presented here was supported by partnership grant by the Social Sciences and Humanities Research Council of Canada. Grant # 895-20131021. We would like to thank our co-researchers, the study participants for being involved in data collection, data analysis, and sharing of their experiences and knowledge of their daily mobility environments. We would also like to thank our community partners Better Environmentally Sound Transportation (BEST) and Seniors on the Move (SOTM) who helped us recruit our participants and helped to initiate, coordinate, and facilitate SWAN data collection and knowledge mobilization in different parts of Greater Vancouver. This project was successful because it was a team effort.

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Imrie, R. (2013) ‘Shared space and the post-politics of environmental change’, Urban Studies, 50(16): 3446–62. Imrie, R. (2012) ‘Universalism, universal design and equitable access to the built environment’, Disability & Rehabilitation, 34(10): 873–82. Ismail, W.A.W. and Said, I. (2015) ‘Integrating the community in urban design and planning of public spaces: a review in Malaysian cities’, Procedia-Social and Behavioral Sciences, 168: 357–64. Jackson, L. (2003) ‘The relationship of urban design to human health and condition’, Landscape and Urban Planning, 64(4): 191–200. Lid, I.M. (2016) ‘Implementing universal design in a Norwegian context: balancing core values and practical priorities’, Disability Studies Quarterly, 36(2): 1–15. King, A.C., Winter, S.J., Sheats, J.L., Rosas, L.G., Buman, M.P., Salvo, D., Rodriguez, R., Seguin, M.M., Garber, R., and Broderick, B. (2016) ‘Leveraging citizen science and information technology for population physical activity promotion’, Translational Journal of the American College of Sports Medicine, 1(4): 30–44. Larkin, H., Hitch, D., Watchorn, V., and Ang, S. (2015) ‘Working with policy and regulatory factors to implement universal design in the built environment: the Australian experience’, International Journal of Environmental Research and Public Health, 12(7): 8157–71. Lawton, M.P. and Nahemow, L. (1973) ‘An ecological theory of adaptive behavior and aging’, in C. Eiserdorfer and M.P. Lawton (eds) The Psychology of Adult Development and Aging, Washington, DC: American Psychological Association, pp 657–67. Lord, S., Despres, C., and Ramadier, T. (2011) ‘When mobility makes sense: a qualitative and longitudinal study of the daily mobility of the elderly’, Journal of Environmental Psychology, 31(1): 52–61. Mahmood, A., O’Dea, E., Bigonnesse, C., Mahal, T., Labbe, D., Saddiq, S., Qureshi, M., and Mortenson, W.B. (2019) ‘Stakeholders’ walkability/wheelability audit in neighbourhoods (SWAN): user-led audits and photo documentation’, Disability & Society, 35(6): 902–25. DOI: 10.1080/09687599.2019.1649127 Novek, S. and Menec, V.H. (2014) ‘Older adults’ perceptions of age-friendly communities in Canada: a photovoice study’, Ageing & Society, 34(6): 1052–72. Oswald, F., Jopp, D., Rott, C., and Wahl, H.W. (2010) ‘Is aging in place a resource for or risk to life satisfaction?’, The Gerontologist, 51(2): 238–50. Rosso, A.L., Auchincloss, A.H., and Michael, Y.L. (2011) ‘The urban built environment and mobility in older adults: a comprehensive review’, Journal of Aging Research (June), 10p.

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Ryan, R.M., Weinstein, N., Bernstein, J., Brown, K.W., Mistretta, L., and Gagné, M. (2010) ‘Vitalizing effects of being outdoors and in nature’, Journal of Environmental Psychology, 30(2): 159–68. Stafford, L. and Baldwin, C. (2018) ‘Planning walkable neighborhoods: are we overlooking diversity in abilities and ages?’, Journal of Planning Literature, 33(1): 17–30. Tuckett, A.G., Banchoff, A.W., Winter, S.J., and King, A.C. (2018) ‘The built environment and older adults: a literature review and an applied approach to engaging older adults in built environment improvements for health’, International Journal of Older People Nursing, 13(1): 12–17. Williams, G.P. and Willmott, C. (2012) ‘Higher levels of mobility are associated with greater societal participation and better quality-oflife’, Brain Injury, 26(9): 1065–71. Winter, S.J., Goldman, R.L., Romero, P.P., Sheats, J.L., and Buman, M.P. (2016) ‘Using citizen scientists to gather, analyze and disseminate information about neighbourhood features that affect active living’, Journal of Immigrant and Minority Health, 18(5): 1126–38. Winter, S.J., Buman, M.P., Sheats, J.L., Heckler, E., Otten, J.J., Baker, C., Cohen, D., Butler, B., and King, A.B. (2014) ‘Harnessing the potential of older adults to measure and modify their environments: long-term success of neighbourhood eating and activity advocacy team (NEAAT) study’, Translational Behavioural Medicine, 4(2): 226–7.

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3

Urban community vignette Lillian Wells This vignette is based on my lived experience over time. My first job as a social worker in the early 1960s was with older adults (in one of the first home care programs in Canada). I learned much from them on how to live my life and how to optimize life as I grew older. My practice has focused on clinical work and community development, especially in the areas of health and gerontology. With students and colleagues, we developed an empowerment model of practice in long-term care with resident councils, initiatives with families, and staff training. In the 1990s, a colleague enticed me to become a member of the Toronto Council on Aging, in order to raise awareness of the needs of older adults, improve their quality of life, foster their involvement in all aspects of community life, and support the experience of aging through education and leadership. I speak from my own experience, combined with what I have learned from older friends and from the wider community of older people through informal contacts and also research.

Aging in Toronto I have lived in Saskatchewan, Manitoba, and now Ontario; in small towns, mid-sized cities, and for over 50  years in Toronto. While Toronto has great diversity and a rich array of social, recreation, education, volunteer, and employment possibilities, it is so very large and complex that it is difficult to know what these opportunities are and how to access them. Similarly, health and social services can be difficult to navigate, even for someone like myself who has experience and skills in this area. Toronto has superior health resources, however, there can be long waiting times. Concepts of informed consent and person-centred care are increasingly accepted. However, that being said, many seniors report a paternalistic approach that diminishes their confidence, silences their voice, and lessens their autonomy.

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In terms of municipal services, Toronto has recently implemented a Senior Strategy, appointed a councillor as the Seniors Advocate, and passed a motion to assess policies through a senior’s lens. The city council is restructuring its services to seniors, giving them higher priority and providing more coordinated service. Public transportation options are being slowly improved. Some years ago, seating was designated for seniors but indicated by tiny signs that were often poorly placed so not visible to passengers. Today there is clear signage for priority seating and the seats, in a different colour, stand out. Newer buses and streetcars are accessible, but many subway stations are not. Understanding neighbourhood context is vital – a high proportion of older adults live in my community. The area of Toronto in which I live is on average middle class and considered to have few unmet needs. However, according to Statistics Canada, one of its neighbourhoods holds the highest density of seniors (23%) in Toronto which is about 50% higher than the city’s average. Of these, 82% live in rental apartments, 37% spend more than 30% of their income on housing, 40% live alone, and 48% have some activity limitations. We need to understand these implications and how to prevent adverse impacts. The reality is that older people have often outlived family and friends, and it can be difficult to reach out on your own to new experiences, when familiar supports are unavailable. New technologies such as smartphones are becoming increasingly important for contacting people and services and for obtaining information, but they are not necessarily designed for ease of use by seniors. Ageism is evident with older people seemingly invisible and ignored by service providers, community leaders, media, and the general public. It has been termed the last socially accepted prejudice. Internalized ageism is a barrier when seniors, themselves, accept negative stereotypes about being old. Overall, older adulthood can be an enjoyable and enriching period of life. A high proportion of seniors live in the community. For most of us it is a happier and more contented time: most describe their health as good. It is a time to continue what one values and try new options. Every stage of life has its strengths.

Barriers to aging well in a large urban area To begin, one has to recognize the age span (65 to over 100) and the heterogeneity of seniors. The life of someone aged 95 who golfs

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Urban community vignette

regularly and is a board member of a local children’s daycare is different from a person of 65 on limited income who uses a walker and lives alone, and from the grandmother who doesn’t speak English and looks after her grandchildren or from the man caring for his spouse with dementia. Lives differ and age is just a number. In selecting one main barrier, I would choose accessibility. This means universal design in the built environment. Many older buildings in Toronto have steps, heavy doors, and no elevators, but even some newer buildings have such problems. It means improving walkability, having well-lit and maintained sidewalks with snow and ice removal, safe ways to cross streets, and convenient stores, banks, health and social services, ethnic-, cultural-, and faith-based facilities within walking distance. Online banking and ordering of food and other supplies are helpful, but can increase isolation and lead to lack of stimulation. Parks and streets need to have accessible seating. Lack of public washrooms can be a severe barrier. Access to public and private transportation, including that required by people with physical and cognitive limitations, is necessary. We need to think about accessibility beyond wheelchair access. What does it mean for those who find walking or other movements painful or for those with poor balance, or who are forgetful? Does the built environment provide facilities to enhance social connectedness? The social environment is equally vital. Are values of respect, equity, and inclusion embedded in policy and services? Do leaders, service providers, and community members of all ages (including older people themselves) reflect these values in their attitudes and behaviours? Or, are seniors seen as unimportant, a burden, using up resources and not contributing to society? Do older adults have a voice and are their desires, talents, and abilities recognized and responded to? Do seniors’ services really match their needs? Recently I attended an exercise class intended for seniors but scheduled for 9am – meaning that participants had to combat crowded buses and clogged roads; moreover, it was not designed for those in this group, the music was too fast-paced, and the instructor was not experienced. Questions that I want us to think about are: Do older people have access to services geared to their needs? Do they have access to services that are affordable for them? The data and my experience in the field shows that seniors are increasingly lacking food security and needing to use food banks. Poverty and poor health are serious barriers that limit accessibility.

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What needs to be done? First, we need to recognize that what is designed for seniors will benefit all, rather than excluding some people of any age. Secondly, and central to any discussion about older adults, is that we need to ensure seniors themselves are involved in the planning, implementation, and evaluation of what affects them. Most older adults want to remain in their own communities. We need to have a range of housing choices (shared housing, and models such as naturally occurring retirement communities) where the residents decide on priorities that will optimize their wellbeing. There is clear evidence that these lower-cost community services can enrich older people’s lives and decrease use of emergency departments, hospitals, and institutional care. Current home care uses a medical model and focuses on personal care and health-related issues such as bathing. Using a social, person-focused model, service is geared to what the individual values to enhance wellbeing. We also need to address the accessibility barrier as previously highlighted. Social isolation and loneliness are serious problems that have major impacts on health and wellbeing. And last, but not least – we need to develop and implement an antiageism strategy to ensure that anti-ageism is at the centre of all policies affecting older adults – without it, interventions will not be nearly as successful as they should be.

My experience living in an urban environment People’s experiences will always vary depending on the individual and family, and in Toronto, a city of neighbourhoods, location makes a big difference. For example, personally, for the most part, I do not need to commute long distances in my daily life and a short car ride, half an hour’s walk or bus journey, and the subway enable me to go where I want. I have a solid network of family, albeit at a distance, friends, and colleagues. The neighbourhood shopping centre with friendly, knowledgeable and courteous staff is convenient, as is the library, community centre, and church. I belong to a walking group and am an active volunteer, and in addition I do some part-time employment. The recent death of my husband and several long-term friends has required grieving and adjustments. The local funeral home holds a helpful bereavement group. I have access to a superior physician, physiotherapist, audiologist, and dentist. As I still have a car, I am able to drive friends with mobility issues. I can participate in cultural,

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Urban community vignette

recreational, and educational opportunities. I have the opportunity to belong to a church group that sponsors refugee families. Currently I live in the family home, but in the future plan to move to a lifelease apartment in the neighbourhood that is closer to resources and transportation. During most of my working life women earned a lower salary than men in comparable positions but I do have a comfortable income. Mine is not an uncommon type of story for older adults.

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4

Walking in the city: seniors’ experience in Canada and France Marie-Soleil Cloutier and Florence Huguenin-Richard In Canada, as well as in other Western countries, mobility, defined as the ability to move between different activity sites, tends to decrease past 65 years old for all modes of transportation, even if today’s elderly are more motorized than before (Armoogum et al, 2010; Turcotte, 2012; Böcker et al, 2017). Accordingly, seniors’ mobility is characterized by a decrease in the number of trips and distances travelled to reach those activity sites (grocery stores, library, friend’s home, etc), a situation worsened by the loss of their driving licence (Lord et al, 2009a, 2009b; Chapon, 2010). Moreover, there is little attention given to seniors’ mobility experience outside of the actual, quantitatively measured, travel behaviour (Franke et al, 2019). Walking is therefore essential as an alternative mode of travel to nearby destinations and its promotion is a way to perpetuate seniors’ socialization and greater autonomy, a guarantee of healthy aging. A recent article on accessibility to retail activities in Spain highlighted again the importance of taking into account seniors in our mobility planning. The authors found that willingness to reach retail stores on foot by seniors (>65 years old) was significantly different from other population sub-groups, potentially contributing to social exclusion (Arranz-López et al, 2019). Long neglected to the benefit of the automobile, walking, a non-polluting mode of transport beneficial to health, is today revalorized in urban policies, particularly in major cities. However, this encouragement to walk should be based on an assessment of the safety and comfort of built urban environments in order to better document the (in) adequacy between the walking environment and the needs and travel habits of elderly pedestrians.

Walkability and aging Research on walkability has been abundant in recent decades, but several authors point out the lack of consensus on the definition of this concept; it is used to encompass all the measurement of the walking

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environment, including environmental features, but also the experience of pedestrians in such environments (Lo, 2009; Forsyth, 2015). While in North America this concept is linked to a movement seeking to promote physical activity through ‘active’ modes of transport, it is rather seen as a solution for environmental problems (air pollution in cities) in European countries (Huguenin-Richard et  al, 2014). The numerous methods found within this body of literature can be categorized under three methodological approaches, some of the research combining them in walkability indexes. The first type of approach relies on digital spatial data from various – mostly official – sources, such as cities and other levels of government. The spatial superimposition of data ‘layers’ enables the calculation of indicators taking into account, for example, the road network characteristics (such as connectivity), population density or land use, and commercial activity (Kayser, 2008; Robitaille et al, 2011; Lee and Talen, 2014). The second sub-group include work on perceptions and pedestrian behavioural choices. Using questionnaires and interviews, mental maps, or exploratory walks, researchers documented the quality of the environment, the atmosphere, the perception of space and the aesthetics (Ewing et al, 2006; Develey, 2012; Gehl, 2012; Charreire et  al, 2013). The third, the walkability audit, relies on field data collection at the street level, recording features considered important for walking (Paquin, 2014). These features are often chosen from results from the two previous approaches, by expert panels, or pedestrian themselves in focus groups. Most of these observation tools combine elements of the built environment and observers’ perceptions for all sections and intersections of a predefined area or route. These audits are probably the ones that most accurately reflect the reality experienced by pedestrians when walking, but they require a consistency in the judgement of observers or a simplification of response choices when combining them in an index. This is why it is important to train observers, keep the same observers for all data collection, and make sure they are aware of their own bias, related to their age, gender, physical condition, and so on. In order to help this judgement consistency, we can restrict the response modalities to dichotomous choices (yes/no) or to ordinal scales (values from 1 ‘not at all’ to 3 ‘many’), so as to avoid too much variability in the assessment of the presence of trees/benches/shade/street lighting, and so on, or in the evaluation of an element’s quality (pavement, ground marking, etc) (Moudon and Lee, 2003; Negron Poblete and Lord, 2014). These walkability tools and methods have been developed for an average adult population and do not necessarily represent the specific

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Walking in the city

needs of seniors. However, research on aging has identified several obstacles to walking among seniors, whether it is street level (uneven sidewalks, obstacles), street furniture (benches to rest, lighting), or distance to shops (Chaudet, 2012). Moreover, the feeling of insecurity, in which manifests in a fear of falling or being jostled, negative encounters, aggression, or robbery, is also a recurring element of seniors’ experience in cities (Blackman et  al, 2003; Nader, 2012; Vine et al, 2012; Cerin et al, 2013; Nathan et al, 2014). Other issues related to difficulty dealing with complex crossing situations, such as a multi-lane boulevard (Dunbar et al, 2004) or a street with cycling infrastructure (Lachapelle and Cloutier, 2017) can lead seniors to decide not to go out of their house. On the other hand, the aesthetics of the landscape and the presence of green spaces are elements of the built environment that encourage seniors to walk (Grant et al, 2010; Hunter et al, 2011). Finally, the few walkability audits with seniors as a target audience are mostly useful for understanding the link between the urban environment and physical exercise through walking in older adults (Chaudhury et al, 2011; King et al, 2011), but not in terms of having a better idea of their mobility as pedestrians.

Research question The objective of this chapter is twofold: to describe, through a pedestrian audit adapted to elderly pedestrians, the type of walking environment they encounter in Montréal, Canada, and Lille, France, and to compare results of these audit to seniors’ experience in both locations. European cities are, at their core, well-known to be denser both in population and built areas, with very organic street networks based on the natural growth of the city. The historical characteristics of old city centres and retained and respected, slowing down redevelopment and keeping land use mix. Under these circumstances, one would assume that walkability levels would be higher in Europe, considering that their built and road environment characteristics correspond to ideal walkable environment: dense, connected, and with numerous destinations to walk to. This is why we decided to compare two cities with similar characteristics in Canada and France. This comparison follows a data collection which is part of two projects studying walking and pedestrian safety among seniors: the MAPISE project: MArche à PIed chez les SÉniors, led by a an international team of researchers from France (Huguenin-Richard et al, 2014), and the PARI project: Piétons âgés, risque et insécurité, led by a team in Québec, Canada (Cloutier et al, 2016).

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Methods and analysis Study area The study area includes two neighbourhoods in Lille (Wazemmes and Lomme-Lambersart) and two in Montréal (Rosemont and Verdun). These neighbourhoods were chosen for three reasons: they have a large population of elderly residents (between 13% and 20%); they represent an array of urban forms and density (from 16 to 26 inhabitants per square kilometre); and they have metro stations at the centre. All street segments in a radius of 600m (Lomme-Lambersart and Rosemont) or 800m (Wazemmes and Verdun) around a metro station were included in the data collection for each neighbourhood (see Figure 4.1). All these neighbourhoods are located at the core of their cities and were primarily chosen because of their higher number of pedestrians. The Montréal neighbourhoods are typical of a North American urban form, with grid street plans (see Figure 4.1) and a large proportion of private dwellings, mostly two- to three-storey buildings, constructed before 1960 (59% in Rosemont and 47% in Verdun) and between 1961 and 1980 (22% in Rosemont and 18% in Verdun). The land use is mixed, with residential on local streets, shops on the first floor on major streets and around the metro station, and the presence of small local parks throughout the area. Objective measure of walkability: the MAPISE audit tool The walkability audit, built as part of the MAPISE project, is based on five indicators under three dimensions: road and urban/personal safety, accessibility, and street quality, including attractiveness and aesthetics. The observation form was created by combining existing audit tools and specific elements related to seniors’ needs and concerns found in previous research. In addition, pre-test interviews with seniors (n=10) helped finalize the tool. These indicators were calculated from street and intersection characteristics, all observed at the street segment level (see Table 4.1). Items positively related to a more walkable environment were given more points than others (range from 3 to 0 points for each item). For example, if the road was a pedestrian or a shared space, it was given 3 points, and 0 points if the speed limit of the road was 50km/h. As for items based on count (eg attractiveness indicator), the total number of destinations or activity sites was divided by the length of the street segment, and this ratio was added as points to the total score. The detailed grid, the operationalization of the indicators, and

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Figure 4.1: Study area and walkability audit results

Walking in the city

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Aging People, Aging Places Table 4.1: The MAPISE walkability audit dimensions, indicators and characteristics per street segment and crossing Safety Road safety • Road type • Traffic • Number of lanes • One-way street cycling infrastructure on the sidewalk • Driveways For each crossing: • Presence of a traffic/ pedestrian signal • Road marking • Length of the crossing • Curb ramp • Traffic-calming measures at the crossing

Accessibility • Presence of a sidewalk • Width of the sidewalk • Sidewalk obstructions • Parking • Benches • Bus shelters • Type of surface (pavement) • Quality of the surface

Street quality Attractiveness Number of: • Local shops • Medical offices • Parks or other leisure or religious buildings/ entry • Bars, cafés, restaurants Aesthetics • Trees and vegetation • Cleanliness • Mural painting • Blind wall

Personal safety • Street lighting • Graffiti • Vacant lot or buildings

the score for each item are described in other publications (HugueninRichard et al, 2014; Cloutier et al, 2017). Field surveys on both sides of the street of each segment of the study area were carried out by students and the authors of this chapter after a training session explaining the objective of the study and the observation form. The data was then coded and mapped in a geographic information system (GIS) using ArcGIS software (ESRI, 2019). Because of budget and time restrictions, more segments were audited in France than in Québec, but the methodology was the same in both countries. The final measure of walkability is the sum of the five indicators: Walkability = Road Safety + Personal Safety + Accessibility + Attractiveness + Aesthetics. Sensitive measure of walkability: tracking of pedestrian paths, walkabouts, and interviews The second data collection method used in this project records pedestrian paths through ‘tracking’, or ‘following’ the pedestrian at a distance, a form of non-participatory direct observation. This method was used in other research, but in our case, the pedestrian did not know we observed him/her (Granié and Espiau-Nordin, 2008)

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and we did not use a GPS tracking system (Julien and Carré, 2002). These observations start at a pedestrian attractor specific point, where the observer randomly chose a pedestrian and followed him/her at a distance, recording walking and crossing behaviours. The advantage of this technique is that there is no prior recruitment of people to observe (which can be difficult) and an absence, a priori, of bias both in the observed behaviours and in the adaptation of behaviours towards more conformity – a phenomenon that happens when the person is knowingly being observed. For this study, the starting points were the metro stations at the centre of each study area in Lille, and the end of the observation was either where the pedestrian reached his/her destination (eg entering a building) or after an eight-minute threshold. Two observers collected the data. During this period of time, the observer follows the unknowing pedestrian for eight minutes and records the exact tracking duration, the route taken (including which side of the road was taken) and the crossing locations (including if it was on a formal crosswalk or not) on a paper street map. Other characteristics were also recorded: age group (adults, young seniors, and older seniors), pedestrian’s load (bags, dog, etc), mobility aid, support person, and weather and pavement conditions (wet or not). It is worth noting here that age categories are based on the observer’s judgement of the pedestrian’s outward appearance. It was found that older seniors are then the ones with apparent signs of aging (grey hair, bent back) or disabilities (slow speed, walking aid). The collected itineraries were digitized and integrated in the same GIS as the audit data, based on the middle point of each street segment, in order to preserve the anonymity of the destinations. Paths that were too small and street segments that had less than half of their length as part of an itinerary were then excluded from the final database. Walkabouts with two women and one man in Montréal (see Plante, 2018 for details), and interviews using blank maps with 15 seniors (10  women, 5  men) in another city in Québec (see Thouin and Cloutier, 2018 for details) were the last qualitative data collection related to this project. Walkabouts require the researcher to walk with the participant on a familiar path and record his/her feelings while experiencing it (Petiteau and Pasquier, 2001; Miaux, 2008), and interviews have the same goal, but at the participant’s home, using blank maps. Both are comprehensive approaches, close to ethnographic work, through which the researcher tries to understand the logic of the respondent. They are indicative of how the participants live in the city, through their walking experiences and mobility patterns.

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Transcripts of those walkabouts and interviews were qualitatively analyzed to be compared and partly explain the results from the audit and tracking paths. Analysis A first analysis of neighbourhood walkability is based on the spatial data from the audit in both cities (four neighbourhoods). The final scores for each street segment were divided between good, average, and poor walkability, and they were used to compare the walkability between Montréal and Lille, but also to compare it to tracking paths taken within the same street network.

Findings Walkability audit: Average scores and discontinuity in route Table 4.2 presents the proportion of street segment per walkability categories (good, average, poor) and dimensions for all the study area. First, we can see that the Canadian neighbourhoods have better walkability in general: the proportion of street segments with average or good walkability is higher in Rosemont and Verdun than in the two French areas. This is partly due to specific dimensions, such as road and personal safety. Verdun, but especially Rosemont, perform better for those indicators because of the lower traffic on local streets, while Wazemmes, the central neighbourhood of Lille, has a low score for personal safety because of the presence of (unauthorized) graffiti and poor lighting. Rosemont also scores higher for accessibility and aesthetics, with two-thirds of its segments in the ‘good’ category, mostly due to the presence of large sidewalks and trees. The attractiveness indicator is low in all the neighbourhoods, but this is due both to our strict definition of what should be included in this dimension, and to the land use being mostly residential outside of the main avenues for all the areas studied. Figure 4.1 illustrates the walkability results for each neighbourhood. What first strikes us when looking at the map is the discontinuity in any route a senior pedestrian would take outside of the main avenues. The origin-to-destination path is not guaranteed to be fully walkable because of ruptures in any of the dimensions between a street segment and the next one: safety or other issues may occur along a route, leading the pedestrian to poorer walking conditions before he/she can reach a better street.

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Table 4.2: Proportion of street segments according to their walkability audit results

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Verdun (n=80)

Lomme-Lambersart (n=167)

Wazemmes (n=427)

Personal safety (%)

Accessibility (%)

Attractiveness (%)

Aesthetics (%)

Good

69

67

68

 0

67

39

Average

32

33

30

14

30

60

Poor

 0

 0

 2

86

 4

 2

Good

75

25

28

 0

15

16

Average

14

63

68

 8

70

59

Poor

11

13

 5

93

15

25

Good

57

20

31

 8

19

14

Average

28

80

58

30

77

55

Poor

16

 0

12

62

 5

31

Good

26

 2

34

 3

16

45

Average

53

90

57

15

66

47

Poor

21

 7

10

82

18

 8

Walking in the city

Rosemont (n=57)

Road safety (%)

Total walkability index (%)

Aging People, Aging Places

Without going into full details per street segment, we can still point out three elements that have a strong impact on walkability. Walkabouts and interviews helped us understand a little bit more about what senior pedestrians have to face. First, the presence of crosswalks with curb extension, therefore reducing the time spent on the road by shrinking the distance between the two sidewalks, contributes to a better walkability (Figure 4.2, a). Similarly, the presence of a marked or raised crosswalk, or bollards to clearly mark the beginning and end of the crossing are all elements that make a difference for a senior pedestrian. Seniors also told us they prefer crosswalks with pedestrian signals, making it easier to decide when to cross: ‘You know, there are streets where it’s going too fast, and we can’t cross easily […] Even where there is a pedestrian signal, cars are coming from all sides, it’s complicated […] Me, I just want more time to cross, because, you know, to be honest, I’m slower than I used to be!’ (Woman, 68, walkabout) (interviewer asking: Can you identify the least safe intersections on your path?) ‘Well, there is none, but I always cross at traffic signal when I have the choice.’ (Man, 84, interview) ‘The intersection at Dallaire and Rhéaume, it’s hard to cross where there is no stop sign. I don’t like intersections without traffic signals or stop signs.’ (Woman, 81, interview) Second, good visibility (no obstruction) around the crosswalk also seems to be important for seniors: the recurrent presence of garbage bins or parked vehicles on the sidewalk gave low scores of walkability to Lille’s streets compared to Montréal, where it is prohibited everywhere (Figure 4.2, c and d). As we have previously highlighted, this is a dimension where the Canadian street configuration is actually better because of its wider sidewalks, but even in this context, one participant insists on why she prefers sidewalks separated from the street: ‘A strip of grass between the street and the sidewalk is more pleasant to walk, it’s better looking and nice to walk there, there is less noise, you know, because of the distance to the street.’ (Woman, 75, walkabout)

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Walking in the city Figure 4.2: Examples of street features increasing (a, b, d, f) or decreasing (c, e) the walkability audit index in Montréal and Lille

(a) Curb extension in Verdun

(b) Curb extension in Verdun

(c) Parked car and garbage bin on the sidewalk in Lomme-Lambersart

(d) Large sidewalk in Rosemont

(e) Slippery pavement in Wazemmes: cobblestone

(f) Bollards at a crosswalk in Wazemmes

Source: Huguenin-Richard et al, 2014 and Google Street View

Third, the type of pavement and the street furniture along potential paths, including on the sidewalk, are also important elements. Such features help improve continuity of the routes taken, but also help seniors’ balance, which is an important consideration in connection

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with their fear of falling; a cracked or slippery sidewalk/pavement or the absence of benches or bollards to lean and rest upon, might affect their willingness to take that route (Figure 4.2, e and f). This participant from Montréal insists on the poor quality of the sidewalks: ‘There is no spot to stop and rest between the (senior) residence and downtown, there are benches missing on the path. And there is no toilets either […].’ (Woman, 88, interview) ‘Most sidewalks are broken, have big holes and level change, it’s not easy to walk on them.’ (Man, 88, interview) ‘Near the corner of Lasalle I think, the asphalt sidewalk is very uneven  … So we walk in the street because we are afraid to sprain our ankles if we walk on the sidewalk.’ (Man, 80, walkabout) Pedestrian path tracking in Lille and walkabout in Montréal: where did the seniors walk? To explore how the street segments chosen by the observed pedestrians were similar or not to our audit, we compared the visited segments to the audited one. A total of 206 tracking paths were recorded in both neighbourhoods in Lille, 104 in Wazemmes and 102 in LommeLambersart. Almost half of them were men (43%) and two-thirds were seniors (67%), as expected, since it was a research project on this specific age group. Out of the 206, 177 paths (all ages) were integrated to the streets segment database. Figure 4.3 illustrates the frequency of tracking paths for the two neighbourhoods in Lille. It came as no surprise that the two main streets where pedestrians would find the most destinations (shops, offices, etc) were the ones with the highest frequency in our sample. Similarly, Canadian participants noted having destinations on their path as a positive experience, or a negative one where there was none: ‘[I]t’s because it’s on my path: I stop where it’s interesting for me. So, I like reading very much, it’s clear to me that I will stop at a bookstore or a library, it’s natural for me. It’s on my path, you know.’ (Man, 80, walkabout) ‘No, there is nothing nearby. I would like to stay on Perreault Street, but closer to the downtown area. There

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Figure 4.3: Tracking paths for pedestrians in Lomme-Lambersart and Wazemmes

Walking in the city

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are no shops, banks, or pharmacies here.’ (Woman, 83, interview) ‘Oh yes, it’s part of who we are, to look everywhere when you walk … Me, I am interested in new shops, I’ll go in to see what they sell. (interviewer asking: is this something you would do if driving?) Oh no, no, when in a car, you see nothing!’ (Woman, 75, walkabout) Table  4.3 presents differences in street segment proportions for each category and dimension (all ages). We can see that pedestrians followed in Lomme-Lambersart walked in better environments in terms of personal safety, accessibility, and attractiveness: there are between 29% and 46% more street segments in the ‘good walkability’ category. However, road safety did not seem to be easy to manage on these paths since there are 33% more segments in the ‘average walkability’ category that were visited by pedestrians compared to the general audit. As for Wazemmes, the pedestrians we followed took paths with similar walkability than the rest of the neighbourhood, except for attractiveness and aesthetics. More ‘average’ and less ‘poor’ walkability results are found in our sample compared to the general audit. This aesthetics result echoes what seniors told us in interviews in Canada: they would rather walk on a nicer street (with beautiful houses and trees) than a safer street, especially if they walk without a specific destination, just to exercise and ‘go out’: ‘I enjoy the scenery, I look at houses, decorations, that kind of things … someone will add flowers on their yard, and it’s beautiful. Especially if it was brushwood before and that they re-do everything.’ (Man, 80, walkabout) ‘The Montée-du-Sourire street, the Nautl street, it’s very residential. There is also new development, it’s beautiful and quiet to walk there and look at the new houses.’ (Man, 84, interview)

Implications for practice Our field work in two fairly different walking contexts (France and Canada) combines various methods that highlight several implications for practice.

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Table 4.3: Differences in proportion between tracking paths and audit street segments according to their walkability results in Lomme-Lambersart and Wazemmes

65

Good Lomme-Lambersart (n=375)

Wazemmes (n=492)

Personal safety (%)

Accessibility (%)

Attractiveness (%)

Aesthetics (%)

–28

39

29

46

–13

3

Average

33

–39

–20

–12

18

15

Poor

–5

0

–8

–35

–5

–17

Good

2

2

–4

10

–2

8

–3

0

5

29

11

–6

1

–2

–1

–39

–9

–1

Average Poor

Walking in the city

Road safety (%)

Total walkability index (%)

Aging People, Aging Places

First, as seen in the growing literature on senior pedestrians, it seems they have different behaviours and decision-making habits when walking in cities compared to younger pedestrians. Accordingly, the distance they travel is shorter, and even if some of them do go out just for leisure, they will choose to go out where there are destinations of interest (shops, parks, interesting landscape or architecture, etc). Encouraging a mix of residential and commercial activities in neighbourhoods, near seniors’ place of residence for instance, would be ideal. In addition to shorter distances, they also walk more slowly, a fact proven in other research (Asher et al, 2012; Avineri et al, 2012; Bollard and Fleming, 2013). This slower walking speed can have consequences on their safety when crossing, especially if cities do not adapt their traffic signals. Giving seniors more time to cross is a practice that should be more frequent. Recent questioning of this practice within the engineering profession is reassuring (Montufar et al, 2007; Romero-Ortuno et al, 2010; Rastogi et al, 2012). We hope this new knowledge makes its way to official manuals used by cities (Transport Association of Canada, 2014). Finally, seniors do not seem to follow the ‘best’, walkable route when walking in their neighbourhood. As we said earlier, this can partly be explained by the discontinuity in the street network walkability, but it is also related to their fear of falling or being jostled. Seniors told us that they prefer commercial streets with destinations, but at the same time, would change side or make a detour to avoid crowded sidewalks. Other seniors told us that they would choose their path for the aesthetics only, especially when they are walking just for leisure purposes. Finally, all participants insisted on the need to adapt the sidewalk to add ‘rest areas’ for them: benches and accessible public toilets are definitely lacking from our cities and would be beneficial not only to seniors. Secondly, seniors seem to appreciate the space given to pedestrians, but especially its ‘exclusive’ usage by pedestrians. They need visibility and freedom of movement, again, to be sure not to fall. This includes the presence of crosswalk and pedestrian signals where it is harder to cross so that drivers can see them. It also includes the maintenance of sidewalks: winter and ice can be scary, especially in Canada, but obstruction of this pedestrian space with garbage bins and parked cars is a real problem in France all year round. If we were surprised at first about the result of our audit in Montréal scoring better than Lille, our experience walking those neighborhoods made it clear that the extra and exclusive space given to pedestrians in North American cities is actually better for seniors. Several seniors we met told us about specific times of the year or days of the week where they would not go out

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because of the use of their space (ie the sidewalk) by others (garbage day or snow removal period). In short, to adapt our cities to growing senior populations, city planners should build and modify their street networks as if they were doing so for their own mother or grandfather. Then all of us would feel safe when walking and crossing. References Armoogum, J., Hubert, J.P., Roux, S., and Le Jeannic, T. (2010) ‘Plus de voyages, plus de kilomètres quotidiens: une tendance à l’homogénéisation des comportements de mobilité des Français, sauf entre ville et campagne’, La Revue du Service de l’Observation et des Statistiques (SOeS) du Commissariat Général au Développement Durable (CGDD), (December): 5–24. Arranz-López, A., Soria-Lara, J.A., Witlox, F., and Páez, A. (2019) ‘Measuring relative non-motorized accessibility to retail activities’, International Journal of Sustainable Transportation, 13: 639–51. Asher, L., Aresu, M., Falaschetti, E., and Mindell, J. (2012) ‘Most older pedestrians are unable to cross the road in time: a cross-sectional study’, Age and Ageing, 41: 690–4. Avineri, E., Shinar, D., and Susilo, Y.O. (2012) ‘Pedestrians’ behaviour in cross walks: the effects of fear of falling and age’, Accident Analysis & Prevention, 44: 30–4. Blackman, T.I.M., Mitchell, L., Burton, E., Jenks, M., Parsons, M., Raman, S., and Williams, K. (2003) ‘The accessibility of public spaces for people with dementia: a new priority for the “open city”’, Disability & Society, 18: 357–71. Böcker, L., Van  Amen, P., and Helbich, M. (2017) ‘Elderly travel frequencies and transport mode choices in greater Rotterdam, the Netherlands’, Transportation, 44: 831–52. Bollard, E. and Fleming, H. (2013) ‘A study to investigate the walking speed of elderly adults with relation to pedestrian crossings’, Physiotherapy Theory and Practice, 29: 142–9. Cerin, E., Lee, K.-Y., Barnett, A., Sit, C., Cheung, M.-C., Chan, W.M., and Johnston, J. (2013) ‘Walking for transportation in Hong Kong Chinese urban elders: a cross-sectional study on what destinations matter and when’, International Journal of Behavioral Nutrition and Physical Activity, 10(78). Chapon, P.M. (2010) ‘Une étude objective des territoires de vie de personnes âgées: une analyse de la mobilité au moyen de traceurs GPS’, 9ème Congrès International Francophone, 30èmes Journées Annuelles de la Société Française de Gériatrie et Gérontologie. Nice, France, 20 October.

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Charreire, H., Mobillion, V., Nader, B., Misslin, R., Enaux, C., Bochaton, A., Bastian, T., Andreeva, V., Simon, C., Weber, C., and Oppert, J.-M. (2013) ‘Évaluer les mobilités actives dans les espaces urbains: enjeux méthodologiques en santé publique’, Colloque francophone de la plate-forme intégratrice Comportement Piétons (COPIE). Montréal, 20–22 November. Chaudet, B. (2012) ‘Les territoires du “bien vieillir” au prisme de la mobilité quotidienne des personnes âgées’, in J.-P. Viriot-Durandal, C. Pihet, and P.-M. Chapon (eds) Les défis territoriaux face au vieillissement, Paris: La Documentation Française, 17–30. Chaudhury, H., Sarte, A.F.I., Michael, Y.L., Mahmood, A., Keast, E.M., Dogaru, C. and Wister, A. (2011) ‘Use of a systematic observational measure to assess and compare walkability for older adults in Vancouver, British Columbia and Portland, Oregon neighbourhoods’, Journal of Urban Design, 16: 433–54. Cloutier, M.-S., Huguenin-Richard, F., Granié, M.-A., and St-Louis, A. (2017) ‘Audit de marchabilité: une étude comparative entre Montréal et Lille’, in S. Lord and D. Piché (eds) Vieillissement et aménagement : Perspectives plurielles, Montréal: Presses de l’Université de Montréal, 161–88. Cloutier, M.S., Bergeron, J., Lachapelle, U., and Lord, S. (2016) ‘Projet PARI: Piétons Âgés: Risque et Insécurité routière chez une population grandissante’. Québec: Programme de recherche en sécurité routière FRQSC, SAAQ, FRQS. Develey, L. (2012). ‘Et si on marchait à Morgarten ? Etude de la marchabilité et des facteurs incitants à la marche dans un quartier chaux-de-fonnier’. Master’s thesis, University of Lausanne. Dunbar, G., Holland, C.A., and Maylor, E.A. (2004) Older Pedestrians: A Critical Review of the Literature, London: Department for Transport. ESRI (Environmental Science Research Institute) (2019) ArcGIS Version 10.3. ERSI. Ewing, R., Handy, S., Brownson, R.C., Clemente, O., and Winston, E. (2006) ‘Identifying and measuring urban design qualities related to walkability’, Journal of Physical Activity and Health, 3: 223–40. Forsyth, A. (2015). ‘What is a walkable place? The walkability debate in urban design’, URBAN DESIGN International, 20: 274–92. Franke, T., Sims-Gould, J., Chaudhury, H., Winters, M., and Mckay, H. (2019) ‘Re-framing mobility in older adults: an adapted comprehensive conceptual framework’, Qualitative Research in Sport, Exercise and Health, 12(3): 336–49. Gehl, J. (2012). Pour des villes à échelle humaine, Montréal: Éditions Écosociété.

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Granié, M.A. and Espiau-Nordin, G. (2008) ‘Qualitative study on secondary school children as pedestrian by autoconfrontation method’, Territoire en Mouvement, 1: 39–57. Grant, T., Edwards, N., Sveistrup, H., Andrew, C., and Egan, M. (2010) ‘Inequitable walking conditions among older people: examining the interrelationship of neighbourhood socio-economic status and urban form using a comparative case study’, BMC Public Health, 10: 677. Huguenin-Richard, F., Granié, M.-A., Coquelet, C., Dommes, A., and Cloutier, M.-S. (2014) ‘La marche à pied pour les séniors: un mode de déplacement durable?’. Rapport final du projet MAPISE. France: PREDIT, Ministère de l’Écologie, de l’Énergie, du Développement durable et de la Mer. Available at: http://www.bv.transports.gouv. qc.ca/mono/1180593/01_Rapport.pdf. Hunter, R.H., Sykes, K., Lowman, S.G., Duncan, R., Satariano, W.A., and Belza, B. (2011) ‘Environmental and policy change to support healthy aging’, Journal of Aging & Social Policy, 23: 354–71. Julien, A. and Carré, J.R. (2002). ‘Risk exposure during pedestrian journeys’, Recherche – Transports – Sécurité, 76: 173–89. Kayser, B. (2008). ‘L’environnement construit comme déterminant de l’activité physique: la marche’, Urbia, les Cahiers du Développement Urbain Durable, 7: 31–42. King, A.C., Sallis, J.F., Frank, L.D., Saelens, B.E., Cain, K., Conway, T.L., Chapman, J.E., Ahn, D.K., and Kerr, J. (2011) ‘Aging in neighborhoods differing in walkability and income: Associations with physical activity and obesity in older adults’. Social Science & Medicine, 73: 1525–33. Lachapelle, U. and Cloutier, M.S. (2017) ‘On the complexity of finishing a crossing on time: elderly pedestrians, timing and cycling infrastructure’, Transportation Research Part A: Policy and Practice, 96: 54–63. Lee, S. and Talen, E. (2014). ‘Measuring walkability: a note on auditing methods’, Journal of Urban Design, 19: 368–88. Lo, R.H. (2009) ‘Walkability: what is it?’, Journal of Urbanism: International Research on Placemaking and Urban Sustainability, 2: 145–66. Lord, S., Joerin, F., and Thériault, M. (2009a) ‘Évolution des pratiques de mobilité dans la vieillesse: un suivi longitudinal auprès d’un groupe de banlieusards âgés’, Cybergeo: European Journal of Geography, article  444. Available at: https://journals.openedition. org/cybergeo/22090#quotation.

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Lord, S., Joerin, F., and Thériault, M. (2009b) ‘La mobilité quotidienne de banlieusards vieillissants et âgés: Déplacements, aspirations et significations de la mobilité’, Canadian Geographer/Le Géographe canadien, 53: 357–75. Miaux, S. (2008). ‘Comment la façon d’envisager la marche conditionne la perception de l’environnement urbain et le choix des itinéraires piétonniers: l’expérience de la marche dans deux quartiers de Montréal’, Recherche – Transports – Sécurité, 25: 327–51. Montufar, J., Arango, J., Porter, M., and Nakagawa, S. (2007) ‘Pedestrians’ normal walking speed and speed when crossing a street’, Transportation Research Record: Journal of the Transportation Research Board, 2002: 90–7. Moudon, A. and Lee, C. (2003) ‘Walking and bicycling: an evaluation of environmental audit instruments’, Health Promotion, 18: 21–37. Nader, B. (2012) ‘Perception, appropriation et représentations des territoires de vie des 75 ans et plus dans le XIVème arrondissement parisien: l’apport des cartes mentales’, in J.-P. Viriot-Durandal, C. Pihet, and P.-M. Chapon (eds) Les défis territoriaux face au vieillissement. Paris: La Documentation Française, 45–60. Nathan, A., Wood, L., and Giles-Corti, B. (2014) ‘Perceptions of the built environment and associations with walking among retirement village residents’, Environment and Behavior, 46: 46–69. Negron Poblete, P. and Lord, S. (2014) ‘Marchabilité des environnements urbains autour des résidences pour personnes âgées de la région de Montréal: application de l’audit MAPPA’, Cahiers de Géographie du Québec, 58: 233–57. Paquin, S. (2014) ‘Audit de potentiel piétonnier actif sécuritaire (PPAS): guide d’utilisation. Direction de santé publique de l’Agence de la santé et des services sociaux de Montréal’. Petiteau, J.-Y. and Pasquier, E. (2001) ‘La méthode des itinéraires: récits et parcours’, in M. Grosjean and J.-P. Thibaud (eds.) L’espace urbain en méthodes. Marseilles: Éditions Parenthèses, 63–78. Plante, A.-M. (2018) ‘Étude de l’environnement de mobilité quotidienne d’aînés avec l’aide d’un processus participatif: une évaluation des perceptions et de la valeur ajoutée’. Master’s thesis, University of Montréal. Rastogi, R., Chandra, S., Vamsheedhar, J., and Das, V.R. (2012) ‘Parametric study of pedestrian speeds at midblock crossings’, Journal of Urban Planning & Development, 137: 381–9. Robitaille, E., Comtois, D., and Lasnier, B. (2011) ‘Neighbourhood walkability and travel to work choices: The case of CMAs in Québec’, Cahiers de Géographie du Québec, 55: 429–48.

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Romero-Ortuno, R., Cogan, L., Cunningham, C.U., and Kenny, R.A. (2010) ‘Do older pedestrians have enough time to cross roads in Dublin? A critique of the traffic management guidelines based on clinical research findings’, Age and Ageing, 39: 80–6. Thouin, A. and Cloutier, M.-S. (2018) ‘Défis et possibilités pour les piétons âgés en région: le cas de Rouyn-Noranda (Québec)’, Cahiers de géographie du Québec, 62: 247–61. Transport Association of Canada (2014) ‘Manual of Uniform Traffic Control Devices for Canada’, Ottawa: Transport Association of Canada. Turcotte, M. (2012) ‘Profil des habitudes liées au transport chez les aînés’. Tendences sociales canadiennes, 93: 3–18. Vine, D., Buys, L., and Aird, R. (2012) ‘Experiences of Neighbourhood Walkability Among Older Australians Living in High Density InnerCity Areas’, Planning Theory & Practice, 13: 421–44.

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5

Urban practitioner vignette Marianne Wilkat and Barry Pendergast, with Natalie S. Channer In this vignette, we examine the challenges and opportunities of aging in urban Canada. In addition to sharing our own experiences of growing older in a major Canadian city, we also call upon the work we have been doing to help the city become a better place for everyone to age. As local government efforts have continued to fall short, residents (like us) have begun to take matters into their own hands. In this vignette, we summarize some of the challenges for creating an age-friendly community in Calgary, introduce our organizations, and outline some of the obstacles and opportunities we have faced. Finally, we provide some recommendations for other organizations looking to make an impact in their communities.

Challenges for creating an age-friendly community in Calgary One of the most concerning aspects of aging in Calgary is that the majority of housing available for seniors is extremely expensive. It is far cheaper for people to stay in their own homes, only paying for taxes, utilities, and maintenance. Another problem in Calgary is the practice of keeping roads and cycle paths safe during the winter, but not the sidewalks. Ploughing and piling snow in front of bus stops makes boarding the bus difficult and puts pedestrians at risk by forcing them into designated bicycle lanes. Public transportation is not subsidized by the government, and bus pass prices have recently been raised. This means that low-income seniors may not be able to afford the bus, which could contribute to increased isolation and, as a result, a decline in wellbeing. Older people in our local community often feel like they aren’t a priority. The City of Calgary does not seem interested in improving public services for older adults. They would rather, for example, make an incredibly expensive financial investment into a privately held NHL hockey arena. The order of priorities neglects the importance of building strong community links and moving towards

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a more intergenerational city. It has also recently been announced that community pools will be closing, which currently provide safe places for people of all ages to exercise. Even though it is claimed that Calgary is a World Health Organization designated ‘Age-Friendly City’, the political decisions made about public investments show it is becoming less so. Many feel that governments at all levels are broadly aware of aging communities but are simply not adapting or investing enough to support older people. Federal pensions are particularly low, leaving a significant proportion of the older population living on limited incomes without extra governmental financial support. The City of Calgary also does not engage with its older adults in the planning process as much as it should. For example, there were a series of meetings a few years ago to make Calgary ‘age-friendly’, with lots of ideas suggested to planners; however, in our estimation, all of them were ignored. Engagement meetings still take place, but they are often run by private consultants trying to acknowledge the aging population. We believe that this is not the job of private entities, but the job of municipal government and city council.

Calgary Aging in Place Co-Operative (CAIP) approach to supporting aging The foundational goal of the CAIP was to bring to light the plight of seniors in their own homes and in doing so to help alleviate some of the pressures of maintaining a home in later life. The concept was born after discovering that almost everybody in the community wanted to stay in their own homes, due to the sense of familiarity and maintaining independence. We were also very aware that as people age they often lose their spouse, which commonly leaves women isolated and under pressure to maintain their homes. Therefore, we realized that as aging people are not as agile, the best way we could help was to facilitate housing maintenance. This includes snow removal, small repairs, housekeeping, laundry services, and yard cleaning. These are problems that people face right across Calgary, which is why our co-operative is not confined to one postal area. However, this poses challenges. We are registered as a non-profit and only survive because of our volunteers. The wide geographic distribution of our volunteers helps us serve a wide range of community members, but it also prevents us from involving our co-operative with social inclusion projects (as it would not be possible for our volunteer drivers to bring everyone to one location for events).

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Urban practitioner vignette

Challenges and opportunities for CAIP In terms of the challenging aspects of running the co-operative, the most troublesome part is the declining health of our board members, coupled with attaining more volunteers and funding. We desperately need help with various things such as advertising, maintaining our webpage, managing funding, and updating our newsletters. We used to have paid staff to handle advertising, complaints, and demands, but they had to be dismissed due to the lack of funding sources (grants we had attained had run out). Therefore, the co-operative is now run solely by volunteers. It is important to note that although we have shrunk in recent years, our message has spread. There are now several private companies providing the services that we envisioned. The fact that our co-operative operates at a city-wide level opens up many opportunities. We have committed service personnel who will travel relatively long distances to include everyone in the larger city region. Because of this, we are able to support a greater number of seniors in their own homes. Another exciting achievement of the co-operative was being recognized by the city for having an innovative idea to support housing. This was incredibly rewarding because we are daring to be different, providing a service to support people staying in their own homes based all over the city, instead of being confined to a single condo building that does not feel like home.

Oakridge Seniors’ Association approach to support aging The Oakridge Seniors’ Association takes another approach to support aging in the community. The ultimate intention of the association is to reconnect older people within the local area and to inspire them to become active members of the community. The concept of the association was influenced by the loss of neighbourliness many older people experience in Calgary, and as socialization plays such a critical role in preventing loneliness, we thought that bringing people together in any way would be beneficial. Inspired by the Village to Village Network in the United States, our association reconnects people in their separate homes. We are committed to finding ways for people to meet regularly and engage in various activities. For example, we arrange monthly ‘socialize and learn’ events, which now have robust turnouts. These events include visits to local pubs, coffee sessions, sailing, pickleball, tai chi, and guest speakers like Calgary Police providing information about scams and fraud. We are also working to develop community hubs in people’s homes. The idea of this is to

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Aging People, Aging Places

create an opportunity for people to meet each other within walking distances of their homes as a way of reconnecting. The association now has approximately 250 people in its database and more are joining from outside the local community. Currently, most participants are from within the local community and are from the same middle-class background. The association is conscious of this and is trying to attract different groups of people from across Calgary, as well as extend to people who are immobile and unwell. In the future, the association plans to identify and engage those in the community who need more help, alongside the organized social activities.

Recommendations for other organizations For emerging organizations, the best recommendation would be to ensure that you have sufficient funding and grants lined up over multiple years, because functioning as a non-profit organization is incredibly difficult. Second, in order to garner enough support to be established as a non-profit, you must interact with many different groups who will need to endorse and understand the idea first. Often, there can be little understanding, help, or compassion from companies or the municipal government that you would hope to collaborate with. Having community-led support can be invaluable, but innovative ideas are not always enough to succeed. Commitment to engaging with the public, different stakeholders, and companies will benefit a project enormously. When the success of a project is determined by many different groups, it raises the question of who must step up and acknowledge aging as an investment in our future, and this is often only painstakingly achieved through collaborations run primarily by volunteers. In order to continue the visions of organizations such as ours, it is vital to acknowledge that issues related to succession planning can, and likely will, arise. New board members, with enthusiasm and ambition, must be appointed to replace retirees and continue social change. It is also worth noting that many organizations concern themselves with every small detail when facilitating interaction with the public, overlooking the simplicity of successful gatherings. Encouraging socialization can be as simple as collecting people together and simply maintaining their interest, rather than building the organization into an empire. Many older people are keen to voice their opinions about how their associations are run, which can be an opportunity for engagement and collaboration. The key to success in tackling isolation is to find a way to gather people where they can be stimulated to think outside of their current circumstances and open their minds to the possibilities in the moment and beyond. 76

Urban practitioner vignette

Part 1 overview Urban Canada generally offers older adults more services and opportunities in closer proximity compared to other places in Canada. This concentration of services, destinations, and supports are integral to the quality of life of older adults. However, the chapters and vignettes from this part have shown that when elements of infrastructures are inaccessible, many of the benefits of density are negated (eg poorly maintained sidewalks, overwhelming number of services, long waiting times at the medical facilities). In an urban setting, it is necessary to think at both the macro and micro scale – macro for overarching city-wide services like public transport and micro for individual neighbourhoods and improving the direct contexts that older adults live in each day. Takeaways for practice • In large urban areas, there is often a disconnect between city-level statements and what is happening on the ground. There is a need for neighbourhood-level planning with context-informed interventions that older adults are directly involved in. • There needs to be more municipal investment in critical infrastructures that influence mobility and quality of life, such as: maintenance of sidewalks throughout the seasons, accessible public transit, and affordable, appropriate, and accessible housing. • Ageism is still pervasive in all aspects of the urban milieu, including in services and programs that are supposed to be age-friendly. Many services still act in a paternalistic manner and could be improved through education campaigns and targeted legislation. • There is a need to enforce accessibility requirements on business owners, transitions to the public realm, and the public realm itself. • Planning with older adults (not for older adults) about their communities is critical. The question of how to engage should include a combination of tools. For instance, older adults could lead audits or examine personal experiences through innovative methods such as photovoice and go-along interviews. • Urban areas are often assumed to be walkable by virtue of the (general) mix of land uses and proximity to destinations. However, walkability is much more than distance. It is about how particular places make people feel (eg taking a longer route to avoid crowds) and personally experience the area. There is a need to understand the socio-spatial relationality of walking when developing interventions. Questions to consider • How does the city officially understand the needs of older adults, and who has power to make decisions?

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Aging People, Aging Places • How does your city engage the older adults in your community? Who is left out from those conversations? • If your city is committed to being age-friendly, what measures are they taking? How are they ensuring that all neighbourhoods in the area are treated in context? • Try it yourself – how difficult is it to find senior-focused services? • Is maintenance a part of the city’s age-friendly plans? How do they prioritize maintenance of sidewalks, clearing of snow and other debris? • How are the non-profit organizations supported by the city?

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PART II

Suburban

6

Aging in suburban Canada Maxwell Hartt, Natalie S. Channer, and Samantha Biglieri In this overview chapter, we call upon data from Statistics Canada and the academic literature to present some stylized facts and figures regarding suburban older adults and a synthesis of the challenges and opportunities of aging in suburban environments. This chapter serves to provide (1) a snapshot of Canadian suburban demographic trends, (2) an overview of the state-of-the-art thinking on suburban aging, and (3) contextual framing for the in-depth research chapters and vignettes that make up the suburban part of this book. Canada’s built environment and population growth predominantly occurs on the (sometimes sprawling) urban fringe. Put simply, Canada is a suburban nation. In Canada’s largest metropolitan areas, including Vancouver, Montréal, and Toronto, the proportion of suburban residents exceeds 80% (Gordon and Janzen, 2013). Generally, traditional forms of suburban locations can be characterized by a variety of factors including the proportion of single-family housing, car commuting patterns, population density, and home-ownership rates. However, we recognize that the modern suburban landscape is complex and diverse (Keil, 2017) and that there is no single perfect operational definition of suburban (Forsyth, 2012). We adopt the following operational definition in order to provide a generalized overview of suburban demographic trends in Canada: suburban areas are dissemination areas (as defined by Statistics Canada) with a population density between 1,000 and 4,000 people per square kilometre with over 60% of commutes made by car, or simply with a population density of 400–1,000 people per square kilometre (Channer et al, 2020). Using the data from the Statistics Canada (2019a) population estimates, we found that more than half (18  million) of Canada’s population resides in suburban areas. Of those 18 million, just over 3  million are aged 65 and over. Proportionally, 17% of suburban Canadians are aged 65 and over, compared to urban (15%) and rural (18%). The proportion of older adults across Canada is expected to

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rise rapidly in upcoming years as more of the baby boom generation turns 65. In 2018, 17% of the country’s population were aged 65 or over, compared with 14% in 2011. According to Statistics Canada’s (2019b) demographic projections, by 2024 one in five Canadians is expected to be aged 65 and older. Canada’s demographic shift is not only about baby boomers reaching retirement age. Nationwide, the cohort of Canadians aged 85 and over is also growing very quickly. As of 2016, almost 364,000 suburban Canadians were 85 years of age or over. Examining the older adult suburban population by province (Figure 6.1), it is apparent that the largest proportion reside in Ontario. Proportionally older adults are overrepresented in Ontario as 38% of suburban Canadians reside there, yet it is home to 39% of suburban older Canadians. Similarly, Québec and British Columbia also have proportionally higher numbers of older residents. The Prairies provinces (Manitoba, Saskatchewan, Alberta) are young in comparison. Figure 6.1: Canada’s suburban population by region and age Older (65+) Working (25–64) Young (0–24) 8,000,000 7,000,000

Suburban population

6,000,000 5,000,000 4,000,000 3,000,000 2,000,000 1,000,000 0

Older (65+)

Atlantic

Québec

Ontario

178,285

732,790 1,187,155

Prairies 531,215

British Territories Columbia 451,210

2,470

Working (25–64)

500,580 2,060,725 3,622,840 2,188,140 1,279,060

18,435

Young (0–24)

250,030 1,110,290 2,014,610 1,247,570

10,950

Source: Statistics Canada, 2019a

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The Prairies are home to 22% of Canada’s suburban population but 17% of older suburban Canadians. Suburban Canada’s population is relatively heterogeneous, compared to rural locations (Chapter 11), but is still significantly less diverse than urban Canada (Chapter 1). Table 6.1 highlights a few key statistics that help paint a picture of lived experiences and potential vulnerabilities related to aging in Canada’s suburbs. Approximately 12% of suburban older adults are living on a low income (defined by Statistics Canada’s after-tax low-income measure), which as a cohort of low socioeconomic status, they represent an understudied segment of the older adult population with potentially unique mobility-related needs and characteristics (Chudyk et al, 2017). This is also similar for the 7% of older people who live in majority immigrant neighbourhoods and may face more serious consequences of social isolation from infrastructural barriers (Syed et  al, 2017). The association between low socioeconomic status and decreased car travel is already well established in older adults (Frank et al, 2010; Turcotte, 2012). Low-income older adults may have an increased reliance on walking to get to places to meet their daily needs (including basic, social, and medical) in order to preserve financial resources or as a result of financial restrictions that prohibit them from owning a car or utilizing other travel options (Chudyk et al, 2017). Table  6.1 also shows that 7% of suburban Canadians aged 65 and over live in neighbourhoods where the principal language is neither English nor French. This proportion of the population sits between that of rural locations (1%) and urban ones (27%). Relying on communicating in a language other than one of Canada’s official languages may limit the accessibility to important services or further advance challenges of confidence and social isolation. Although the dual factors of low income and language barrier play a central role in suburban older adult vulnerability, the percentage of people who live in these neighbourhoods (12%) is significantly lower than its urban Table 6.1: Number of Canadian suburban residents by age, low income, immigrant neighbourhood and foreign language neighbourhood Number of Canadian suburban residents 65+ 85+ 65+ Low income 85+ Low income Total 3,083,125 364,784 422,850 56,718 Immigrant neighbourhoods 216,570  26,524  26,080  3,626 Foreign-language neighbourhoods 218,585  26,469  25,955  3,428 Source: Statistics Canada, 2019a

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counterparts (34%). In the rest of this chapter, we summarize the existing research on aging in Canadian suburban communities and further unpack the challenges and benefits of suburban aging.

Challenges to aging well in the suburbs Key debates in suburban aging centre around the built environment and the extent to which it is (un)suitable for an aging community. Suburban areas are often characterized as low-density, car-dependent built environments that lack services. Long distances separating residents from services may limit the ability of older residents to age in place successfully. Suburban built environments developed with few transit options or walkable destinations constrain older people’s mobility (Penger and Oswald, 2017). Such mobility limitations are enhanced when residents are no longer considered safe to drive their own vehicles. Consequently, residents are not able to age in place with an independent and active lifestyle as it is increasingly difficult to reach destinations outside their home (Golant, 2019). The sprawling nature of many suburban settlements requires older occupants to rely on privately owned vehicles for the majority of their transportation. However, many older adults do not, or can no longer, drive. Furthermore, the likelihood of not driving increases with age, as does physical and cognitive vulnerability. As a result, there is a physical segregation in suburban communities between older adults and the ability to access the services they require. A study conducted in Mississauga, a large suburban municipality located in the Region of Peel in Southern Ontario, revealed that providing a healthy and supportive environment for older adults is a considerable challenge due to automobile-centric infrastructure (Mitra et al, 2015). Perceived risks associated with traffic safety and walkability were identified in the study, with personal safety and sidewalk conditions being the most common barriers to walking. Older adults documented in the study did not rely on walking as their major mode of transportation; almost all of them had to rely on automobiles or someone to travel with for their daily needs. As a result, limited accessibility was identified as an inconvenience. Suburban layouts that favour automobile use create structural challenges for their aging communities, forcing many to alter their daily activities to accommodate less travel. Recognizing the importance of mobility, in Chapter 10 Chris Kawalec discusses how ensuring that older adults are able to get around is one of the four fundamental goals of the Age-Friendly Peterborough Community Action Plan.

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For older adults to remain in their suburban homes, they will almost certainly have to adapt their lifestyles according to their level of autonomy, mobility, financial, and social resources. Appropriate consideration of the location and accessibility of services frequently used by older adults is vital if members of the community are to successfully age in place. For those who do not drive, the accessibility of services can alleviate problems of transportation deficiency (Kim, 2011). The increased diversity of suburban populations, compared to that of rural areas, is another vital element to consider when creating an age-friendly community. Understanding vulnerability at the neighbourhood level is paramount to accommodating the older generations because whether people are living alone, on a low income, disabled, or have an ethnic minority background, they experience their environment differently. In Chapter 7, Lindsay Herman, Ryan Walker, and Mark W. Rosenberg examine the experiences of two of the most at-risk and potentially isolated communities among the overall older adult population in Saskatoon. Their study of the LGBTQ community and older adults experiencing physical or cognitive frailty provides important insight to the function of bonding social capital in intersectional aging environments. A study in Québec City’s post-war suburbs (Lord and Luxembourg, 2006) found that older adults have been forced to adjust their lifestyles to accommodate the automobile infrastructure when they no longer can utilize it themselves. Females who live alone are particularly vulnerable as they are more isolated and disadvantaged by the lack of close proximity services and suitable public transportation options. The study found that people had to redesign their daily activities and needed support when they were confronted with losing their driving licence. As driving is regarded as a non-negotiable practice in these suburbs, more investment needs to be made into alternate transportation options that are suitable for the aging community in order to preserve their social participation. The study concluded that neighbourhood mobility and accessibility to amenities are fundamental issues in making the aging residential experience a positive one. Among these, the diversity of suburban older adults must also be considered to ensure ample opportunities for people to age in place.

Opportunities to age well in the suburbs Despite suburban communities having to overcome built environment challenges, useful infrastructure is already in place which can be retrofitted for an age friendly neighbourhood. Technological advances

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continue to provide new opportunities to support older adults and new ways for them to connect with their environments. As a result, Golant (2019) contends that older adults in suburban areas are becoming more self-reliant and less constrained by mobility limitations. New technologies that add safety features in automobiles and the home are becoming more widespread and need to be considered when planning age-friendly communities. Vehicle safety features include lane departure warnings, collision warnings, improved emergency braking, blind spot warnings, parking assist systems, and semi-autonomous cars which can compensate for driving limitations and enable more people to use privately owned vehicles later in life. Technological advances in mobility are not only limited to automobiles either. In Chapter 9, Jennifer Dean and Edward Donato examine how e-bikes and e-scooters offer new mobilities (as well as physical and social benefits) for older adults in the Waterloo Region who desire to age in place. Golant (2019) also argues that there is scope for improving the information, activities, goods, and services that can be delivered to people’s dwellings which could make aging in place a viable and enjoyable option for more people. Such services include social media and e-commerce through internet connectivity, smart home appliances, home shares for joint home care, telemedicine, and robot technologies. In short, it may be possible to change the mobility needs of older adults and out-of-home behaviours through new constructions of connectivity. Structurally, suburban areas are expected to incorporate more mixed-use and pedestrian-accessible built environments to reduce the need for vehicular travel. Kim (2011) contends that developing activity clusters with existing infrastructure to contain more commercial and social service facilities in suburbs has the potential to alleviate transportation deficiency among older adults wishing to age in place. Changing land use patterns to accommodate small-scale commercial growth and modernizing existing infrastructure is an opportunity to accommodate the growing older population of Canada’s suburbs. Opportunities to improve the suburban aging experience are not only limited to infrastructure. Existing and new community support groups can provide facilities and volunteers to introduce novel programs that can target built environment-specific issues and encourage inclusion. In Chapter 8, Candace Skrapek and Elliot Paus Jenssen present their own experience of bringing together older adults while working with the Age-Friendly Saskatoon Initiative. Programs like these can be especially important for providing opportunities to people

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who could be considered disadvantaged due to factors such as low socio-economic and minority status. In British Columbia, a project called the Seniors Support Services for the South Asian Community (S4AC) was developed in response to the underutilization of available recreation and seniors’ facilities in a suburban neighbourhood (Koehn et al, 2016). The project was possible through the collaboration of the municipality and a registered non-profit agency that could offer a wide range of services to immigrant and refugee communities. Community agency staff were fluent in Punjabi and adapted exercise activities to make them culturally appropriate for the groups. The program was successful in delivering physical activity sessions that supported the needs of those taking part by considering language barriers, financial constraints, transportation, and flexibility with expected exercise attire. These successful collaborations are only made possible by increased NGO presence, more funding opportunities, volunteers, and research interests which are less likely to be available in more rural locations. Another example, developed as a collaborative project between the Vancouver Board of Parks and Recreation, the regional Health Authority, and researchers from the University of British Columbia, is the Arts Health and Seniors program (Phinney et al, 2014). This community-engaged arts program was delivered through working partnerships with four community centres, local leaders acting as champions for the project, and each centre sponsoring a group of seniors to attend weekly art workshops. There is no one-size-fitsall solution to providing services for a diverse older population, but having capacity for collaboration is a strong start to providing older adults with suitable engagement opportunities. References Channer, N.S., Hartt, M., and Biglieri, S. (2020) ‘Aging-in-place and the spatial distribution of older adult vulnerability in Canada’, Applied Geography, 125. Chudyk, A., Sims-Gould, J., Ashe, M., Winters, M., and McKay, H. (2017) ‘Walk the talk: characterizing mobility in older adults living on low income’, Canadian Journal on Aging, 36(2): 141–58. Forsyth, A. (2012) ‘Defining suburbs’, Journal of Planning Literature, 27(3): 270–81. Frank, L., Kerr, J., Rosenberg, D., and King, A. (2010) ‘Healthy aging and where you live: community design relationships with physical activity and body weight in older Americans’, Journal of Physical Activity and Health, 7(1): 82–90.

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Golant, S. (2019) ‘Stop bashing the suburbs: mobility limitations of older residents are less relevant as connectivity options expand’, Journal of Aging Studies, 50: 2–9. Gordon, D. and Janzen, M. (2013) ‘Suburban nation? Estimating the size of Canada’s suburban population’, Journal of Architectural and Planning Research, 30(3): 197–220. Keil, R. (2017) Suburban Planet: Making the World Urban from Outside In. Cambridge, UK: Polity Press. Kim, S. (2011) ‘Assessing mobility in an aging society: personal and built environment factors associated with older people’s subjective transportation deficiency in the US’, Transportation Research, 14: 422–9. Koehn, S., Habib, S., and Bukhari, S. (2016) ‘S4AC case study: enhancing underserved seniors’ access to health promotion programs’, Canadian Journal on Aging, 35(1): 89–102. Lord, S. and Luxembourg, N. (2006) ‘The mobility of elderly residents living in suburban territories: mobility experiences in Canada and France’, Journal of Housing for the Elderly, 20(4): 103–21. Mitra, R., Siva, H., and Kehler, M. (2015) ‘Walk-friendly suburbs for older adults? Exploring the enablers and barriers to walking in a large suburban municipality in Canada’, Journal of Aging Studies, 35: 10–19. Penger, S. and Oswald, F. (2017) ‘A new measure of mobility-related behavorial flexibility and routines in old age’, GeroPsych: The Journal of Gerontopsychology and Geriatric Psychiatry, 30: 153–63. Phinney, A., Moody, E., and Small, J. (2014) ‘The effect of a community-engaged arts program on older adults’ well-being’, Canadian Journal on Aging, 33(3): 336–45. Syed, M., McDonald, L., Smirle, C., Lau, K., Mirza, R., and Hitzig, S. (2017) ‘Social isolation in Chinese older adults: scoping review for age-friendly community planning’, Canadian Journal on Aging, 36(2): 223–45. Statistics Canada (2019a) ‘Population estimates on July 1, by age and sex’. Table 17-10-0005-01, Ottawa, Statistics Canada. Available at: https:// www150.statcan.gc.ca/t1/tbl1/en/tv.action?pid=1710000501. Statistics Canada (2019b) ‘Projected population, by projection scenario, age and sex, as of July 1’. Table 17-10-0057-01, Ottawa, Statistics Canada. Available at: https://www150.statcan.gc.ca/t1/tbl1/en/ tv.action?pid=1710005701. Turcotte, M. (2012) ‘Profile of seniors’ transportation habits’, Components of Statistics Canada Catalogue no. 11-008-X: Canadian Social Trends. Ottawa: Statistics Canada. Available at: https:// www150.statcan.gc.ca/n1/pub/11-008-x/2012001/article/11619eng.htm.

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An age-friendly city? LGBTQ and frail older adults Lindsay Herman, Ryan Walker, and Mark W. Rosenberg In Saskatoon, Saskatchewan, and across Canada, an aging demographic is changing the way communities function. We are faced as well by an increasingly diverse community, where identities, abilities, and lived experiences stand to impact the ways in which older adults interact both socially and physically with the urban environment (Rosenberg and Everitt, 2001; Kobayashi et al, 2011). While aging changes the experience of daily life, the intersection of age and diversity can compound these experiences, subjecting older adults to a ‘double jeopardy’ (Rosenberg and Everitt, 2001) in accessing important spaces, services, and opportunities for health and wellbeing. Popularized by the World Health Organization’s Age-Friendly Cities Guide (2007), age-friendly community development encompasses an approach to the physical, social, and political fabric of cities that includes a careful consideration of older adult lived experience (Greenfield et al, 2015). Beyond the more traditional age-friendly service pillars of housing, transportation, healthcare, and recreation, age-friendly development theory has included consideration of social capital as a foundational component to healthy and sustainable aging infrastructure (Buffel et al, 2012; Lager et al, 2015). Fostered through social networks and the physical proximity to others of similar circumstances, social capital – particularly as it relates to older adults – can encourage an improved sense of community belonging, wellbeing, and support (Putnam, 1995).

Problem We pose the question: What would an age-friendly community look like for older adults who belong to the most marginalized groups in society? This chapter examines the experiences of two of the most atrisk or isolated communities among the overall older adult population in Saskatoon, Saskatchewan; namely, members of the LGBTQ community, and those experiencing physical or cognitive frailty.

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Saskatoon is Saskatchewan’s largest city, with a population of roughly 270,000. Over 80% of its footprint has developed in a suburban pattern, mostly automobile-oriented (Gordon et al, 2018). Amplifying the voices of more vulnerable older adults addresses heightened experiences with ‘civil risk’ (Kobayashi and Ray, 2000) faced by those whose identity characteristics stand to increase their exclusion from mainstream institutions and perpetuate their social and spatial marginalization in older age. By investigating community support dynamics within these two marginalized older adult populations, one of our objectives is to better understand the function of ‘bonding social capital’ (ie support among those with similar group identities) in intersectional aging environments (Helliwell and Putnam, 2004).

Methods and analysis The work began in 2016 in consultation with the Saskatoon Council on Aging, an organization serving the older adult population in Saskatoon, and OUTSaskatoon, an organization serving the LGBTQ community. It continued through to 2018. Semi-structured one-toone interviews were held with 37 older adults. Ten were from the LGBTQ community and 27 were older adults experiencing physical or cognitive frailty. Frailty resulted from very old age or life circumstances that caused much of the experience of everyday life to be impacted by limited physical mobility or chronic pain, for example. Frailty could also be caused by a cognitive or other mental health issue that impacted significantly on daily decisions of what to do, how to do it, and what aspects of the surrounding community were, as a result of frailty, difficult to access and interact with. Open-ended questions in the interview guide focused on housing, transportation, recreation, the general community experience, and level of civic engagement. Audio recordings of each interview were transcribed to text files and analysed with the assistance of NVivo  10 qualitative analysis software, where participant perspectives were organized and coded. Open and axial coding was carried out, whereby overarching domains and relationships were identified and refined (Hays and Singh, 2012; Corbin and Strauss, 2015), leading further to patterns and integrative themes (Rubin and Rubin, 2005).

Findings While access to effective and appropriate housing, transportation, recreation, and healthcare is significant to all older adults, the results

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of this research show that those experiencing marginalization due to sexuality or frailty face a compounding set of barriers. Age and experiences with difference intersect to make resource access more challenging or introduce variants on what constitutes effective and appropriate services. We begin with participant perspectives on housing, and then examine transportation, health services, and recreation, touching on the main pillars of age-friendly communities. The findings section concludes with a discussion of overcoming marginalization with social capital and embracing diversity in older age. Housing While frail older adults placed more focus on the physical supports embedded in their housing circumstances and other age-based services bundled or proximate to housing, LGBTQ older adults perceived housing as an opportunity to ensure social proximity to fellow LGBTQ community members. Housing and frailty: the centre of everything Those older adults experiencing physical or cognitive frailty expressed a daily reality defined by a shrinking scope of everyday mobility. Whether initially dictated by long-term chronic illness, the onset of dementia, or the inevitable limitations of an aging body, frailty not only limited participants’ energy, but also their ability to access other agebased services with ease. As one’s ability to complete daily tasks, visit friends and family, and travel to appointments or grocery stores begins to decline, the immediate surroundings (and the support structures inherent to these spaces) become fundamental to one’s wellbeing. What may be seen as an enjoyable convenience for some can instead be reinterpreted as a necessity of dignified aging for those experiencing frailty. Supported-living environments can promote a movement away from single-family homes or apartment buildings that are no longer safe or accessible due to changing physical or cognitive realities. […] ‘especially with all this emphasis on ‘aging in place’. Sure, I could age in place, I could stay [in my single-family home]. I could probably get grants … to put those things in the house that carry you up the stairs. It would be difficult … And one of the things people emphasize is doing that. They emphasize taking out your bathtub and putting in one of these things so you can open the door and walk in….

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that’s a problem. And I’m really suspicious of this ‘aging in place’ conventional wisdom or trend or whatever you call it. Because for people on a fixed income, that’s a problem. You have to make all these adjustments to a big house in order to stay there. And where does that money come from? And also, you have a house that you’ve got a certain amount of asset locked into … if you can liberate that asset, you can use it towards other expenses in a more sensible way.’ (Participant 11: Frailty group, female, 70–84 years old) Yet supported-living housing options are financially inaccessible to many on fixed incomes, and there are long waiting lists to get into these developments. Appropriate housing is of particular concern for Saskatoon older adults experiencing frailty as it often intersects with living in poverty. Long-term chronic illness was a strong indicator of poverty among several participants interviewed. For these individuals, subsidized public housing buildings were the only affordable solution to age-oriented housing. While these buildings were praised for providing alternatives to housing in the for-profit market, questions regarding their long-term suitability for those with declining physical ability were unsettling for many. ‘If your health deteriorates and you have to move out, where do you go that you can afford?’ (Participant  27: Frailty group, female, 55–69 years old) ‘Yeah, that’s big. Because those nursing places are starting at $2,000 [per month]…so where do you go? You’ll be out on the corner.’ (Participant 26: Frailty group, female, 70–84 years old) For older adults experiencing frailty, housing is the cornerstone upon which all other age-related services are accessed, and upon which physical and emotional wellbeing depend. It plays a central overall role as a domain of control and social network, where access to services and experiences in the broader community outside may seem more tentative than for other older adults. Housing and homophobia Participants from Saskatoon’s LGBTQ community reflected a preference towards housing arrangements that united members of

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their community, ensuring spaces perceived as safe and removed from institutional or religious influence. A fear of homophobia across many older adult-related service sectors was present among the LGBTQ participants surveyed, but nowhere more so than in regard to housing. Participants reflected a sense of ‘otherness’ in age-based housing environments and noted fears of being socially alienated or physically mistreated as a result of their sexuality. ‘A lot of gay seniors that go into senior’s homes, they don’t identify as gay anymore for the simple reason [that] they don’t want to be discriminated [against] at that level  … what nursing home can I go to that I can put sequins on my wheelchair, you know?’ (Participant 37: LGBTQ group, male, 55–69 years old) ‘Please shoot me before I have to go into one of those [senior’s residences], because they’re just awful  … and of course, they’re entirely religious-centric. Or there are straight-centric ones too. So there’s nothing here for a gay person to feel comfortable in, that I’ve seen.’ (Participant 35: LGBTQ group, male, 55–69 years old) ‘My concern is still there for those nursing homes and private care homes … most of them you don’t know, and you’ll never know, but the fact is you don’t know the other people that are patients in that residence … you don’t know when they’ll come and if they’re my age, let’s face the reality that a lot of people my age who are still you know, of that mindset that ‘gay is evil’, and you’re evil, and you can’t possibly have a good life, and that God doesn’t love you and all that.’ (Participant  34: LGBTQ group, male, 70–84 years old) The socially constructed exclusion of LGBTQ older adults from supported-living developments has impacts on long-term physical and cognitive wellbeing. An inability to benefit from the internalized support structures, medical aid, and transportation assistance inherent to supported-living developments that often become necessary with aging and onset of physical or cognitive frailty is a concern among participants. As an alternative to traditional age-based supported housing environments, many LGBTQ participants expressed a preference for the development of LGBTQ-centred age-based housing,

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pairing the housing and services with support from within their social networks. Lesbian women further refined the notion expressing their experiences of intersecting forms of oppression: ageism, homophobia, and sexism. Together these have created an increased prevalence of poverty and sense of alienation from the broader whole of society. Lesbian-oriented housing developments and co-operatives were a common preference among these participants. ‘And, of course, because we are a female family we are low income, and it never fails … two women with minimal pensions. So finances are a struggle always.’ (Participant 29: LGBTQ group, female, 55–69 years old) ‘I think that there’s a comfort level for all of us [lesbian older adults] in that because we’re all in the same boat and we can have conversation that makes sense with each other … many, many times there have been conversations about starting a housing co-op or something like that, that would only house lesbians and partners. I think that conversation happens because we’re nervous about being separated from each other, and that’s not just nervous about being separated from [our] partner, but from [our] community.’ (Participant 30: LGBTQ group, female, 55–69 years old) Collectively, the experiences of LGBTQ older adults and housing demonstrates the ongoing sense of exclusion by more marginalized older adult communities from supported-living environments designed to accommodate housing needs as one ages. Poverty, fear of discrimination, and perceptions of ‘otherness’ contribute to unique housing realities, and the importance of LGBTQ considerations among age-friendly housing conversations. Transportation Participants expressed that the use of public transportation was a secondary preference to travelling by personal vehicle – either as a driver or passenger. Further, its use was due to a lack of a driving licence, restrictive physical mobility, or to financial limitations. Given the suburban pattern of Saskatoon’s built form, public transit is seen as a residual service in a city where private auto-mobility is the key to freedom and mobility.

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Frailty and the significance of accessible transportation While transportation is an important function of city design and amenities for residents at all ages and stages of life, older adults experiencing health- or age-based frailty have a unique relationship with mobility services. Because public transit (and most city form) is built with able-bodied users in mind, the accessibility of services and desired daily life patterns become limited for frail older adults. ‘In the winter you don’t go out as much if the weather is really, really cold. And as I said about the transit system, the regular bus, if they can’t lower the ramp or kneel the bus then you can’t get on. And a catch there too is that sometimes when the City clears the snow, especially when the buses pull up they don’t do it good enough so now they’re up on a bunch of packed snow so [the bus is] up even higher and it makes it more difficult.’ (Participant 27: Frailty group, female, 55–69 years old) When physical mobility becomes limited, lack of appropriate transportation resources also plays an important role in participants’ ability to maintain social and recreational connections in their community. A lack of transportation certainty can limit not only attendance at regular medical appointments, but also older adults’ willingness to attend and enjoy public events and recreational spaces. ‘I’ve used the bus, but you can’t really make it to appointments on time if you try to catch the bus. I mean, it runs every half hour of the day, and every hour at night. I guess that’s one of my things, is that I don’t get any entertainment, because you just can’t rely on the evening bus service for one, to get there and back that well.’ (Participant 14: Frailty group, female, 55–69 years old) Collectively, for those experiencing age- or health-based frailty, relationships with transportation amenities can become more strained, as physical accessibility features, transportation schedules, and predictability become increasingly pertinent to ease of mobility. A popular transportation option among participants was the use of specialized and age-based transport. In the form of either the public Access Transit program, or the private buses provided by some

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supported-living developments, these transportation options offer predictability for more physically or cognitively frail older adults. ‘I also use Access Transit, which is a very, very good service … you have to book the Access a week in advance. Whereas the City bus you can go out and take it. But I prefer the Access because they help you more, you know … I still have to lift my walker when I’m by myself, but if you go on Access the driver does that. They lift your walker onto the bus – just the service is more … they’re really good, they are all so courteous and helpful.’ (Participant 25: Frailty group, female, 85+ years old) As the Saskatoon participants made clear, a frailty-informed transportation infrastructure must address factors of distance, safety, accessibility, predictability, and, where necessary, have built-in support features. While existing transportation options provide a basic level of dependable mobility, the freedom to access services and social networking opportunities is curtailed by a need for pre-booking and a significant amount of pre-planning. When service frequency is lower, such as in the evenings, getting to and from engagements may become too risky to venture. Health services Though marginalization was likely to impact one’s relationship with Saskatoon’s age-based health services landscape, it is important to acknowledge the general praise that many participants expressed towards Saskatoon health services overall. Those with positive reflections were less likely to elaborate on their experiences. For these participants, there was a general sense of compassion, care, and attention from health service providers. ‘I can say from experiences  … we were in and out of the hospital system on a daily basis. Every hospital. And emergency, intensive care, you name it, we were there – because a friend of ours got very, very ill… they treated us like family… so I have to say the system worked really well in that particular circumstance.’ (Participant 34: LGBTQ group, male, 70–84 years old)

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Generalized barriers to health services among older adults With the above praise for Saskatoon health providers and services in mind, participants identified a number of barriers facing older adult access to health services. Waiting lists, prescription costs, physical proximity to services, the importance of advocates, and physician attitudes towards geriatric care were all noted. Concerns about waiting times were particularly common among participants experiencing physical frailty. Where medical appointments and potential emergencies grow in frequency, the waiting times associated with both emergency room visits and specialist appointments can delay important medical care and leave participants less inclined to seek aid in the first place. For many participants, the cost of prescription medication was another primary concern. Given that social and physical marginalization often intersects with limited financial resources, the affordability of necessary medication was a heightened consideration among many. Those experiencing physical frailty as the result of long-term illness or age were also more likely to rely on regular access to medication to ensure daily wellbeing, magnifying the implications of financially inaccessible prescription costs. ‘I’m not sure just how much I spend [on pharmaceuticals], but I think I spend close to a thousand dollars a year. Now [for] people who are on very low incomes, this is just impossible for them. So they are just not getting the medical supplies they need.’ (Participant 10: Frailty group, male, 85+ years old) The physical accessibility of services was another important consideration, particularly among those with increased physical frailty or reduced transportation alternatives. Medical office models that incorporate a number of health services, labs, and specialists in a common location were praised among many participants for centralizing services and reducing necessary transportation time. The Saskatoon Community Clinic, that follows a centralized service model, was the common recipient of such praise. ‘Oh yes, that’s tremendously helpful. When I go to see my doctor if I need medication or I often need an x-ray or bloodwork, they are all under the same roof. They are all there and it’s just super helpful.’ (Participant 10: Frailty group, male, 85+ years old)

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Other participants expressed the importance of having an advocate to help navigate Saskatoon’s health system, and to provide assistance and take notes to assist the patient in an appointment setting. Finally, some participants expressed concern regarding the attitudes of physicians and nurses towards geriatric care and older adult patients. Participants noted barriers in obtaining a physician that was willing to work with an individual’s given set of needs or circumstances, as well as concerns regarding the integrity of particular service providers when working with more marginalized older adults. ‘You almost have to have an interview to get a doctor to take you on, especially if you have disabilities. They may not necessarily be all that interested in you, because as you age and have new difficulties you become a lot of work. So some of them are, you know, less receptive.’ (Participant 12: Frailty group, female, 55–69 years old) Real and perceived homophobia in the health services system LGBTQ older adult participants expressed a distinctive separation and concern from existing health services. Most experienced a sense of social otherness and prejudice from within the health services system. Whether motivated by first-hand experiences or by more generalized assumptions regarding societal prejudice, both are equally significant in their impact on one’s willingness to use health services in preventative and emergency health situations. ‘We are far less inclined to go to the doctor, then we’ll leave it longer. My partner will leave it, which is why she ended up in the hospital … and we’ve seen that with a few of our friends.’ (Participant  29: LGBTQ group, female, 55–69 years old) A perceived prejudice towards same-sex couples within the health system was highlighted by participants, who expressed a reduced likelihood of feeling acknowledged as legal partners for issues of medical consent and ongoing visitation. Ensuring access to an LGBTQ-friendly physician was a key concern. ‘Coming from Vancouver where, being part of the LGBTQ community, I went to a gay doctor, I went to a gay dentist,

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I went to a gay massage therapist.’ (Participant 36: LGBTQ group, male, 55–69 years old). ‘I asked him specifically … how he functions, ‘are you gayfriendly?’ ‘Yes I am’. But it’s not quite that simple. You can tell. I mean, everybody’s a good actor. Some people can be very good actors, and I’m sure doctors can be as well.’ (Participant 35: LGBTQ group, male, 55–69 years old) The presence of good health services does not necessarily generate equitable access. Access is affected by perceived or real barriers, whether the subtle application of heterosexual norms during consultations and treatment, or overt homophobic discrimination. Recreation For many participants, particularly those experiencing age or healthbased frailty, housing developments provide an important source of entertainment and can foster a sense of social belonging. The physical proximity of recreation opportunities provided in age-based condominiums, public housing buildings, and supported-living developments are of heightened significance to those whose physical or cognitive circumstances limit their regular transportation to outside activities. Whether publicly or privately owned, age-based housing developments were credited by many of the frailty group participants for incorporating a broad range of both scheduled and unscheduled recreational activities into daily life. ‘We have exercise every morning in the building. And I’ve been one of the exercise leaders, though I’m slowing down on that now … and I sing in our choir here. And we practice on Thursday every week and sing in the church on one Sunday of each month … There are card games that go on every night, so I participate in some of those … we have coffee at 10am every morning downstairs and that’s a social activity.’ (Participant 10: Frailty group, male, 85+ years old) ‘On Monday nights they have Kaiser. On Wednesday nights we have Bingo. On Thursday nights we have Canasta … but we also have a birthday party once a month, and that’s on a Friday afternoon. We have a potluck supper the first

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Thursday of every month. And then there’s a catered meal twice a month, which is only $10 and it’s catered by the café in the bar. So there’s stuff to do.’ (Participant 13: Frailty group, female, 55–69 years old) While in-house recreational programming allows older adults with limited physical mobility to stay connected, active, and engaged, an individual’s exclusion from such housing developments can in turn hinder recreational involvement and increase a reliance on functional and accessible transportation to maintain social connectedness, all the more challenging in Saskatoon’s suburban development pattern of segregated land uses. Those residing outside of age-based housing developments and in single-family homes or apartments were more likely to recognize constraints on their social participation – particularly during colder months – and to express the reduced availability of recreational opportunities for older adults in general. Both those within and outside of age-based developments were inclined to recognize the improved recreational opportunity within these residences, and the shortcomings in recreational capacity for those living outside of them. LGBTQ recreation and community: finding a safe space LGBTQ participants prioritized in-group recreational networks as the result of perceived ‘otherness’ and discrimination, and in a desire to maintain close support networks within their immediate community. A fear of homophobia and prejudice marked the social decision-making of many LGBTQ older adults, prompting a landscape of recreational activities created by the LGBTQ community itself. LGBTQ older adult recreational activities include a seniors’ brunch club, intimate friend circles, night-life opportunities, and an age-based conversation group (programed through OUTSaskatoon). Fear and previous experiences with rejection from workplaces, family settings, and religious institutions instilled concern and reserve among participants. LGBTQ participants reflected on the need to stay in close proximity to members of their community as a survival mechanism against external homophobia, noted as being of heightened concern within the aging community. In addition to housing environments, LGBTQ participants expressed the importance of safe recreational spaces. ‘[…] the facilities that I would like to be in as a gay man aren’t here … a quiet bar or a quiet pub for gay people …

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being in a crowded bar with a bunch of straight people that are “friendly” is not the same … so it’s a congregating place.’ (Participant 35: LGBTQ group, male, 55–69 years old) Having a network of safe spaces, where self-actualization in a social context is comfortable and enjoyable, is an important part of creating an overall age-friendly community. Overcoming marginalization with social capital Within each of the participant groups interviewed, social capital development was foundational to an ongoing quality of life, and overcoming age-based service barriers, exclusion, and physical isolation. Bonding social capital (Helliwell and Putnam, 2004) amid networks founded in group sameness and homogeneity, is particularly apparent among older adults experiencing marginalization. A sense of kinship and support evident within each of the participant groups interviewed highlights the function of bonding capital in overcoming experiences of social and service exclusion in older age, despite difference in the nature of these individual group experiences. While physical proximity aids in the development of social capital among physically frail older adults within housing developments, the ongoing sense of social inclusion and belonging is an important component of general wellbeing and joy. ‘You sure don’t have to feel lonesome. If you do, you just get out of your room and come up to a place like that and come across the hall there where a TV is there and that’s on all day long. And oh the pool table is here, and the shuffle board is here.’ (Participant 24: Frailty group, male, 85+ years old) ‘The thing is, there’s so much camaraderie, and if anyone thinks that you need a hand with something, they’re there to help.’ (Participant 9: Frailty group, female, 85+ years old) Particularly for those living alone, the social support of fellow residents within age-based buildings promoted recreational inclusion, regular outings, and support in both the access of healthcare and transportation services. LGBTQ participants often used social networks to compensate for a sense of isolation and exclusion from mainstream age-based

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environments, noting the importance of connecting these networks with built environment as well as social and service experiences. ‘So here, like just about anything else, the first question I ask is not if they’re gay-friendly, it’s are they gay? Are members of their family? Or a friend of yours? Or however you want to put it. That’s not the only thing that I’m going to be looking at, but it is something that I want to make sure. I want to keep it in the family. So that sort of applies to housing and to doctors and to social events. If I’m going to a coffee house, I want to make sure it’s a safe place for me to be.’ (Participant 35: LGBTQ group, male, 55–69 years old) A sense of exclusion from mainstream and age-based environments underlines the role of the LGBTQ social network as one of ensuring welcoming, intentional, and LGBTQ-friendly spaces within which older adults may enjoy social connection, a sense of place, and access to important age-based services. For many, the functions of this network are quieter and less visible than other marginalized older adult communities, largely due to a sense of needing to conceal one’s identity in order to maintain appropriate health-, social-, and housingbased services. Embracing diversity in older age Ageism (Angus and Reeve, 2006), or the discrimination and exclusion of individuals or communities driven by their age and stage of life, was acknowledged for its presence both within and outside of the older adult community itself. ‘This is a system, this is a culture, that absolutely hates aging.’ (Participant 11: Frailty group, female, 70–84 years old) ‘I think cities are built with young people in mind … I really do.’ (Participant 1: Frailty group, female, 70–84 years old) Combating ageism is an important consideration in the production of a society that is inclusive and appreciative of its older adult members. Societal acceptance of the realities of aging is fundamental to ensuring that the appropriate services, resources, and amenities are available at all stages of life. Without an acceptance of aging both within and outside of the older adult population, older adults

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remain less inclined to seek assistance and lifestyle modifications, and to obtain increased support when it becomes necessary to ensure a high quality of life. ‘And that’s one thing, as you get older, you need help. And I’ve heard a lot of older people say ‘I don’t need any help!’, but ten minutes later they’re sitting there rubbing their knees or their shoulders. They need help, but won’t accept it.’ (Participant 24: Frailty group, male, 85+ years old) For LGBTQ older adults, society-wide heteronormativity and overt expressions of homophobia are significant barriers to wellbeing and positive aging. Many participants noted their sexual identity as a limiting factor in their sense of inclusion, access, and belonging to a number of service areas, particularly as they relate to aging. From concerns of homophobia within the health services system to a lack of inclusive housing environments, LGBTQ older adults struggle to maintain their personal identity while ensuring equal access to important age-based amenities. ‘I always have the feeling [of otherness] – it follows me around, you know there’s something that wasn’t for me.’ (Participant 34: LGBTQ group, male, 70–84 years old) While the dominance of heterosexuality pervades a number of agebased service environments, several participants expressed an additional concern regarding the presence of homophobia within the aging population itself. ‘People who are homophobic in this day and age are more the people of my age or older. Younger people are far more accepting. It just seems to be an issue [among older adults].’ (Participant 30: LGBTQ group, female, 55–69 years old) While LGBTQ-friendly spaces are growing in prevalence across Canada, work remains to be done in ensuring acceptance and respect within age-oriented spaces. For as long as homophobia discourages LGBTQ older adults from accessing mainstream service environments or age-based amenities, the pervasive nature of this prejudice will limit the effectiveness and feasibility of existing and future age-friendly development initiatives.

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Conclusions and implications for practice As a whole, an age-friendly paradigm that guides urban development and institutional design must, at its core, appreciate the realities and nuances of aging, in its physical, cognitive, and sociocultural dimensions. Creating accessible supported-living environments, considerate service environments, and operationalizing social capital are three implications for practice that would enhance agefriendly community development for older adults from the LGBTQ community and those contending with physical or cognitive frailty. Accessible supported-living environments Housing is the foundation to health and wellbeing among Saskatoon’s older adults. While various housing styles may provide desirable conditions at different stages of age and health, there remains among participants an underlying focus on the importance of accessible and appropriate supported-living options. Those participants currently residing in privatized supported-living developments credited these residences for their improved sense of safety, accessible transportation options, rich social environments, and general quality of life. The privatized and often religious-centric nature of these developments were acknowledged by many as financially and socially restrictive. In order to foster physical and social meeting points, ensure housing that meets a changing set of needs, and to promote centralized recreational and transportation resources, supported-living developments must be made available to Saskatoon’s older adults living in the face of financial or social exclusion. With public investment an age-friendly housing framework is one that would recognize the availability and affordability of supported-living developments as an essential component to health and equity in older age. Acknowledging that marginalization and othering is experienced by LGBTQ older adults, appropriate supported-living developments may necessitate socially homogeneous environments that foster a sense of inclusion and group safety, encouraging spaces where a social enclave (Herman et al, 2020) built with strong bonding social capital may benefit residents. Considerate service environments Across both participant groups, there was a sense of marginalization in mainstream age-based service environments. Whether age-based service shortcomings take the form of inaccessible physical spaces

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or a heteronormative framework of care and understanding, older adults experiencing life at the margins of the larger older adult population often struggle in one way or another to fully benefit from conventional age-based offerings. For those experiencing physical or cognitive frailty, the design and accessibility of service environments and recreational opportunities are important considerations. Whether physically or cognitively based, frailty-informed service design considerations include more commonly recognized physical accessibility features (eg accessible washrooms, ramps, automatic doors, etc), in addition to greater systemic and societal empathy for physical and cognitive abilities. Prevalent scepticism towards health services environments among LGBTQ older adult participants has left many resistant to seeking necessary care, particularly in cases in need of more serious intervention or home-care services. Effective intersectional healthcare resources necessitate the implementation of campaigns and programs that not only improve the service delivery and patient interaction between older adults and their health service providers, but that help communicate publicly to older adults the presence of LGBTQ-positive health services and supports. Operationalizing social capital This chapter has highlighted the role of bonding social capital in defining functional support networks alongside, or as substitutes for, mainstream age-friendly services and supports. The same factors that contribute to a social group’s isolation or exclusion can provide the glue that connects older adults within more homogeneous social environments. Though the function of bonding capital differed between each of the participant groups, social network and peer reliance were foundational and often overlooked components to a healthy and happy life in older age. Though supported-living environments were credited by older adults experiencing physical or cognitive frailty with centralizing a number of age-oriented services, a key benefit of these developments was their tendency to encourage physical proximity between older adults themselves. Promoting easier transportation and recreation, physical proximity promotes social support, activity, and a sense of community. Acknowledging the inherent social network structures of supported-living and age-based developments underlines the need to ensure accessibility to such residences at a variety of price points, and to those who may experience a sense of social otherness.

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Bonding social capital networks valued by LGBTQ older adult participants were particularly evident. Driven equally by a sense of commonality and belonging, and by fear of discrimination, these older adults reflected on an encompassing sense of otherness, particularly among older adult communities. The LGBTQ older adult social network functions to provide advocacy, support, and companionship. In addition to promoting housing, healthcare, and recreational environments that foster both a real and perceived openness towards the aging LGBTQ community, inclusive age-friendly development will hopefully follow from enhancing collaboration between LGBTQ social network members and broader age-based agencies over time. Acknowledgements The authors thank the research participants for sharing their time, experience, and expertise. A special thank you to Dr. Kathi Wilson for her work on the project overall. The research has funded by an Insight Grant from the Social Sciences and Humanities Research Council of Canada.

References Angus, J. and Reeve, P. (2006) ‘Ageism: a threat to “aging well” in the 21st century’, Journal of Applied Gerontology, 25(2): 137–52. Buffel, T., Verté, D., De Donder, L., De Witte, N., Dury, S., Vanwing, T., and Bolsenbroek, A. (2012) ‘Theorizing the relationship between older people and their immediate social living environment’, International Journal of Lifelong Education, 31(1): 13–32. Corbin, J. and Strauss, A. (2015) Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory (4th edn), London: Sage. Gordon, D.L.A. with Hindrichs, L., and Willms, C. (2018) ‘Still suburban? Growth in Canadian suburbs, 2006–2016’, Council for Canadian Urbanism, Working Paper 2. Greenfield, E.A., Oberlink, M., Scharlach, A.E., Neal, M.B., and Stafford, P.B. (2015) ‘Age-friendly community initiatives: Conceptual issues and key questions’, The Gerontologist, 55(2): 191–8. Hays, D.G. and Singh, A.A. (2012) Qualitative Inquiry in Clinical and Educational Settings, New York: Guilford Press. Helliwell, J.F. and Putnam, R.D. (2004) ‘The social context of well-being’, Philosophical Transactions: Biological Sciences, 359(1449): 1435–46. Herman, L., Walker, R., and Rosenberg, M. (2020) ‘Age-friendly communities and cultural pluralism: examining Saskatoon’s ChineseCanadian social enclave’, Canadian Journal on Aging. DOI: 10.1017/ S0714980820000148.

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Kobayashi, A., Preston, V., and Murnaghan, A.M. (2011) ‘Place, affect, and transnationalism through the voices of Hong Kong immigrants to Canada’, Social & Cultural Geography, 12(8): 871–88. Kobayashi, A. and Ray, B. (2000) ‘Civil risk and landscapes of marginality in Canada: a pluralist approach to social justice’, The Canadian Geographer, 44(4): 401–17. Lager, D., Van Hoven, B., and Huigen, P.P.P. (2015) ‘Understanding older adults’ social capital in place: obstacles to and opportunities for social contacts in the neighbourhood’, Geoforum, 59: 87–97. Putnam, R.D. (1995) ‘Bowling alone: America’s declining social capital’, Journal of Democracy, 6(1): 65–78. Rosenberg, M. and Everitt, J. (2001) ‘Planning for aging populations: inside or outside the walls’, Progress in Planning, 56(3): 119–68. Rubin, H.J. and Rubin, I.S. (2005) Qualitative Interviewing: The Art of Hearing Data (2nd edn), London: Sage. World Health Organization (2007) Global Age-Friendly Cities: A Guide, Geneva: World Health Organization.

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Suburban community vignette Candace Skrapek and Elliot Paus Jenssen Situated in the middle of Canada’s prairie region, Saskatoon is the largest city in the province of Saskatchewan. Nestled on the meandering South Saskatchewan River, Saskatoon has many natural features that make it an attractive place to call home. The warm, long summer days, green, clean spaces, and a variety of social and cultural events contribute to active living, social engagement, and community participation. Saskatoon offers safe, friendly neighbourhoods, a variety of housing options, excellent educational opportunities, public and accessible transit services, increasingly accessible buildings and services, and a range of health and community services. Winter poses challenges for all residents, especially older adults who face safety issues related to icy and cold conditions and resulting in reduced opportunities for social connectedness. The 2016 Canadian Census lists the population of Saskatoon’s Census Metropolitan Area (CMA) as 295,095, 10.9% of whom are Indigenous people. The CMA’s population grew 12.5% between 2011 and 2016 – far outpacing the national growth rate of 5%. Population growth was due primarily to immigration related to Saskatoon’s rapid economic expansion. Like most cities in Canada, Saskatoon has grown outward from its historic core into mixed-development suburbs. Most older adults live in these car-dependent communities. Saskatoon’s Nutana Suburban Centre has the highest density of seniors in Canada. This model of suburban development poses many challenges for citizens as they age, often forcing unwanted moves in order to access needed supports and services. In 2016, 13.5% of the Saskatoon population was age 65 or older. The older adult population is culturally and socially diverse and consists of multiple generations with vastly differing characteristics, needs, and resources. The most rapidly growing group are those 85 years of age and older.

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The Age-Friendly Saskatoon Initiative This vignette is informed by the voices of hundreds of older adults who participated in the Saskatoon Council on Aging (SCOA)-led Age-Friendly Saskatoon Initiative (AFSI) between 2011 and 2016. Beginning in 2009, a group of older adult SCOA volunteers (authors included) became increasingly concerned about the lack of public policy focused on the unique needs of the aging population. SCOA, a non-profit organization dedicated to promoting positive aging for all, decided to seek the opinions of older adults in Saskatoon. The goal was to promote a community conversation that would lead to changes in attitudes about aging and older adults and provide direction on how to create a more age-friendly city. Based on the World Health Organization (WHO)’s Global Age-Friendly Cities, the AFSI involved three phases and took five years to complete. The aims of the AFSI were: • To promote civic engagement and volunteerism of Saskatoon’s older adults; • Gather information about factors promoting and hindering positive aging in Saskatoon; and • Provide a foundational planning document to support the development and coordination of policies, programs and services directed toward addressing the needs of older adults. SCOA’s approach to the AFSI was unique because older adults, like us, provided leadership in planning, development of partnerships, research and delivery of all phases of the project. The older adult leadership and key community partners acted together to ensure the diverse voices of hundreds of older adults were heard throughout the engagement.

Older adult voices The AFSI began by asking older adults to address the fundamental question ‘Is Saskatoon an age-friendly city?’ Using the WHO’s eight dimensions of an age-friendly city as a framework, older adults identified characteristics of Saskatoon that supported their quality of life and independence, aspects of the community needing improvement, and made suggestions about how Saskatoon could become more agefriendly. So, what did older adults say about growing old in Saskatoon? What ideas did they have about actions that would positively impact their

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quality of life? What were barriers? What actions have been taken to implement their recommended actions? Older adults described the age-friendliness of Saskatoon as highly dependent on factors that typically influence realities of (sub) urban life. Time of year, neighbourhood, housing, degree of health challenges, mobility level, financial resources, support systems, access to information, and sociocultural factors such as gender and ethnicity all impacted quality of life and independence. Saskatoon’s older adults came to describe their community as a ‘tale of two cities’ for two reasons. The first has to do with weather and the striking difference between the age-friendliness of Saskatoon in summer and winter months. The second has to do with equally striking differences between the age-friendliness experienced by older adults who have good health, strong family and social supports, good housing, and financial security and those who do not. Older adults with poor health, limited family and social supports, inadequate income for their needs or who experience discrimination based on race, ethnicity, gender, or disability face barriers more advantaged older adults do not. Nearly 90% of older adults live independently in Saskatoon and want to continue to do so. Many told SCOA that although their current needs in housing and health care were being met, they were highly anxious that this would not be the case if their health declined, social situation changed, or income dropped. Many older adults described how the lack of affordable, accessible, and appropriate housing and health and social care services created significant barriers which impact their quality of life. In order to age in place, older adults expressed their desire for more innovative, creative options for healthcare, housing, and services. They wanted better access to relevant information and effective avenues of communication that would enable them to be informed and to stay connected. Older adults wanted a say in decisions that affect them personally and input into community and political decisions impacting older adults, including those that would lead to a more age-friendly city. Older adults identified ageism as the greatest barrier they encounter when trying to access programs and services. They told us about ageist experiences in many aspects of their lives, including seeking healthcare, housing, and employment, doing business, and attending events. Some described situations in which they felt marginalized from personal decision-making, despite being the person most impacted by the outcome. The experiences of older adults with disabilities were particularly poignant, telling of their struggles with public washrooms, getting

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around in public buildings, and accessing activities. First Nations and Métis, visible minority, and LGBTQ2+ older adults also told how ageism compounded discriminations they experience. Overall, people felt that a shift in attitude of the community, policy leaders, and older adults themselves is fundamental to community change and countering ageism. Older adults see the advantages an age-friendly city offers people of all ages. They also believe the entire community has a role in creating an age-friendly city – not one individual, group, or agency has the full responsibility or capacity for community change.

Actions and recommendations To facilitate the implementation of the solutions identified by older adults, SCOA took the lead in collaborating with community partners to begin implementation of recommended actions. Exemplars include partnerships/collaborations with: 1. Saskatoon City Council and City Administration to ensure the opinions of older adults are considered in planning initiatives such as the Active Transportation Plan and the Winter City Strategy; 2. The City of Saskatoon Police Service, Fire Department, Transit Services, and Leisure Services to develop targeted programs for older adults including: – Age-friendly training videos for frontline workers; – Seniors Police and Fire Academy; – Remembering When™, a community-based fire- and fallprevention program; and – Hub Clubs providing neighbourhood social and educational opportunities. 3. The Saskatchewan Human Rights Commission to address ageism and age-related discrimination. 4. Community-based organizations, including: – OUTSaskatoon examining ways to meet needs of older LGBTQ2+ people in congregate living; – Saskatoon Housing Authority and the University of Saskatchewan addressing peer bullying in seniors’ housing; – Settlement agencies in developing age-friendly supports for older refugees and immigrants; – Agencies serving the Indigenous population in identifying their specific needs and suggestions for change; and

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– Health and fitness organizations to establish the SCOA Globe Walk providing opportunities for physical activities and social interactions for over 3,000 seniors; and 5. Development of age-friendly resources such as a Directory of Services for older adults seeking employment opportunities and support.

Conclusion The prospect of higher numbers of older people in our community is an exciting opportunity – one that will challenge us to make positive changes in our city, our institutions, and our attitudes. As Saskatoon grows and the population ages, urban planning must address the disconnect between seniors’ desire to age in place and the characteristics of suburban living that prevent that from being a reality. The AFSI has achieved a significant level of success in its efforts to positively change community conversations about an aging population in Saskatoon. This was largely due to the enthusiasm and expertise that older adult volunteers provided and the thousands of hours that they dedicated over the five years of the initiative to ensure the attainment of the project goals. In 2017, following the completion of the AFSI, the City of Saskatoon applied for and was granted full membership in the WHO Global Age-Friendly Cities Network. To end, we will leave you with a quote directly from the AFSI’s Implementation and Evaluation report: ‘For the limited investment made, this project’s reach has extended deeply into the community and touched all levels of leadership and decision making.’

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New micro-mobilities and aging in the suburbs Jennifer Dean and Edward Donato In 2007, the World Health Organization (WHO) launched their Age-Friendly Cities (AFCs) program in response to the global trend towards aging populations and increasing urbanization (WHO, 2007). The WHO anticipates that by 2050, approximately 22% of the global population will be over the age of 60 with the majority residing in sub/urban areas (WHO, 2007). In the Canadian context, one in four residents will be 65 years or older by 2036 with well over 70% residing in (sub)urban communities (PHAC, 2011). Moreover, the intensity of older adults will be most acutely felt in small and mid-sized cities where the mean older adult dependency ratio will grow by 103% and 90% respectfully by 2036 (Hartt and Biglieri, 2018). Given the certainty of demographic change and the heterogeneity of the older adult population (Garvin et al, 2012; Stafford and Baldwin, 2018), there is a time sensitive need to understand how to support older adults who desire to age in place – that is, to live safely and independently in their existing communities (WHO, 2007).

Aging in place, wellbeing, and mobility Since the beginning of the twenty-first century, there has been a renaissance of academic literature linking built environments and human health in order to address the rising rates of chronic diseases, a warming climate, loss of green space to urban sprawl, and automobile dependency (Frank et al, 2003, 2006). Geographers and planners have played an important role in acknowledging the importance of local built environments to population health and wellbeing throughout the life course (Laws, 1993; Frank et al, 2006; Andrews et al, 2007; Gilroy, 2008; Cutchin, 2009; Garvin et al, 2012; Kerr et al, 2012). In the North American context, the design of many urban built environments has been widely critiqued as not conducive to an active and healthy lifestyle and generally unsupportive of aging in place (Frumkin, 2002; Frank et al, 2003; Gilroy, 2008; Mercado and Páez,

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2009; Zegras et al, 2012; Cerin et al, 2017). The challenges of active living in many Canadian built environments is exacerbated for older adults who have limited mobility as they age due to (1) shrinking activity spaces over time (Shoval et al, 2011), (2) onset of physical and cognitive disabilities for some (WHO, 2007), and (3) loss of driving abilities for others (Rapoport et al, 2013). Specifically, the traditional suburban design of many Canadian urban areas makes physical activity and active transportation (for example, walking or cycling) challenging due to poor street connectivity, low residential density, and single-use zoning (Frumkin, 2002; Frank et al, 2006; Kerr et al, 2012). Further, aging in place within many autodependent sub/urban areas means a lack of necessary infrastructure (cycling lanes, quality sidewalks and walkways) and desirable destinations (shops, public transit stops, recreational and commercial facilities, benches) to support active transportation (Mercado and Páez, 2009; Cerin et al, 2017). The Canadian Institute of Planners (CIP) is now widely promoting land use policies that support active modes of transportation while reducing automobile use for improved population health (CIP, 2014), climate action (CIP, 2018a), and sustainable development (CIP, 2018b). Indeed, the importance of physical activity for the health and wellbeing of older adults has been widely touted with more recent research acknowledging that shifting to active transportation modes can have significant benefits for this age cohort compared to younger cohorts (Cerin et  al, 2017). Beyond physical activity, older adult mobility is positively correlated with social interaction (van den Berg et al, 2011; Aird and Buys, 2015), happiness (Ravulaparthy et al, 2013; Ryan et al, 2016), and reduced loneliness (van den Berg et al, 2016). Yet, in both European and North American contexts, older adults face individual and environmental barriers to walking (Lee and Dean, 2018; Stafford and Baldwin, 2018) and are less likely to cycle (Black and Street, 2014; Ma and Dill, 2017) than younger populations. Overall, research exploring older adult engagement in active transportation and the subsequent effect on their quality of life is still in its infancy. Research from Europe suggests that cycling is the preferred mode of transportation for many older adults in semiurban areas because they can more easily travel the longer distances between nodes by bike than by foot (Kemperman and Timmerman, 2009; Van  Cauwenberg et  al, 2012). However, the majority of studies on cycling for transport among older adults are conducted in communities with an established cycling culture, such as the Netherlands, as well as Portland in the North American context.

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While these findings are useful, they rarely reflect the environments where older adults reside in Canada. This is due in large part to the absence of safe and consistent cycling infrastructure in many sub/ urban environments (Winters et al, 2011, 2013; Ryan et al, 2016; Edge et al, 2018), as well as the increasing physical exertion required by many adult cyclists as they age (Ma and Dill, 2017). More research in areas with limited cycling culture is needed in order to better understand facilitators and barriers to active mobility for older adults (Ryan et al, 2016). This chapter contributes to the small but growing area of research on older adult mobility and active transport by exploring how the recent emergence of new mobility options, notably electric bicycles and electric scooters, can help mitigate unhealthy built environments in automobile-dependent sub/urban Canadian communities.

On the potential of new micro-mobilities The global concern over climate change has resulted in calls to reform urban transportation systems in order to reduce greenhouse gas emissions (ie alternative biofuels and electrification) and promote sustainable modes of transport such as public transit, walking, and cycling (IPCC, 2014; Edge et al, 2018). The emergence of new micromobility options, including electric bicycles and electric scooters, has provided increased opportunity to reduce automobile use for shorter trips (eg  less than 10km) or provide a first-/last-mile solution to accessing public transit (Fishman and Cherry, 2016; Edge et al, 2018). Both e-bikes and e-scooters have emerged in North American cities as part of the new mobility paradigm that promotes electric, connected, and also shared mobility alternatives to the automobile (WSP, 2017). Shared micro-mobility options accounted for over 84 million trips in the US in 2018 (NACTO, 2018b), significantly fewer trips than the automobile, but an indication of the growing impact these mobility options have for shorter trips. ‘E-bike’ is an umbrella term for a range of small vehicles powered exclusively by electric motor (for example, mopeds or assisted-mobility devices) or a combination of electric motor and human propulsion (pedal-assisted bicycles). The latter type resembles conventional bicycles but are regulated to a speed of 32km/h in most Canadian jurisdictions (Edge et al, 2018). These characteristics of pedal-assisted e-bikes (hereafter referred to as ‘e-bikes’) allow riders to travel further distances, handle hilly terrain with ease, bear heavier loads (eg children or groceries), reduce physical exertion, and cycle for longer time

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periods comfortably (Fishman and Cherry, 2016; Edge et al, 2018; MacArthur et  al, 2018). Accordingly, e-bikes have significantly changed personal transportation in countries like China, Germany, and the Netherlands (Fishman and Cherry, 2016). In the North American context, however, e-bikes have been found to displace automobile trips among both new riders and avid cyclists (MacArthur et al, 2018). Further, e-bikes also maintain or improve physical activity levels in many riders by increasing both the frequency and length of cycling trips among existing cyclists (MacArthur et al, 2018) and have increased perceptions of road safety and travel enjoyability for both riders and passengers (Edge et al, 2018). A more recent micro-mobility option in many North American communities are kick-style electric scooters, which first arrived in 2017 and became a disruptive force in existing transport systems (PBOT, 2018). Like e-bikes, electric scooters require a small battery to power the motor, but riders provide significantly less effort to propel the scooter. E-scooters are not currently regulated in most Canadian jurisdictions, but several pilot studies are ongoing where e-scooters are able to ride in cycling lanes, roadways, multi-use trails and, in some communities, sidewalks (Ministry of Transportation Ontario, 2019). Given their recency, there are few studies that examine the impact of e-scooters on travel behaviour or mobility. One study in Portland found that e-scooters were primarily used for transportation (71% of trips) and were most likely to displace other active modes of transport (37% of trips) (PBOT, 2018). Understanding the role of new mobilities in Canada is important given the primary mode share among Canadian commuters: 78% use an automobile, 12% use public transit, and 7% use active modes (Statistics Canada, 2017). This varies greatly based on geography and level of urbanization: public transit comprises almost 25% of commuting trips in Toronto, Ontario, while active transport makes up 17% of commuting trips in Victoria, British Columbia, with these numbers declining in surrounding suburbs and exurbs (Statistics Canada, 2017). Outside of urban areas, mobility options beyond the automobile are limited and pose significant challenge to older adults seeking to age in place.

Older adults and new mobilities For the growing population of older adults, new mobilities may offer alternative recreational activities and utilitarian travel modes to maintain mobility and support aging in place. Yet there is very limited

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research examining e-bike adoption specifically among older adults, and virtually nothing with respect to the emergence of e-scooters. Indeed, cycling studies with older adults have suggested that electric bicycles may be beneficial for increasing mobility among this population (Musselwhite, 2015; Ryan et al, 2016). Specifically, older adults report that hilly terrain, physical ability, and arriving sweaty to destinations are primary barriers to utilitarian cycling, all of which are often mitigated by the adoption of e-bikes (MacArthur et  al, 2018). Several studies on e-bikes have indicated that their ability to reduce physical exertion while still maintaining some level of physical activity made them a promising transportation technology for older adult populations (Gojanovic et al, 2011; Langford et al, 2015; Edge et  al, 2018; MacArthur et  al, 2018). In a recent survey of almost 1,800 North American e-bike owners, the majority of riders were male (71%), white (85%), over the age of 45 (67%), with a postsecondary degree (64%) (MacArthur et al, 2018). It is unsurprising then, that older adults are ubiquitous in the marketing materials of major North American e-bike manufacturers, while online groups and blogs dedicated to older adult e-bike ridership are rapidly growing. Currently, only three academic studies explicitly explore e-bike ridership among older adults. In their Australian survey of 69 e-bike owners aged 65 years and older, Johnson and Rose (2015), found that the vast majority had previously cycled (88%) and made e-bike purchase decisions based on reducing physical exertion (54%), replacing car trips (60%), maintaining health and fitness (42%), and continuing riding with a medical condition (35%). Although the vast majority (94%) still owned a personal vehicle, e-bike displaced a car in over half of commuting and recreational trips. Most significantly, e-bikes replaced the number of trips respondents took using a traditional bicycle with 36% no longer using their pedal bike. However, e-bike ownership increased the total number of trips made by respondents with almost 35% of participants riding e-bikes on a daily basis and 88% on a weekly basis. The findings indicated that e-bikes ‘extended life on the bike’ (Johnson and Rose, 2015, p 276) for past cyclists while increasing the total number of active trips made, thus prolonging active mobility for older adult riders. In their study of contrasting European cycling cultures, Jones and colleagues (2016) conducted interviews with 22 e-bike owners aged 43–70  years old residing in the UK (n=10) and the Netherlands (n=12). They focused on participants’ motivations for purchasing e-bikes, perceived impacts on travel behaviour, and user experience. Overall, participants reported that e-bikes allowed them to prolong

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cycling when health conditions arose, when physical ability levels were deteriorating, or they just need the additional support from the motor. For non-cyclists, e-bikes were a gateway to introducing some physical activity and more active transportation into their daily life. Accordingly, e-bikes displaced 55% of trips taken by automobile, and almost 60% of trips take by traditional bicycles, with smaller mode share impacts on public transit (36%) and walking (14%). The findings also suggested that there were technological barriers to riding e-bikes including cost, weight, and limited battery range on the bikes, as well as social barriers including stigma and safety. Finally, the comparative analysis highlighted the importance of highquality cycling infrastructure, as in the case of the Netherlands, which eliminate many of the environmental barriers (proximity to cars, speed limits, parking) discussed by participants in the UK. The first Canadian study on older adults and e-bike mobility explored the perceived barriers and facilitators to e-bike adoption in a suburban community. Leger and colleagues (2019) utilized interviews with 17 key informants with expertise in older adult activity, aging in place, active transportation or cycling, and eight focus groups with 37 participants between the ages of 60 and 97 with a range of e-bike and cycling experience. The results indicated that participants did or would adopt e-bikes for four reasons: increased convenience, reduced physical exertion, reduced reliance on a vehicle, and fun. Notably, e-bikes were described as a transition technology for older adult riders who were struggling to maintain existing levels of cycling but wanted to delay cessation. This was particularly salient among participants for whom cycling was a social activity (members of cycling clubs, shared time with spouse), and for those with recent health issues (stroke, knee replacement). The study also acknowledged three specific barriers to e-bike adoption for older adults: cycling infrastructure and road safety, regulation, and stigmatization. As was the case in previous studies, participants felt that the general inadequacy of cycling infrastructure in the community impacted their comfort and willingness to adopt e-bikes, particularly given the prominence of automobility. The relative recency of e-bikes in the Canadian context meant that absent or unclear regulation of e-bikes was a barrier to uptake. Finally, the social stigma of being an older adult cyclist was noted by many participants as a barrier, as was the stigma associated with needing assistance from the motor especially for avid cyclists (Leger et al, 2019). While research on new mobilities and older adults is still in its infancy, these three studies suggest that e-bikes have increased the ease, frequency, and enjoyment of active transportation for older

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adult riders. The broader literature on new mobilities suggest that the electric motor assist can support riders as they travel longer distance, ideal for enhancing active mobility in sprawling suburban communities. Accordingly, this research examines the experiences of active older adult cyclists in the Waterloo Region in order to explore the viability of new mobilities as an alternative mode of transportation for older adults in a Canadian suburban community. The study was guided by three research objectives: (1) to understand older adults’ perceptions and experiences of e-bikes influence their future adoption; (2) to explore the potential of e-scooters to influence active mobility among older adults; and (3) to investigate the barriers and facilitators to new mobility adoption among older adults in a sub/urban community in Canada.

Methods Our study sought to understand whether e-bikes could prolong older adult mobility for active older adults residing in Waterloo, Ontario, using an exploratory and participatory approach. We recruited a purposive sample (Patton, 2014) of 12  avid cyclists who were members of cycling clubs for older adults (defined by the clubs as 55 years and older). Data collection included a two-part, modified go-along interview (Dean, 2016; Carpiano, 2009). In phase one, we introduced the experienced cyclists to two e-bike and e-trike models (Figure 9.1), which they rode along a 6-kilometre predetermined route that included roadways and a multi-use trail. One researcher followed behind each participant and recorded their trip using a bike-mounted camera for phase two. Figure 9.1: E-bike models used in the study

E-Prodigy Whistler electric bicycle (Eprodigy, 2019)

Pedego electric tricycle (Pedego Electric Bicycles, 2019)

Source: E-Prodigy, www.eprodigybikes.com/products/6 and Pedego, https://pedegoelectricbikes. ca/product/trike/

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The second phase took place two days later when the participants took part in a semi-structured interview. The interview began with participants reflecting on their perceptions of e-bikes, their experience riding the two models in phase one, then watching their recorded trip and commenting on the physical and social environments they encountered along the way. The modified go-along interview approach allowed the 12 participants to reflect on their experience riding the e-bike and e-trike, highlight facilitators and barriers to future adoption, and shed light on the importance of local environments for supporting active aging in place. Interviews were audio recorded and transcribed verbatim. We conducted a thematic analysis using a framework approach common in health research (Gale et  al, 2013). In framework analysis, researchers create predetermined categories from the literature – in this case existing barriers and facilitators to e-bike adoption – and then deductively code the transcripts. Secondary codes are then inductively created from the broader categories (Gale et al, 2013). Each of the 12 transcripts was coded separately and then compared across participants. Here we present the results of that analysis based on three emergent themes: (1) perceptions and experiences of e-bike technology, (2) barriers to adoption in suburban communities, and (3) e-scooters as a risk to prolonged mobility.

Results Participants in this study were already active older adults due to their membership in a cycling club. Over half of the participants (seven) adopted cycling as an activity after retirement as a way to maintain mobility, physical activity, and social interaction. The vast majority of them took part in the study because they were keen to try an e-bike and e-trike as they were already contemplating their future value for themselves or relatives. Perceptions and experiences of e-bike technology While all 12 participants were familiar with e-bikes, only three had actually tried them prior to the study. The majority of riders found the e-bike model to be comfortable and easy to ride, aside from a few riders for whom the frame was too small. All participants found the technological components (battery, gears, pedal-assist controls) easy to learn and use as avid cyclists:

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‘[My experience was] just the same as having a new bike and getting used to the new gears. So, it’s kind of that same thing for the e-assist, I thought it was very easy to get it.’ (Participant 9, female, 60s) In contrast, the low-speed, three-wheeled and upright design of the e-trike made it less appealing for avid cyclists who felt that their centre of gravity and balance were compromised (indeed, the e-trike is designed for riders with mobility and balance challenges). Many participants stated that riding the e-trike was significantly different from the road bikes they regularly used and thus considered e-trikes more as an assisted-mobility device than a bicycle. Some participants suggested that e-trikes would benefit riders with major health and/or mobility issues, with a few noting that they would consider cycling cessation rather than e-trike adoption highlighting the stigma associated with this model: ‘it kind of looks like [it’s for a] really old person’ (Participant 11, female, 60s) and ‘The kids probably think “what’s that old lady doing on that tricycle?”’ (Participant 9, female, 60s). Common to both models was concern about the weight of the bike, which participants thought was prohibitive for adopting e-bikes later in life. However, the models used in this study were older and heavier than some of the newer technology entering the market, which has a lower price point. However, most expressed an interest in purchasing an e-bike for themselves in the future to maintain their current level of cycling and/or physical activity, which many describe as important for active aging: ‘Having a more active lifestyle is going to be more critical going forward’ (Participant 6, male, 50s) and ‘I think a lot of people are more thinking about fitness than they have in the past … people are concerned [about] the idea of “move it or lose it”’ (Participant 4, male, 70s). Other participants noted that they would purchase an e-bike for a spouse in order for them to join the cycling club for exercise and/ or increase their social interaction. Barriers to adoption in suburban communities The current provincial legislation for e-bikes permits their use wherever bicycles are allowed unless otherwise noted by the municipality (some ban the mode on multi-use trails due to the increased speed). In Waterloo, e-bikes are allowed on roadways, cycling lanes, and multi-use trails and thus do not require any additional infrastructure. However, as this study took place in a predominantly suburban community,

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almost all participants noted that the general lack of quality cycling infrastructure would be a barrier to adopting e-bikes in the future. Notably, the city’s cycling network was disconnected, and older adult cyclists had to share the road with much faster-moving automobiles, which many perceived as unsafe. This was especially true for e-trikes which had a much larger footprint than the bikes due to the parallel rear wheels and increased concerns about sharing on roads or multiuse trails (see Figure 9.1). Participants in this study also noted that the signage for multiuse trails, speed limits, and wayfinding needs to be enlarged to accommodate older adult riders, especially on faster-moving e-bikes: ‘When you’re moving faster like that, I think it would be advantageous if signs are bigger because that’s a very unusual split in the trail. Especially if you’re not used to it and don’t know it’s coming.’ (Participant 11, female, 60s). In addition, participants felt that an increase of bike parking, preferably protected parking, would be ideal for future adoption given the more expensive price point of e-bikes. The most widely discussed infrastructure issue was related to sharing multi-use paths with other active transport users. In particular, participants worried that the faster speeds of e-bikes would result in greater injuries to pedestrians in the event of a collision and some questioned whether e-bikes would be able to handle the quick changes of direction needed to avoid a collision with distracted pedestrians and other new modes such as e-scooters (see Figure 9.2). Further, the design of many Waterloo neighbourhoods also made utilitarian cycling challenging due to both the topography and frequent hills, as well as the single-use zoning that kept housing separate from other destinations. Participants noted that e-bikes would help to mitigate some of those challenges in the future: ‘What would deter me from biking in the future would be the hills so to know that I had that assist in those difficult moments, rather than getting off the bike and walking it up the hill … I would be more inclined to continue to ride a bike.’ (Participant 7, female, 60s) ‘I would find [e-bikes] really handy if you wanted to go downtown, for example. You can just jump on the e-bike and you’d be there in no time.’ (Participant 11, Female, 60s)

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New micro-mobilities and aging in the suburbs Figure 9.2: E-trike pedestrian interaction on multi-use trails

Several participants echoed the sentiments of Participant  11, that e-bikes can better connect them to desired destinations in the largely suburban Waterloo. E-scooters as a risk to prolonged mobility Participants expressed modest concern over the recent arrival of e-scooters on the multi-use trails in Waterloo, as part of Canada’s first e-scooter share pilot (CBC, 2019). The e-scooter pilot in Waterloo used a dockless system meaning that e-scooters could be parked in any of the designated spots but occasionally were left on the trails and impeded other users. The avid cyclists in the study noted that the speed of e-scooters (24km/h), like e-bikes, posed a safety-risk for other trail users – especially older adult pedestrians. Participants discussed safety concerns of e-scooters potentially increasing the risk for pedestrians and other trail or sidewalk users due to collisions and tripping on abandoned scooters. Indeed, Participant 9 admitted that ‘the e-scooters kind of intimidate me’ because of their speed and unfamiliarity that could result in injury for other road users. However, in a Southern California study the vast majority of injuries were actually to riders (91%) due to falling (80%) or collisions with stationary objects (11%) (Trivedi et  al, 2019). In the same study, injuries to non-riders (9% of all injuries) included being hit by a scooter (52%) and tripping over a scooter (24%). This study only reports the hospital-treated injuries and the expected number of minor injuries not requiring a hospital visit are likely higher. There is a need for more research on how e-scooters influence mobility of older adult riders and older adult pedestrians/cyclists.

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Further, participants noted that a larger fleet of e-scooters would only add to the congestion on the limited active transport infrastructure in the city (Figure 9.3). Some even indicated that they preferred to ride on the road, even though it was perceived as more dangerous, because cars were more predictable than the ‘sporadic’ travel behaviour of pedestrians, cyclists, and e-scooters on shared trails. Figure 9.3: E-bike rider at a busy intersection along a multi-use trail

None of the research participants tried or intended to try the e-scooters predominantly due to the significantly less physical activity required to ride them. Some were unclear of the benefits e-scooters would provide them as active adults who used a bicycle, while others stated a definite preference for e-bikes over the newer scooters. Despite the plethora of e-scooter-sharing services operating in communities across North America, there is little demographic data on riders to shed light on their usage among older adults. Unlike e-bikes, older adults are not the target market for e-scooter companies, but the specific make-up of e-scooter riders is unknown as providers do not routinely collect demographic data on ridership, neither do the municipalities in which the e-scooters operate. In one study of e-scooter riders in Portland, 58% were male with just under the majority of all riders between the ages of 16–29 years (44%) (PBOT, 2019). Exploring older adult use of e-scooters is an important area of future research.

Supporting older adult mobility in place Though nascent, this study and the literature on new mobilities that support active transportation and physical activity among older adults is promising. E-bikes in particular have allowed older adult cyclists to

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continue cycling for transport and recreation by reducing the physical exertion required to propel the bike. In many cases, this has resulted in more and longer trips for older adult riders (Johnson and Rose, 2015). For those new to cycling or active transportation more broadly, e-bikes act as a convenient and less passive option than the automobile (Jones et al, 2016; Leger et al, 2019), and in some sub/urban environments may offer time savings when factoring in parking (Edge et al, 2018). Overall, older adult riders reported that e-bikes have physical and social benefits that will allow them to continue engaging with their local communities and remain in place. Translating these benefits to the long winter season in Canada has also been noted as a challenge by researchers (Edge et al, 2018). However, some avid riders modify their bikes with studded tyres to better handle slippery conditions, while others note that the heavier weight of the e-bikes tend to improve traction in winter conditions (Edge et al, 2018). Further, advances in battery technology to withstand cold temperatures as well as snowremoving practices that prioritize cycling infrastructure (Waterloo introduced this in 2019) will further support winter riding among those who desire to do so. Given these assets of e-bikes, municipalities intending to support older adults through AFC policies need to acknowledge the importance of new mobilities for residents who desire to age in place. Indeed, in this study and others, potential and actual adopters of e-bikes later in life noted that in suburban many communities cycling infrastructure was inadequate (Johnson and Rose, 2015; Jones et al, 2016; MacArthur et al, 2018; Leger et al, 2019). Older adult participants in this study were well aware of the benefits of e-bikes and their potential to prolong their mobility later in life; the ability to try two models of e-bikes was their primary reason for participating in the study. E-bike ownership and sales in North America are increasing rapidly among the general population (MacArthur et al, 2018). While policymakers may have reservations about the uptake of new mobility options in suburban contexts, e-bikes are already in the homes of active populations including older adults. Advocates of healthy cities and sustainable transportation reform have long called for investment in separated and protected cycling infrastructure, yet these calls rarely consider an aging perspective (Stafford and Baldwin, 2018). Some promising examples do already exist, such as 8–80 cities and AAA (All Ages and Abilities) for bikeway design (NACTO, 2018a), but these policies do not incorporate the growing number of e-bikes and e-scooters expected in the future. This is an important consideration for future policymakers.

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The results from the e-bike/e-go-along participants highlight the necessity of considering older adults in the design of existing and future cycling lanes to accommodate less frequent/confident cyclists or those riding the wider e-trike model. Moreover, as new mobility options like e-scooters emerge, increasing the width of cycling lanes will address broader concerns with safety and congestion on active transportation infrastructure. This is an important area of future research to enhance the safety and comfort of older adults as both cyclists and pedestrians in a more active transportation system. Age-friendly cities are growing in significance (WHO, 2007), but there is still a disconnect between the objectives of the AFCs program and adequate infrastructure to support active transportation for aging in place. Integrating transportation planning and new mobility providers into discussions of older adult mobility in Canadian sub/ urban communities will benefit this growing portion of the population by facilitating their ability to age in place. References Aird, R.L. and Buys, L. (2015) ‘Active aging: exploration into self-ratings of “being active”, out-of-home physical activity, and participation among older Australian adults living in four different settings’, Journal of Aging Research, Volume 2015: 1–12. Andrews, G.J., Cutchin, M., McCracken, K., Phillips, D.R., and Wiles, J. (2007) ‘Geographical gerontology: the constitution of a discipline’, Social Science & Medicine, 65(1): 151–68. Black, P. and Street, E. (2014) ‘The power of perceptions: exploring the role of urban design in cycling behaviours and healthy ageing’, Transportation Research Procedia, 4: 68–79. CIP (Canadian Institute of Planners) (2014) ‘Healthy communities practice guide’. Available at: http://cip-icu.ca/getattachment/Topicsin-Planning/Healthy-Communities/CIP-Healthy-CommunitiesPractice-Guide_FINAL_lowres-1.pdf.aspx. CIP (Canadian Institute of Planners) (2018a) ‘Policy on climate change planning’. Available at: http://cip-icu.ca/Files/Policy-2018/policyclimate-eng-FINAL.aspx. CIP (Canadian Institute of Planners) (2018b) ‘Planning cities for all: implementing the new urban agenda’. Available at: http://cip-icu. ca/getattachment/Topics-in-Planning/New-UrbanAgenda/CIPNUAC-2018-Soul-Posters.pdf.aspx. Carpiano, R.M. (2009) ‘Come take a walk with me: the “go-along” interview as a novel method for studying the implications of place for health and well-being’, Health & Place, 15(1): 263–72.

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Mercado, R. and Páez, A. (2009) ‘Determinants of distance traveled with a focus on the elderly: a multilevel analysis in the Hamilton CMA, Canada’, Journal of Transport Geography, 17(1): 65–76. Ministry of Transportation Ontario (2019) ‘Ontario Regulation 389/19. Pilot project – electric kick-scooters’. Available at: https://www. ontario.ca/laws/regulation/r19389?_ga=2.43560357.1405971534. 1575045392-384205291.1575045392. Musselwhite, C. (2015) ‘Further examinations of mobility in later life and improving health and wellbeing’, Journal of Transport and Health, 2(2): 99–100. NACTO (National Association of City Transportation Officials) (2018a) ‘AAA cycling’. Available at: https://nacto.org/publication/ urban-bikeway-design-guide/designing-ages-abilities-new/. NACTO (National Association of City Transportation Officials) (2018b) ‘Shared micromobility in the U.S.: 2018’. Available at: https://nacto.org/shared-micromobility-2018/ Patton, M.Q. (2014) Qualitative Research and Evaluation Methods – Integrating Theory and Practice. UK: SAGE. PBOT (Portland Bureau of Transportation) (2018) ‘2018 e-scooter findings report’. Available at: https://www.portlandoregon.gov/ transportation/article/709719. PHAC (Public Health Agency of Canada) (2011) ‘On the road to age-friendly communities’. Available at: https://www.canada.ca/en/ public-health/services/health-promotion/agingseniors/publications/ publications-general-public/on-road-friendly-communitiesbrochure.html. Rapoport, M.J., Naglie, G., Weegar, K., Myers, A., Cameron, D., Crizzle, A., Korner-Bitenksy, N., Tuokko, H., Vrkljan, B., Mazer, B., Gélinas, I., Man-Son-Hing, M., Marshall, S. and Porter, M.M. (2013) ‘The relationship between cognitive performance, perceptions of driving comfort and abilities, and self-reported driving restrictions among healthy older drivers’, Accident Analysis & Prevention, 61: 288–95. Ravulaparthy, S., Yoon, S., and Goulias, K. (2013) ‘Linking elderly transport mobility and subjective well-being: a multivariate latent modeling approach’, Transportation Research Record: Journal of the Transportation Research Board, 2382: 28–36. Ryan, J., Svensson, H., Rosenkvist, J., Schmidt, S.M., and Wretstrand, A. (2016) ‘Cycling and cycling cessation in later life: findings from the city of Malmö’, Journal of Transport & Health, 3(1): 38–47.

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Shoval, N., Wahl, H.W., Auslander, G., Isaacson, M., Oswald, F., Edry, T., Landau, R., and Heinik, J. (2011) ‘Use of the global positioning system to measure the out-of-home mobility of older adults with differing cognitive functioning’, Ageing & Society, 31(5): 849–69. Stafford, L. and Baldwin, C. (2018) ‘Planning walkable neighborhoods: Are we overlooking diversity in abilities and ages?’, Journal of Planning Literature, 33(1): 17–30. Statistics Canada (2017) Census Profile, 2016 Census. https:// www12.statcan.gc.ca/census-recensement/2016/dp-pd/prof/index. cfm?Lang=E. Trivedi, T.K., Liu, C., Antonio, A.L.M., Wheaton, N., Kreger, V., Yap, A., Schriger, D., and Elmore, J.G. (2019) ‘Injuries associated with standing electric scooter use’, JAMA Network Open, 2(1): e187381. Van Cauwenberg, J., Clarys, P., De Bourdeaudhuij, I., Van Holle, V., Verté, D., De Witte, N., De Donder, L., Buffel, T., Dury, S., and Deforche, B. (2012) ‘Physical environmental factors related to walking and cycling in older adults: the Belgian aging studies’, BMC Public Health, 12(1): 142. Van den Berg, P., Arentze, T., and Timmermans, H. (2011) ‘Estimating social travel demand of senior citizens in the Netherlands’, Journal of Transport Geography, 19(2): 323–31. Van den Berg, P., Kemperman, A., de Kleijn, B., and Borgers, A. (2016) ‘Ageing and loneliness: the role of mobility and the built environment’, Travel Behaviour and Society, 5: 48–55. WHO (World Health Organization) (2007) Global Age-Friendly Cities: A Guide, Geneva: World Health Organization. Winters, M., Brauer, M., Setton, E.M., and Teschke, K. (2013) ‘Mapping bikeability: a spatial tool to support sustainable travel’, Environment and Planning B: Planning and Design, 40(5): 865–83. Winters, M., Davidson, G., Kao, D., and Teschke, K. (2011) ‘Motivators and deterrents of bicycling: comparing influences on decisions to ride’, Transportation, 38(1): 153–68. WSP (2017) ‘New mobility now: a practice guide’. Available at: https://www.wsp.com/en-GL/news/2017/new-mobility-now-isthe-time-to-take-action. Zegras, C., Lee, J.S., and Ben-Joseph, E. (2012) ‘By community or design? Age-restricted neighbourhoods, physical design and baby boomers’ local travel behaviour in suburban Boston, US’, Urban Studies, 49(10): 2169–98.

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10

Suburban practitioner vignette Chris Kawalec with Madison Empey-Salisbury

Age-friendly Peterborough community action plan In Peterborough, individuals over the age of 65 make up over 20% of the regional population. With an aging population, the need for a community plan addressing seniors’ issues was growing, and in response, the Age-Friendly Peterborough Community Action Plan (‘the Plan’) was created. The Plan outlines four fundamental goals: (1) older adults’ basic needs are met, (2) older adults are able to get around the community, (3) older adults are supported to build and maintain relationships, and (4)  older adults have the opportunity to learn, grow, and contribute. The Plan has been up and running since 2017 and as a result, many new projects and programs have been implemented, and further research conducted. For instance, a recreation, leisure, and facilities study was recently undertaken to help figure out how to increase participation in recreational activities from older adults. The study was conducted at city, county, and First Nations scales. Despite a substantial older adult population, the study found that low participation in recreation has contributed to the challenges at Peterborough’s three senior activity centres. This information will help shape how Peterborough will address recreation for older adults. Noteworthy projects under the Plan have included: the annual Summit on Aging educational conference, the annual Seniors’ Showcase (seven years running), developing local TV broadcasts on aging, helping to secure a community transportation grant to serve rural and First Nations communities, a walkability assessment program for municipalities, an age-friendly business program, and a navigation project to help older adults find housing and health services. The impetus for the Plan can be traced back to 2013 when the Peterborough Council on Aging (PCOA) proposed the notion for the development of a community plan in accordance with the World Health Organization’s Global Age-Friendly movement. The PCOA was an ad hoc organization made up of local organizations,

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institutions, businesses, and volunteers all interested in advancing the priorities of older adults. The Plan was made possible largely through the involvement and commitment from these various stakeholders with the financial support secured from external grants and municipal resources. It was decided by the PCOA that the Plan would be a ‘community plan’, led by the City of Peterborough, with an understanding that a broad community collaboration would be needed to develop and implement it. This collaborative effort would need to draw on surrounding townships, First Nations, various municipal departments, local organizations, businesses, educational institutions, volunteers, and various other stakeholder groups to be successful. Upon its completion, the Plan was adopted formally by all local councils, including the City of Peterborough, County of Peterborough, all eight local townships, Curve Lake First Nation, and Hiawatha First Nation. The funding of the Plan itself was a considerable success, combining grants and non-profit sources with dedicated funding from the City and County of Peterborough. Initial funding was secured to develop the Plan through a grant from the Trillium Foundation. Funding to implement the Plan came from a generous donation from the local United Way, designated by a local donor towards seniors’ issues along with a municipal operating budget. This funding allowed the Plan to set ambitious goals for implementation of senior-oriented programs throughout the area over the next three to four years and avoid having to rely on the uncertainty of applying for grants. A significant factor that supports the Plan’s current level of success can be attributed to the creation of a dedicated full-time Age-Friendly Co-ordinator position at the City of Peterborough. This generated the staff resources to allow the scope of work to increase dramatically. Without this position, the goals of the Plan would be far more modest due to the time and co-ordination resources. 2017 also saw the creation of the Age-Friendly Peterborough Advisory Committee (AFPAC), which replaced the PCOA. AFPAC is a formal committee created by City Council to oversee the implementation of the Plan and advise on issues related to the aging demographic. Various working groups and task forces were also created, made up of members from the broad community collaborative, to support the Plan. Older adults serve as volunteers at all levels. This structure is supported by the Age-Friendly Co-ordinator. These working groups and task forces carry out most of the work. Project development, planning, implementation, and evaluation are done at this level.

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Challenges Though the Plan has been deemed an initial success, there are still challenges to achieving the creation of a truly age-friendly community in Peterborough. While the area is made up of urban, suburban, rural, and First Nations areas, the challenges facing the aging suburban population specifically can be divided into two categories at this time: housing and transportation. In terms of housing, the suburbs pose many challenges to older adults, like living on a fixed income and being burdened with the cost of house maintenance, or facing lack of mobility without a car, distance to health and social services, and the increasing prevalence of isolation. Suburbs in Peterborough are often comprised of single-detached residential zones edged by large arterial commercial roads. As a result, they are often uncomfortable places to walk and the distances from home to amenities are great. In response, Peterborough is conducting a housing study to inventory housing options and investigate areas that require different housing types, to enable older adults to downsize while still aging in community. This study will also help older adults make informed housing decisions based on their income and health status. With respect to rural housing, many of the townships advocated for more long-term care facilities in rural settings. The work of the Township of Havelock-BelmontMethuen resulted in the construction of a new facility currently underway in the Village of Havelock. The City of Peterborough is also in the final stages of the update to the Official Plan, which is focusing on developing complete streets, complete communities, as well as safe and accessible mobility options. In terms of transportation, all city buses have now been updated to be fully accessible and the cost of transit passes is significantly discounted for seniors. The City recently introduced a new ‘Community Bus’, which is separate from regular transit routes, stops at destinations important to older adults, and is based on engagement with older adults. It has been in service for a year at the time of writing and has become increasingly popular. The City is also undertaking a full review of its transit routes to improve service for all residents. Community Care Peterborough operates a transportation program that provides rides to older adults and people with disabilities using volunteer drivers. This program mitigates some of the issues of mobility faced by many older adults that live in isolated areas with limited access to reliable transportation. Another exciting program developed by the AFPAC is transit training, which promotes and reduces barriers to using public transit. Part of this training will include hands-on

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demonstrations geared towards older adults. The overall goal of this training is to educate older adults on transit use and demonstrate its viability as a mode of transportation. Rural transportation is a significant challenge in many communities. The Township of Selwyn was successful in receiving a provincial grant to develop a rural transportation service between the township, Curve Lake First Nation, and the City of Peterborough. While this service will assist all age groups, the potential benefits to older adults are significant. This service is funded for three years with the hope that it can be sustained over the long term and expanded to other communities in the County of Peterborough.

Adapting to an aging population With an aging population, adaptation and accommodation are of the utmost importance. Peterborough has demonstrated a commitment to their aging population through the Plan. The Plan was pitched to the various councils and the community as an adaptation strategy and substantial focus was placed upon its implementation and evolution throughout the Peterborough area, resulting in it being recognized as a high priority by all the governments that adopted it. Within this Plan, housing, transportation, education, isolation, and health services were noted as top priorities for the aging population.

Recommendations Much of the Plan’s success can be attributed to five key factors: (1)  continued political support from the community and local decision-makers; (2)  stable funding; (3)  dedicated agencies, nonprofits, and others willing to implement the goals of the Plan; (4) a governance structure that relies heavily on community involvement and reports directly to Council; and (5) a dedicated staff co-ordinator committed to collaboration and communication with all stakeholders. While the City of Peterborough led the project, it would not have been possible without the commitment of the surrounding townships and First Nations, various committees, working groups and organizations, and the numerous other volunteers invested in the project. For other municipalities or organizations hoping to generate similar levels of success in their future initiatives, the overarching key to success was in-depth engagement and leadership from older adult community members.

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Part 2 overview Canada is a suburban nation, and the chapters and vignettes in Part 2 of the book have shown that the older adults that live within these suburban areas have diverse histories and experiences of place. While the suburbs are increasingly diverse and variegated spaces, they are often characterized by reliance on the car for mobility, land use separation, a lack of accessible public transportation, and fewer social infrastructures. These characteristics can make it more difficult to age in place, especially when it is no longer feasible to drive. Takeaways for practice • Transportation concerns are of great importance to older adults living in the suburbs. A context-specific approach that plans with diverse older adults in mind is needed to build age-friendly public transport. • E-bikes encourage active transportation and independence, and older adults are willing to consider using them. Practitioners need to consider how to accommodate e-bikes in the right of way and how to protect these users from cars. Potential programming could include e-bike sharing in suburban neighbourhoods. • When planning for housing, it must be accessible (including home modifications), and financially affordable (many cannot afford retirement or nursing home fees). Consider specialized housing for marginalized groups, like members of the LGBTQ2+ communities, and more frail older adults, which make them feel safer, included, accepted, and builds social capital. • Winter poses heightened risks for older adult social isolation and physical health due to a lack of maintenance of public transportation (eg snow piled in front of bus stops) and active transportation infrastructure (eg uncleared sidewalks). • The social isolation produced by distance may be reduced with technology and pre-arranged gatherings by non-profits. • A successful age-friendly plan is one that considers the diversity of neighbourhoods within a municipality (instead of treating it as a homogeneous whole), has continued political support, stable funding, dedicated nongovernmental groups and agencies, a governance structure that reports to council directly, and a dedicated staff co-ordinator. • There is a need to address the homophobia, disableism, sexism, racism, and ageism structurally inherent within current healthcare services, congregate living facilities, and social/recreational services. Canada is home to people from many diverse backgrounds and contexts and practitioners should be considering targeted services to ensure that people feel safe, included, and understood, and have access to culturally appropriate supports. Practitioners must become educated in these realms to be able to provide support to all Canadians.

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Aging People, Aging Places Questions to consider • How does the municipality you live in officially understand the needs of older adults, and who has power to make decisions? • How does your city engage the older adults in your community? Who is left out from those conversations? • If your city is committed to being age-friendly, what measures are they taking? How are they ensuring that all neighbourhoods in the area are treated in context? • What is your municipality doing when it comes to public transportation, and affordable housing for older adults? • Is maintenance a part of your municipality’s age-friendly plans? How do they prioritize maintenance of sidewalks, clearing of snow? • How are the non-profit organizations supported by the municipality?

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PART III

RURAL

11

Aging in rural Canada Natalie S. Channer, Samantha Biglieri, and Maxwell Hartt In this overview chapter, we call upon data from Statistics Canada and the academic literature to present some stylized facts and figures regarding rural older adults and a synthesis of the challenges and opportunities of aging in rural environments. This chapter serves to provide (1)  a snapshot of Canadian rural demographic trends, (2) an overview of the state-of-the-art thinking on rural aging, and (3) contextual framing for the in-depth research chapters and vignettes that make up the rural part of this book. Anyone remotely familiar with Canada’s geography would not be surprised to learn that by land area, Canada is predominantly rural. Concentrated areas of population cover very little of Canada’s expansive 9.9  million square kilometres. Upwards of 90% of the Canadian population live within 160 kilometres of the almost 9,000-kilometrelong Canada–US border (CBC News, 2009). In short, the vast majority of Canada is sparsely populated. Broadly speaking, we consider these sparsely populated places to be rural. Although there is no single perfect definition of a rural environment, rural can be operationally defined as an area with a population density under than 400  people per square kilometre (Channer et  al, 2020). Using data from Statistics Canada (2019) population estimates, we found that 8.5  million of Canada’s roughly 35 million people live in rural areas. Of those 8.5 million, approximately 1.5 million are aged 65 and over. Like everywhere in Canada, the cohort of Canadians aged 85 and over is growing quickly. Almost 150,000 rural Canadians are 85 years of age or over (Statistics Canada, 2019). Canada’s rural population is aging faster than its urban and suburban counterparts. Older Canadians, aged 65 and over, make up 18% of Canada’s rural population in comparison to 17% of the suburban population and 15% in urban areas. More than a quarter of Canadians aged 65 or older live in rural areas, as proportionately, the population of older Canadians tends to be higher in rural areas (Menec et al, 2015). Canadian rural populations also have a higher ratio of older

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adults to working-age adults (known as the old-age dependency ratio). The growing intergenerational imbalance is explained by the dual process of (1) rural youth migration to urban centres for employment, and (2) older Canadians relocating from urban and suburban to rural areas for retirement (Forbes and Hawranik, 2012). Looking at the older adult rural population by province (Figure 11.1), we can see that the largest proportion reside in Ontario. In fact, proportionally rural residents are overrepresented in Ontario as 29% of rural Canadians live in Ontario, yet it is home to 31% of rural older Canadians. The Atlantic provinces (Nova Scotia, New Brunswick, Newfoundland, Prince Edward Island) and British Columbia also have proportionally higher numbers of older rural residents. In contrast, the Prairie provinces (Manitoba, Saskatchewan, Alberta) are relatively young. The Prairie provinces are home to 20% of rural Canadians, but only 16% of older rural Canadians.

Figure 11.1: Canada’s rural population by region and age Older (65+) Working (25–64) Young (0–24) 3,000,000

Rural population

2,500,000 2,000,000 1,500,000 1,000,000 500,000 0

Older (65+)

Atlantic

Québec

Ontario

Prairies

264,735

382,555

479,330

248,270

British Territories Columbia 181,070

5,310

Working (25–64)

697,550 1,140,275 1,307,095

877,170

477,600

35,965

Young (0–24)

318,100

568,690

223,325

27,205

562,935

684,425

Source: Statistics Canada, 2019

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Although rural Canada is growing more diverse, it is still ethnically homogeneous relative to its suburban and urban counterparts. Table 11.1 shows that only 1% of rural Canadians aged 65 and over live in neighbourhoods where the principal language is neither English nor French. Even fewer live in majority immigrant neighbourhoods. While the dual factors of low income and language/immigrant barriers play a central role in urban and suburban older adult vulnerability (as seen in Chapters 1 and 6), very few rural residents experience these issues. However, it is important to note that due to the small proportion of rural older residents in low-income immigrant and foreign-language neighbourhoods, they may be especially isolated and vulnerable. Key debates on rural aging centre on the built environment and the extent to which it disserves the older population. Rural environments come with limitations associated with lack of funding, service availability, and geographical isolation. Issues of service accessibility are especially important for the almost quarter of a million lowincome older adult rural residents (Table 11.1). Proportionally, there are fewer low-income (defined by Statistics Canada’s after-tax lowincome measure) older adults in rural areas (14%) than urban (21%), but there are also considerably fewer services. Of course, there are also benefits to aging in a rural environment. Rural areas have great potential for localized projects and have a long history of supportive social and informal care networks. In the rest of this introductory chapter to Part III, we summarize the existing research on aging in Canadian rural communities and further unpack the challenges and benefits of rural aging. Table 11.1: Number of Canadian rural residents by age, low income, immigrant neighbourhood, and foreign language neighbourhood Number of Canadian rural residents 65+ 85+ 65+ Low income 85+ Low income Total 1,561,270 225,718 148,040 22,533 Immigrant neighbourhoods 6,325 844 710 148 Foreign-language neighbourhoods 16,690 1,760 1,435 214 Source: Statistics Canada, 2019

Challenges to aging well in rural Canada Rural communities are often associated with expansive land areas and low population densities. These characteristics present a range

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of challenges for maintaining and improving age-friendly services. Walkability, healthcare access, extreme weather, and internet coverage are just some of the potential barriers to rural age-friendly living. Declining service provision in rural communities can also enhance the need for other services, such as transportation options. Maintenance issues, financial barriers, geographical location, lack of communication, and human resources and infrastructure can all impede older adults’ access to regional services (Ryser and Halseth, 2012). As women often outlive their husbands, they can be especially vulnerable to these challenges. In Chapter 14, Olive Bryanton, Lori E. Weeks, and William Montelpare examine the lived experiences of women aged 85 and over in Prince Edward Island to better understand how and why older rural women are, or are not, able to age in place. Among their findings and recommendations, they conclude that adequate and affordable transportation is absolutely critical to the wellbeing of older women. Many rural areas lack regional transportation services specifically targeted towards older adults. Furthermore, many rural communities do not have public transport or taxi services. Unless one lives directly ‘in town’, sparsely populated rural communities present challenges of walkability to even the most able-bodied older Canadians due to long distances between services. Mobility constraints are further enhanced by the challenges of Canadian winters. Winter weather does not only impact older adults – service delivery and caregiving (both formal and informal) also face weather-related challenges. Rural winter conditions pose difficulties to staff recruitment and retention, resulting in underserviced remote areas (Skinner et al, 2009). Rural regions are, by definition, less developed. As such, housing choices may be very limited. Most rural housing units are singledetached dwellings. Older adults may be faced with the option of adapting to available housing or adapting the housing to suit their needs. Compared to their urban counterparts, rural older adults live in older houses with fewer amenities and have higher home maintenance costs (Keating et al, 2011). They also have lower rates of computer ownership and internet connectivity. The lack of adequate internet services in rural communities is a widespread issue in Canada, with many communities relying on dial-up connections. Keating et al (2011) note how important the issue of connectivity is – highlighting the potential for information technology to assist rural residents with health information searches, telemedicine, and social connections.

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Rural communities can be relatively isolated and distant from urban centres. Their isolation can impact the functionality and reliability of healthcare services for older residents. Several studies have concluded that there is less accessibility and lower quality of healthcare services for rural seniors (Morgan et al, 2002; Forbes et al, 2006; Andrews et al, 2010; Menec et al, 2015). Attracting and retaining healthcare providers is a major challenge in rural areas (Menec et al, 2015). As a result, there are simply not enough healthcare professionals for the growing older adult population (Andrews et al, 2009). The Province of Ontario’s Ministry of Health and Long-Term Care (2011) outlined several obstacles for retaining rural healthcare services, including geographical remoteness, long distances, and low population density. Gregorio et  al (2014) suggest that limited healthcare availability, coupled with professional healthcare workers and government policy failing to account for the diversity of rural communities creates a ‘double burden’ for older adults. Provincial governments impose standard benchmarking techniques on diverse rural communities that often disregard place-specific levels of need and the unique challenges of service delivery in smaller and more spatially remote populations (Hanlon and Halseth, 2005). Due to limited healthcare and transportation provision, rural older adults may need to be over-reliant upon personal social support networks. According to Clark and Leipert (2007), the restructuring of the healthcare system and the reduction of home care forces personal social networks to bridge the service availability gap. However, informal support networks may not have the capacity to address the pertinent and complex medical needs of older Canadians (Ryser and Halseth, 2012). For example, welfare restructuring and ongoing changes in work arrangements in Mackenzie, British Columbia, have affected how families and peer networks negotiate caregiving responsibilities (Hanlon et al, 2007). Because Mackenzie has a comparatively low proportion of older adults, it is unlikely to attract the support of public, private, and voluntary organizations targeted at older adults. Therefore, older adults must rely more heavily on informal networks than they would in urban centres. Hanlon et al’s (2007) study identified rural challenges of care responsibilities as a social division, a problem that is unique to rural communities through the informal and voluntary care dimensions of rural settlement systems. Hanlon et al (2007) found that the unique rural challenges of limited formal service delivery and welfare restructuring increases pressure on familial networks to support and provide care for their older community members.

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Opportunities to age well in rural Canada Despite the aforementioned challenges, the socially cohesive nature of many rural communities makes them well positioned for localized initiatives. As Della Webster and Sylvia Humphries explain in Chapter 13, ‘in a rural area, you can depend on your neighbours for support.’ Residents of close-knit rural communities are more likely to have protective instincts that are supportive of their older population (Morgan et al, 2002). Such an instinct highlights a unique opportunity for rural neighbourhoods to become more age friendly. An example of an approach that provides support and increases awareness of available resources is a ‘buddy system’ that links former caregivers to family members who are newer to the caregiving role (Morgan et  al, 2002). The buddy system encapsulates one major advantage of rural communities. Small-scale projects can have a considerable impact – especially when they further develop connections within the community. Menec et al (2015) examined the extent to which neighbourhoods in Manitoba are considered age-friendly by residents and found that the communities with a higher percentage of residents aged 65 and over were viewed as more age-friendly. Their findings demonstrate the responsiveness of the local community to the needs of older adults – a benefit that is often amplified in rural locations. The study also found that age-friendliness can be achieved by small and relatively less-affluent communities. Despite economic inhibitors, if rural areas have a higher proportion of older Canadians, they are more likely to have better social environments, more opportunities for social participation, and even more home support (Menec et al, 2015). Chapter 15 focuses on Cape Breton Regional Municipality, a region that has been aging demographically and declining economically for decades. In the chapter, John Whalley highlights key local and provincial policies that aim to help older adults stay connected to community life. Rural locations often offer strong community networks and informal social support that is invaluable to healthy aging neighbourhoods. Strong social networks in rural locations have significant benefits to healthy aging, such as providing support, familiarity, and security (Andrews et al, 2010; Gregorio et al, 2014; Wiersma and Denton, 2016). In rural areas, caring is often seen as a community responsibility (Wiersma and Denton, 2016). While community networks that consist of committed residents, families, and healthcare providers cannot fully replace formal services, they still play a significant role in creating age-friendly communities. Wiersma and Denton (2016) found that

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community member support and assistance significantly contributed to older adults’ ability to remain in their own homes. Living within a small rural community can actually be a favourable environment for older people, especially those living with dementia (Gregorio et al, 2014). The breadth and depth of community support is an asset to rural communities that may not typically be available in larger urban centres. Rural communities also provide opportunities for older adults to have a closer proximity to nature which can have wellness benefits and contribute to a healthy aging environment. Natural environments have been found to have both direct and indirect influences on wellness for rural older adults, helping grow social connectivity and quality of life (Winterton et al, 2016). Older adults in rural areas of Canada state that their relationship with their surrounding natural environment is important and that it influenced their choice to live in a rural location (Herron and Skinner, 2013). Proximity to nature also can provide cleaner air and encourage physical activity. References Andrews, G., Campbell, L., Denton, M., and McGilton, K. (2009) ‘Gerontology in Canada: history, challenges, research’, Ageing International, 34: 136–53. Andrews, M., Morgan, D., and Stewart, N.J. (2010) ‘Dementia awareness in northern nursing practice’, Canadian Journal of Nursing Research, 42(1): 56–73. CBC News (2009) ‘Canada: by the numbers’. Available at: https:// www.cbc.ca/news/canada/by-the-numbers-1.801937. Channer, N.S., Hartt, M., and Biglieri, S. (2020) ‘Aging-in-place and the spatial distribution of older adult vulnerability in Canada’, Applied Geography, 125. Clark, K. and Leipert, B. (2007) ‘Strengthening and sustaining social supports for rural elders’, Online Journal of Rural Nursing and Health Care, 7(1): 13–26. Forbes, D. and Hawranik, P. (2012) ‘Looming dementia care crisis: are Canadian rural and remote settings ready?’, in J. Kulig and A. Williams (eds) Health in Rural Canada, Vancouver, BC: UBC Press, pp 447–61. Forbes, D., Morgan, D., and Janzen, B. (2006) ‘Rural and urban Canadians with dementia: use of health care services’, Canadian Journal of Aging, 25(23): 321–30. Gregorio, D., Ferguson, S., and Wiersma, E. (2014) ‘From beginning to end: perspectives of the dementia journey in northern Ontario’, Canadian Journal on Aging, 34(1): 100–12.

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Hanlon, N. and Halseth, G. (2005) ‘The greying of resource communities in northern British Columbia: implications for health care delivery in already-underserviced communities’, The Canadian Geographer, 49(1): 1–24. Hanlon, N., Halseth, G., Clasby, R., and Pow, V. (2007) ‘The place embeddedness of social care: restructuring work and welfare in Mackenzie, BC’, Health & Place, 13(2): 466–81. Herron, R. and Skinner, M. (2013) ‘The emotional overlay: older person and carer perspectives on negotiating aging and care in rural Ontario’, Social Science & Medicine, 91: 186–93 Keating, N., Swindle, J., and Fletcher, S. (2011) ‘Aging in rural Canada: a retrospective and review’, Canadian Journal on Aging, 30(3): 323–88. Menec, V., Hutton, L., Newall, N., Nowicki, S., Spina, J., and Veselyuk, D. (2015) ‘How “age-friendly” are rural communities and what community characteristics are related to age-friendliness? The case of rural Manitoba, Canada’, Ageing and Society, 35(1): 203–22. Morgan, D., Semchuk, M., Stewart, N., and D’Arcy, C. (2002) ‘Rural families caring for a relative with dementia: barriers to use of formal services’, Social Science & Medicine, 55: 1129–42. Ontario Ministry of Health and Long-Term Care (2011) ‘Rural and northern health care report’. Available at: http://www.health.gov. on.ca/en/public/ programs/ruralnorthern/docs/exec_summary_ rural_ northern_EN.pdf. Ryser, L. and Halseth, G. (2012) ‘Resolving mobility constraints impeding rural seniors’ access to regionalized services’, Journal of Aging & Social Policy, 24(3): 328–44. Skinner, M., Yantzi, N., and Rosenberg, M. (2009) ‘Neither rain nor hail nor sleet nor snow: Provider perspectives on the challenges of weather for home and community care’, Social Science and Medicine, 68(4): 682–8. Statistics Canada (2019) ‘Population estimates on July 1, by age and sex’. Table 17-10-0005-01, Ottawa, Statistics Canada. Available at: https:// www150.statcan.gc.ca/t1/tbl1/en/tv.action?pid=1710000501. Wiersma, E. and Denton, A. (2016) ‘From social network to safety net: dementia-friendly communities in rural northern Ontario’, Dementia, 15(1): 51–68. Winterton, R., Warburton, J., Keating, N., Peterson, M., Berg, T., and Wilson, J. (2016) ‘Understanding the influence of community characteristics on wellness for rural older adults: a meta-synthesis’, Journal of Rural Studies, 45: 320–7.

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A profile of the rural and remote older population Mark W. Rosenberg This profile is predicated on the assumptions of the diversity of the older population living in rural and remote Canada and the diversity of the communities themselves. The profile is constructed around four major themes: being older and living in rural and remote parts of Canada; the challenges and barriers to living in rural and remote areas; social inclusion, engagement, and ageism; and food and income security.1 The concluding section emphasizes directions that need to be taken and knowledge gaps.

Being older and living in rural and remote parts of Canada The people in general and the older population in particular living in rural and remote communities share a set of characteristics that distinguish them from the urban population of Canada (DesMeules et al, 2011). There are higher proportions of low-income people and older people, higher proportions of people and older people with less education, as well as higher rates of smoking, obesity, and mortality. On a more positive note, it is argued that people in general and older people in particular have a stronger sense of community belonging than their counterparts living in urban Canada (DesMeules et  al, 2011). Focusing only on older people, Keating and Eales (2011) paint a more nuanced picture of older people living in rural and remote communities contrasting ‘community active and stoic seniors’ who have the resources to age well and ‘marginalized seniors’ whose health is poor, who live on low incomes, and have poor social connections. A fourth group, ‘frail seniors’, are mainly described in terms of their status and higher service needs. Looking back to the 1990s, Joseph and Cloutier-Fisher (2005) characterized older people living in small-town and rural Canada as ‘vulnerable people living in vulnerable places’. Their perspective was coloured not only by demographic changes, but by the loss of services and their consolidation in larger urban places. Consolidation of services

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was intended to address the fragmentation of services and to save money. Davenport et al (2009) characterized communities as being either ‘service rich’ or ‘service poor’ in Atlantic Canada, where rural communities were mainly identified as service poor. Paradoxically, the efforts of provincial and territorial governments to reduce the fragmentation of services and to improve accessibility through onestop organizations (for example, the Community Care Access Centres (CCACs) in Ontario or Centre Local de Services Communautaires (CLSCs) in Québec) likely negatively affected the older population living in rural and remote areas who found themselves even farther away from services then they had in the past and there is still evidence to suggest that fragmentation of services is an ongoing issue. More recently, Skinner and Winterton (2018) provide a more optimistic view arguing that rural communities as places for older people are ‘both dynamic and contested’. By the former, they mean that there is growing diversity among older people living in rural and remote communities and by the latter they mean that older people in rural and remote communities are seeking ways to improve their lives by taking advantage of new technologies and challenging governments to provide better services.

Challenges and barriers to living in rural and remote areas of Canada These challenges and barriers can be subdivided into the key areas of daily living: housing; transportation; community and social services; healthcare services; voluntarism; and technology. Two broad themes run throughout this section: the lack of accessible services (economic, geographic, and sociocultural barriers to access) and the lack of coordination and integration of services. Housing There is little current systematic data that differentiates urban and rural housing stocks. What is assumed today is that home ownership rates in rural and remote communities are even higher than the overall rate in Canada, that the percentage of homeowners who are older living in rural communities is higher than in urban areas, that the percentage of the rural housing stock in need of repair and occupied by older people is higher in rural than urban communities, and that the percentage of housing stock adapted for older people who have disabilities is lower in rural than urban communities. What is also assumed is that

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in most rural and remote communities, alternative housing options for older people (seniors’ apartment buildings with various levels of care, nursing homes, or palliative care hospices) simply do not exist, or that older people seeking or needing alternative housing options will need to move to larger population centres away from other family members and friends. Linked closely to this issue is that when older people need to move from their homes in rural and remote communities to larger communities, the differences in the costs of housing between housing markets becomes an issue (housing in larger urban communities is generally more expensive than that found in rural and remote communities). In their study of housing concerns, Weeks and LeBlanc (2010) held focus groups with a mix of Indigenous older people, older people with disabilities, and older people from ethnic minorities from across Canada. Although many of the older people involved in the study were not from rural and remote communities, the issues that were raised in the focus groups are instructive to understanding the challenges faced by older people living in rural and remote communities: affordability; maintenance costs; needing to relocate but being unable to afford the costs of relocating; suitability of housing (not having enough space or having too much space); cultural appropriateness about where they are living; security within and outside of their homes; accessibility issues related to disabilities; and availability of alternative housing options. Examining aging at home in rural New Brunswick, Simard et  al (2015) found that family and community support, resourcefulness and resilience, engaging in leisure activities, and the living environment are the main factors that allowed older people to age in place. At a broad policy level, the housing challenges of older people living in rural and remote settings raises questions about the emphasis placed on aging in place. In a very different context, Golant (2015) argues for the need to age in the right place, but creating the right places in rural and remote communities in Canada will be a double challenge taking into account the limited capacity of constrained funding bases and the lack of services in rural and remote communities. There continues to be a major need for research on the supply, mix, quality, appropriateness of housing, and housing behaviours in rural and remote communities. Transportation Generally, older people living in rural and remote areas travel longer distances on average to access supplies (groceries, for example) and

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services (such as healthcare) of all types and expect to do so at the local level. Most travel is by private vehicle since public transit services are usually severely limited or non-existent as is accessible transit through a public transit authority. If older people cannot drive or no longer drive, then they are dependent on other family members, friends, volunteer organizations, or in limited situations, paying for taxi services. Studies across Canada (Ryser and Halseth, 2012; Marr, 2015) offer similar stories of how the lack of transportation leads to social isolation; that dependency on volunteer services or taxis can be expensive for older people using them on a regular basis; that the volunteer services are vulnerable (to the loss of funding or drivers); and how winter weather exacerbates all of these issues. While there are many examples of rural and remote communities where not-for-profit organizations provide transportation services for older people and individuals with disabilities, they mostly seem to have the same characteristics. For example, Timiskaming Home Support in Ontario is fairly typical of the limitations of these types of services. They only offer their services Monday to Friday from 8.30am to 4.30pm; reservations in advance are required; there is a small fee for each trip taken; last-minute cancellations are billed; escorts or companions may be required during the trip; and the geographic area of service is limited. With the centralization of many services, the issue of the lack of regional transportation services in rural and remote communities has also been raised (Ryser and Halseth, 2012). The Council of Canadian Academies (2017), whose focus was mainly on inter-city travel, travel across Canada, and to destinations outside of Canada, noted that a key knowledge gap in their study was the lack of information on the travel habits and needs of the older population living in rural and remote communities. Community and social services It is difficult to separate the research on community and social services from the research on healthcare for the older population in the context of rural and remote communities because often the same government, not-for-profit, or for-profit organizations offer some combination of home care (both medical and/or non-medical services), transportation services, activity programming, food services (eg meals on wheels), and even in some cases, housing. The ability to provide services in the community is dependent on formal and informal caregivers. Formal caregivers include case managers, home care nurses, personal

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support workers, physiotherapists, social workers, and so on. Informal caregivers are mainly family members and friends. In research from the late 1990s, Allan and Cloutier-Fisher (2006) found that older people living in rural and remote communities tended to have higher rates of home care use in contrast to older people living in urban areas in British Columbia. They argued that this might reflect a substitution effect for the lack of general practitioner and specialist services in rural and remote communities. Using similar data at the national level, Forbes and Janzen (2004) found that rural users of home care must be more resourceful and have actual lower levels of informal support in the community in order to receive home care services. In contrast to the cross-sectional research of Allan and Cloutier-Fisher, using a longitudinal design, Mitchell et al (2007) found that smalltown and rural older people in Manitoba were less likely to receive home care. In the case of dementia care in community settings, Forbes et al (2006) noted that older people with dementia were more likely to live in rural areas and that they were more likely to have unmet healthcare needs. Forbes and Hawranik (2011) found that, although family members are highly committed to providing care, they are poorly supported by formal care providers and other family members. The result is that family caregivers often feel isolated from other family members and friends. In a more recent study of older people with dementia living in rural communities in Southern and Northern Ontario, Herron and Rosenberg (2017) found that communities are ‘not there yet’ for older people in the early stages of dementia. More positively, Herron and Rosenberg emphasized the role that older people with dementia can offer their communities, but there are also issues of delayed services and the refusal to use services that did not fit the cultural values and gender roles of persons with dementia. Across all community and social services, two recurring themes are (1) the importance of informal caregivers because of the lack of formal caregiver support and (2) the gendered nature of formal and informal caregivers. Formal and informal caregivers are much more likely to be women than men and, in the case of informal caregivers, more likely to be spouses, daughters, or daughters-in-law. In a study of long-term care facilities in rural Ontario and Manitoba, Leach and Joseph (2011) analyzed the intersection of healthcare restructuring, patient classification systems, and gender, pointing out issues such as the lack of skills due to barriers in gaining access to training and the lack of infrastructure that exists in rural long-term care facilities. Most importantly, they point out that long-term care facilities are needed

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in rural and remote communities because they have the capacity to contribute to communities both because of the services that they provide to older people who can no longer live in their homes and the jobs, services, and taxes that they generate for communities as a whole. Conversely, if rural and remote communities decline like any other economic activity, long-term care facilities are in jeopardy of also closing. Looking at the issues that surround the supply of community and social services in rural and remote communities, five trends have dominated the discussions in recent years. First, provincial and territorial governments have sought to address the fragmentation of services by creating one-stop organizational structures responsible for a multitude of community and social services that had operated separately and independently (the creation of CCACs). In theory, the one-stop organizational structures have made it easier for older people and their families and friends to find, and in some cases access the services that they require. Second, provincial and territorial governments have centralized services to larger urban places from small-town and rural and remote communities, resulting in older people having to travel longer distances to access services. Third, to resolve co-ordination issues between community and social service providers mainly working in community settings and medical care providers mainly working in hospital settings, provincial and territorial governments created regional health authorities (the Local Health Integration Networks (LHINs) in Ontario). Fourth, fragmentation of community and social services remains an issue. Fifth, co-ordination issues remain between community and social service providers and healthcare providers in mainly hospital settings. The co-ordination issues manifest themselves most obviously when older people in hospitals are wrongly accused of being ‘bed blockers’ because there is no one or nowhere to discharge them into the community because of the lack of both formal and informal caregivers or residential care beds. Centralization has, however, come with various costs to both older people and the providers in rural and remote communities. In a study carried out in Northern British Columbia, Hanlon et al (2007) found that with centralization of services, older people and other users of community and social services were likely to face the erosion of flexibility in services and a decline in personalization. In Ontario, Skinner and Rosenberg (2006) found that for-profit and not-forprofit organizations both faced the same ‘growing demand for and complexity of care’ that comes with an older population and especially an older population that is increasingly dominated by the oldest-aged

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cohorts. Skinner et al (2008, p 97) found service providers remained ‘unconvinced that the close ties among rural people and their shared sense of community can compensate for the lack of formal in-home and community care.’ Not all the research on community and social service delivery for older people living in rural and remote locations is negative. Vincent et al (2010) found that the rural communities outperformed the urban communities on some rehabilitative services for older people who are stroke patients in a set of communities in and around Montréal. In dementia-friendly communities in rural Northern Ontario, Wiersma and Denton (2016) found ‘strong social networks and informal social support’ and ‘the strong commitment by community members, families and health care providers’ created a ‘culture of care’, allowing older people with dementia to continue to live in their communities. The question is how to create these communities in other rural and remote communities. Healthcare services Over a long period of time, there seems to be a consistent message that older people living in rural and remote areas across Canada have lower rates of utilization of healthcare services mainly due to the lack of supply of general practitioners and specialists. A second consistent message is that older people living in rural and remote communities are likely to travel greater distances than older people living in urban Canada to access healthcare services. Research shows that this is generally the case for general practitioner services and specialist services and/or if one looks at utilization by seniors with particular morbidities. Allan et al (2011) found that older people living in rural areas have lower rates of utilization of medical doctor visits than older people living in urban areas. Although older people living in rural and remote areas are known to have lower incomes, they found that income level had no statistically significant effects on utilization. However, McDonald and Conde (2010) found that older people in rural and remote communities made fewer visits to a general practitioner, to a specialist, and to a dentist compared to urban older people after controlling for the concentration of physicians and specialists by health region and individual health status. Of growing concern are three related issues: attracting healthcare workers (particularly physicians) given the persistent shortage in rural and remote communities; the aging of the healthcare workforce; and the retention of highly qualified healthcare workers in rural and

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remote communities (Pitblado, 2011). For example, less than 8% of physicians practice in rural areas whereas about 19% of people in Canada live in rural areas. All three issues are well-documented in the Canadian Journal of Rural Medicine, with considerable emphasis on: working conditions (positive and negative) in rural and remote settings; how to attract healthcare workers and assessments of the strategies that have been tried; and how to retain physicians in rural and remote settings. In summing up the current situation regarding community, social and healthcare services for older people in rural and remote settings, it would be misleading to say that things have not improved since the 1990s when provincial and territorial governments began implementing regional health authorities and one-stop organizational structures to expand the levels and variety of services that exist for the older population in rural and remote settings. There, however, remain the persistent challenges of the relative lack of services, integration and co-ordination issues, the struggles of informal caregivers who are mainly women, and the over-reliance on volunteers to provide services and fill in the gaps where formal community, social and healthcare services are missing or are inadequate (Hanlon and Halseth, 2005). Voluntarism Volunteers are a critical resource in the provision of informal and formal services in rural and remote communities (Skinner et  al, 2012). The very nature of voluntarism creates an unequal and uneven geography of service provision for seniors in rural and remote communities because who volunteers and for what will vary from community to community. In rural and remote communities, volunteers provide a vast array of services, including: driving older people to activities, meals on wheels, housework, companionship, and so on. Often the volunteers are other older people (Skinner, 2014). A unique aspect of voluntarism in rural and remote communities is that often healthcare professionals are also called on to volunteer above and beyond their professional work, what Hanlon et al (2011) have called ‘stealth voluntarism’. While no one would argue against the important roles that volunteers play, there are some aspects of voluntarism that are highly problematic in the context of providing services for seniors in rural and remote communities. First and foremost is their sustainability given that by definition they are voluntary. Stemming from this core

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issue are questions of leadership (poor management skills or decisionmaking), succession (someone to take over when the current leaders step down), capacity (when someone gives up volunteering often there is not enough capacity to maintain services at the same level), financial stability (dependence on contributions), and co-option (having to behave like for-profit organizations to survive). Technology Another way that older populations living in rural and remote communities are able to age in place is through the role of new ‘smart’ technologies and the internet. Smart technologies are making homes and appliances in them easier to manage even with the most severe disabilities or at the end of life (Demiris and Hensel, 2009). Security and surveillance systems provide warnings and messaging to call centres in case of intruders or any type of emergency, but especially health emergencies. The internet and its attendant communications and social media software can provide virtually immediate connectivity for medical advice (telemedicine) and ways to reduce social isolation among older people (Mahmood et al, 2008). Telemedicine also has the potential to overcome some of the supply issues identified by older people and formal healthcare workers looking for advice and expertise that does not exist in rural and remote communities. Concerns have been raised, however, about how far to go in making homes smart. The most immediate barriers to taking full advantage of smart technologies and the internet are costs, education, support, and availability in rural and remote areas (Rosenberg and Waldbrook, 2017). While the costs of smart technologies and the internet continue to decline, they remain a barrier for lower-income older people. What is arguably becoming an even more important barrier to the adoption of smart technologies and the internet is the learning curve for a current generation of older people who did not grow up taking advantage of them. To improve adoption more support is required (Mahmood et  al, 2008). In the coming decades, this issue might disappear as each new successive cohort of older people is more likely to have grown up using smart technologies throughout the life course. Improving access to internet and mobile phone services at affordable prices for older people needs to be a priority for governments should they wish seniors living in rural and remote communities to take full advantage of smart-, cellular-, and internet-based technologies. It should also be noted that are still many parts of rural and remote Canada where internet services are simply unavailable.

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Social inclusion, engagement, and ageism There are two visions of ‘growing old’ in rural and remote communities. One vision is a ‘protective and supportive’ environment where older people are valued and supported by their families and friends and respected for their wisdom and their long-standing roles in their communities. The contrary vision is one of isolation and neglect where the children have moved away, and older persons are living in homes that they can no longer maintain. Although anecdotally there are numerous stories about the high level of engagement of older people in rural and remote communities, the evidence about whether older people living in rural and remote communities are more engaged or more isolated than older people living in urban areas is sparse. Havens et al (2004) found that different factors predicted social isolation and loneliness in contrasting older people from rural and remote areas and older people from urban areas in Manitoba. In a more recent qualitative study, issues such as intense engagement in caregiving, limited economic resources, and a restricted range of opportunities for social engagement were identified as barriers to social inclusion and engagement (Rozanova et al, 2012). Rozanova et al (2012) also found that older people wanting to return to work faced various barriers when trying to re-enter employment as a result of negative attitudes about older people. At the most negative extreme is elder abuse. Stones and Bédard (2002) found that there is a lower threshold for elder abuse in rural settings than in urban settings. From the little that has been written, it is obvious that while social inclusion, engagement, ageism, and elder abuse have received considerable attention in the context of urban Canada or in studies that do not distinguish rural from urban older people, it is clear that there is a need for more research in rural and remote settings.

Food and income security There are good reasons to believe that older people living in rural and remote place are more likely to find themselves on limited incomes, lacking in public and private pension funds, and with less savings once they exit the work force permanently (Halseth and Ryser, 2010). The lack of income security is, however, not necessarily easily detected within rural and remote communities. In relative terms, what can be detected more easily are older people who are facing issues like food insecurity and the inability to pay utility bills, which are often manifestations of their income security issues.

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The literature on retirement income levels of older people across Canada paints a picture of most older people being OK (Brown, 2011), but this might not be the case in the future because of the decline in collective pension plans as part of employer–employee compensation packages, later entry into the labour force, and more people having histories of precarious employment either early in or throughout their working lives. When particular vulnerable groups of older people are examined (older immigrants, for example), higher poverty rates are found (Kaida and Boyd, 2011). Although focused on the older urban population, MacDonald et al (2010) found that the maximum Guaranteed Income Supplement and the Old Age Security benefit were not enough to cover the cost of basic needs. This might be more important in the case of older people living in rural and remote communities where it is less likely that older people who have never worked have other sources of retirement income. In a study in Nova Scotia, four household scenarios were created comparing urban single and married older people and rural single and married older people and their ability to pay for a nutritious diet living only on their Canada Pension Plan and the Old Age Security Benefit (Green et al, 2008). What is instructive is that the monthly food bills were higher under the rural single and married scenarios than under the urban single and married scenarios and that under both single scenarios, the incomes were not enough to afford a nutritious diet. Although contextually based in urban Canada, Keller et al (2007) raised the interesting issue of the role that service providers, especially those who go to older people’s places of residence, might play a role in identifying and intervening to prevent food insecurity. This idea might be extended to other issues that older people face such as social isolation.

Conclusions This chapter highlights the trends, barriers, and challenges that older people face living in rural and remote communities in Canada. While it acknowledges the diversity of older people in taking into account demographic and socio-economic characteristics of seniors living in rural and remote communities, what is missing is knowledge on other dimensions of diversity such as ethnicity, race, immigration, and gender identity among older people living in rural and remote communities. Some of the research gaps that have been highlighted include: the lack of research on the supply, mix, quality, appropriateness of housing, and housing behaviours in rural and remote communities; the lack

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of information on the travel habits and travel needs of older people living in rural and remote communities; the lack of research on social isolation, engagement, and ageism in rural and remote communities; and the lack of research on income and food security. Another thread that runs throughout this chapter is the need for governments at all levels to address questions of how to improve the supply and quality of services in rural and remote communities. Housing, transportation, technology, and community, social, and health services require improvements in rural and remote communities. What is, therefore, clear is that there remains much to be done at all levels of government, by not-for-profit and for-profit organizations, formal and informal caregivers, and older people themselves to address the issues raised in this chapter. Note 1

Chapter 12 is based on material used in a report prepared for the Canadian government (Rosenberg, M.W. (2018) Report on Seniors Living in Rural and Remote Communities, Ottawa: Employment and Social Development Canada). Chapter 12 does in no way represent the official view of ESDC or the Government of Canada and the book is in no way endorsed by ESDC or the Government of Canada. In the original report prepared for the Canadian government, a fifth section focused on older Indigenous people living in rural and remote parts of Canada. Since the next part of the book examines the challenges facing older Indigenous people living in Canada in much more detail, and to avoid redundancies, we have removed this section from this chapter.

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Ryser, L. and Halseth, G. (2012) ‘Resolving mobility constraints impeding rural seniors’ access to regional services’, Journal of Aging and Social Policy, 24: 328–44. Simard, M., Dupuis-Blanchard, S., Villalon, L., Gould, O., Éthier, S., and Gibbons, E. (2015) ‘L’influence du contexte sociolinguistique minoritaire sur le maintien à domicile des aînés en milieu rural dévitalisé: Le cas d’Acadieville au Nouveau-Brunswick’, Canadian Journal on Aging, 34: 194–206. Skinner, M.W. (2014) ‘Ageing, place and voluntarism: towards a geographical perspective on third sector organisations and volunteers in aging communities’, Voluntary Sector Review, 5: 161–80. Skinner, M.W., Hanlon, N., and Halseth, G. (2012) ‘Health and social care issues in ageing resource communities’, in J.C. Kulig and A.M. Williams (eds) Health in Rural Canada, Vancouver: UBC Press, pp 462–80. Skinner, M.W. and Rosenberg, M.W. (2006) ‘Managing competition in the countryside: Non-profit and for-profit perceptions of long-term care in rural Ontario’, Social Science & Medicine, 63(11): 2864–76. Skinner, M.W., Rosenberg, M.W., Lovell, S.A., Dunn, J.R., Everitt, J.C., Hanlon, N., and Rathewell, T.A. (2008) ‘Services for seniors in small-town Canada: the paradox of community’, Canadian Journal of Nursing Research, 40(1): 80–101. Skinner, M.W. and Winterton, R. (2018) ‘Rural ageing: contested spaces, dynamic places’, in M.W. Skinner, G.J. Andrews, and M.P. Cutchin (eds) Geographical Gerontology. Perspectives, Concepts and Approaches, London: Routledge, pp 136–48. Stones, M.J. and Bédard, M. (2002) ‘Higher thresholds for elder abuse with age and rural residence’, Canadian Journal of Aging, 21: 577–86. Vincent, C., Robichaud, L., Desrosiers, J., Belleville, S., Demers, L., Viscogliosi, C., and Deaudelin, I. (2010) ‘Provision of rehabilitation services in Québec following stroke: a comparative survey conducted by postal questionnaire’, Canadian Journal on Aging, 29: 193–203. Weeks, L. and LeBlanc, K. (2010) ‘Housing concerns of vulnerable older Canadians’, Canadian Journal on Aging, 29: 333–47. Wiersma, E.C. and Denton, A. (2016) ‘From social network to safety net: dementia-friendly communities in rural northern Ontario’, Dementia, 15: 51–68.

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Rural community vignette Della Webster and Sylvia Humphries There are a few things that you need to know to live well in rural Canada. These are true for all adults but becomes even more important as you age. First, you absolutely need a reliable vehicle. You need to know what to do and be prepared for emergencies, such as power outages, snowstorms, ice buildup, and vehicle and machine breakdowns. Luckily, in a rural area, you can depend on your neighbours for support. And in turn, you must be willing to share and offer up your own snowblower, lawn mower, rhubarb, or dishes for potlucks. You need to remember that everyone is related by marriage or were classmates (so keep your negative comments to yourself). Make sure to wave to everyone who drives by (two fingers off the steering wheel is the usual acknowledgement). Rural places are small, so you know the foibles of others and can (usually) deal with them. But because they are small, there is always anxiety that healthcare practitioners will leave the community. The small size of rural communities can also lead to social isolation, especially if you are new to the area. The saying goes that ‘residents are friendly but not welcoming’. Most people have their own social network and don’t need to include you. Newcomers have to be forward to enter into existing groups; they need to be assertive in making friends, offering to join or create a group, or have children to ‘break the ice’ for them. The good news is that these networks are incredibly strong in rural areas. In our experience, rural women support each other particularly well and age very well as a result. In this vignette, we share our observations and knowledge of aging experiences, challenges, and opportunities in two communities in rural New Brunswick. We will start with an overview of each community, followed by a summary of the unique barriers and opportunities to aging well in rural areas.

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Charlotte County West, New Brunswick Charlotte County West, New Brunswick, is aging. Young people are leaving for work, education, and better opportunities, and older people from across Canada are moving into the area to retire. The proportion of residents 65 years of age and older is 22% and growing. The two largest towns in Charlotte County West are St. Stephen (2016 population: 4,415) and St. Andrews (2016 population: 1,786 – but much higher in the warmer months). St. Stephen was formerly an industrial town and the centre of services, but no longer as services such as the hospital and courts have been moved to the larger urban area (Saint John, NB) about an hour and a half away. St. Andrews, originally a Loyalist town with fishing, courts, gaol, and the land registry is now a tourist area anchored by the Algonquin Hotel and Kingsbrae Garden, two major fishing research facilities, and a community college. In short, St. Andrews is a tourist town. There are many people living in poverty in Charlotte County West. Families below the poverty line in St. Andrews represent 6% of the population and in St. Stephen, they represent 17%. The two towns are surrounded by extensive areas of high concern in the ‘Ridges’ and three populated islands, including the island of Campobello connected to the United States by bridge and which only has seasonal ferry service to the rest of Canada. A community consultation recently identified five key challenges in Charlotte County West: (1) lack of transportation, (2) social isolation, especially among seniors, (3) food insecurity, (4) lack of affordable housing suitable for seniors and workers, and (5) fear of school closure.

Greenwich, New Brunswick The Greenwich area of New Brunswick consists of small hamlets that are governed by a local service district of officials that are elected by the people in the area. There is a Greenwich Recreation Association Inc. (GRA) that has a board of directors elected by members of the community and is operated as a local community not-forprofit organization. Approximately 20% of the population are seniors, 65 years of age and over. Unfortunately, for economic reasons, many of the young families have moved away from the area to seek work in Central, Western, or Northern Canada. As a result, the New Brunswick Department of Education made a decision to close the elementary school and bus the children to a larger school about 19 kilometres away. The closing of

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the school was devastating for the entire community. After two years mourning the loss of the school, the GRA successfully submitted a business proposal to the New Brunswick government to purchase the former elementary school for $1. The former school became known as the River Road Hub in November 2017. At the time of writing, the majority of the participants in the programming at the River Road Hub are seniors. These activities include line and square dancing, pickleball, senior fitness classes, Pilates, card and walking clubs, bingo, and community breakfasts to name a few. Similarly, we have incorporated intergenerational activities which have been embraced by the community such as Family Fun Day, Field Day, and Christmas in the Village.

Barriers and opportunities to aging well in a rural area In both of our communities, transportation is a major barrier to aging well. In rural life, everything depends on having transport. Services (medical, courts, specialized programs) have been centralized, and many seniors do not have adequate transportation to access the services offered in larger areas. Winter and night driving are particularly dangerous. The lack of public transportation is a big factor in issues of social isolation. The lack of local amenities tailored to seniors, such as specialized grocery stores, clothing, shoes, and equipment, is also a barrier. Of course, everything is on the web, but many seniors would prefer an actual person to speak to and not everyone can afford internet services (despite it having become almost a necessity). Adequate, affordable housing is also a major issue, especially for those with disabilities. Even for those who can afford it, accessing trained reliable tradespeople to help renovate housing for age-friendly design can be difficult. Transportation All levels of government need to work together to improve public transportation in rural areas. The province needs to permanently invest in affordable rural public door-to-door transportation similar to the investment made into our provincial roads system. By collaborating with insurance providers, a provincially funded dial-a-ride program would allow persons to transport seniors without additional costs to them. Such a program would allow seniors to get to medical appointments, shop for groceries, and go to various events and activities. It would reduce anxiety and social isolation. A dial-a-ride

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program already exists in St. Stephen, but it is primarily for hospital appointments in the two major hospitals in Saint John. The service needs to be more widespread, offer a wider range of services, and be permanently funded by the province. Social isolation Seniors do not need adequate transportation just to get to medical appointments. Having a range of healthy, engaging activities is crucial to combat social isolation. One exciting example in Greenwich is the Healthy Chefs project. The project benefits rural seniors, a population prone to social isolation and loneliness, by engaging them in social, inclusive activities. Seniors come together once a week for four weeks to plan and prepare a meal which they can enjoy collectively. It not only helps seniors improve their cooking skills, nutritional intake, and social interactions, but also enhances the leadership and participation of seniors in community activities. The New Brunswick Department of Social Development, Wellness Branch, should encourage all rural communities to implement their own Healthy Chefs program. Programs organized and run by and for seniors have tremendous benefits for the community. Spindrifters, for example, is a community group for the 50-plus population in and around St. Andrews run by volunteers with an elected board. They organize activities (exercise classes, good morning walks, card games), speakers, monthly hikes, a parade of picnics and potlucks, and identify other relevant events within the community. All with the goal of increasing the emotional, physical, social, and spiritual wellbeing of their members. Housing All levels of government need to collaborate so that there is a National Housing Strategy for seniors that includes a program that can be adapted for rural areas. Specifically, public and private actors need to work with New Brunswick Housing and Disability New Brunswick to assist seniors with renovations to their homes so that they can live comfortably and safely. Seniors need to be supported in their homes with tailored recommendations to ensure safety. For example, where to install grab bars, night lights, and advice on installing safety strips. There also need to be more housing options, like the seniors’ condo building in St. Stephen and the seniors’ apartment building in St. Andrews, for those who may want to move or downsize.

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Broadly speaking, it is time to put ageism to rest. Seniors need to be treated as people rather than clients. Rural communities should be encouraged to become age-friendly communities and seniors should play a central role in making this happen. St. Andrews and Greenwich have already begun working on becoming official AgeFriendly Communities, but it would be easier with more, and more accessible, provincial funding. All towns and cities, regardless of whether they are rural, urban, or suburban should be supported in becoming age friendly.

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Supports and limitations of aging in a rural place for women aged 85 and older Olive Bryanton, Lori E. Weeks, and William Montelpare Women over the age of 85, living in a rural environment, such as that of Atlantic Canada, are often considered to be an invisible cohort. This invisibility is primarily due to social isolation which occurs when older adults lose members of their social networks, including friends and family. As suggested by Walkner and colleagues (2018) this issue is compounded for those living in rural areas since geographical distance from others and lower populations pose additional challenges to daily social interaction. This is significant for elderly women, as they generally outlive their male partners, and staying connected to familiar surroundings is crucial to positive aging (Loe, 2010). For example, in Prince Edward Island (PEI), women account for 67% of people who are 85 and older (Statistics Canada, 2017b). Between 2011 and 2016, the number of Canadians aged 85 and older grew by 19%, which is nearly four times the rate for the overall Canadian population (Statistics Canada, 2017a). Furthermore, the Canadian population aged 85 and older is expected to triple when baby boomers begin to reach this age group in 2031 (Statistics Canada, 2012). Considering this shift in population distribution, it is important to recognize that women comprise a larger proportion of older adults because they are more likely to live longer. This imbalance will have serious sociodemographic impacts as women will have higher levels of frailty, depression, and widowhood while having less education (Weir, 2014; Strömquist, 2015). Recognizing the importance of societal awareness of this cohort is imperative as women are twice as likely to be poor as a result of having lower incomes from pensions, which can be attributed to interruptions in their careers to take care of children and other family members (Silver, 2003; Kim et al, 2013; Weir, 2014; Strömquist, 2015; Statistics Canada, 2017a).

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Currently, research related to older women tends to focus on urban areas, but we cannot ignore older women who live in rural places. Rural communities, compared to urban ones, tend to be poorer, lacking in infrastructure, and have fewer social and health services (Hanlon and Halseth, 2005; Hanlon et al, 2007). Resource limitations and gaps between the vulnerable group discourse (older women as frail, isolated, unable to cope) and the realities of older women’s lives (capabilities and capacities) have been documented in the literature (Jacka, 2014), but positive features have also been identified. Davis and Bartlett (2008) argue that rural communities may provide unique advantages to older adults because of strong community connections and family networks. Keating and colleagues (2011) suggest that the longer older persons have lived in their homes, the more likely they are to know their neighbourhood, community resources, and neighbours.

Problem and research questions For an older woman living in a rural environment a variety of challenges or opportunities can impact on their ability to continue aging in their location of choice. In this chapter, we focus on learning about the realities of women aged 85 and older living in rural communities and what supported or limited their ability to continue aging in their location of choice. The following questions guided our inquiry: What are the lived realities for women over 85 living in rural communities? What supports or limits their ability to live in a rural community and to age in place?

Theoretical/philosophical perspective This research was informed by critical social theory enhanced with a critical feminist gerontological lens. Critical theoretical approaches tend to rely on dialogic methods, which help us to understand how people learn to perceive and challenge their situation. Reflective dialogue allows the researcher and the participants to question the natural state and is guided by an interest in emancipating people and groups from irrationality, unsustainability, and injustice (Merriam and Tisdell, 2016). As argued by Garner and Faucher (2014), not only is there a responsibility for feminist gerontologists to advocate for older women, but there is a responsibility to facilitate advocacy efforts by older women themselves. They suggest that advocacy from a feminist gerontological perspective includes pressuring organizations or governments to respond to the needs of older women and working to

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eliminate stereotypes, change societal attitudes, and broaden the range of roles available to aging women. Morgan et al (2010) suggest that feminist theory fundamentally recognizes that knowledge is socially constructed, that oppression and privilege are created and maintained through societal institutions, and that women provide a unique perspective due to their position as a marginalized group within the dominant culture.

Methods Our approach relied on dialogic methods combining individual interviews and photovoice to foster conversation and reflection. This reflective style of dialogue allowed the first author and the participants to explore and question the status quo and to learn together while engaging in the research process. We adapted photovoice methods, a qualitative participatory approach (Wang and Burris, 1997), to explore the realities and societal conditions of older women living in rural communities as they aged in place (Bryanton et al, 2019). This approach enabled the exploration of values, meanings, beliefs, thoughts, experiences, feelings, and circumstances (Creswell, 2014; Patton, 2015; van den Hoonaard, 2015; Merriam and Tisdell, 2016). Our participatory research approach (Demiris et al, 2008; Doyle and Timonen, 2010) emphasized collaboration with the participants who contributed their stories and analytic insights individually with the researcher, and through participant group meetings. Thus, the photovoice process was chosen as the main tool to investigate the realities of older women aging in rural communities, and to bring their voices forward.

Participant recruitment Participants self-selected for this study, which involved two steps for the first author: (1) publicizing the need for participants; and (2) checking the eligibility of each participant. To inform participants about the study, a variety of approaches were used including: a poster to display on bulletin boards; a poster to distribute to groups or organizations that involved older adults; and interviews with TV, radio, and a daily newspaper. The inclusion criteria were: • Women 85 years of age or older at the time of data collection; • Living in a rural PEI community defined as a community located more than 1 kilometre from a grocery store, doctor, pharmacy, or bank;

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• Living alone or with someone in situations that did not limit their opportunities to participate in activities of their own choice; • Demonstrated physical dexterity and mobility to use a digital camera; • Demonstrated cognitive ability to review and describe the purpose and meaning of the photographs; and • Were interested, willing, and had resources to arrange their own transportation to participate in group meetings, a public showing of the photographs, and publicity activities. Wang (1999) recommends seven to ten participants for a photovoice project. According to Kumar (2014), groups of this size are small enough so that members can share and take part in discussions and nurture a sense of belonging and group commitment. A total of ten women participated in this study. The individual interviews took place in the participants’ homes in a variety of rural communities across the three counties of PEI. The group meetings were held at the University of PEI. Data collection occurred from November 2016 to May 2017, and the final group meeting, the knowledge-sharing open house, was held on 29 July 2017 at the University of PEI.

Photovoice process According to Wang and Burris (1997), the three main goals of photovoice are: (1)  to enable people to record and reflect their community’s strengths and concerns; (2) to promote critical dialogue and knowledge about important issues through large and small group discussion of photographs; and (3) to reach policymakers. Because photovoice is flexible and our study population consisted of women living in the upper limits of longevity, our approach focused on empowerment of the study participants. We first focused on relationship building during the participant screening stage. During the initial phone call, the first author screened the participants to ensure they met the inclusion criteria. If they were eligible, a brief description of the study and the expectations of the participant were discussed, and if interested, an appointment was made to meet in person. At this meeting, the study and expectations were described in detail, and if the participant was still interested, a detailed consent form was reviewed and signed, and an appointment was made to conduct a semi-structured face-to-face interview. In keeping with relationship building, at the initial group meeting, an ice-breaker helped the participants get to know each other and lunch

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was unstructured social time. At this meeting, the participants were given identical digital cameras to facilitate the learning and practice process. The process began with camera training including learning about the basic components, taking random pictures, and learning how to view and delete pictures. Then a discussion about ethics led to the distribution of the necessary consent forms the participants would need if they took pictures of people. Following lunch, the participants were given a list of possible photographs to take: • • • • •

Something you use every day Something that could help you stay healthy Something you use when eating dinner Something you find interesting in this clinic space Something that enables you to age in place

Participants were instructed to write a reason why they took a picture and how it was related to aging in place. This was followed by a sharing of practice photographs and a discussion about why they were taken. The participants were given two weeks to take pictures of what supported or limited their ability to age in place. Because they were using digital cameras, they were instructed that they could take as many pictures as they wished, but before the first author met with them individually, they had to select the six photographs they liked the most. At the individual meetings, the first author brought a portable printer and printed their six favourite photographs. The participants were then asked to select the four photographs they believed best represented their reality and those were the photographs they submitted to the study. They were asked to describe each of the four photographs and to provide a caption, if possible. They were also advised that at the upcoming group meeting they would present their photographs and describe why they took them. The second group meeting was approximately five hours long and included lunch. The participants brought their four photographs, which were displayed on a screen so everyone could see them. They all finished describing their photographs before lunch; afterwards, as a group, they categorized the photographs. The first author had printed the photographs on eight 10in sheets of paper and together, the participants sorted and grouped these images. This was a form of participant-led analysis that transferred power from the researcher to participants and was congruent with a participatory research approach. The study data included the semi-structured interviews,

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the participants’ descriptions of their photovoice photograph, and the participant impact statements which were the women’s experiences of being involved in the photovoice portion of the study.

Data analysis Analysis began as soon as data collection started. Patton (2015) argues that transcribing is part of data management and preparation, thus, the transcribing process provided the first author an opportunity to become immerse in the individual interviews and the data as a whole. NVivo Pro 11 was utilized to aid in organizing and retrieving the coded data. We utilized a thematic analysis process. Themes were named, reviewed, and defined. To ensure rigour, two authors coded each transcript independently and then met to compare and come to a consensus on coding.

Findings Participant characteristics The women represented variations in age, marital status, number of children, education, and housing, and portrayed a variety of circumstances that illustrated their versions of aging in place as older women in ten different rural communities across PEI. The women ranged in age from 85 to 91, seven were widowed, two married, and one divorced. The number of children they had ranged from one to ten. Three had completed college/university, four had some university education, and three did not complete high school (Table 14.1). The women revealed that although they were over 85, their quality of life continued to be perceived as good because they remained socially active, and their resilience was evident as they continued to be actively involved with family and friends and, regardless of ability, continued contributing to their communities. Interacting forces influencing aging in a rural place This study revealed that a set of interacting forces supported or limited daily life for the women aging in a rural place. These forces included the women’s own agency, their family/friend support, their social involvement, transportation, and financial security.

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Supports and limitations of aging in a rural place Table 14.1: Participant profiles (n=10) Name Arlene Betty Charlotte Edith Freda Geraldine Harriet Ida Joan Kathleen

Age 89 86 86 91 86 86 91 85 85 85

Marital status Widow Widow Married Widow Divorced Widow Widow Widow Widow Married

Number of children  7  1 10 10  6  7 10  4  2  7

Level of education Grade 10 Some university Some university Grade 9 College Some university Grade 8 College University Some university

Residence type Bungalow Bungalow Bungalow Rented house Apartment Granny suite Granny suite 2 storey home Bungalow 1.5 storey home

Note: The participants responding to this study were all white Anglo-Saxons. Seven were living in middle-class circumstances, one lower income. There were participants from each of PEI’s three counties.

Agency According to Crockett (2002), human agency is the process of striving toward and realizing one’s goals, and it falls under the rubric of selfregulation, which is the capacity to regulate one’s emotions, attention, and behaviour in order to achieve. The women used different strategies to maintain wellbeing and remain in control as they grew older. These strategies included what Tkach and Lyubomirsky (2006) described as social affiliation, and passive or active leisure. Betty said, ‘throughout the day I usually have a meeting, this week I have one day off and that’s today to meet you, that’s all and every other day this week I’m busy.’ She also spoke about leisure, ‘I like doing handicraft, I do a lot of afghans … I always have something going you know, I knit knee wraps for the seniors’ home, now I got a pile of stuff to go to Summerside and I want to get some more yarn.’ The women demonstrated an ability to adjust to changes and new conditions and made use of existing support networks through reciprocal relations with family and neighbours. As Charlotte described ‘Jerrid [her grandson] comes down from church with us … he has chromosome 13 that wasn’t developed properly or something and he was slow development, he comes with me and he gets the groceries with me and he enjoys it, he thinks he’s doing the whole thing … I couldn’t manage to get the groceries in and that type of thing right now.’ Their roles in their families were emotionally strong and relatively autonomous, even the frailer women, who could not engage fully in community events,

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contributed through helping in an unpaid capacity. As Harriet said: ‘I can still sew with the sewing machine and I enjoy that very much and people enjoy it when I give them little quilts, a little while ago twins were born in the neighbourhood and I give them each a little quilt, they were so happy with it.’ Some of the women were proactive and had planned for the future. Ida said, ‘I have my son as the legally [sic], he is all set up to look after me – my decisions and power of attorney and all that stuff – I have it all done and have had for years.’ The women’s agency was enhanced as they experienced interdependency. In the past they often transported their grandchildren when their own children were busy with other things. Their children and grandchildren now provided supports when the older women needed help. Recognizing the capabilities and resilience of older women emancipated and empowered them and helped remove the stigma of being a burden to society. For instance, as Ida noted, she gave away over 50 knitted sweaters and a number of coffee cup cosies to family and friends saying, ‘I try to use up the yarn I have because I know when I kick the bucket my son will be aghast at the yarn lying around.’ The women did not see themselves as passive recipients of support, instead, they described themselves as actively giving back by providing support for family, friends, and/or neighbours. Figure 14.1: Making baby quilts

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Family/friends support All women had at least one family member living within 20 kilometres of their home and verified the importance of support as they described their activities and their range of contact with family members, friends, and neighbours. The women described numerous supports family members provided including: snow shovelling, daily delivery of dinner, installing hand rails, vacuuming, transportation to the city or specific appointments, temporary nursing care, maintaining equipment, grass cutting, bringing out and putting away patio furniture, paying for a new furnace, washing walls and ceilings, and helping with internet issues. There was a clear distinction, between the mutually supportive bonding relationships that women had with neighbours. The underlying trust and reciprocity associated with these relationships were central to their day-to-day lives. Betty explained it this way: ‘[…] neighbours are a comfort in a different way than your family; I mean you confide in your family very much closer than you would with your neighbours. But still at the same time, the neighbours provide the constant companionship they’re here all the time when your kids are out working and things like that  … it’s the constant companionship with the neighbours who don’t work every day and that’s dropping in all the time. It’s a comfortable feeling for sure. It makes you feel safe because when I go away, they watch my house and when they’re away I pick up their mail and if I saw strangers, I would call the son who lives farther away and tell him there is somebody around their house.’ Social involvement The current medicalized perception society holds about older adults as being frail, weak, lonely, and dependent on others has the potential to reinforce ageism (Dionigi et al, 2011). For most of the women in this study, social involvement was intense, meaningful, and beneficial. Activities included involvement in community improvement and fundraising activities. Some of the women talked about attending church services. Freda noted that she not only attended church, she also played the piano for one of the churches. She said, ‘I played the piano for the local Presbyterian church for years. Really, I’m Anglican, but I don’t think God cares. Anyhow, they pay me and that’s good.’

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Joan pointed out that this year she is chairing the Christmas hamper program for the Lions Club. Charlotte was involved in local decision-making and said: ‘I chair the resolutions and legislation committee and we are preparing a resolution for safety for bicycles on this road. It is one of five routes that the department of tourism has given for bicyclists and it’s not safe.’ Betty kept busy with community groups and was actively involved with a seniors’ group, church, Women’s Institute, a local museum, and a variety of workshops; for some activities she was a participant and for others was the organizer. Transportation Two of the women depended on others for their transportation and at times were unable to do the things they wanted or needed to do. Geraldine described her situation by saying: ‘I have to hire somebody to take me, usually my son takes me or my daughter that lives over there but it’s fine if they’re not working but when they’ve got a job then I have to scramble around to get somebody to take me to my appointment.’ Although eight of the women continued to drive their own car, none of them was totally independent and needed backup support for appointments in the city, driving in winter weather, attending events after dark, and appointments for specific treatments. For some, even though they did not feel comfortable driving, they felt like they had no choice. As suggested by Charlotte, the car is ‘a necessary means of transportation when living in a rural community with no public transportation’. The thoughts surrounding what they would do if they were no longer able to drive was emotional, and profoundly negative. When asked what she would if she could no longer drive, Freda said, ‘Oh please let me die first.’ Financial security The women’s financial resources varied, but their perception of how much they needed was based on their own assumption of what was enough. Freda said, ‘I manage on my old age security, old age supplement, a bit of CPP [Canada Pension Plan] but I manage fine.’ Betty, a retired teacher, said:

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‘Life perhaps would be very different if you didn’t have a steady income like a pension plan. I think that’s what makes your life so comfortable in both your mind and your body. I think it’s very comforting to know that you have a pension to rely on.’ Charlotte, who still had a spouse, was a bit hesitant when asked if she had the financial resources needed to continue the lifestyle they have chosen. She was not sure and said: ‘I do as long as my husband is living. Twenty-seven dollars and my old age pension that’s my income, his pension is adequate of course. Then, if he dies, I only get 60% so I don’t know whether I could manage, I know that has happened to a lot of my friends here; women whose husbands have died and they [the husbands] were the breadwinners and they were the ones who had the pension and when they died their [women’s] income was cut back, and they just couldn’t maintain the house and pay all the expenses. They had the same living expenses except for food and they just couldn’t do it.’ Other aspects of finances that are important for the women is being able to do your own banking and Geraldine was not always able to do that: ‘I always feel better when I do that [banking] myself, I try to get in once a month and pay my telephone bill and my electric light bill, other than that I just let one of my family take the debit card and do it. You can always go through your statement, it’s wonderful to get your statement every month.’ Although matter-of-fact about her circumstance, it was evident there was discomfort in having to give someone else her bank card and PIN to do the banking when she noted she was able to go through her monthly bank statement. Although most of these women felt their financial situation was satisfactory, some still had concerns and were being cautious, but optimistic, and seemed prepared to be careful in their spending if they needed to do so.

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Knowledge-sharing open house At the second group meeting, it was agreed that a knowledge-sharing open house would be held and each participant would talk about their own photographs and explain how they represented a support or limitation for them as they continued to age in their location of choice. Family, friends, academics, and policymakers were invited to the event which took place in July 2017. Each participant had their four framed photographs displayed on music stands and they were with their photographs when attendees arrived (Figure 14.2). Approximately 50 people attended, including the provincial Minister of Family and Human Services who was responsible for seniors’ issues. She spent a long time talking with each participant learning from them about their photographs. Refreshments for the event included a celebratory cake which had a picture of the participants on the top. At the end of the gathering, the participants were given the digital cameras as a thank you for their time and willingness to share their lived realities with us and the guests at the knowledge-sharing open house. Five months after the open house, the Minister of Family and Human Services announced a new program to support older adults wishing to age in place. The minister noted she was inspired by this study and the opportunity to meet and talk with the women. The Seniors Figure 14.2: Sharing pictures and stories

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Independence Initiative (Government of Prince Edward Island, 2017) provides financial assistance for practical services making it easier for seniors to remain in their own homes and communities. A few months following the new program announcement, the first author met with the minister and asked what she meant when she said she was inspired by our study and the opportunity to meet the women. She said ‘I got your invitation. I came to support your work. I walked into the knowledge-sharing open house with nothing on my mind and when I walked out my head was spinning.’ This statement acknowledges the power and value of photovoice which incorporated the women, their photographs, and their words. The minister’s opportunity to engage with the women and their photographs enabled her to learn from the experts themselves, which had a powerful impact on her.

Conclusion This qualitative study of women aged 85 and older provided insight into the daily realities of women living in the upper limits of longevity. Using two inquiry methods, semi-structured face-to-face interviews and photovoice, we examined older women’s daily lives and societal influences. We found that the following interacting forces in some ways enabled, and in other ways challenged, daily life for aging in place: their own agency; social involvement; informal support; transportation; and financial security. From a critical feminist gerontological perspective (Calasanti et al, 2006), it is essential that the voices of older women are heard. By listening to the women in this study, and learning about their lived realities, we found that women over 85 continue to play an active role and contribute to the development of healthy, safe, and vibrant rural community living for all ages. A complex picture emerged whereby the women in this study were self-sufficient and played a key role in the maintenance and growth of their communities. They provided support to their family, friends, and neighbours, and challenged the status quo by exhibiting their capabilities and advocacy for change in their communities and policies, while providing evidence of what they needed to enhance their options and ability to continue the lifestyle they had chosen. Of great importance are findings from this study which showed how and why these older rural women managed to live in rural places; how and why they are often on the edge of being able to age in place; and how they are making decisions on where and how to age in a rural place. With changes in any one of the interacting forces, they could

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lose their chosen lifestyle and would have major decisions to make about where to live. We need to challenge why this situation exists (Morgan et al, 2010) and advocate for greater financial independence for older women. The findings of this study counter the prevalent ageist assumption that women living in the upper limits of longevity are bound to become passive, dependent, and expensive recipients of care from the formal system, and from family, friends, and neighbours (Grenier and Hanley, 2007; Pierini and Volker, 2009; Kim et al, 2013). Older women do not need to learn that they are old, but they would benefit from education and learning opportunities that enhance their quality of life, help them realize their own power and agency, and allow them to share their knowledge to inform others. Implications for practice Our results confirmed that adequate and affordable transportation is an essential basic service that is critical to the wellbeing of older women (Bryanton et al, 2010; Lee et al, 2018). Because one-size-fitsall solutions do not work, initiatives need to be tailored to the unique needs of rural communities. Although typically used in a research context (Wang and Burris, 1997), photovoice offers an interesting and innovative option for practitioners to identify community needs. The findings of this study demonstrated that older women can show how their agency enables them to live on their own terms as they age in a rural place. These older women also reveal that with appropriate resources, their ability to age in a rural place increases. They know what they want and need, and they actively seek ways to enable solutions. Thus, as suggested by Jacka (2014), there is a need for a shift in focus from the policy discourse of vulnerability and dependency, to discourse recognizing agency, capacity, and the importance of older women’s contributions to society. This represents a shift in policy from a deficiency-based to an asset-based model of policy research and programming. To borrow a phrase from disability rights activists, ‘Nothing About Us, Without Us’ should be a priority for decision makers developing research, programs, or services that affect older women’s lives. Currently, there is no mechanism for older women to come together to discuss issues and concerns, to draw on one another’s experiences, and to formulate ideas that respond to needs in order to inform policy and decision makers. As identified by Garner and Faucher (2014) practitioners operating from a feminist gerontological lens have a

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responsibility to facilitate advocacy efforts by older women themselves. Thus, opportunities should be developed for older women to learn together and share knowledge that is necessary to create change. References Bryanton, O., Weeks, L.E., and Lees, J.M. (2010) ‘Supporting older women in the transition to driving cessation’, Activities, Adaptation & Aging, 34(3): 181–95. Bryanton, O., Weeks, L., Townsend, E., Montelpare, W., Lees, J., and Moffatt, L. (2019) ‘The utilization and adaption of Photovoice with rural women age 85 and older’, International Journal of Qualitative Methods. http://doi.org/10.1177/1609406919883450. Calasanti, T., Slevin, K.F., and King, N. (2006) ‘Ageism and feminism: from “et cetera” to center’, National Women’s Studies Association Journal, 18(1): 13–30. Creswell, J.W. (2014) Research Design: Qualitative, Quantitative, and Mix Methods Approaches (4th edn), Thousand Oaks, CA: Sage Publications. Crockett, L.J. (2002) ‘Agency in the life course: concepts and processes’, Faculty Publications, Department of Psychology, 361. Available at: https:// digitalcommons.uni.edu/psychfacpub/361. Davis, S., and Bartlett, H. (2008) ‘Healthy ageing in rural Australia: issues and challenge’, Australasian Journal on Ageing, 27(2): http://doi. org/10.1111/j.1741-6612.2088.00296.x. Demiris, G., Oliver, D.P., Dickey, G., Skubic, M., and Rantz, M. (2008) ‘Findings from a participatory evaluation of a smart home application for older adults’, Technology and Health Care, 16: 111–18. Dionigi, R.A., Horton, S., and Bellamy, J. (2011) ‘Meanings of aging among older Canadian women of varying physical activity levels’, Leisure Sciences, 33: 402–19. Doyle, M. and Timonen, V. (2010) ‘Lessons from a communitybased participatory research project: older people’s and researchers’ reflections’, Research on Aging, 32(2): 244–63. Garner, S. and Faucher, M.A. (2014) ‘Perceived challenges and supports experienced by the family caregiver of the older adult: a photovoice study’, Journal of Community Health Nursing, 31(2): 68–74. Government of Prince Edward Island (2017) Seniors’ Independence Initiative. Available at: https://www.princeedwardisland.ca/en/ information/seniors-independence-initiative. Grenier, A. and Hanley, J. (2007) ‘Older women and “frailty”: aged, gendered and embodied resistance’, Current Sociology, 55(2): 211–28.

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Hanlon, N. and Halseth, G. (2005) ‘The greying of resource communities in northern British Columbia: implications for health care delivery in already-underserviced communities’, The Canadian Geographer, 49(1): 1–24. Hanlon, N., Halseth, G., Clasby, R., and Pow, V. (2007) ‘The place embeddedness of social care: restructuring work and welfare in Mackenzie, BC’, Health & Place, 13(2): 466–81. Jacka, T. (2014) ‘Left-behind and vulnerable? Conceptualising development and older women’s agency in rural China’, Asian Studies Review, 38(2): 186–204. Keating, N., Swindle, J., and Fletcher, S. (2011) ‘Aging in rural Canada: a retrospective and review’, Canadian Journal on Aging, 30(3): 323–38. Kim, J., Richardson, V., Park, B., and Park, M. (2013) ‘A multilevel perspective on gender differences in the relationship between poverty status and depression among older adults in the United States’, Journal of Women & Aging, 25: 207–26. Kumar, R. (2014) Research Methodology: A Step-By-Step Guide for Beginners (4th edn), London: Sage Publications. Lee, E.A.L., Same, A., McNamara, B., and Rosenwax, L. (2018) ‘An accessible and affordable transport intervention for older people living in the community’, Home Health Care Management & Practice, 30(2): 54–60. Loe, M. (2010) ‘Doing it my way: old women, technology and wellbeing’, Sociology of Health & Illness, 32(2): 319–34. Merriam, S.B. and Tisdell, E.J. (2016) Qualitative Research: A Guide to Design and Implementation (4th edn), San Francisco: Jossey-Bass. Morgan, M.Y., Vardell, R., Lower, J.K., Kintner-Duffy, V.L., Ibarra, L.C., and Cecil-Dyrkacz, J.E. (2010) ‘Empowering women through photovoice: women of La Carpio, Costa Rica’, Journal of Ethnographic & Qualitative Research, 5: 31–44. Patton, M.Q. (2015) Qualitative Research & Evaluation Methods (4th edn), Thousand Oaks, CA: SAGE Publications. Pierini, D.M. and Volker, D.L. (2009) ‘Living alone in community and over 85 years old: a case study’, Southern Online Journal of Nursing Research, 9(1): 1–14. Silver, C.B. (2003) ‘Gendered identities in old age: toward (de)gendering?’, Journal of Aging Studies, 17(4): 379–97. Statistics Canada (2012) ‘Annual demographic estimates: Canada, provinces and territories’, Table  2.1-3: Annual population estimates by age group and sex at July  1, provincial perspective – PEI’. Available at: https://www150.statcan.gc.ca/t1/tbl1/en/ tv.action?pid=1710000501.

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Statistics Canada (2017a) ‘A portrait of population aged 85 and older in 2016 in Canada’. Catalogue no. 98-200-X. Available at: https:// www12.statcan.gc.ca/census-recensement/2016/as-sa/98-200x/2016004/98-200-x2016004-eng.cfm. Statistics Canada (2017b) ‘Population by broad age groups and sex, 2016 counts for both sexes, Canada, provinces and territories, 2016 Census’ (table). Ottawa, Ontario. Statistics Canada. Available at: https://www12.statcan.gc.ca/census-recensement/2016/dp-pd/ hlt-fst/as/Table.cfm?Lang=E&T=11. Strömquist, N.P. (2015) ‘Women’s empowerment and education: linking knowledge to transformative action’, European Journal of Education, 50(3): 307–24. Tkach, C. and Lyubomirsky, S. (2006) ‘How do people pursue happiness?: Relating personality, happiness-increasing strategies, and well-being’, Journal of Happiness Studies, 7: 183–225. van  den  Hoonaard, D.K. (2015) Qualitative Research in Action: A Canadian Primer, Oxford, UK: Oxford University Press. Walkner, T.L., Weare, A.M., and Tully, M. (2018) ‘“You get old. You get invisible”: social isolation and the challenge of communicating with aging women’, Journal of Women & Aging, 30(5): 399–416. Wang, C.C. (1999) ‘Photovoice: a participatory action research strategy applied to women’s health’, Journal of Women’s Health, 8(2): 185–92. Wang, C.C. and Burris, M.A. (1997) ‘Photovoice: concept, methodology, and use for participatory needs assessment’, Health Education and Behavior, 24: 369–87. Weir, A. (2014) ‘Power, gender, and the politics of our selves’, Critical Horizons, 15(1): 28–39.

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15

Rural practitioner vignette John Whalley The Cape Breton Regional Municipality (CBRM) is a beautiful region of approximately 2,400  square kilometres located on Cape Breton Island in the eastern part of Nova Scotia. As is the case with many economic regions in Atlantic Canada, Cape Breton Island has long been characterized by both an aging and declining population. For many decades, each year hundreds of young adults have migrated out of the region for educational and work opportunities in other areas of Nova Scotia and Canada. The result has been a consistent shift in the shape of the CBRM’s age pyramid. There have been ever fewer young people, and far more people in the older age cohorts. In 2016, almost 23% of CBRM’s total population was aged 65 or older. More broadly, during the 2006 to 2016 period, the share of people across all parts of Nova Scotia aged 65 years of age and older increased by 33%. It is likely that within another decade, approximately one-quarter of the provincial population will be at least 65 years of age. In terms of the geographical distribution of the population within the CBRM, approximately 72% of the total residents live within small urban and suburban communities with total populations below 30,000  people. Historically, a number of these communities were established around natural resource industries – namely fishing harbours or coal seams/mines. Sydney, founded in 1785, is the largest of the small urban centres and Sydney’s principal industry for many decades was steelmaking. In total, these small urban communities account for approximately 4% of the entire land mass of the region. The other 28% of the population is widely scattered about the remaining 2,300 square kilometres. These rural residents have access to relatively little physical public infrastructure. Within this context, the CBRM is increasingly challenged to identify initiatives and programs that will effectively accommodate and support an aging population. CBRM is among the poorest municipalities in Nova Scotia, and in Canada for that matter (as measured by taxable assessment per capita). This reality has impacted the decisions that have been taken by both the CBRM’s municipal council and by the

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administrative staff. More specifically, the focus over the years has been on the provision of ‘core’ municipal responsibilities (policing services, fire services, the construction and maintenance of public infrastructure, and the development and maintenance of water and wastewater services). Beyond the core responsibilities, there has been great reluctance to engage in initiatives that may be defined as being discretionary. One notable exception within CBRM has been the region’s active transportation strategy, which has been enthusiastically supported by the municipal council and has resulted in far better infrastructure for walking and cycling in the region.

CBRM’s approach to an aging population At the current time, there is no obvious coherent municipal strategy related to the aging population within CBRM and how best to promote and support it. Instead, there are some separate pieces of policy and initiatives that have been approved over an extended period. CBRM in its formal planning processes does engage the communities across the region on a variety of issues; however, there has not been a dedicated process of engagement related to the significance of and implications of an aging populace. CBRM’s Municipal Planning Strategy (MPS) is the official legal document that regulates, under the terms of the Nova Scotia Municipal Government Act, what the municipal government can do and what types of developments require the approval of municipal council. With respect to policies associated with recreational programs and facilities, there is recognition in the MPS of the growing share of the population that is 65 years of age and older. The document, however, does not go beyond a general recognition of the implications of aging for CBRM’s municipal infrastructure, services, and programs. The CBRM’s 2017 Recreation Master Plan was more explicit regarding the aging population. It states ‘[…] senior resident activity must be inherent in planning and creating all programs and facilities. This is critical to ensure aging populations are healthy, happy, and active.’ The Plan also recommended that a seniors’ active living committee be created. The intention was that this committee would advise the department on how best to ensure the interests and needs of seniors would ‘be inherent in planning and creating all programs and facilities’. There is no indication that such a committee was created. In terms of the evolution of the public transportation system in the CBRM, the past few years have been fascinating. In 2015, CBRM transit was in jeopardy of being dramatically reduced due to very low

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usage. The municipality was reluctant to continue to subsidize a system in which the gap between annual expenditures and annual revenue was growing. However, the recent very substantial increase in the number of international students attending Cape Breton University has resulted in a dramatic increase in usage, new routes, and an increasing recognition of the importance of a public transit system. The federal and provincial governments have also contributed funds allowing CBRM to acquire new buses and, as a result, improve the quality of the service. The service has become a far more viable means of transportation for people of all ages. But it is important to note that international students were the key stimulus to be able to achieve a critical mass of riders necessary for the service to be viewed as both a reasonable transportation option and a necessary municipal service for the community.

Nova Scotia’s approach to an aging population The availability of provincial funding for the CBRM public transit system is likely related to Nova Scotia’s Action Plan for an Aging Population, better known as Shift. There are three specific goals that comprise the strategy: (1) value the social and economic contributions of older adults; (2) promote healthy, active living; and (3) support aging in place, connected to community life. In April 2019, the Nova Scotia government released an 18-month report card of a series of initiatives designed to address the various commitments that are contained in the strategy. Among the wideranging measures that have been taken to date, one of the initiatives is related to the provision of funding to the CBRM Recreation Department to conduct community consultations in support of the development of an age-friendly community implementation plan. Although this seems somewhat a duplication of the work that was previously done as part of the 2017 Recreation Master Plan, it shows that the CBRM has not lost sight of the need to focus on the needs of an aging population. Perhaps more significantly, the provincial government did explore the development of a Statement of Provincial Interest on Healthy Built Environments ‘[…] that supports healthy, sustainable communities, and addresses issues related to aging in place’. Another dimension of the changing demographic profile of Nova Scotia is reflected in the new approach to accessibility. The government of Nova Scotia, through its Accessibility Act, has a goal of having all public facilities in the province accessible by 2030. The Act, which was passed by the provincial legislature in 2017, recognizes

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accessibility as a basic human right. It ‘[…] establishes a framework for preventing and removing barriers in the built environment, education, employment, transportation, information and communication, and goods and services’. The work is being led by an Accessibility Advisory Board which, among other things, advises on the development of standards related to all aspects of accessibility. The priorities set out in the strategy include standards development; awareness and capacity building; collaboration and support; compliance and enforcement; monitoring and evaluation; and government of Nova Scotia – leading by example.

Summary remarks While there are some modest municipal initiatives to date within the CBRM, so far, the government of Nova Scotia has led the process of change needed to support an aging population. The provincial government has undertaken a series of very tangible initiatives that have had, and will continue to have, a very positive impact within the CBRM. Yet there is much work to be done. It is encouraging that the issue has been identified as a priority, a provincial strategy has been developed, and resources are being allocated to implement the goals highlighted in the strategy. The CBRM’s long history (more than five decades) of aging and decline, however, does seem to be at a turning point. Based upon the most recent sub-provincial demographic estimates from Statistics Canada, the population of Cape Breton appears to be stabilizing due to the influx of international students studying at Cape Breton University. This is an amazing turn of events in a region of Canada which for more than half a century has experienced persistent high unemployment and out-migration. While there is a real need to focus on building more age-friendly and accessible communities, this work can now take place in a more hopeful and optimistic climate. There is an unmistakeable new energy and vigour in communities of every size across the entire region.

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Part 3 overview Idyllic images of rural Canada, with their close-knit communities and bucolic greenspaces are both true, and simultaneously, more complicated. Rural older adults in Canada face multi-faceted issues related to public transportation, sustained voluntarism, demographic decline, and access to health and social services. All issues that vary greatly between different areas. Takeaways for practice • The provincial government plays an integral role in supporting older adults in rural places due to the limited capacities of rural governments and amalgamations of multiple towns over large geographies. At times, the increased role of the provincial government is effective, such as the commitment of funding to municipal age-friendly planning. But not always, such as the integration of services into one-stop shops that pushed services out of communities, requiring longer travel times. • There is a need for contextual solutions to rural problems. Rural Canada is not homogeneous and programming/services must be adapted to the context to be effective. • There is need for transportation alternatives that are context-specific, like a door-to-door service in one community or a small bus with a route in another. • Ensuring financial stability for older adults to age in place is integral, including support for transportation, and housing accessibility modifications. • Internet must be considered an essential service in Canada. Access to highspeed internet will help rural older adults take advantage of the multitude of telemedicine and virtual care resources, as well as participate in social groups online. • Rural areas can have strong networks of community care and reciprocity which provide informal care beyond the classic ‘caregiver–care recipient’ relationship. However, it is important to recognize that voluntarism is contingent and fragile, and can create unequal geographies of service provision. • When planning with older adults, it is integral to focus on their agency and their assets, not exclusively on their vulnerabilities. Older adults have needs that must be met, but they are also providing care to their communities in different ways. Questions to consider • How does the town you live in officially understand the needs of older adults, and who has power to make decisions? • How does your municipality engage the older adults in your community? Who is left out from those conversations? • If your town is committed to being age-friendly, what measures are they taking?

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PART IV

Indigenous

16

Aging in Indigenous Canada Sarah E. Nelson Older Indigenous people are in a unique position within what is now Canada. With relationships to place that extend over millennia and shape the ways that communities are structured, as well as the ongoing challenges and oppressions of living within a colonial society that regulates much of everyday life and limits opportunities in many Indigenous communities, aging for Indigenous individuals has multiple layers of complexity that involve both opportunities and challenges, and that relate closely to the places in which people live. ‘Indigenous peoples’ is an umbrella term, used internationally to refer to the original peoples of a place. In Canada, ‘Indigenous peoples’ include over 70 distinct language groups and hundreds of different nations (Statistics Canada, 2017). In Canada, the Constitution Act recognizes three main Indigenous groups: First Nations, Métis, and Inuit (Government of Canada, 1982), although each of these groups masks a huge amount of diversity, and Indigenous peoples generally prefer to be identified by nation, such as Cree, Mi’kmaq, or Omàmìwinninì – rather than as part of these larger groupings. The 2016 Census counted 1,673,785 Indigenous people in Canada, a number that grew by 42.5% since 2006, and Indigenous peoples now make up at least 4.9% of the overall population of Canada (Statistics Canada, 2017). While the Indigenous population in general is younger than nonIndigenous populations in Canada, the proportion of Indigenous people aged 65 years or older is also increasing more quickly than in other populations, rising from 4.8% in 2006 to 7.3% in 2016 (Wilson et al, 2010, 2011; Statistics Canada, 2017) (Figure 16.1). This is giving rise to scholarship on a number of issues for older and aging Indigenous people, including urbanization and relationships to land (Wilson and Cardwell, 2012); health disparities and experiences of dementia and memory loss (see Chapter 17, this volume; Hulko et al, 2010; Wilson et al, 2010; Lanting et al, 2011; Bourassa et al, 2015; Warren et al, 2015); and the provision of services in culturally appropriate ways that also account for the different, sometimes challenging,

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Figure 16.1: Proportion of the population aged 14 and under and 65 and over by Indigenous identity 0–14 years

65 years and over

35 33

30 Proportion of population

29.2

25 22.3

20 15

16.4 16.3

10 8.7

5

6.4

4.7

0 First Nations

Métis

Inuit

Non-Indigenous

Source: Statistics Canada, 2017

geographies of Indigenous aging in Canada (see Chapters 18, 19, and 20, this volume). These issues give rise to a number of challenges for Indigenous communities, but also to a number of opportunities for older Indigenous people and those working with them, going forward.

Urbanization Indigenous people, like the rest of people in Canada, are experiencing increasing rates of urbanization. Just under 7% of the Indigenous population lived in urban areas in the 1950s; this has grown steadily and remained at over 50% of the population – which, overall, is growing – since 2006. In 1951, amendments were made to legislation that had since the 1920s severely restricted the movement of Indigenous peoples to cities. Since the removal of these legislative restrictions, urban Indigenous populations have grown more numerous again (Newhouse and Peters, 2003; Peters, 2004, 2006). Recent scholarship has revealed that the numbers of Indigenous people counted by the Census as living in major cities may be dramatically underestimated. One study conducted in Toronto found that there may be as many as 55,000 people identifying as Indigenous living in the city – almost three times the Census estimate of 19,270  people (Rotondi et  al, 2017). However, the numbers of Indigenous people living on reserves

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in rural areas have also been growing over a number of years, resulting in net growth in both rates of living on reserves and living in urban areas (Norris and Clatworthy, 2003). This is due to the overall growth of Indigenous populations in Canada, and because more people feel safe and proud to identify as being of Indigenous identity or ancestry (Norris and Clatworthy, 2003; Palmater, 2011; Statistics Canada, 2017). The relationships of Indigenous communities to land and place in Canada are complex, stemming from long histories of close relationships to land, but with communities having also been subjected to a great deal of interference and dislocation since the first arrival of European settlers. Reserves, for example, are portions of land that are set aside for the use of a First Nation, with the land itself being held in trust for that First Nation by the Crown, under the federal Indian Act (Government of Canada, 1985). There are a small number of urban reserves in Canada, but the majority are in rural or remote areas (Peters, 2007). The Indian Act also gives the federal government self-invested power to define who is identified as a ‘status’ First Nations person – that is, someone who is eligible for registration under the Indian Act, and therefore entitled to live on reserve and receive certain types of benefits and services (Government of Canada, 1985). Status First Nations individuals currently make up less than 45% of Indigenous peoples in Canada, leaving more than 55% of Indigenous peoples without access to these services and benefits (Statistics Canada, 2017). Federal services are further reduced to only those individuals living on a reserve, with only a limited suite of benefits available to status First Nations people who leave a reserve to live elsewhere, for example in a city (Lavoie et al, 2010). This can lead to difficulties for older Indigenous people who move to urban areas, who may feel cut off from benefits and services previously available on reserve. Health outcomes have been found to be worse for Indigenous people living in urban areas than for non-Indigenous people, pointing to a range of disparities in quality of life and the social determinants of health that impact Indigenous people’s health in cities differently than non-Indigenous people (Wilson and Cardwell, 2012). In addition, Indigenous people often feel excluded from federal, provincial, and municipal planning processes. In Chapter 19, John Lewis contextualizes the expressed needs of older Métis community members for transportation, home and community care, and access to health services and health information in Northern Ontario. Participants in Lewis’s research highlight the need for Métis perspectives to be included in Age-Friendly Communities planning in Ontario, in order to address historical exclusions based on Indigenous and Métis identities.

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Health disparities and provision of services Scholarship in Canada consistently links inequities in health outcomes such as rates of chronic disease, mental health problems, and life expectancy between Indigenous and non-Indigenous peoples to structural inequities stemming from colonialism (Wilson and Young, 2008; National Collaborating Centre for Aboriginal Health, 2012; Wilson and Cardwell, 2012). For example, racism and underfunding in education lead many Indigenous people to leave the educational system early; this in turn leads to higher unemployment rates and higher levels of poverty, which can affect people later in life (Roos et al, 2014). Many older Indigenous community members are survivors of residential schools and as a result experience trauma-related health problems and difficulties functioning in everyday life (Truth and Reconciliation Commission of Canada, 2015). As Connie Paul points out in Chapter 20, these experiences lead to differing needs for older members of the Snuneymuxw First Nation that healthcare providers must take into account. Experiences of racism in healthcare services are, unfortunately, frequently reported by Indigenous community members, and lead many Indigenous individuals to expect substandard healthcare, or to avoid accessing services altogether (Browne et al, 2011; Evans et  al, 2014; Allan and Smylie, 2015). These types of problems can be exacerbated in rural communities, where, as for other older populations, Indigenous people have access to fewer services in the immediate area. Carrie Bourassa and colleagues, in Chapter 17, address the challenges of providing care for older Indigenous community members experiencing dementia, from the perspectives of family caregivers and healthcare providers. Through their communitybased research with the File Hills Qu’Appelle Tribal Council, these researchers provide valuable insight into the services and supports needed to help caregivers in their work supporting Indigenous community members with dementia, in Indigenous rural settings.

Opportunities Along with the challenges related to growing older as Indigenous individuals in Canada, there are many ways in which the places we live support the health and wellbeing of older Indigenous adults. For one thing, older adults in Indigenous communities are often highly respected and actively involved in community life – those who hold community and Indigenous knowledge, healing practices, or ceremonies, often referred to by the title of Elder, are often respected

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and prominent members of Indigenous communities (Hoffman, 2010; Baskin and Davey, 2015; Dobson and Schmidt, 2015). In addition, older community members who may not be referred to formally as Elders, still often actively contribute to the life and wellbeing of Indigenous communities through volunteer work, teaching, and a range of intergenerational activities (Rowe et al, 2019; Nelson and Rosenberg, forthcoming). Larry McDermott, in Chapter 18, highlights the importance of intergenerational activities and infrastructure in considerations of Indigenous aging. McDermott, in Chapter 18, and Connie Paul, in Chapter 20, both emphasize the healing power of reconnecting with cultural practices, including ceremony, medicine, food, law, and governance, in improving the health and wellbeing of Indigenous older people. This type of reconnection can be especially important for older individuals who have attended residential schools, have been adopted out of Indigenous communities, or have experienced other forms of displacement that interfere with individual connections to community structures and knowledge. Reconnecting with one’s community of origin can in itself be a form of healing (see Chapters 18 and 20, this volume; Gone, 2013). Reconnecting to Indigenous community practices also links to the growing literature (and practice) related to Indigenous community resurgence, whereby Indigenous communities in all parts of Canada, and the world, are revitalizing languages, governance structures, healing practices, and economic activities that have been disrupted or suppressed through the past centuries of colonialism (L.B. Simpson, 2011, 2017; A. Simpson, 2014; Corntassel et al, 2018). Indigenous older people experience aging in Canada in unique ways that need to be taken into account in Age-Friendly Communities planning as well as in health and social planning and policy. Indigenous perspectives – including the full diversity of First Nations, Inuit, and Métis peoples – and voices are increasingly being heard, and Indigenous communities and nations are taking hold of their own revitalization. More needs to be done to support and enable this work to continue, but the possibilities for healthy and fulfilling aging within Indigenous communities and Indigenous places in Canada are many. References Allan, B. and Smylie, J. (2015) First Peoples, Second Class Treatment: The Role of Racism in the Health and Well-Being of Indigenous Peoples in Canada. Toronto: Well Living House.

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Baskin, C. and Davey, C.J. (2015) ‘Grannies, Elders, and friends: aging aboriginal women in Toronto’, Journal of Gerontological Social Work, 58(1): 46–65. Bourassa, C., Blind, M., Dietrich, D., and Oleson, E. (2015) ‘Understanding the intergenerational effects of colonization: aboriginal women with neurological conditions – their reality and resilience’, International Journal of Indigenous Health, 10(2): 3–21. Browne, A.J., Smye, V.L., Rodney, P., Tang, S.Y., Mussell, B., and O’Neil, J. (2011) ‘Access to primary care from the perspective of aboriginal patients at an urban emergency department’, Qualitative Health Research, 21(3): 333. Corntassel, J., Alfred, T., Goodyear-Kaʻōpua, N., Aikau, H., Silva, N., and Mucina, D. (2018) Everyday Acts of Resurgence. Everyday Acts of Resurgence: People, Places, Practices. Olympia, Washington: Daykeeper Press. Dobson, C. and Schmidt, G. (2015) ‘Traditional carrier approaches to mental health’, Canadian Journal of Community Mental Health, 34(2): 23–35. Evans, M., White, K., and Berg, L. (2014) ‘“They think you’re lying about your need”: the impact of appearances on health and social service access for aboriginal people in Canada’, The Canadian Journal of Native Studies, 34(1): 55. Gone, J.P. (2013) ‘Redressing First Nations historical trauma: theorizing mechanisms for indigenous culture as mental health treatment’, Transcultural Psychiatry, 50(5): 683–706. Government of Canada (1982) Constitution Act, 1982. Available at: http://lois.justice.gc.ca/eng/Const/page-16.html#h-52. Government of Canada (1985) Indian Act. Available at: http://lawslois.justice.gc.ca/eng/acts/I-5/page-1.html. Hoffman, R. (2010) ‘Perspectives on health within the teachings of a gifted Cree Elder’, Pimatisiwin: A Journal of Aboriginal and Indigenous Community Health, 8(1): 19–31. Hulko, W., Camille, E., Antifeau, E., Arnouse, M., Bachynski, N., and Taylor, D. (2010) ‘Views of First Nation Elders on memory loss and memory care in later life’, Journal of Cross-Cultural Gerontology, 25: 317–42. Lanting, S., Crossley, M., Morgan, D., and Cammer, A. (2011) ‘Aboriginal experiences of aging and dementia in a context of sociocultural change: qualitative analysis of key informant group interviews with aboriginal seniors’, Journal of Cross-Cultural Gerontology, 26(1): 103–17.

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Lavoie, J.G., Forget, E.L., and Browne, A.J. (2010) ‘Caught at the crossroad: First Nations, health care, and the legacy of the Indian Act’, Pimatisiwin: A Journal of Aboriginal and Indigenous Community Health, 8(1): 83–100. National Collaborating Centre for Aboriginal Health (2012) ‘State of Knowledge of Aboriginal Health: A Review of Aboriginal Public Health in Canada’, 1–128. Available at: h​t​t​p​:​/​/​u​b​c​.​s​u​m​m​o​n​.​s​e​r ​i​a​l​s​ s​o​l​u​t​i​o​n​s​.​c​o​m​/​2​.​0​.​0​/​l​i​n​k​/​0​/​e​L​v​H​C​X​M​w​b​Z​u​x​D​s​I​w​D​E​Q​t​d​p​Y​i​E​ E​U​M​_​E​B​R​a​j​d​N​O​i​M​q​P​o​A​9​s​p​N​4​7​E​T​_​n​x​a​B​V​B​C​r​h​5​u​s​d​5​J​9​B​0​B​4​ N​t​U​P​E​9​h​w​s​m​J​l​M​h​d​B​b​Z​i​R​M​u​W​W​I​2​q​0​U​f​k​r​q​r​M​A​f​F​_​A​K​g​9​b​O​P​ T​X​-​-​V​W​j​R​L​D​-​6​w​R​H​M​7​N​B​q​Q​d​r​H​k​O​g​w​-​P​V​2​k​s​7​e​G​k​r​q​s​5​i​f​e​k​0​ j​i​n​X​H​e​q​O​X​t​O​R​g​2​T​L​W​H​z​R​6​m​E​4​3​L​6​-​f​4​E​Z​1​s​_​r​e​o​. Nelson, S.E. and Rosenberg, M.W. (forthcoming) ‘Age-friendly cities and older Indigenous people: an exploratory study in Prince George, Canada’, The Canadian Journal on Aging. Newhouse, D. and Peters, E. (eds) (2003) Not Strangers in These Parts: Urban Aboriginal Peoples. Ottawa, ON: Policy Research Initiative. Norris, M.J. and Clatworthy, S. (2003) ‘Aboriginal mobility and migration within Urban Canada: outcomes, factors and implications’, in D. Newhouse and E. Peters (eds) Not Strangers in These Parts: Urban Aboriginal Peoples. Ottawa, ON: Policy Research Initiative, pp 51–78. Palmater, P.D. (2011) Beyond Blood: Rethinking Indigenous Identity. Saskatoon, SK: Purich Publishing. Peters, E. (2004) Three Myths about Aboriginals in Cities. Canadian Federation for the Humanities and Social Sciences. Ottawa, ON: Canadian Federation for the Humanities and Social Sciences. Peters, E. (2006) ‘“[W]e do not lose our treaty rights outside the … reserve”: challenging the scales of social service provision for First Nations women in Canadian cities’, GeoJournal, 65(4): 315–27. Peters, E. (2007) Urban Reserves. Ottawa: National Centre for First Nations Governance. Roos, L.E., Distasio, J., Bolton, S.L., Katz, L.Y., Afifi, T.O., Isaak, C.A., Goering, P., Bruce, L., and Sareen, J. (2014) ‘A history in-care predicts unique characteristics in a homeless population with mental illness’, Child Abuse and Neglect, 38(10): 1618–27. Rotondi, M.A., O’Campo, P., O’Brien, K., Firestone, M., Wolfe, S.H., Bourgeois, C., and Smylie, J.K. (2017) ‘Our health counts Toronto: using respondent-driven sampling to unmask census undercounts of an urban indigenous population in Toronto, Canada’, BMJ Open, 7(12): e018936.

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Rowe, G., Straka, S., Hart, M., Callahan, A., Robinson, D., and Robson, G. (2019) ‘Prioritizing Indigenous Elders’ knowledge for intergenerational well-being’, Canadian Journal on Aging/La Revue canadienne du vieillissement, November: 1–13. Simpson, A. (2014). Mohawk Interruptus: Political Life across the Borders of Settler States. Durham, NC: Duke University Press. Simpson, L.B. (2011) Dancing on Our Turtle’s Back: Stories of Nishnaabeg Re-Creation, Resurgence and a New Emergence. Winnipeg, MB: Arbeiter Ring Publishing. Simpson, L.B. (2017) As We Have Always Done: Indigenous Freedom through Radical Resistance. Minneapolis, MN: University of Minnesota Press. Statistics Canada (2017) ‘Aboriginal peoples in Canada: key results from the 2016 census’. Available at: http://www.statcan.gc.ca/dailyquotidien/171025/dq171025a-eng.htm. Truth and Reconciliation Commission of Canada (2015) Calls to Action. Winnipeg, MB: Truth and Reconciliation Commission of Canada. Available at: http://www.trc.ca. Warren, L.A., Shi, Q., Young, T.K., Borenstein, A., and Martiniuk, A. (2015) ‘Prevalence and incidence of dementia among indigenous populations: a systematic review’, International Psychogeriatrics, 27(12): 1959–70. Wilson, K. and Cardwell, N. (2012) ‘Urban aboriginal health: examining inequalities between aboriginal and non-aboriginal populations in Canada’, Canadian Geographer/Le géographe canadien, 56(1): 98–116. Wilson, K., Rosenberg, M.W., Abonyi, S., and Lovelace, R. (2010) ‘Aging and health: an examination of differences between older aboriginal and non-aboriginal people’, Canadian Journal on Aging/ La Revue canadienne du vieillissement, 29(3): 369–82. Wilson, K., Rosenberg, M.W., and Abonyi, S. (2011) ‘Aboriginal peoples, health and healing approaches: the effects of age and place on health’, Social Science & Medicine, 72: 355–64. Wilson, K. and Young, K.T. (2008) ‘An overview of aboriginal health research in the social sciences: current trends and future directions’, International Journal of Circumpolar Health, 67(2–3): 179–89.

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Pursuing pathways to care: dementia and aging in Indigenous communities Carrie Bourassa, Mackenzie Jardine, Danette Starblanket, Sebastian Lefebvre, Marlin Legare, Dana Hickey, Jessica Dieter, Betty McKenna, Gail Boehme, and Nicole Akan

Introduction Pursuing pathways to care is critical in the movement towards genuinely addressing the health status, and its relationship to dementia amongst Indigenous older adults in their communities. The proportion of Indigenous older adults who are above 65 years of age continues to rise despite the numbers being lower than for their non-Indigenous counterparts. In 2016, the population Indigenous older adults above 65 was 7.3% compared to 4.6% in 2006, and this is expected to double by 2036 (Statistics Canada, 2017). Along with an aging population, there is also an increase in the rates of dementia among Indigenous Peoples in Canada (Jacklin et al, 2013). Dementia can represent a concern for families, preventing individuals from aging in place and causing distress to individuals and their caregivers. People living with dementia in rural communities experience a dearth of dementia care and services (Jacklin and Warry, 2012). The lack of access to dementia services and specialists in rural communities further exacerbates families’ ability to care for their loved ones at home. Understanding the needs of individuals living with dementia, their families, and culturally safe dementia services can be explored through community-based research. A new aspect of dementia care in the twenty-first century is the introduction of technology, which can now be used for anything from remote access to medical appointments to aiding the at-home continuing care of patients. However, many older adults, especially Indigenous older adults living in rural or remote communities, lack the skills and infrastructure to access this technology. This chapter presents an examination of dementia among Indigenous peoples,

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including dementia care, and rural access to care. This is further substantiated with an example of community-based research (in the form of sharing circles and one-on-one interviews) completed by the Morning Star Lodge of Regina, Saskatchewan, in the File Hills Qu’Appelle Tribal Council’s (FHQTC) 11 First Nations communities to better understand the support needed for Indigenous older adults living with dementia.

Rising rates of dementia There has been a rapid increase in dementia rates among Indigenous communities in Canada in recent years. It has been documented that the rates of dementia are 34% higher than that of non-Indigenous people (Jacklin and Warry, 2012; Jacklin and Walker, 2019). The increase in dementia cases is not isolated to Indigenous communities in Canada, this increase has also been observed in Indigenous communities throughout the world (Smith et al, 2008; Mayeda et al, 2016). Projections of dementia in Canada indicate that the number of confirmed cases will double in the next 30 years (Alzheimer Society of Canada, 2017). The onset of dementia appears at an earlier age in Indigenous communities and is more prevalent in males (Jacklin and Walker, 2019). However, one contributing factor to the rising rates of dementia in Indigenous communities could be the increased life expectancy in the general population (Henderson and Henderson, 2002; Jacklin et al, 2013). Dementia and related illnesses such as Alzheimer’s disease are an evolving and persistent issue for the wellbeing of Canada’s aging population and for the families and communities of those affected by dementia. Dementia is the most common neurodegenerative disorder, with approximately 540,000 Canadians living with some form of dementia as of 2017 (Alzheimer Society of Canada, 2017). The Alzheimer Society of Canada (ASC) also reports that the economic cost of dementia in 2016 was an estimated $10.4 billion and is estimated to rise to $16.6  billion by the year 2031. These costs are mostly attributed to the 56,000 Canadians receiving their primary dementia care from hospitals, which the ASC argues is not the appropriate location for any dementia patient to be receiving care (Alzheimer Society of Canada, 2017). Furthermore, the ASC has suggested a move away from a biomedical, Western medicine approach to a more holistic, familial, and traditional approach that can be delivered by informal caregivers such as family and community members. This is relevant to Indigenous populations in Canada, who

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generally emphasize family care and have strong community bonds, as well as cultural needs that include traditional medicines.

Dementia care in rural communities In 2002, the Commission on the Future of Health Care in Canada acknowledged that disparities in access to healthcare and healthcare providers were significant barriers to healthcare delivery for those living in rural and remote regions of Canada (Romanow, 2002). The health status of people living in rural communities, particularly northern communities, is not as good as their urban counterparts due to the lack of medical services and a shortage of practitioners (Wilson and Cardwell, 2012; McBain and Morgan, 2005). Although healthcare in rural regions is a major concern for Canadian governments, and despite per-capita healthcare expenditures that are among the highest in the world, rural patient health outcomes continue to lag behind the rest of Canada (Young et al, 2015). The model currently in place to diagnose and treat dementia in Indigenous communities, especially rural communities, is substandard and does not meet the needs of the population (Jacklin and Warry, 2012). The rapid increase in dementia within the communities is creating challenges in all levels of healthcare (Webkamigad and Jacklin, 2016). The colonial healthcare system dictates the assessment and care that Indigenous peoples will receive and the varying levels of cultural understandings that healthcare practitioners may hold have a direct effect on the healthcare experience that Indigenous Peoples will have (Pitawanakwat et al, 2016). In order for Indigenous peoples to have unbiased access to dementia resources and services, strategies must be put in place that are culturally safe and free of systemic racism. Culturally safe assessment and care may lead to earlier and more accurate diagnosis of dementia in Indigenous communities. In rural communities, healthcare services often lack specialization in dementia-related diseases, and most are designed for aging adult health, rather than dementia. Diagnosis of dementia differs between communities depending on community-based knowledge, access to specialists, healthcare practitioner belief, local cultural understanding, and training specific to dementia (Jacklin and Warry, 2012). Culturally safe assessment and care may lead to earlier and more accurate diagnosis of dementia among Indigenous peoples (Pitawanakwat et al, 2016). To meet the needs of Indigenous peoples, proper education and training programs must be redesigned to provide effective, accurate, and culturally safe care. Training for healthcare providers must include the

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implications of colonization, cultural safety, and Indigenous knowledge and traditions on health (Jacklin et al, 2016).

Caregiving in rural Indigenous communities In some Indigenous communities it can become the responsibility of the family to provide care to their aging relatives (Jacklin et al, 2016). While this may seem to add burden to the family and to the community as a whole, most people see it as their duty and are happy to take care of their relatives; this is due to strong family bonds built on respect, responsibility, and reciprocity (Jervis et al, 2010; Jacklin et al, 2016). Unfortunately, there is a lack of resources for in-home caregivers, especially for those in rural communities. Caregivers do the best that they can to care for their loved one(s) with very little knowledge and understanding about dementia. Varying access to resources, healthcare staff, and community values can make caregiving for a person living with dementia in a rural setting completely different from caregiving in an urban setting, and consequently there are various perspectives to be considered. This is especially true for Indigenous caregivers who have their own unique perspectives, values, knowledge, and traditions (Jacklin et al, 2013).

Aging in place In Canada, the aging population and the subsequent increase in dementia patients challenges the ability of many rural communities to provide dementia care (Morgan et al, 2009). The paucity of dementia services translates into more burden on families and less ability to age in place, which refers to older adults’ ability to age in their home community with the provision of support services. Aging in place has many benefits for both the individual and their community. For example, aging in place improves quality of life, prevents traumatic removal from a home community to a care facility, maintains some independence and control, and is more cost-effective (Vanleerberghe et al, 2017). Indigenous older adults, Elders, and Knowledge Keepers have valuable roles in community wellbeing for example, passing on cultural practices, Traditional Knowledge (TK), healing methods, and language (Baskin and Davey, 2015). Aging in place fosters Elder involvement in community activities, promoting the health and wellbeing of future generations. Although there are several benefits to aging in place, families can need more support to care for someone living with dementia than is available in rural Indigenous communities.

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Technology can provide some of the extra support necessary to age in place and care for older Indigenous adults living with dementia.

Dementia and technology Many older adults face challenges around technology literacy when using technology, especially computers. Differences in access to formal education, work/computer experience, the complexity and technical nature of digital information as well as the natural processes of aging may compromise older adults’ capacity to make sense of and use computers. Other factors that can influence the use of technology can include availability of alternatives (help by family or spouse), social influences (persuasion by family or friends), as well as the older adult’s desire to age in place (the stronger the desire to live at home, the greater the motivation to learn a new technology). The list of factors that can influence the use of technology can be extended to biological reasons. Deterioration of the five senses and cognitive capacity can cause slower responses, which make it much more difficult to use many technologies such as standard keyboards and mobile devices. A digital divide that is developing: individuals who do not have the proper access or skills in using ICT become marginalized as healthcare services migrate towards being completely digitized (Currie et  al, 2014). As of 2011, about 19% of the Canadian population lived in rural or remote communities (Currie et al, 2014). While projections for the growth of the telehealth market are optimistic, and much of this optimism is predicated upon the increasing demand for remote medical care, telehealth is often difficult to establish firmly largely because of unreliable internet connectivity, which can be limited or of poor quality (Alexander, 2001; Muttitt et al, 2004). The situation is exacerbated by infrastructure challenges that make many systems outdated and unreliable (Raven et al, 2013; Canada’s Public Policy Forum, 2014). The most modern standards of internet service continue to elude many rural communities.

Dementia and research Although the rates of dementia have been increasing, it has not been a focus in Indigenous health research until fairly recently (Jacklin and Warry, 2012). There is certainly a transition period for Indigenous people, where they are learning and negotiating the cultural meaning of the illness in their communities (Henderson and Henderson, 2002). Participants of the Saskatoon Community Clinic Grandmothers Group

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in Saskatchewan described dementia as ‘going back to the baby stage’, which is something they considered a normal part of life (Lanting et al, 2011, p 109). This is consistent with the worldviews of several Indigenous communities in Ontario (Jacklin and Warry, 2012; Pace, 2013). Although some dementia symptoms can be considered normal parts of life, there is a need for research in the field of dementia as Indigenous peoples have a desire to understand this emerging illness in their communities in a culturally meaningful way (Jacklin and Warry, 2012).

An example of community-based research to examine dementia needs Research has an important role in not only responding to rising rates of dementia among Indigenous peoples, but also identifying methods to increase access to culturally relevant dementia care including technology. Collaboration with communities is essential to identifying community research needs and ensuring research projects will benefit the community involved. The role of community-based research (CBR) in identifying essential components of technology use by Indigenous older adults living with dementia can be observed through a recent study completed by Morning Star Lodge (MSL), an Indigenous Community-Based Health Research Lab in Regina, Saskatchewan. The MSL research team developed a unique relationship with the File Hills Qu’Appelle Tribal Council (FHQTC) to partner in creating more culturally safe dementia care for Indigenous peoples living in rural areas. A Community Research Advisory Committee (CRAC) was created to guide the research team through the research process, ensuring the research is meeting the needs of the community. The CRAC consisted of community representatives from each of the 11 First Nations belonging to the FHQTC: Carry the Kettle, Little Black Bear, Muscowpetung, Nekaneet, Okanese, Pasqua, Peepeekisis, Piapot, Standing Buffalo, Star Blanket, and Wood Mountain. Driven by community, the research project aimed to identify services and supports needed for Indigenous older adults living with dementia. The CRAC members and research team collaborated to examine the issues facing Indigenous older adults who require dementia care through the development of interview questions and nineteen oneon-one interviews. Participants included individuals who had firsthand knowledge of dementia programs and services; were coping with their own memory loss; or were caring for someone with dementia. The FHQTC CRAC worked closely with the research

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team to identify and gather the research data for this project and create themes based on the response of the interviewees. The project was led by a community research coordinator with guidance and direction from the CRAC. When doing community-based research with Indigenous communities, it is important to follow local protocols and traditions, which in this case included gifting cloth and tobacco for participation in the project. In addition, the OCAP® principles of Ownership, Control, Access, and Possession are important for research involving First Nations peoples and ensuring data is properly collected, protected, used, and shared. Topics covered in the interviews included gaps in healthcare, information needs, preventative measures, and the emotional, physical, and social challenges faced by dementia patients and their caregivers.

Data analysis using novel Indigenous method CCDAP/NAKPA The Collective Consensual Data Analytic Procedure (CCDAP) is a qualitative data analysis method that was adapted from a process first developed by Métis physician and researcher Dr. Judith Bartlett (Bartlett et al, 2007). Subsequently, and with Dr. Bartlett’s permission, the process was streamlined and digitized by MSL to include a preanalysis in an effort to reduce analysis time and accommodate remote communities. The process was renamed in ceremony as Nanâtawihowin Âcimowina Kika-môsahkinikêhk Papiskîci-itascikêwin Astâcikowina (NAKPA), meaning ‘Medicine/Healing Stories Picked, Sorted, Stored’ in the Cree language. The CCDAP/NAKPA process ensured a high degree of consensus over the coding system and an equally high degree of consistency in its application. Moreover, the CCDAP/NAKPA is an innovative Indigenous methodology that can be used to analyse data that is significant given that there are few Indigenous methodologies for analysis.

Components of dementia care for rural Indigenous communities A discussion of the themes identified during the CCDAP/NAKPA process are useful for further description of dementia services needed for Indigenous older adults and their caregivers living in rural communities. These themes include: 1. Traditional Knowledge (TK)

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2. Family concerns and awareness 3. Elderly inclusion and support 4. Lack of resources and services 5. Funding/lack of funding 6. Healthcare providers’ experiences with dementia patients 7. Technology 8. Government and organizations’ involvement 9. Assessment 10. Symptoms of dementia Traditional Knowledge The community members described a definite need and interest for TK in dementia care. It was suggested that integrating TK into dementia care might result in better health outcomes. Healthcare providers spoke about the benefits of partnerships with Indigenous peoples and the inclusion of TK into dementia care and health plans. In addition, community members spoke about TK and its role in assisting memory. This included TK such as language, which is vital and can improve the wellness of people with dementia. Community members felt that there is tremendous value in embracing TK. They noted that not enough healthcare practitioners have understandings of TK. Furthermore, they pointed out that spirituality in healthcare is vital and this should also include access to traditional healing. Another type of TK that community members discussed, which may have an impact on dementia, was diet. They pointed out that changes in diet over the past decades have been damaging to the health of Indigenous peoples. They felt that traditional foods such as teas, wild game, fish, pemmican, and berries may be beneficial to brain health. Family concerns and awareness Several family concerns were raised by community members. One of the concerns discussed was how difficult it could be to see their family member who was living with dementia. They elaborated that while updates are provided by phone, more involvement with their relative living with dementia is needed. Family involvement is an important component of dementia care because family visits are critical for holistic wellness. Appropriate resources and education for families as well as the general public is required. In addition, older adults living with dementia are often concerned about being a burden.

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Elderly inclusion and support Community members have noted how important it is to avoid excluding people living with dementia. There is a need to include them in daily activities and social events as it helps in stability and memory. It was noted that being aware of their settings helps to reduce their anxiety. They also stated that older residents living in care homes and who had chronic illnesses were the priority, often leaving the people living with dementia to fend for themselves. However, it is important for healthcare providers (in care homes) to always consider the clients’ perspectives and use reality therapy to bring the patient back to present day. Lack of resources and services Community members have identified a lack of resources available for Indigenous peoples with dementia. While it is agreed that there are some programs that try to accommodate those needs, there is major diversity in these programs, resulting in missed opportunities. Barriers in access to resources and services add to the frustration for both people living with dementia and their caregivers. Furthermore, while there are resources outside of care homes, there is a lack of support and there are barriers in accessing in-home care and care on reserves. There is also an identified gap in knowledge related to types of dementia. For example, many community members have pointed out that they did not know about some or any of the services available for dementia patients, or how to access long-term care. One useful suggestion from Indigenous communities for improved care was a dementia support group. It was also suggested that there should be someone assisting people with dementia at all times. Ultimately, many felt that the care and support should be provided at home, and that the resources and services should support aging in place. Funding/lack of funding A lack of funding has been observed in some Indigenous communities. In addition, although some places and programs offer cultural programming, many do not. This imbalance often leaves people in rural communities having to either travel to access cultural programming or go without. However, general lack of funding is often observed in the area of in-home care on reserve.

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Healthcare providers’ experiences with dementia patients Healthcare providers often felt that they knew enough about services to help dementia patients and are comfortable in addressing dementia patients’ needs. They also felt that they could comfortably work with their patients in their homes. Although many of the healthcare providers had extensive training and experience working in dementia care, there were some who felt they did not have enough training about or understanding of dementia to provide proper care. In order to determine exactly what would be needed in terms of training, further inquiries are required. There is a need for more Indigenous healthcare providers, especially males. Healthcare providers spoke of creating networks with Indigenous communities to provide care for dementia patients, however, some organizations do not adapt well. It is important to have an understanding of the background of the dementia patient, and to show more compassion and love. Technology Community members often feel that technology could be useful in remote communities, especially for caregivers at home. Suggestions included alerts and monitoring available at all times for the patients and using technology as a tool to provide training. Technology could also be used by patients to meet healthcare practitioners without having to leave their homes. Technology can have an important role in assisting patients with their medication and support cognitive function and memory. Some Indigenous older adults have noted the use of technology such as music and DVDs for preventing confusion and assisting memory. There is, however, the concern that many older adults, especially older adults with dementia, may get confused while using technology. Many older adults have not had access to advanced technology, and often find devices confusing. Having more intricate technologies could confuse them further, adding undue stress and deterring technology use. This is evidenced by some older adults becoming confused with e-health, leading them to avoid this useful service. Government and organizations’ involvement According to the Saskatchewan MLA Warren Kaeding, the minister in charge of seniors’ issues, the aging population is a top priority.

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However, community members often feel that dementia has not been an important issue for government. Furthermore, community members have described the need for a bridge to connect Indigenous research with organizations and institutions and to fuse TK with research. It has also been noted by Indigenous communities that organizations put more energy into critical care than into coping with a diagnosis and treatment. Assessment There is often a client assessment, which is followed by a referral to a physician. Assisting patients to get referrals to specialists and clinics is important. Participants noted that there is a stigma that delays diagnosis. Formally assessed dementia patients are more likely to go into acute care. Some participants who are also healthcare providers spoke about prioritizing based on need. Sometimes the testing and diagnostics are explained to patients. Participants also felt that holistic assessment is important, both Western and TK. It was found that some patients experience racism at events for dementia patients. Some participants suggested using humour to assess dementia patients, and appropriate assessment tools help ensure cross-cultural care. Symptoms of dementia Participants expressed that the family notices symptoms of dementia first, although they might not realize that the cause is dementia. Only some of the participants knew that the symptoms are related to dementia. They thought that it is important to identify the causes of confusion in dementia patients. Participants talked about causes for dementia related to lifestyle such as drinking alcohol, having type-2 diabetes, and smoking. Some have noticed that there is a stage of dementia that affects eating. Some dementia patients show aggression. It was mentioned that senior-tosenior violence has occurred.

Conclusion It is often assumed that the perspectives of caregivers of people living with dementia would be generally negative, however, research has shown that many caregivers actually maintain positive outlooks while they care for family or community members. Familial relationships

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show that people are often happy and see it as their obligation that they can take care of loved ones themselves, rather than someone else not related to the family or community at all. The data identified technology use as a way to age in place. Access to technology varies according to demographics but most communities face issues around accessibility and readiness. Research has identified certain possibilities for the use of technology to explore the impacts of Indigenous cultural factors. The protection of TK is critical to this exploration. Culturally relevant technology use is also key. Indigenous communities want to become more familiar with technology such as mobile apps, web-based applications, and use of devices such as tablets to mobilize knowledge for individuals living with dementia and their caregivers. Acknowledgements We would like to acknowledge that the research conducted in this project was done in Treaty 4 Territory; home of the Cree, Saulteaux, Dakota, Lakota, Nakota, and homeland of the Métis. Morning Star Lodge entered into a research agreement with the File Hills Qu’Appelle Tribal Council (FHQTC), who assembled a Community Research Advisory Committee (CRAC) of representatives from their communities, these individuals included Ethel Dubois, Judy Sugar, Sylvia Obey, Lois Dixon, Natalie Jack, Lorraine Walker, Millie Hotomani, Orval Spencer, Leona Peigan, Rozella McKay, Roxanne Quewezance, Rhonda Van  Der Breggen, Mindy Koochicum, Glenda Goodpipe, Bonnie Peigan, and Melissa Blind. Their direction and dedication to this project was instrumental in its success. As always, the research that we engage in is for the community and is by the community.

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Muttitt, S., Vigneault, R., and Loewen, L. (2004) ‘Integrating telehealth into aboriginal healthcare: the Canadian experience’, International Journal of Circumpolar Health, 63(4): 401–14. Pace, J. (2013) ‘Meanings of memory: understanding aging and dementia in First Nations communities on Manitoulin Island, Ontario’. Ph.D. dissertation, University of Waterloo, Waterloo, ON. Pitawanakwat, K., Jacklin, K., Blind, M., O’Connell, M.E., Warry, W., Walker, J., McElhaney, J., Pitawanakwat, B., Smith, K., LoGiudice, D., and Flicker, L. (2016) ‘Adapting the Kimberly indigenous cognitive assessment for use with indigenous older adults in Canada’, Alzheimer’s and Dementia, 12(7): 311. Raven, M., Butler, C., and Bywood, P. (2013) ‘Video-based telehealth in Australian primary health care: current use and future potential’, Australian Journal of Primary Health, 19(4): 283–6. Romanow, R. (2002) ‘Building on values. The future of health care in Canada’. Available from: https://qspace.library.queensu.ca/bitstream/ handle/1974/6882/BuildingOnValues.pdf?sequence=5. Smith, K., Flicker, L., Lautenschlager, N.T., Almeida, O.P., Atkinson, D., Dwyer, A., and LoGiudice, D. (2008) ‘High prevalence of dementia and cognitive impairment in Indigenous Australians’, Neurology, 71(19): 1470–3. Statistics Canada (2017) ‘Aboriginal peoples in Canada: key results from the 2016 Census’. Available at: https://www150.statcan.gc.ca/ n1/daily-quotidien/171025/dq171025a-eng.htm. Vanleerberghe, P., De Witte, N., Claes, C., Schalock, R.L., and Verte, D. (2017) ‘The quality of life of older people aging in place: a literature review’, Quality of Life Research, 26(11): 2899–2907. Webkamigad, S.C.M. and Jacklin, K. (2016) ‘Dementia health literacy among First Nations people in Ontario: integrating western and Indigenous understanding’, Alzheimer’s and Dementia, 12(7): 1006–7. Wilson, K. and Cardwell, N. (2012) ‘Urban aboriginal health: examining inequalities between aboriginal and non-aboriginal populations in Canada’, The Canadian Geographer, 56(1): 98–116. Young, T.K., Ng, C., and Chatwood, S. (2015) ‘Assessing health care in Canada’s north: what can we learn from national and regional surveys?’, International Journal of Circumpolar Health, 74(1): 28436.

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Indigenous community vignette Larry McDermott As an individual who has lived in the same place for 50 years, my relationships with the living community around me have changed. In the last ten years, there has been so much change happening – some good, some not. Much of my work has been in the arena of environmental stewardship and ‘conservation’, including engaging with Indigenous law and the commitments made in treaties between Indigenous nations and settler governments in order to protect the land and the people who depend on that land. Even though I am often thinking about the wellbeing of my Algonquin community, our responsibilities globally as Indigenous peoples factor into community wellbeing on a local level, through honouring all of life, all of creation, and the fact that we are all connected. International success and cooperation have an impact on the health and wellbeing of Indigenous peoples locally. I recently gave a guest lecture at Trent University, and talked to the class about fishing in the St. Lawrence before the seaway was built. I’ve watched these sorts of changes happen, these big projects. To me, it’s part of the patriarchy – you have big egos, with big projects, running over anyone in their way, including Indigenous communities. At one point, in the late 1980s or so, there were plans to put a giant power transmission line right through this property (where Plenty Canada is located), and I was part of the activism that stopped that. People are generally powerless to stop these kinds of projects, though. There are so many hydro dams, for example – how much life do they wipe out? There is no offsetting that. I have watched the socio-economics of this area rapidly change. It used to be that if you needed to raise a barn or put up a new roof, the whole neighbourhood would come and help. I remember there was less equipment around – there was still a lot of horse farming. There was also a safety net; people looked after each other. There was a lot more functional human interaction. There might be one combine harvester in the area that just went around to everyone’s farm. The more that people were able to achieve economic independence

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through buying their own equipment, the more we became alienated from each other. I used to know everyone around here. Now I know only one or two families out of 20 in the immediate area. In this area change hasn’t come as fast as in other parts of North America, but there has still been dramatic shift in the way that we interact with each other. With respect to health, when I came to this area, we had house visits from doctors. That service doesn’t exist anymore. Besides that, you had your doctor, you had nurses in hospitals, but there were people who knew about bush medicine, and they knew it well. There were a lot of home remedies. My brother Fran was our medicine person – he knew the medicines so well, we would walk the land together and see the impacts of different changes on the plant medicines growing there. There aren’t as many people around anymore who know the medicines the way he did. I’m in my 70s now, and in terms of services, I’m not confident that I’ll get much more than support for physical illnesses and injuries. Institutional structures and services for seniors around here are not comfortable with diversity. As an Indigenous senior, I had a meeting with someone in a senior position at the health clinic about how they can serve Indigenous people better, and I really felt like I wasted my time. I never got any feedback. People are often confused about engaging with Indigenous peoples. There are a lot of checkboxes to tick off, and people feel they have to be seen to be engaging with Indigenous communities, but they’re not really ready to make lasting changes, and the capacity and education aren’t there. I wonder what percentage of people in this area know that residential schools ever happened, for example. That ignorance then affects policy; it affects services; it affects the delivery of those services. As an older Indigenous person, you have to find other ways to thrive. When it comes to socialization and culture for seniors, the ability to get together, have fun, and share culture in a social atmosphere is so important. In rural areas we are fortunate to have township halls and agricultural societies, but they’re deeply rooted in settler culture. They haven’t changed much since the pioneers showed up. As hard as I worked in the years that I was serving on local and county council, that still hasn’t really changed. When my daughter was killed, we brought the women’s drums to the township hall, and we honoured her in our own way, but it was hard and I’m not sure that they would allow us to do that again. It’s the same with funeral homes – we have done smudges, but often it has to be outside. If I pass away, how would my family handle that in a way that honoured who I am, and who a

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lot of my friends are? As much as possible I try to do things on the land, and I think about it a whole lot – more than ever as I get older, and for a lot more people than myself. I see some small openings, such as a land acknowledgement commitment being undertaken by a local township council. The council has been very open and respectful, and the acknowledgement involves more than just acknowledging Algonquin historical occupancy of the land – it incorporates prior commitments and responsibilities of local government based in treaties and wampum agreements that need to be upheld. It’s important, also, to think about youth. I sit on the Indigenous advisory committee for the school board here. In Indigenous communities you see lots of intergenerational activities and events – pow wows, for example. In May 2020, Plenty Canada provided a venue for the school board to do land-based learning through iLead, an Indigenous land-based learning program. There is a new recreation plan in Perth (a town nearby), and a staff member who was co-ordinating that plan interviewed me, but I don’t think it will go anywhere. Interviews are better than nothing, but over the last ten years I’ve done a lot of that type of interview, and yet things more or less stay the same. I just think, when it comes to the municipal infrastructure that we have here, accommodating Indigenous peoples is not the council’s first thought. When you’re talking about aging – and I don’t want to lose sight of youth – it comes back to building infrastructure. We need to do recreational planning and land use planning that are welcoming to and supportive of the first relationship that Europeans had here – with Indigenous peoples. I will end this chapter on a positive note. I was part of the National Advisory Panel working to implement Canada’s conservation targets – targets aligning with commitments made at the Convention on Biological Diversity that was held in 2010 in Nagoya, Aichi Prefecture, in Japan. Those responsible for upholding Canada’s commitments realized that success lies in working together with Indigenous communities, through Indigenous Protected and Conserved Areas (IPCAs), as well as other Indigenous-led initiatives to protect the land and waters. In 2017, myself and Blackfoot cultural and spiritual adviser, Elder Dr. Reg Crowshoe, conducted a pipe ceremony as part of launching the Pathways One process leading to recommendations of the National Advisory Panel and the Indigenous Circle of Experts, and setting the tone for the creation of ethical space throughout the process of meeting Canada’s conservation and biodiversity targets. This ceremony brought Indigenous leaders together with people

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working within federal, provincial, and territorial governments in a space of remarkable openness towards Indigenous knowledge systems and respect for the land. Together, we were able to create an ethical space of engagement where Indigenous peoples, ways of learning, and knowledge systems came together in a safe environment to discuss solutions as equals with federal and provincial ways of knowing and concepts of ‘conservation’, in order to find ways to bring about real solutions to protect the land and water and all those who rely on them for life. The methodologies of engagement that we worked on throughout this process also have local applications. The more we are able to create these ethical spaces in our own lives and communities, the better chance we will have at creating just and sustainable futures, for older people and for all generations.

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Métis older adults and the negotiation of nativeness John Lewis By now, most community planners and local government decision makers are acutely aware of the changing demographic character of North American communities and of the challenges that this change represents for community services and physical infrastructure. In brief, the retirement of the baby boomer generation has already begun, and in just two decades it is projected that 20% of the North American population will be 65 years or older (Menec et al, 2015; Statistics Canada, 2019). In response, the Age-Friendly Communities (AFC) movement has acquired considerable policy and research traction since its launch by the World Health Organization (WHO) in 2007 (World Health Organization, 2007). Beginning in 2013, the Province of Ontario has made several incremental efforts to expand its AFC policy efforts based on three linked strategic policies and investments – that is, the launch of the Finding the Right Fit Age Friendly Communities Planning Guide, the Ontario AFC Planning Grants Program, and funding for an AFC Outreach and Community Support Program (Ontario Seniors’ Secretariat, 2013). Despite growing attention to the needs of older adults throughout Ontario for nearly a decade, consideration of the needs of Indigenous (ie First Nations, Métis, and Inuit) peoples has been conspicuously absent in recent provincial and municipal AFC research, community engagement, and policy activities (Health Council of Canada, 2013; Ramage-Morin and Bougie, 2017). Where there has been consideration and inclusion of Indigenous voices in local AFC initiatives, those voices are largely represented by First Nations peoples and organizations. This is often based on the assumption that Indigenous perspectives are broadly similar and can be ‘captured’ by First Nations representation, or that other Indigenous peoples and communities such as the Métis do not exist throughout much of Ontario. A key premise of Ontario’s Finding the Right Fit guide is that AFC planning ought to reflect and respond to the circumstances of

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communities at the local level. In other words, Ontario is a very large territory and the needs of older adults are likely to vary considerably between communities such as Kenora and Kingston. Moreover, the methods and criteria that are used to evaluate communities that are separated by considerable geographic, economic, and cultural differences, ought to reflect local needs and perspectives. Recent efforts by a handful of Ontario local governments to engage with Indigenous communities and organizations in their AFC planning activities reflects Finding the Right Fit’s call for more nuanced AFC planning. However, the absence of Métis voices from these processes is particularly concerning. The need for Métis voices in Ontario’s AFC planning is no less significant and perhaps of greater urgency for the province’s Métis people than its non-Indigenous (settler) population. For instance, rates of chronic illness such as arthritis, cancer, and cardiovascular disease are increasing among Métis older adults and are more prevalent than among the older adult First Nations and settler populations (Wilson et al, 2011; Foulds et al, 2013; Statistics Canada, 2017). In addition, settler healthcare providers often do not appreciate how culture and health are inextricably linked. For Métis older adults, seeking culturally appropriate health services can often lead to frustration with and withdrawal from service delivery when their identities and traditions are either treated as synonymous with those of First Nations peoples or challenged and dismissed outright. This chapter presents work that has advocated for and seeks to develop a greater level of nuance in Ontario’s AFC planning. It supports the provincial and federal governments’ respective calls for greater recognition of Ontario and Canada’s considerable cultural diversity, and the need for Indigenous voices in AFC planning in particular to reflect the perspectives and needs of older Indigenous peoples. However, based on conversations with older adult citizens of the Métis Nation of Ontario (MNO), it challenges the mostly inadvertent but sometimes deliberate erasure of Métis identity and voices from recent conversations about how to address the well-being of Ontario’s diverse and rapidly aging population.1

Who are Ontario’s Métis people? In general terms, the aging of Canada’s population has been extensively documented, however, the challenges of aging among Métis people have received much less research and policy attention than First Nations and Inuit communities and settler populations in

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particular (Anderson et al, 2017; Cooper et al, 2019). Within Ontario, there are approximately 20,000 people who self-identify as Métis, are registered as citizens within the MNO, and are recognized by the federal and provincial governments as one of three ‘Aboriginal peoples of Canada’ under section 35 of the Constitution Act, 1982. Precisely who Ontario’s Métis people are, their origins, and their experiences of racial exclusion by settlers and other Indigenous people has significant implications for understanding whether Métis older adults feel supported through community-led AFC initiatives. Since 2004, the MNO has defined Métis people as ‘a distinct Aboriginal people with a unique history, culture and language and territory that includes the waterways of Ontario, surrounds the Great Lakes and spans what was known as the Pacific Northwest’ (Métis Nation of Ontario, 2019a). The Métis are descended from people who were born from mixed marriages between European men largely engaged in the fur trade and First Nations women in the late eighteenth and nineteenth centuries. Indeed, the word Métis has its roots in the French adjective that describes someone who is ‘mixed’ or of ‘mixed blood’, which is largely the basis for contemporary (mis)conceptions and confusion surrounding Métis identity. As Métis scholar Brenda Macdougall argues, the ‘product of being mixed really has nothing to do with Métis identity’, as the progeny of those first unions between Indigenous and European people did not self-identify as Métis and nor were they identified as such by settler society (Macdougall, 2017; Canadian Broadcasting Corporation, 2019). Born into the fur trade, subsequent generations of mixed-ancestry people intermarried with one another and formed distinct communities along the upper Ottawa River and Upper Great Lakes region extending into what would become the prairie provinces (Peters et al, 1991). Based on his review of Métis history in Ontario, Driben notes that within the Southern Great Lakes territories of the Iroquois Confederacy, the children that were born from relationships between French or Anglo/Scottish fur traders and Indigenous women were likely adopted directly into Native society (Driben, 1987). In effect, membership within Iroquoian society was established through matrilineal lines and, to the extent that their mothers were ‘Indian’, so were their children. However, further north in Algonquin, Anishnaabeg, Cree, and Assiniboine communities, cultures that were predicated on patrilineal descent meant that the offspring of European fathers and Indigenous mothers could not be recognized and included within the community. Neither were they to be embraced by the dominant European society. Separate communities

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were formed based largely but not exclusively on the fur trade and over time the hallmarks of a culture emerged that was characterized by a unique language (ie Michif), a spirituality that has been referred to by some as a form of folk Catholicism, seasonal rounds and economic relationships that became the foundation for a collective history and identity. As Jacqueline Peterson posits, Métis people are more than the product of their blood quantum (Peterson, 1978). What has come to be Métis culture and the Métis homeland is the expression of over two centuries of ethnic and cultural evolution that is neither First Nations nor European, rooted in the Upper Great Lakes region of Ontario and which moved by necessity into the Canadian West (Desmarais, 2013). Ontario’s contemporary Métis citizens includes anyone who is able to demonstrate through valid genealogical documentation that they are descended from Métis ‘root ancestors’ who resided within the historic Métis homeland (ie the Upper Great Lakes and Western Prairies). ‘The MNO also emphasizes that the mere identification of a mixed Aboriginal ancestry individual in the historic record does not make that individual a Métis…’ (Métis Nation of Ontario, 2019b) Nonetheless, there are many who inappropriately self-identify as Métis based largely on the (real or possible) existence of a First Nations or Inuit relative or ancestor, and can demonstrate no connection to Métis root ancestors, culture, or communities. In part this confusion exists and will likely persist because Métis identity continues to be conflated with notions of ‘mixed blood’ and challenges Métis people continually to redefine their identity in terms of a collectively held history and culture. Beyond the contemporary confusion that underpins notions of Métis identity, from the perspective of the Crown, the fixation on blood quantum as the hallmark of Métis identity has historically been considered an essential step towards assimilation. In the midnineteenth century, the Canadian government began to distinguish different classes or types of Indigenous people, which tended to view the Métis as less than authentic ‘Indians’ because of their diluted bloodline (Green, 2011). Under the British North America and Indian Acts, control of Indigenous peoples was maintained through identity regulation, which artificially divided Indigenous peoples into three distinct cohorts with differing claims to rights and recognition from the Canadian state. These artificial divisions not only created inequitable

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policies towards Indigenous peoples, but also laid the foundation for unequal power relations, racism, and competition between Métis, First Nations, and Inuit peoples. From the Crown’s perspective, mixedblood people challenge the boundaries of authority and threaten European supremacy in several ways. In effect, Métis people could pass as or be indistinguishable from Europeans, which could be leveraged fraudulently to obtain the privileges of whiteness. Conversely, Métis indigeneity represents a challenge to First Nations’ prerogatives to land and natural and social resources, as well as larger conceptions of who is entitled to be considered ‘first peoples’ (Teillet, 2013). As such, in the mid-nineteenth century, Crown representatives refused to negotiate treaties with the Métis because they were ‘too white’ to be considered Indigenous (Logan, 2015). In effect, as mixedblood people who were excluded from membership in ‘Indian’ communities, the Crown eliminated any need for treaty negotiation and elected instead to address questions of Métis land entitlement on an individual basis (Macdougall, 2017). Métis people were regarded as being effectively on their own – that is, not part of a community or a nation – and were offered land in the form of ‘scrip’, which was a legal document issued by the Canadian Department of the Interior that could be exchanged for land (Desmarais, 2013). Depending on the type of scrip received, it could be redeemed by the holder either for cash or for land. Due to poverty and the location of scrip land at considerable distances from Métis settlements, many chose to sell their scrip with more than half of the land certificates issued returning to the federal government’s ownership. Since Métis people have largely been portrayed by government and the larger settler society as little more than miscegenized white people, the Crown has refused to negotiate and engage with Métis as a community and more particularly as a legitimate nation on equal terms with their First-Nations cousins. Ultimately, this negation of Métis as a people has compromised their ability to secure collectively a land base from which they could address their material and spiritual needs. Despite persistent denials of indigeneity, Métis communities were unprepared for the Canadian government’s contradictory imposition of the residential school system on Métis children in the latter half of the nineteenth century (Chartrand et al, 2006). Funded by the federal government and enforced by Christian churches, residential schools were primarily intended to alienate First Nations and Inuit children from land, language, spirituality, and community to begin the enterprise of forced assimilation. For the Canadian government, residential schools included Métis children in order to complete the process of

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biological assimilation by breaking the traditional extended family structures that had become a foundation for their cultural, spiritual, and physical wellbeing, which was in turn grounded in the lands that they could no longer call theirs. For settler society at that time, the material and cultural support that was available through cohesive Métis families was regarded as a type of collectivization that was not sanctioned by the state and rooted in extreme poverty, which did little to enhance the health and education of Métis children (Chartrand et al, 2006). Precisely how many Métis children experienced the residential school system until the last school’s closure in the mid-1990s is unknown, as neither the federal government nor the churches have maintained records specifically pertaining to Métis students. However, based on the oral testimony of former Métis students, it is well established that they experienced considerable cultural alienation and abuse (Health Council of Canada, 2013). The legacy of residential schools continues to resonate through Métis communities as contemporary survivors contend with the loss of culture, spirituality, and mental trauma. This is significant not only to appreciate the experience and needs of aging residential school survivors as many regard moving away from home or community into a retirement residence as reliving their childhood experiences. However, it has impacted their descendants as well, who struggle to reconnect with an increasingly distant culture, disparate network of family relationships, and abuse that they endured from psychologically traumatized survivor parents. For the Métis, the Canadian government’s narrative of Indigenous authenticity continues to be reflected in legal and policy frameworks (Beatty and Berdahl, 2011). The categorical distinctions reflected in the Constitution between Aboriginal peoples are also firmly entrenched into the Canadian state’s legal framework and the consciousness of both settlers and First Nations, with the balance of influence in the Indigenous political arena tipped towards those regarded as ‘Indian’ under the Indian Act. While the federal government assumed jurisdictional responsibility for ‘Indians’ and eventually accepted the same responsibility for the Inuit, it has historically denied jurisdictional responsibility for Métis people, declaring them to be the responsibility of the provinces (Macdougall, 2016). Métis people have only recently been recognized as a federal responsibility, but they remain largely entitled to receive the same provincial services as all other Canadians (Gaudry and Andersen, 2016). The health needs of Métis people generally are not well understood, and there is even less research and policy attention that has been directed towards the needs of Métis older adults. In part, this is a reflection of the gap

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in health policy and programming where the federal government has not collected data because the Métis have not historically come under their jurisdiction, and the provinces have not collected data because they are constitutionally recognized as Aboriginal people and are therefore considered to be under Ottawa’s purview. In addition, many researchers and policymakers continue to define Indigenous peoples as a demographically singular and largely young population and consequently focus on the health and wellbeing challenges that younger First Nations people face. As an Indigenous people with the largest and fastest-growing population of older adults, the distinctiveness of Métis culture, resistance to Métis identity and selfdetermination, disruptions to cultural continuity, and restricted access to culturally appropriate resources are all factors that warrant a specific consideration of the needs and determinants of successful aging for Métis older adults.

Understanding the Métis perspective The significance of AFC planning for Ontario’s Métis people is growing. As the proportion of Métis older adults is projected to increase over the next decade, geographic isolation and the diminished capacity of traditional family and community relationships to provide culturally relevant and safe care challenges the ability of Métis older adults to age well and age in place. Moreover, as Ontario’s local governments strive in greater numbers to address the aging of nonIndigenous residents, they are turning in greater numbers towards the use of frameworks developed by the World Health Organization and/or the Finding the Right Fit guide prepared by the Ontario Ministry of Seniors’ Affairs and Accessibility (MSAA). To support the development of local age-friendly action plans and evaluate the Finding the Right Fit planning framework, the Ontario government provided funding to 53 municipalities to support their planning and community engagement work. Of the municipalities that received funding, three actively engaged with Indigenous communities and organizations, only two of which were Métis community councils located in Ontario’s north. From the author’s interaction with a handful of AFC project leads, the lack of Métis engagement reflected a general lack of knowledge regarding the presence of Métis community councils throughout Ontario and within their particular jurisdictions. Established frameworks such as Finding the Right Fit do not direct community planners and decision makers to reach out to Indigenous communities and organizations. To address this omission, between

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2017 and 2018 the MSAA began a series of engagement meetings with the Métis Nation of Ontario to build Métis voices into the Finding the Right Fit framework through two community engagement sessions. The first was to convene an initial ‘scoping’ meeting led by the author – a Métis citizen, community planner, and age-friendly researcher – with senior MSAA and MNO staff and Métis senators to discuss and establish the need for a Métis perspective in the province’s AFC framework and municipal action plans. The scoping meeting was intended to be a learning/discovery process where representatives from both governments would discuss their respective interests and needs for age-friendly community planning and obtain direction from the MNO regarding the nature and timing of future engagement meetings with MNO citizens. From this meeting, it was determined that the MNO would like to see greater recognition of the distinctive needs of Métis older adults and consideration of those needs in the province’s AFC framework and municipal action plans. From this came the second engagement event which comprised a meeting of Métis older adults from community councils throughout Ontario. The second meeting was held in early 2018, where 30 Métis older adults attended to learn about the province’s definition of and strategies for age-friendly community planning and, more particularly, to discuss the quality-of-life challenges that the Métis participants encountered as they have aged. From this discussion, three broad themes emerged that partially reflect the challenges that older adults encounter generally, but which largely capture the Métis experience. Service accessibility Of the WHO’s eight domains that describe an age-friendly community, the participants underscored Transportation, Housing and Community Support, and Health Services as being the most salient to their needs: ‘We have small outlying areas that don’t have access to transportation and that is one of the biggest problems, to get people to the services needed, such as doctor’s appointments.’ (Métis engagement meeting participant) Access to medical and specialized medical services in particular can be a significant issue for any older adult living in rural or remote areas of Ontario. A large proportion of MNO citizens reside in Ontario’s north and near north where diminished access to local and regional

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transportation networks can challenge the capacity of older adults to reach medical services, as well as their ability to travel to community events and participate in the social fabric of the Métis community. Social engagement is an important factor for maintaining or enhancing the quality of life of older adults. Whenever possible, Métis citizens will step into the rural transportation services gap, either informally as friends, or more formally through voluntary service arrangements with Métis community councils. The challenges of accessibility were expressed not only in terms of transportation availability, but also in terms of the ease with which Métis older adults obtain information about provincial and local government programs and services. The issue is that multiple agencies representing different levels of government are providing information about older adult services with the consequence that potential clients become lost in an information maze that confuses or fails to reach the intended audience: ‘I hear that such and such service is offered by the government. The problem is I can’t figure out how to get information about it or, when I do get a live human being, they don’t seem to know what I’m talking about or who the right person to talk to is.’ (Métis engagement meeting participant) Effective communication of information about services and events is a key means for older adults to maintain crucial social bonds. For several of the participants in the community engagement meeting, effective information communication means relying on trusted and established sources, which largely comprise family and community networks that disseminate information by word of mouth, as well as relying on MNO community council staff. Cultural suppression ‘There is a legacy to the abuse and mistreatment that has not only been inflicted on the present generation, but through our parents and grandparents. What was done to them has been passed down and still affects people today.’ (Métis engagement meeting participant) Along with First Nations and Inuit peoples, the history of Métis people with settler society encompasses a legacy of forced assimilation and

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near cultural erasure. Government funded and church-led residential and day schools were the clearest expression of a systematic assault on Métis, First Nations, and Inuit cultures as children were separated from families to be stripped of language, culture, and relationships. In addition to the physical and psychological trauma associated with residential schools, generations of Métis people have suppressed their identity due to the shame that has been associated with rejection or social exclusion by both the dominant European culture, as well as by First Nations. In effect, to be Métis has historically meant to be something less than or inferior to settler Canadian culture, and at the same time ‘too white’ to be considered authentically Native. Meeting participants recounted experiences of physical violence in their youth, as well as social and economic exclusion from the life of their local communities: ‘Where I grew up was mostly a white community but there was a reserve just outside of town. We didn’t fit in with either. One saw us as dirty half-breeds while the folks from the reserve didn’t think of us as Native enough. It was tough but we just thought “screw ’em, we’ll just mix with our own.”’ (Métis engagement meeting participant) The consequences of cultural repression and violence have had profound impacts on the mental health of Métis older adults who have lived through the worst expressions of cultural genocide. Moreover, that legacy has been passed to younger and future generations of Métis (intergenerational trauma). In effect, the depression, anxiety, and aggression that manifests from experiencing and attempting to cope with cultural repression can have profound and negative consequences for the children and grandchildren of Métis older adults: ‘I didn’t grow up with that much bigotry, but you could see how it affected my dad and it eventually got to us too. He took a lot of the frustration that he must have got from the abuse as a kid out on us.’ (Métis engagement meeting participant) Contemporary expressions of cultural suppression are less overt but nonetheless remain deeply engrained in interactions with Métis people. For instance, there is a deep and pervasive misunderstanding within settler society about who Métis people are, particularly in relation to other Indigenous peoples, which can be commonly expressed and

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encountered by Métis older adults in one of two ways. First, it can occur when a Métis older adult presents themselves to a health or social services provider and self-identifies as Indigenous or Aboriginal. From the participants at the engagement meeting, self-identification can result in being told either that ‘you don’t look native’ or ‘that doesn’t count’: ‘I’ve given up asking for services when I’ve been into the hospital because I’m Métis. If you don’t have the look, and I mean you pass as white, you’re either going to get ignored or called out for being a wanna-be.’ (Métis engagement meeting participant) On other occasions where the service provider intends to provide cultural support, a First Nations Elder is contacted and introduced to a Métis older adult. From the perspective of Métis people, the prevalent settler conception of Métis identity is that they are fundamentally a people of mixed Indigenous origins who therefore ought to grasp and relate to the traditions and worldviews of First Nations people. However, to be Métis is to belong to a unique culture. The expectation of Métis people is that they will be acknowledged and respected for being an Indigenous nation but not one whose culture is synonymous or interchangeable with another. In whatever form cultural suppression is manifest, the perpetual denial or misapprehension of that culture precludes Métis older adults from access to the expressions of their culture – For example, language; art, music, and dance; food and spirituality – that can enhance their wellbeing as they age. Self-determination and governance ‘It’s a challenge to have faith in institutions and governments that have either not recognized who you are or, when they do, try their utmost to erase it and turn you into something else.’ (Métis engagement meeting participant) A legacy of cultural repression and, more recently, cultural misapprehension affects the relationship between Métis people and the non-Indigenous institutions and service providers that ostensibly exist to address their needs. The typical solutions offered to address deeply entrenched racist attitudes and/or cultural ignorance include awareness training for service providers and more engagement with Métis communities to influence age-friendly action plans and

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seniors’ strategies as they are developed by settler local governments. Communicating and engaging with Métis people and community councils to address the needs of older citizens is a desirable, albeit partial, means of building cultural understanding and developing planning documents that reflect what it means to be a Métis older adult. However, the scepticism that exists towards settler governments runs deeply within the broader Métis consciousness. Ultimately, the most appropriate people to be developing and delivering culturally appropriate services to Métis older adults are others ‘who share that identity’ (Weaver, 2001, p 245): ‘We always used to look after our own and that’s the way it needs to be moving forward. Our people need to be given the resources to be able to provide services and look after our own seniors, not somebody in a government office who hasn’t got a clue or care about us.’ (Métis engagement meeting participant) The hope and expectation is that Métis community councils and aging-at-home service providers employed by the MNO will be empowered to work actively with their counterparts in municipal and provincial agencies to deliver and evaluate the programs that are provided to older citizens. However, well before any form of joint planning and service delivery can be realized, acknowledging the presence of Métis communities throughout Ontario and building meaningful communication remains a missing and essential first step. Building cultural understanding and a more nuanced appreciation of the needs of Métis older adults is a gradual process, one that ought to be premised on placing those who best appreciate the experiences and needs of Métis older adults in a more central planning and serviceprovider role.

Discussion There are three challenges associated with the development of an AFC planning framework that reflects the needs of Métis older adults. The first is the need to depart from monolithic cultural and ethnic constructs such as ‘Indigenous’ or ‘Aboriginal’ in policy and research discourse, which reflects a settler mindset that denies the vast cultural diversity that exists both between and within Métis, First Nations, and Inuit communities (Chretien, 2008; Brooks-Cleator et al, 2019). Implicitly, it is a denial of diversity of artistic expression, linguistic and

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regional differences, and the social, political, and economic experiences of alienation that have existed historically and continue into the present. In brief, for Métis, First Nations, and Inuit older adults to feel respected and recognized in the community, a pan-Indigenous one-size-fits all approach to aging well initiatives is inappropriate, as Métis, First Nations, and Inuit peoples all have distinct identities and experiences that shape their needs and preferences. The second challenge comes from the usual refrain made in policy recommendations that more consultation and engagement ought to occur between local governments and Métis community councils to capture the needs and preferences of their older adults. As a first step, building recognition and acceptance of the diversity that exists between Métis, First Nations, and Inuit peoples can only be obtained when there is meaningful engagement that occurs through direct dialogue and regular communication. Precisely what ‘meaningful’ engagement entails will depend on a community’s prior experience with policymakers and researchers who have sought to obtain data from community members or garner feedback to new policies and the legacy of (mis)trust that those experiences have left with a community. In general terms, however, it is safe to assert that meaningful engagement among Métis communities and decision makers needs to be a relationship-building process that takes considerable time to cultivate trust. In other words, meaningful engagement does not entail inviting Métis community council representatives to attend occasional age-friendly steering committee meetings, with the expectation that engagement and dialogue will cease once a plan or strategy has been crafted. Moreover, meaningful engagement is built on the recognition that Métis (as well as First Nations or Inuit) representatives are not just one more stakeholder or voice that is entitled merely to influence decision making. As a rights-bearing people recognized by the Canadian Constitution (Gunn, 2015), the expectation is that engagement will occur on the basis of government-to-government dialogue and shared decision-making, and that Métis governments have the right to lead or directly influence decisions that will impact the wellbeing of their citizens. The third and perhaps more intractable challenge comes from addressing the racism that is rooted in questions of Métis authenticity as a people that are Native to Canada. Racialization and the process of creating categories of people with impenetrable boundaries has historically been used to alienate Métis people from lands and families and continues to find expression through the federal government’s assumption of a fiduciary duty for ‘Indians’ and Inuit people (Beatty

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and Berdahl, 2011; Macdougall, 2016). Artificial racial distinctions imposed through Canadian federalism have created the conditions for inequitable access to healthcare and services among people recognized as Aboriginal through the Constitution, which served to exacerbate marginalization and suffering, particularly among Métis older adults. These circumstances will likely change as the Canadian Supreme Court has affirmed that Métis and Non-Status Indians are ‘Indians’ under the Constitution and that the federal government’s fiduciary responsibility extends to them as well (Gaudry and Andersen, 2016). The most challenging factor, however, will continue to be the expressions of racism that lead to Métis older adults feeling misplaced or unwelcome as they seek access to programs and services that are intended for Indigenous seniors. For the foreseeable future, Métis people will continue to negotiate their identity, which partly involves resisting prevailing conceptions about the authenticity of the Métis as an Indigenous or Native people because their culture, biology, and physical appearance do not align with dominant discourses about what it means to be Native (Lawrence, 2004). More engagement and cultural awareness training to confront colonial racial assumptions on the part of caregivers, service providers, and decision makers are partial responses that will likely bear limited fruit. A more appropriate response would be to recognize the traditional value that Métis people placed on the family and extended kin networks. Within Métis culture, it has been the tradition for grandparents to ‘adopt’ their grandchildren, with the latter assuming responsibility for their grandparents’ care and wellbeing when they become adults (Hourie and Carrier-Acco, 2006). Family, community, and culture have historically been the foundation of what it means to successfully age among Métis older adults. Policy that recognizes and provides the autonomy to Métis governments to build on this foundation is both necessary and timely as federal and provincial Canadian governments move both to address the challenges of an aging population and to dismantle racial colonial structures. Note 1

In addition to Métis, First Nations, and Inuit, the terms Indigenous, Aboriginal and ‘Indian’ are used in various places in the chapter. I refer to ‘Indian’ with quotation marks to reflect the historically inaccurate use of the word, which was applied to the peoples of North America on and following European contact and contained within the Canadian federal government’s Indian Act, 1985. The term Aboriginal is used when reference is made to the Canadian constitution, and Indigenous as it is commonly used in current policy and academic discourse. As stated in the discussion portion of the chapter, in broad terms, the first peoples of Canada ought to be referred to as First Nations, Métis, and Inuit.

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References Anderson, S., Copeland, J.L., and Currie, C.L. (2017) ‘Community belonging and sedentary behaviour among Métis Canadians: a gendered analysis’, International Journal of Indigenous Health, 12(2): 3–14. Beatty, B. and Berdahl, L. (2011) ‘Health care and Aboriginal seniors in urban Canada: Helping a neglected class’, The International Indigenous Policy Journal, 2(1): 1–16. Brooks-Cleator, L.A., Giles, A.R., and Flaherty, M. (2019) ‘Community-level factors that contribute to First Nations and Inuit older adults feeling supported to age well in a Canadian city’, Journal of Aging Studies, 48: 50–9. Canadian Broadcasting Corporation (2019) ‘Métis means much more than “mixed blood”’. Available at: https://www.cbc.ca/radio/ unreserved/from-scrip-to-road-allowances-canada-s-complicatedhistory-with-the-m%C3%A9tis-1.5100375/m%C3%A9tis-meansmuch-more-than-mixed-blood-1.5100783. Chartrand, L.N., Logan, T.E., and Daniels, J.D. (2006) Métis History and Experience and Residential Schools in Canada, Ottawa: Aboriginal Healing Foundation. Chretien, A. (2008) ‘From the “Other Natives” to the “Other Métis”’, The Canadian Journal of Native Studies, 28(1): 89–118. Cooper, E.J., Sanguins, J., Menec, V., Chartrand, A.F., Carter, S., and Driedger, S.M. (2019) ‘Culturally responsive supports for Métis Elders and Métis family caregivers’, Canadian Journal on Aging/La Revue canadienne du vieillissement, 39(2): 1–14. Desmarais, D.A. (2013) ‘Colonialism’s impact upon the health of Métis elderly: history, oppression, identity and consequences’, Doctoral dissertation, Faculty of Graduate Studies and Research, University of Regina. Driben, P. (1987) Aboriginal Cultures of Ontario: A Summary of Definitions and Proposals Made by Native Peoples of Ontario to Preserve Their Cultural Heritage, Toronto: University of Toronto Press. Foulds, H., Shubair, M., and Warburton, D. (2013) ‘A Review of the Cardiometabolic Risk Experience Among Métis Populations’, Canadian Journal of Cardiology, 29(8): 1006–13. Gaudry, A. and Andersen, C. (2016) ‘Daniels v. Canada: racialized legacies, settler self-Indigenization and the denial of Indigenous peoplehood’, TOPIA: Canadian Journal of Cultural Studies, 36: 19–30. Green, J. (2011) ‘Don’t tell us what we are (not): reflections on Métis identity’, Aboriginal Policy Studies, 1(2): 166–70.

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Gunn, B. (2015) ‘Defining Métis people as a people: moving beyond the Indian/Métis dichotomy’, Dalhousie Law Journal, 38(2): 413. Health Council of Canada (2013) Canada’s Most Vulnerable: Improving Health Care for First Nations, Inuit, and Métis Seniors, Toronto: Health Council of Canada. Hourie, A. and Carrier-Acco, A. (2006) ‘Métis families’, in L. Barkwell, L.M. Dorion, and A. Hourie (eds) Métis Legacy II: Michif Culture, Heritage and Folkways, Saskatoon/Winnipeg, MB: Gabriel Dumont Institute and Pemmican Publications, pp 56–63. Lawrence, B. (2004) ‘Real’ Indians and Others: Mixed-Blood Urban Native Peoples and Indigenous Nationhood, Lincoln, NE: University of Nebraska Press. Logan, T. (2015) ‘Settler colonialism in Canada and the Métis’, Journal of Genocide Research, 17(4): 433–52. Macdougall, B. (2016) ‘The power of legal and historical fiction (s): the Daniels decision and the enduring influence of colonial ideology’, The International Indigenous Policy Journal, 7(3): 1. Macdougall, B. (2017) Land, Family and Identity: Contextualizing Métis Health and Well Being. Prince George, BC: National Collaborating Centre for Determinants of Health. Métis Nation of Ontario (2019a) ‘Who are the Métis?’. Available at: http://www.metisnation.org/ culture-heritage/who-are-them%c3%a9tis/. Métis Nation of Ontario (2019b) ‘Ontario Métis root ancestors’. Available at: http://www.metisnation.org/registry/citizenship/ ontario-m%C3%A9tis-root-ancestors/. Menec, V., Hutton, L., Newall, N., Nowicki, S., Spina, J., and Veselyuk, D. (2015) ‘How “age-friendly” are rural communities and what community characteristics are related to age-friendliness? The case of rural Manitoba, Canada’, Ageing & Society, 35(1): 203–23. Ontario Seniors’ Secretariat (2013) Finding the Right Fit: Age-Friendly Community Planning, Toronto: Queen’s Printer for Ontario. Peters, E.J., Rosenberg, M.W., and Halseth, G. (1991) ‘The Ontario Métis: some aspects of a Métis identity’, Canadian Ethnic Studies/ Etudes Ethniques au Canada, 23(1): 71. Peterson, J. (1978) ‘Prelude to Red River: a social portrait of the Great Lakes Métis’, Ethnohistory, 25: 41–67. Ramage-Morin, P.L. and Bougie, E. (2017) Family Networks and Health among Métis Aged 45 or Older, Ottawa: Statistics Canada. Statistics Canada (2017) The Housing Conditions of Aboriginal People in Canada, Ottawa: Statistics Canada.

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Statistics Canada (2019) ‘Canada’s Population Estimates: Age and Sex, July 1, 2018’. Available at: https://www150.statcan.gc.ca/n1/dailyquotidien/190125/dq190125a-eng.htm. Teillet, J. (2013) Métis Law in Canada, Toronto: Pape Salter Teillet. Weaver, H. (2001) ‘Indigenous identity: what is it and who really has it?’, American Indian Quarterly, 25: 240–55. Wilson, K., Rosenberg, M.W., and Abonyi, S. (2011) ‘Aboriginal peoples, health and healing approaches: the effects of age and place on health’, Social Science & Medicine, 72(3): 355–64. World Health Organization (2007) Global Age-Friendly Cities: A Guide, Geneva: World Health Organization.

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Indigenous practitioner vignette Connie Paul My Name is Connie Paul, R.N. That is my outside world name, but I carry three other real names: Yetta, from my great-grandmother, this name belonged to her grandmother, she was Okanagan; Teltitelwet, from my great-grandfather’s mother’s name, she was Coast Salish,1 from Mill Bay; and Hanakim Zim Lisms, given to me by four chiefs and their wives from four Nisga’a houses after 18½ years of service.2 I have worked for 30  years as a nurse. What kind of nurse? All kinds. I have been a trauma nurse, community care nurse, home care nurse, nurse manager, nurse leader, palliative care nurse, outpost nurse, remote nurse, funny nurse, traditional nurse, artistic nurse, poet nurse. Above all, keeper of their stories. The story-telling nurse. If someone was to ask me my advice about nursing in an Indigenous community, I would say nurse the environment, and nurse the family, including their pets. Find a safe way to hear their stories. Above all do not leave. Remain in community. It takes years and years to develop the relationship to client, family, and community. Take the time to find out what the political leaders feel. You need their support. Attend the band meetings. Attend the funerals and memorials. Attend the cultural events, if invited. Elder care involves consulting our Elders directly.3 It means protecting their safety as they define it. Have an Elders’ luncheon and ask them to tell you what they need. You will be pleasantly surprised that they know their own truth. Elders themselves will tell you what makes them safe, and what makes them unsafe. Elders themselves will tell you what they need to be self-actualized. They will tell you themselves what they need. They are able to set their own priorities. If Elder abuse is an issue in the community, then this will be identified. If Elder neglect is an issue, then they will tell you. If Elder mobility is an issue, then this will be brought up. If Elder isolation is an issue, then this will be discussed. None of this needs to be assumed. Should you do this work, however, then there is an expectation that you will follow up on what was identified.

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The reason that consulting with Elders – in their homes, in their community, in their environment – is important has to do with the trauma that many older people in First Nations communities are living with. Many have attended residential schools or have relatives who attended them. Many have spent time as young people in Indian hospitals. Many have had their families separated by a child welfare system that targeted First Nations children. Snuneymuxw First Nation health centre is making changes to the ways that healthcare is provided in order to take this trauma, as well as the existing knowledge of the community, into account. It is an accredited health agency and we are proud of the work that we do. We are building a new health centre that will have doctors, nurses, dental services, a pharmacy, a teaching centre, an Elders’ center, Chinese medicine, traditional and spiritual healing, infant development, and of course, student learners. Our goal is to be a teaching and learning centre. We will provide care to Indigenous and non-Indigenous clients. We are increasing the circle of care and transforming knowledge to include the wealth of knowledge that resides within the community itself. The following are a few examples of how our Nation is assisting clients and families, and adapting and transforming professional health services that touch our clients: • We offer trauma-informed workshops run by Elders that address people’s Indian residential school experiences; • We collaborate with multiple levels of government as well as nongovernmental agencies: federal, provincial, local, regional, local university, non-profit, Indigenous and non-Indigenous agencies, and the private sector; • We also work with the First Nations Health Authority (FNHA), the first Indigenous-run federal government agency in Canada, which provides leadership that addresses First Nations health issues from First Nations perspectives; • We provide health administration that is fiscally responsible; • We hold an annual community consultation; • We have developed our own model of care; • We have developed our own policies from the workers who live with those policies; • We have developed traditional recognition and community awards for outstanding achievement; • We believe in providing learning opportunities for students from colleges and universities. I would like to conclude with a story:

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Through the aging eyes of a Coast Salish elder When I was a child, we had a segregated healthcare system. We went to the Indian hospital here in Nanaimo, not the white man’s hospital. That was no different than our education, which was also segregated. We were sent to what was called the Indian residential school, but that stopped. People forget that at one time we had to ride with the cattle on the train. Today we can sit with white people. We can vote. We can go to ‘public’ school. I have witnessed changes in our healthcare. Many years ago, the health centre was owned by Health Canada, Federal Government. Then the band took over our own services using something called a Health Transfer Agreement. We were then responsible for our own staff. Programs changed, and our culture was integrated into our programs. At one time, the Provincial Health Authority would not come on reserve. I have been told that in 2007, though, all the governments came together. I have been told that there was an agreement called the ‘Tripartite Agreement’. I believe that health services transformed under the leadership of our own people. Do not get me wrong, we have paid with our health. But more recently, things have become beautiful. It has been about ten years now, and Island Health Authority nurses, social workers, occupational therapists, physiotherapists, mental health teams, and crisis teams now come on reserve. Two years ago, we began to have our own First Nations doctor coming on reserve, working in our health centre, helping us heal. We are getting a new health centre, with a pharmacy, life labs, and a dental clinic. This summer, an Elders’ room will be opened for our Elders, giving them a place in our health centre. Today I have access to our Home Care Nurse, Community Health Nurse, our Elders’ Co-ordinator, our Community Health Representative, our home care support workers. We even have a traditional medicine woman teaching us how to make our medicines. I have made medicine for my aching bones out of a plant that grows in our forest: a once-lost knowledge that is being shared with us. I have had the experience of a Chinese medicine at our clinic; wow – acupuncture. I participate in a women’s group where we have come together, young and old. I am learning for the first time an old weaving art form. Traditional loom, wool that will be shocked and spun. I am learning how to dye wool the colours of earth. We have found a

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traditional teacher who will teach Elders our own culture. I am an old person learning about my culture. I have a place to heal and be heard. How beautiful is that? Notes 1

2

3

Connie works at the Snuneymuxw First Nation Health Centre in Nanaimo on what is now called Vancouver Island, British Columbia. Snuneymuxw territory is located in the centre of Coast Salish territory on the eastern coast of Vancouver Island, the Gulf Islands, and the Fraser River in the Canadian province of British Columbia. Snuneymuxw territory encompasses one of the most productive and resource-rich areas at the heart of the Salish Sea. Coast Salish territory is located on the north-west coast of the Pacific Ocean, spanning the Canada–US border and covering parts of what is now Vancouver Island as well as territory inland along the Fraser River, the Georgia Basin, and the watershed of Puget Sound. First Nations presence in this territory dates back to time immemorial and archaeological sites have been found dating to about 10,000 years ago. This region now hosts the cities of Vancouver, Seattle, and Victoria and the Coast Salish peoples have been subject to a great deal of displacement, disease, and colonial occupation and alteration of their lands – through intensive settlement, resource extraction, relocation of communities, and the operation of Indian hospitals and Indian residential schools. Coast Salish communities are resilient, and are today reclaiming parts of their territory and negotiating in court and with various levels of government for recognition and recompense for past and ongoing wrongs. In Snuneymuxw First Nation, as in many Indigenous communities, older people are often referred to as Elders. This is a term of respect, and at the same time it means that a person is recognized as more than just an older person; it is a word that signifies someone who is recognized by the community as able to hold and pass on teachings. Teachings are principles based on wisdom that has been accumulated through the generations. Teachings have helped us to survive for 10,000 years or more in this environment. Teachings are not laws – whether or not you accept or adopt a particular teaching is up to you. You decide whether that teaching goes from the outside of you to the inside. At the same time, however, each teaching has a reason behind it and has the purpose of keeping the community safe and organized. Thus, ‘Elder’ may be used in a formal sense, for someone recognized by the community; or it may be used informally to refer respectfully to the teachings that an older person has acquired in their lifetime. In this chapter, all older people are referred to as ‘Elders’.

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Part 4 overview Indigenous older people experience aging in Canada in unique ways that need to be taken into account in practice and policy. Indigenous perspectives and voices – including the full diversity of First Nations, Inuit, and Métis peoples – are increasingly being heard, and Indigenous communities and nations are taking hold of their own revitalization. However, there remains a need to recognize and confront the systemic racism and settler colonialism that is pervasive within Canadian society and directly affects the lives of Indigenous older adults. As the chapters in this part show, this is present in everyday health and social care settings, as well as within community settings and public spaces, and is compounded by histories of intergenerational trauma by the Canadian state. The authors of chapters in this part also highlight the healing potential, for older Indigenous people, of developing and/or strengthening connections with one’s Indigenous community, practices, and ways of knowing. Takeaways for practice • Partnerships need to be developed between Indigenous nations and communities and those providing services to older Indigenous people. Partnerships can facilitate the integration of Indigenous knowledges, medicines, and other cultural practices within health and social care services, community settings as well as within all other aspects of age-friendly planning. Providers and non-Indigenous community members must be educated about the impacts of colonization, cultural safety, and local Indigenous knowledge/traditions on health. Healing that can flourish when this integration and understanding does happen, and harm can be caused when it does not. • There is a need for better service access for Indigenous older adults living in remote communities, as access to public transportation, medical services, social events, as well as accessing information on programming from different levels of government is limited. • Elders play an integral role in community wellbeing by passing on cultural practices, Indigenous knowledges, languages, and healing methods. Intergenerational activities are integral to the future health of a community. • Municipalities engaging in age-friendly planning need to involve a range of local Indigenous communities, nations, and/or organizations from the very beginning. Municipalities looking for Indigenous input must, however, recognize that Indigenous communities are not just another stakeholder. They must work to build and maintain a Nation-to-Nation relationship based on mutual trust. • Collective care and responsibility of family members to take care of older Indigenous relatives is seen as a duty, one that many are happy to do, because of strong family bonds of respect, responsibility, and reciprocity. However,

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Conclusion Mark W. Rosenberg The chapters and vignettes in this book are very much reflected in my and my wife’s life stories, and those of our parents, and grandparents. Our grandparents came to Canada at the beginning of the twentieth century. At the time, more than half the population of Canada lived in small towns and rural communities. Audrey’s grandparents ended up in the Okanagan Valley on her father’s side and in Alberta on her mother’s side. On her father’s side, the family faced the racism that was prevalent against anyone coming from Japan in the case of her grandparents and later, racism that all members of the family faced as Japanese Canadians. My grandparents ended up in Toronto and Hamilton. As Jewish immigrants from Germany, Poland, and Russia, they faced the antisemitism of the times even after they and their children (my parents and uncles and aunts) became Canadian citizens. In his final years, Audrey’s father moved back to the Okanagan Valley near where he grew up and where most of Audrey’s family still live. Audrey’s mother and stepfather aged in place in their home just outside of Kelowna. In recent years, it became apparent that they could no longer look after themselves and now live in assisted living. As their youngest son and after I left for university, my father and mother moved to a new house and lived there until he passed away. Soon after, my mother moved into a community for older people that had apartment buildings, communal dining rooms, various amenities, and a nursing home for those who could no longer live independently. My mother had her own apartment until she could no longer look after herself because of the onset of Alzheimer’s disease. She now lives in the nursing home with little or no memory of her past or her current surroundings. As the third generation, Audrey and I were part of the ‘baby boom’. We were both born in the early 1950s. As part of the baby-boom generation, we took full advantage of all of the opportunities that followed. We received university educations about which our parents could only dream. Eventually, we ended up as tenure-track assistant professors with high-quality pension plans and relatively early entry into an affordable housing market. Today, we are both past the age of 65 and still working as tenured, full professors. We own a house

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without a mortgage in a mid-size Canadian city, considered one of the most ‘livable’ cities in Canada (Maclean’s Magazine, 2020). We never had children. When we retire in a few years, we will have our private university pensions and fringe benefits, our private savings and investments, and monthly payments from the federal government in the form of the Canada Pension Plan and Old Age Security payments. Through our provincial health insurance and supplementary private health insurance from the university, most of our healthcare costs are covered and will be insured until our final days. Notwithstanding Audrey’s disability, we are both in excellent health and are financially healthy as well. We have become part of the older population that some call the ‘healthy and wealthy’, for now.

A book in four parts In contrast to our life stories, the data and geographic trends that open each section of this book (Chapters 1, 6, 11 and 16) provide a portrait of what the older population looks like in the second decade of the twenty-first century cross-sectionally in aggregate, in time and place. The life stories of today’s older population, however, reflect the cumulative life stories of older people who were born between 1915 and 1955 (our parents and now us). From the beginning of the twentieth century until the 1950s, much of the older population lived in a world of relative poverty and in some cases absolute poverty, in small towns and rural Canada, where paying for healthcare was a private transaction and your retirement income was what you had saved (our grandparents’ generation). While a very small part of that generation is still part of Canada’s older population today (the oldest-old), much of today’s older population are people who were born between 1930 and 1945. It is this part of the older population who rewrote the political stories of the 1950s and 1960s that resulted in a social insurance and public pension system that has eroded poverty among the older population and ensures that everyone, not just the older population, receives healthcare through provincial and territorial public, universal, comprehensive, accessible, and portable health insurance systems. Much of this part of the older population also took advantage of affordable housing markets, wellpaid continuous, permanent employment, and retired with private pension plans and savings to augment their social insurance payments and public pensions. Over this same period of time (the 1950s and 1960s), Canada went from being a country that was mainly made up of small towns and rural

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communities where our parents grew up, to a country that quickly became urban and suburban where today’s newer cohorts of the older population grew up. Our parents’ generation moved to Canada’s cities or moved from its inner-city neighbourhoods to the first suburbs of Canada’s largest cities as young adults and had their families. It should be no surprise then that aging in place, mobility, and accessibility are dominant themes of the Urban part of the book (Part I). What these chapters also reflect is the mobility paradox that our parents’ generation is now facing. They moved to Canada’s largest cities or moved from inner-city neighbourhoods to outer parts of the city because it was relatively easy to move about or to access the services that they needed as young adults raising their families. Now as the oldest-old (aged 80 and older), they find it increasingly difficult to move around the city or to access services even with the public transportation investments that have been made over time. Planners and policymakers are now playing catch up to find ways to reduce the barriers to mobility and improve accessibility for older people (Chapters 2 and 4). As a result of the changing structure of our cities, someone like Wells (Chapter 3), poignantly reminds us that our cities need to be restructured for an older population and that redesigning our cities will benefit people of all ages. The other take-home messages from Part I of the book come from Wilkat and Pendergast (Chapter 5). City administrations all across Canada have committed themselves to making their cities age friendly. Local governments are not, however, necessarily very good at providing the everyday services that older people need. From their first-hand observations, Wilkat and Pendergast focus on the importance of the social nature of urban life and the important roles that volunteer organizations play in everyday activities (yard work) in helping older people to age in place or simply bringing older people together to break down the loneliness that many older people feel as their loved ones and friends pass away. Part II, Suburban, covers the cumulative stories of the changing profiles of Canada’s older population at a time (post Second World War) when arguably Canada’s cities went through a profound structural change as part of a continent-wide transformation of cities – suburbanization. What also took place was the rapid transformation of the older population who were no longer mainly a white population of immigrants who came from Western Europe or their children (our parents’ generation) who aged in place. Increasingly, the older population is now made up of immigrants or their children (our parents’ generation) who have come from East and South Asia, subSaharan Africa, the Caribbean, or Latin America.1 A key measure

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of the change is that today beyond Canada’s official languages, older people who speak a second a language are likely to speak Mandarin, Cantonese, or Punjabi (Office of the Commissioner of Languages, 2020) or a multitude of other languages reflecting their countries of origin. Immigration has also been key to finding workers to support an older population who had smaller families than in the past and a sector (care for the older population) that is increasingly dependent on younger-aged workers from East Asia. Three other trends of the late twentieth and early twenty-first century also deserve mention in understanding the challenges now faced by Canada’s older population, especially those living in suburbs. First, the growing participation of women in the labour force has meant better incomes for older women as they enter retirement (but still not equal with men’s incomes). Unfortunately, it has also meant that women often face dual and even triple roles as care providers for children, workers, and care providers for older parents and relatives. A second trend is the growing precarity of work, which means people are exiting the workforce early, entering retirement with fewer economic resources, or working more years than in the recent past. The third trend is the growing gender diversity of the older population. How communities in Canada have been planned until recently rarely if ever has gone beyond a masculinist, heteronormative view of the older population. Several of these trends and the issues that they have generated underpin the chapters and vignettes that make up Part II. The frail older population and the LGBTQ+ older populations are among the most socially isolated segments in Canadian cities and particularly in suburban communities. Ageism and homophobia are at the root of socially isolating experiences, while bonded social capital is seen as a way of mitigating some of the issues that the frail and the LGBTQ+ older population face in housing, transportation, recreational and healthcare services according to Herman, Walker, and Rosenberg (Chapter 7). Another challenge typically associated with suburban life is getting around without access to a private car. New technologies such as e-bikes and scooters are potential options for improving mobility for older people as examined by Dean and Donato (Chapter 9). Making Canadian cities and especially suburban areas age-friendly in different seasons is a message that comes out of the vignette from Skrapek and PausJenssen (Chapter 8). In Canada, the focus is mainly on the winter because of its length and the challenges that severe cold, snow, and ice create in isolating the older population. In other countries, it might be the challenges of summer heat. Creating age-friendly communities

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is therefore about creating age-friendly communities for all seasons, for all segments of the older population, and in all parts of the city (Kawalec, Chapter 10). Part III, Rural, is about the contradictions of aging in small-town and rural in Canada (Rosenberg, Chapter 12). Older people now make up a larger proportion of people living in many small towns and rural Canada in comparison to children and youth, but in absolute numbers in comparison with their urban and suburban counterparts, the small-town and rural older population is very small. In fact, the older population already makes up more than a quarter and sometimes more than half of the total population in some places in rural and remote parts of Canada. The positives manifest themselves in the strong social support that older people receive in their communities and the role that volunteers play. Much of the social support and volunteering is older people supporting other older people. On the negative side, geographic isolation often leads to social isolation and volunteer organizations are often fragile, depending on a small number of older people – when they stop, so do the services. Nowhere are the strengths and challenges that older people face better demonstrated than among older women as highlighted by Bryanton, Weeks, and Montelpare in Chapter 14. It is a powerful picture of older women asserting their rights to age in place, supporting themselves, and supporting other older women. The two vignettes (Webster and Humphries, Chapter 13; Whalley, Chapter 15) also highlight the contradictions about aging in smalltown and rural Canada. The lack of resources at the local level leading to a dependence on higher levels of government (the provincial government) to support services either directly or indirectly. The challenges of providing basic services, like the critical need for transportation because it is simply not viable to provide public transit, are repeated throughout this part of the book. There is relatively little research to draw on to examine the issues that older Indigenous people experience in their lives (Part IV). There is also no other group whose lives have been so profoundly shaped by the failures of colonial and post-colonial governments on all levels to recognize and accept Indigenous people as equals. Even in the wake of the Truth and Reconciliation Commission (TPC), Indigenous people have had to continue to fight to have their rights acknowledged and that their cultural frameworks need to be part of any understanding of how Indigenous people face challenges to age well in their own communities (on reserve) and as part of the cities, suburbs, small towns, and rural communities of Canada (off reserve). While it is

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sometimes necessary in social science and planning research to reduce the complexity of older people’s identities to aggregate categories, Lewis (Chapter 19) reminds us about how problematic even a category like Indigenous people can be. What is also striking about the chapters and vignettes in this part of the book is how older Indigenous people are seen in a collective perspective of respect as the Elders of their communities in contrast to the individual perspective of older people retaining their independence that dominates so much of the research and planning literature on older people. If the stories about older Indigenous people are mainly about the lack of culturally appropriate services for them or having to be separated from their families and friends because of the lack of services on-reserve, what the chapters and vignettes are also about is the way older Indigenous people and their communities are increasingly taking charge and creating services that are appropriate for older Indigenous people and that reflect their own cultural values and institutions (Bourassa et al, Chapter 17; Paul, Chapter 20).

Summing up – the here and now In going back over the four parts of the book, there are striking similarities in each, even though the geographies are different and some of the chapters focus on a particular segment of the older population (the frail older population) or a particular service (transportation, for example). One such theme is agency – how important it is that the older people both individually and collectively must create and be responsible for their own solutions. While some authors acknowledge the positive role of governments, especially at the local level, the lack of structural analyses speaks to the need of the research community to examine why issues like the lack of age-friendly transportation and housing options are ubiquitous throughout the book and enduring issues that remain unresolved across Canada. Combined, the introduction, the chapters by researchers, and the vignettes of each part of the book, provide a strong sense of what the older population of Canada looks like now and how the geographies of where the older population lives benefits and challenges them. What is not so obvious is whether future portraits of the older people will look like the current older population or be far different. Optimistically, one might imagine the future older population being increasingly comfortable with smart technologies taking advantage of smart solutions as their housing, transportation, and services become smarter and indeed their communities become smarter. How far

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we want smart technologies to go in terms of monitoring our lives, however, remains an open question: will smart homes resolve many of the current deficiencies in the lack of home care or will autonomous vehicles solve the transportation problems for an older person who can no longer drive their own car? Looking at the trends pessimistically, the future older population might be increasingly unequal between those who enter retirement having had well-paid, permanent and continuous employment, the advantages of home ownership over a long period of time, and various forms of public transfers and private investments and savings (the minority of the older population); and in contrast, the other and larger part of the older population who might enter retirement having been in and out of the workforce their entire working years, having never owned a home, and with only whatever public transfers exist to support them in their later years. Layered upon these two socio-economic visions of the future older population is whether future technological advances will be equally distributed geographically and equitably accessible, or will only the wealthy parts of the cities and wealthy enclaves outside of urban Canada have these future technologies, and will only the wealthy part of the older population be able to afford to take advantage of these technologies. It might be easier to forecast that the future older population will continue to be more diverse because immigration is the only source of net population growth and is likely to continue for the foreseeable future, but whether the ageism, sexism, and racism that negatively affect the lives older people will disappear or grow as other forms of inequality grow is less straightforward to predict. It is also less easy to predict who will provide informal support for the older population with many older people having had fewer children than in the past and those children less likely to live in the same communities as their parents and in-laws. Regardless of whether one takes an optimistic or pessimistic view of the future, the need for structural changes will be required throughout the life course to ensure that future cohorts of the older population and the communities where they live are better prepared to meet the challenges of aging people and aging places. Structural changes will also be needed in terms of how we plan the infrastructure of our communities to ensure that they are age-friendly for everyone.

Epilogue I wrote this conclusion while ‘social isolating’ as people in our community and indeed around the world confronted the worst realities of COVID-19. For the first time and having passed the age of 65, I am

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now part of the high-risk part of the population. I also recently agreed to be president of my community’s largest non-profit organization dedicated to serving the region’s older population. At an existential level, Audrey and I now being part of the high-risk population and having parents over the age of 90 have had to think about whether our parents and indeed we would survive should we become infected. At an institutional level, I was confronted with a myriad of challenges: how would our seniors’ organization continue to provide services, how could we protect our employees and volunteers, and how we could ensure that the organization financially survives, so that we will be around to offer services when the COVID-19 pandemic is over. In the chapters of this book, what I see are many of the everyday challenges that the current older population confronts and that I am now confronting first-hand. What I also see, however, is how our organizations and governments will need to change to ensure that future cohorts of the older population enter their later years in better health and more financially secure – that is, less vulnerable. What will also need to change are the institutions that are charged with protecting the part of the older population who can no longer protect themselves. What the COVID-19 pandemic has exposed is how systems like long-term care facilities have failed older people in ways that no one might have anticipated. Finally, what might be our greatest challenge will be to eliminate the ageist attitudes and views that have come to the fore during the COVID-19 pandemic. Ultimately, what the pandemic is teaching us every day is that there is a long way to go in creating not only agefriendly communities, but age-safe communities, whether one lives in a large city, suburb, small town, rural, or Indigenous community. Note 1

To be clear, the first suburbs were developed earlier in the twentieth century than post-war and visible minority and Indigenous people lived in Canadian cities almost from their beginnings, but the diversity of today’s older population and where they live now are mainly the results of post-war trends.

References Maclean’s Magazine (2020) ‘Canada’s best communities 2019’. Available at: https://www.macleans.ca/best-communities-canada-2019-fullranking-tool/. Office of the Commissioner of Languages (2020) ‘Top 5 languages spoken in Canada’. Available at: https://www.clo-ocol.gc.ca/en/ newsletter/2018/top-5-languages-spoken-canada.

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Index Page numbers in italics refer to tables and figures; ‘n’ after a page number indicates the endnote number.

A

accessibility 36, 249 as barrier to aging well 47, 48 infrastructure accessibility 18, 105 lack of 27, 36 MD users 31, 33–7 Nova Scotia 191–2 parking accessibility 34 recommendations 34–5, 36–7, 47, 77 AFC (Age-Friendly City, WHO) 4–9, 115, 133, 223 Age-Friendly City Framework 5, 89, 110 age-friendly domains and key factors 5 apolitical nature 7 budget and funding 8, 9 City of Toronto 8 critiques 6–7, 128 framework 5–6 government and 4, 5–6, 7, 249 history 4–5 Indigenous Canada 199, 201, 223–4, 229–30, 234–6 leadership 8–9 Ontario 7, 8, 223 Ontario: Finding the Right Fit… 223–4, 229–30 policy implementation 7 politics and 8 recommendations 9, 128 success 8–9 voluntary policy 7, 8 WHO Age-Friendly City status 6, 74, 113, 169 ageism 46, 77, 94, 111–12, 137, 253 anti-ageism 48, 102–3, 112 definition 102 as greatest challenge 254 LGBTQ community and frail older adults 94, 102–3, 250 rural Canada 146, 158, 169 women 184

agency 252 MD users 31, 37–8 rural Canada: women 177–8, 178, 184 aging 2 age-friendly planning 1, 193, 245 Canada 1, 3, 4, 247–8 environment and 27 aging in place aging in place, wellbeing, and mobility 115–17, 118 benefits of 208 CAIP (Calgary Aging in Place Co‑Operative) 22, 74–5 housing 91–2, 151 Indigenous Canada 208–9, 216, 229 rural Canada 151, 182–3, 184 suburban Canada 86, 91–2, 115, 122, 128 urban Canada 19, 20, 249 aging well 2, 4, 46–7 accessibility and 47, 48 Indigenous Canada, challenges to aging well 198–200, 220, 229, 230–4, 251–2 Indigenous Canada, opportunities to aging well 200–1 rural Canada, challenges to aging well 143–5, 150–7, 166, 167–9, 172, 251 rural Canada, opportunities to aging well 143, 146–7, 251 suburban Canada, challenges to aging well 84–5, 250 suburban Canada, opportunities to aging well 85–7, 172 Toronto 48–9 urban Canada, challenges to aging well 17–20, 45, 46–7, 77, 249 urban Canada, opportunities to aging well 20–2, 45, 77 Alberta 16, 82, 142, 247 Alzheimer’s disease 21, 206, 247

255

Aging People, Aging Places Arts Health and Seniors program 87 Atlantic Canada 142, 150, 171, 189 automobility 118 automobile-dependent communities 2, 84, 90, 117 car driving 18, 84, 180 driving licence loss/lacking 18, 51, 85, 94 rural Canada, car-dependency 152, 165, 167, 180 suburban Canada, car-dependency 84, 85, 90, 94, 109, 116, 137, 250 vehicle safety features 86 see also transportation

B

British Columbia 118, 145, 153, 154, 244n1 older population 16, 82, 142 S4AC (Seniors Support Services for the South Asian Community) 87 built environment 2, 3, 9, 115 mobility and 27–8, 116 recommendations 7 rural Canada 143 suburban Canada 84, 86 see also accessibility

C

Calgary 8, 73–4 CAIP (Calgary Aging in Place CoOperative) 22, 74–5 challenges for creating an agefriendly community in 73–4 Oakridge Seniors’ Association 22, 75–6 recommendations 76 WHO Age-Friendly City status 74 Canada 3, 15, 248–9 aging 1, 3, 4, 247–8 future portraits of older population 252–3 see also demographic issues Cape Breton Island 189 CBRM (Cape Breton Regional Municipality) 146, 189, 192 approach to an aging population 190–1 cycling 190 Nova Scotia’s approach to an aging population 191–2 poverty 189

public transport 190–1 walking 190 CCACs (Community Care Access Centres, Ontario) 150, 154 Chief Medical Officers of Health (Greater Toronto and Hamilton Area): Improving Health By Design Report 2 CIP (Canadian Institute of Planners) 116 CLSCs (Centre Local de Services Communautaires, Québec) 150 community support 2, 5, 86, 147, 151, 230 LGBTQ community and frail older adults 90 rural Canada 146–7, 151, 165, 193, 251 suburban Canada 86–7, 90 urban Canada 20, 22, 74–6 COVID- 19 pandemic 253–4 crosswalks 39 MD users and 28, 29, 30, 31–2, 33, 35 urban Canada: walking 60, 61, 66 curbs 39 MD users and 30, 31–2, 35, 38 urban Canada: walking 60, 61 cycling 116–17, 119, 190 see also e-bikes and e-scooters

D

death 48, 74, 144, 171 dementia economic cost of 206 rural Canada 147, 153, 155, 205 urban Canada 20 dementia in Indigenous communities 197, 198, 200, 215–16 access to dementia services 205, 207, 213 aging in place 208–9, 216 community-based research 206, 210–11 components of dementia care 211–15 culturally safe assessment 207 data analysis: CCDAP/NAKPA 211 dementia care in rural communities 207–8 familial/informal caregivers 206–7, 208, 215–16 File Hills Qu’Appelle Tribal Council 200, 206, 210–11

256

Index Morning Star Lodge, Regina, Saskatchewan 206, 210, 211 recommendations 207–8, 216 research and 209–10 rising rates of dementia 206–7, 209 technology 205, 209, 214, 216 see also dementia; Indigenous Canada: aging in demographic issues 15, 247 baby boomers 1, 82, 171, 223, 247 demographic shift 1, 82, 171, 223 female population 171 increase in older adult populations 1, 81–2, 115, 141, 189 Indigenous Canada 197, 198, 198, 199, 205 rural Canada 16, 141–2, 142, 166, 251 suburban Canada 16, 81–3, 82, 82, 109, 115, 133 urban Canada 15–16, 16, 115 see also diversity dignity, sense of 2, 21 disabilities, people with 27, 38, 57, 111–12, 135, 248 dEMAND (Enabling Mobility And Participation among those with Disabilities) 28 disableism 137 housing 150, 151 rural Canada 150, 151, 152, 157 diversity (population diversity) 19, 253, 254n1 cultural diversity 19, 151, 224, 234 Indigenous communities 197, 201, 234–5, 245, 246 rural Canada 143, 143, 149, 150, 159 suburban Canada 83, 83, 85, 89, 109 urban Canada 16–17, 17, 19, 20, 45

E

e-bikes and e-scooters 86, 117–18, 121, 126, 250 barriers to adoption in suburban communities 120, 123–5 benefits 117–18, 119–20, 125, 126–7 e-bike technology, perceptions and experiences of 122–3 e-scooters as risk to prolonged mobility 125–6 e-trike 121, 121, 122, 123, 125, 128

methods 121–2 older adults and new mobilities 118–21 potential of new micro-mobilities 117–18 recommendations 127–8 safety 118, 120, 124, 125 suburban Canada 86, 117, 120, 137 supporting older adult mobility in place 126–8 Waterloo Region 86, 121 winter season 127 elder abuse 158, 241

F

falls 32, 53, 66, 125 First Nations 112, 197, 198, 201, 223, 226–7, 234–5, 236n1, 244nn1–3 Coast Salish territory 243, 244n2 health services 242–3 Peterborough 133, 134, 135, 136 reserves 199 Snuneymuxw First Nation 200, 242, 244nn1, 3 see also Indigenous Canada: aging in food 2, 21, 47, 149, 158–9, 160, 166

G

government 254 AFC and 4, 5–6, 7, 249 disconnect between government powers 7 failure to support older people 74, 249, 252 local government 4, 5–6, 73, 249, 252 local government and Indigenous people 221, 223, 224, 229, 231, 234, 235 provincial government 191, 192, 193, 225, 236, 251 see also services

H

Hamilton 2, 18, 247 health 2, 27, 47, 254 mental health 2, 90, 200, 232, 243 healthcare 5, 7, 248 barriers to health services 97–8 Indigenous Canada 200, 220, 224, 242–3, 245 LGBTQ community and frail older adults 96–9, 105 long-term chronic illness 91, 92

257

Aging People, Aging Places Métis 199, 228–9, 230–1, 233, 236 racism in healthcare services 200, 207 rural Canada 21, 144, 145, 152–3, 155–6, 165, 207 suburban Canada 111 transportation and accessibility to 20, 21, 97 urban Canada 18, 20, 21, 45, 48 see also services home care 145, 253 Indigenous peoples 199, 213, 243 recommendations 48 rural Canada 145, 152–3 homophobia 103, 137, 250 health services system and 98–9 homophobia and housing 92–4 recreation and 100 see also LGBTQ community and frail older adults housing 2, 247–8 accessible features 19 affordability 19, 73, 92, 104, 111, 137, 151, 166, 248 age-based housing 93, 99 aging in place 91–2, 151 cultural diversity and 19, 151 disabilities, people with 150, 151 home ownership 81, 150, 253 housing maintenance 74, 144, 151 immigrants 19 Indigenous Canada 230 LGBTQ community and frail older adults 91–4, 104, 137 recommendations 48, 104 rural Canada 135, 144, 150–1, 159, 166, 168–9 single-detached dwellings 19, 135, 144 single-family housing 81, 91, 100 staying in seniors’ own homes 73, 74, 75, 85, 147, 183 subsidized public housing 92 suburban Canada 85, 111, 135, 137 supported-living housing 91–2, 93–4, 96, 99, 104, 105 urban Canada 18, 19, 45, 48, 73 see also services

I

immigrants 19, 247, 253 rural Canada 143, 143 suburban Canada 83, 83, 249–50 urban Canada 17, 17, 19 impairment 1–2

income and financial security 247–8, 254 retirement income 159, 248, 250, 253 rural Canada, income insecurity 149, 158–9 rural Canada, low incomes 17, 143, 143, 149, 157, 158–9, 171 rural Canada: women’s financial security 171, 180–1, 184 suburban Canada, low income 83, 83 urban Canada, low income 17, 17, 19, 73 women 250 independence, sense of 2, 21, 74, 115, 252 Indigenous Canada 9, 197, 254n1 community changes 219–20 Cree 197, 211, 225 diversity between and within Indigenous communities 197, 201, 234–5, 245, 246 Indian Act 199, 228, 236n1 Indigenous identity/ancestry 199 land and place relationships 199, 221–2 population 197, 198, 198, 199 poverty 200 racism 200, 227, 235 reserves 198–9, 246, 251 residential schools 200, 201, 220, 227–8, 232, 242, 243 revitalization of 201, 245, 252 trauma suffered by Indigenous people 242, 245 see also First Nations; Inuit; Métis Indigenous Canada: aging in 197–8, 201, 245–6, 251–2 accessibility of services and benefits 199, 200, 220, 230–1, 236, 245 AFC planning 199, 201, 223–4 aging in place 208–9, 216, 229 Algonquin community 219, 221, 225 challenges to aging well 198–200, 220, 229, 230–4, 251–2 elder care 241, 245–6 Elders 200–1, 244n3, 245, 252 healthcare 200, 220, 224, 242–3, 245 home care 199, 213, 243 intergenerational activities and infrastructure, importance of 201, 221, 245

258

Index involvement in community activities 200, 201, 208 older population 197, 198, 205 opportunities to aging well 200–1 racism in healthcare services 200, 207 recommendations 199, 201, 245–6 reconnecting with cultural practices 201, 228, 243–4 social exclusion 199, 209, 232 traditional knowledge and teachings 208, 211, 212, 215, 216, 244n3, 245 traditional medicine 207, 220, 245 urbanization 198–9 see also dementia in Indigenous communities; First Nations; Indigenous Canada; Inuit; Métis insecurity food insecurity 149, 158–9, 166 income insecurity 158 urban Canada: walking 53, 66 internet 86, 144, 157, 167, 179, 193, 209, 246 Inuit 197, 198, 201, 226–7, 228, 234–5, 236n1 see also Indigenous Canada: aging in

K

Kalache, Alexandre 4

L

land-related issues Indigenous Canada and 199, 221–2 land use 8, 18, 29, 34, 52, 86, 116, 137 Métis 227–8 urban Canada: walking 53, 54, 58 LGBTQ community and frail older adults (Saskatoon) 85, 89, 250 ageism 94, 102–3, 250 bonding social capital 85, 90, 101–2, 104, 105–6, 250 community support 90 embracing diversity in older age 102–3 health services 96–9, 105 housing 91–4, 104, 137 methods and analysis 90 OUTSaskatoon 90, 100, 112 poverty 92, 94 recommendations 104–6 recreation 99–101, 105

social capital 101–2, 104, 105–6 social exclusion 90, 94, 101–2, 104, 105 social isolation 101, 105, 250 transportation 94–6 see also homophobia LHINs (Local Health Integration Networks, Ontario) 154 ‘local’, definition 3 local community 2, 73, 76, 146, 166, 223–4 local environment 1, 2, 3–4, 25

M

Mackenzie 145 Manitoba 16, 20, 45, 82, 142, 146, 153, 158 MD users (mobility device) 18, 28, 39–40, 123 agency 31, 37–8 continuum of accessibility 31, 35–7 crosswalks 28, 29, 30, 31–2, 33, 35 curbs 30, 31–2, 35, 38 destination: accessibility in public places 28, 31, 33–5 en route: usability and safety of physical paths 30–3, 31 methods 28–9, 39 photovoice 28, 29, 31, 33, 34, 36, 37, 39 recommendations 32–3, 34–5, 36–7, 39–40 sidewalks 28, 30, 31–3, 31 SWAN (Stakeholders’ Walkability/ Wheelability Audit in Neighbourhood) 29, 30, 31–2, 34, 36, 37–8, 39 Métis 112, 197, 198, 201, 236n1 accessibility of services 230–1, 236 AFC planning 199, 224, 229–30, 234–6 cultural suppression 231–3 federal government and 228 healthcare 199, 228–9, 230–1, 233, 236 land issues 227–8 Métis identity 224, 225–7, 229, 232, 233, 236 MNO (Métis Nation of Ontario) 224, 225, 226, 239, 231, 234 Ontario: Finding the Right Fit 223–4, 229–30 Ontario’s Métis people 224–9 racialization/racism 235–6

259

Aging People, Aging Places recommendations 199, 233–4, 235–6 residential schools 227–8, 232 self-determination and governance 233–4 transportation 199, 230–1 understanding the Métis perspective 229–34 see also Indigenous Canada: aging in mobility 51 aging in place, wellbeing, and mobility 115–17, 118 barriers to 18, 28, 249 built environment and 27–8, 116 limited mobility 1–2, 27, 34, 36, 51, 95 mobility planning 51 new technologies in 86 rural Canada 144 quality of life and 18, 32, 34, 77 social inclusion and 32, 35, 38, 39 social interaction and 116 social isolation and 34 suburban Canada 83, 84, 85, 86, 95, 135 urban Canada 17–18, 249 see also e-bikes and e-scooters; MD users; transportation; walking Montreal 15, 21, 81 see also urban Canada: walking

N

New Brunswick 142, 151, 165 Charlotte County West (St. Andrews and St. Stephen) 166, 168, 169 Greenwich 166–7, 169 WHO Age-Friendly City status 169 NGOs (non-governmental organizations) 17, 22, 87 non-profit organizations 22, 87, 110, 152, 154, 254 recommendations for 76

O

Okanagan Valley 247 Ontario 18 Finding the Right Fit… 223–4, 229–30 older population 16, 82, 142 overviews 9, 15–22, 77–8, 81–7, 137–8, 141–7, 193–4, 197–201, 245–6, 248

P

Parkinson’s disease 21 paternalism 7, 45, 77 Peterborough 8 AFPAC (Age-Friendly Peterborough Advisory Committee) 134, 135 Age-Friendly Peterborough Community Action Plan 84, 133–6 disabilities, people with 135 First Nations 133, 134, 135, 136 housing 135 older population 133 PCOA (Peterborough Council on Aging) 133–4 transportation 135–6 physical activity 2, 47 benefits of 21, 116 rural Canada 147 suburban Canada 87, 116 urban Canada 21 see also cycling; walking Plouffe, Louise 4 poverty 47, 248 Indigenous Canada 200 LGBTQ community and frail older adults 92, 94 rural Canada 159, 171, 172, 189, 248 Prairies provinces 16, 82–3, 142 public transport 17, 18, 77, 144, 245, 249, 251 CBRM 190–1 rural Canada 152, 167, 180, 193 social isolation and 167 suburban Canada 118, 135–6, 137

Q

quality of life 2, 4, 22, 77, 111 aging in place 208 Indigenous people 199, 231 mobility and 18, 32, 34, 77 physical activity and 21 social capital and 101 women 176, 184 Québec 20–1, 28, 53, 57, 85 older urban population 16, 82

R

racism 137, 247, 253 Indigenous Canada 200, 207, 227, 235–6

260

Index research-based articles 9, 27–40, 51–67, 89–106, 115–28, 149–60, 171–85, 205–16, 223–36, 252 participatory research 40, 121, 173, 175 retirement 1, 82, 142, 223 retirement income 159, 248, 250, 253 rural Canada 15, 141, 248–9 population 141, 142, 142 rural Canada: aging in 141–7, 149–50, 159–60, 165, 193–4, 251 accessibility of services 143, 144, 145, 149–50, 160, 167, 193 ageism 146, 158, 169 aging in place 151, 182–3, 184 buddy system 146 built environment 143 car-dependency 152, 165, 167, 180 challenges to aging well 143–5, 150–7, 166, 167–9, 251 community and social services 152–4, 156, 167 community support 146–7, 151, 165, 193, 251 connectivity 144, 157 dementia 147, 153, 155, 205 disabilities, people with 150, 151, 152, 157 engagement 149, 158 ethnic diversity/diverse population 143, 143, 149, 150, 159 food insecurity 149, 158–9, 166 geographical isolation 143, 145, 171, 193, 251 healthcare 21, 144, 145, 152–3, 155–6, 165, 207 home care 145, 152–3 housing 135, 144, 150–1, 159, 166, 168–9 immigrants 143, 143 income insecurity 149, 158–9 informal social networks 145, 146, 153, 165, 193 internet 144, 157, 167, 179, 193, 209, 246 low incomes 17, 143, 143, 149, 157, 158–9, 171 mobility 144 nature, proximity to 147 older population 16, 141–2, 166, 251 opportunities to aging well 143, 146–7, 251

physical activity 147 poverty 159, 171, 172, 189, 248 public transport 152, 167, 180, 193 recommendations 160, 167–9, 193 social inclusion 149, 158 social isolation 152, 157, 158, 159, 165, 166, 167, 168, 251 technologies/smart technologies 150, 157 transportation 136, 144, 145, 151–2, 166, 167–8, 193, 251 voluntarism 145, 152, 156–7, 193, 251 walking 144, 190 winter 144, 152, 167, 180 see also CBRM; rural Canada: women rural Canada: women 144, 171–2, 183–5, 251 agency 177–8, 178, 184 challenges to aging well 172 data analysis 176 family/friends support 178, 179 financial security 171, 180–1, 184 interacting forces influencing aging in a rural place 176–81, 183–4 knowledge-sharing open house 182–3, 182 low incomes 171 methods 173, 183 opportunities to aging well 172 participants 173–4, 176, 177 photovoice 173, 174–6, 182, 183, 184 poverty 171, 172 recommendations 144, 184–5 social involvement 179–80 social isolation 171 theoretical/philosophical perspective 172–3 transportation 144, 180, 184

S

safety 115 cycling 117 e-bikes and e-scooters 118, 120, 124, 125 road safety 18, 56, 59, 64, 65, 118, 120 urban Canada: walking 53, 67 Saskatchewan 16, 45, 82, 89, 109, 142, 206, 210

261

Aging People, Aging Places Saskatoon 90, 109 AFSI (Age-Friendly Saskatoon Initiative) 86–7, 110–13 population 109 SCOA (Saskatoon Council on Aging) 110, 111, 112, 113 WHO Age-Friendly City status 113 see also LGBTQ community and frail older adults services centralization of 154–5, 167 consolidation of 8, 149–50 fragmentation of 150, 154 Indigenous Canada, access to dementia services 205, 207, 213 Indigenous Canada, accessibility of services 199, 200, 220, 230–1, 236, 245 one-stop organizational structures 150, 154, 156, 193 rural Canada, accessibility of services 143, 144, 145, 149–50, 160, 167, 193 suburban Canada, accessibility of services 84, 85 see also government; healthcare; housing; transportation sexism 94, 137, 253 sidewalks 39 MD users and 28, 30, 31–3, 31 suburban Canada 84, 116, 137 urban Canada: walking 60, 61, 66, 73 social capital 21, 85, 89 bonding social capital 85, 90, 101–2, 104, 105–6, 250 social exclusion 51 Indigenous Canada 199, 209, 232 LGBTQ community and frail older adults 90, 94, 101–2, 104, 105 social inclusion 5 inclusion in planning, implementation, evaluation 48 mobility and 32, 35, 38, 39 rural Canada 149, 158 rural Canada: women 179–80 urban Canada 20–1, 48 social isolation 253 immigrants 19 LGBTQ community and frail older adults 101, 105, 250 mobility and 34

public transport and 167 recommendations 76, 137 rural Canada 152, 157, 158, 159, 165, 166, 167, 168, 251 rural Canada: women 171 suburban Canada 83, 84, 85, 135, 137 urban Canada 17, 19, 21, 48, 73, 75, 76 social participation 5 Indigenous Canada 200, 201, 208 LGBTQ community and frail older adults: recreation 99–101, 105 local environment and 27 mobility and 116 participatory research 40, 121, 173, 175 seniors’ participation in planning 74, 77, 184–5, 199 urban Canada 18–19, 21 socialization 34, 51, 75–6, 220 Spain 51 Statistics Canada 15, 46, 81, 82, 141, 192 suburban Canada 15, 81, 137, 249 population 81–3, 82, 82 suburban Canada: aging in 81–7, 137–8, 249–50, 254n1 accessibility of services 84, 85 aging in place 86, 91–2, 115, 122, 128 built environment 84, 86 car-dependency 84, 85, 90, 94, 109, 116, 137, 250 challenges to aging well 84–5, 250 community support 86–7, 90 ethnic diversity/diverse population 83, 83, 85, 89, 109 healthcare 111 housing 85, 111, 135, 137 immigrants 83, 83, 249–50 language barrier 83, 87 low income 83, 83 low socio-economic status/ decreased car travel relation 83 mobility 83, 84, 85, 86, 95, 135 older population 16, 81, 109, 115, 133 opportunities to aging well 85–7 physical activity 87, 116 recommendations 85, 112–13, 137, 250–1 sidewalks 84, 116, 137 social isolation 83, 84, 85, 135, 137

262

Index transportation 84, 85, 86, 116, 118, 135–6, 137 walkability 84 walking 83, 84, 116 winter 109, 127, 137, 250 see also e-bikes and e-scooters; LGBTQ community and frail older adults; Peterborough

T

technology dementia in Indigenous communities and 205, 209, 214, 216 mobility and 86 rural Canada 150, 157 smart technologies 157, 252–3 see also e-bikes and e-scooters; internet Toronto 15, 45–6, 48–9, 81, 247 Toronto Seniors Strategy Accountability Table 8 transportation 5, 18 Access Transit program 95–6 active transportation 2, 18, 116, 118, 120, 126–7, 128, 137, 190 affordability 144 LGBTQ community and frail older adults 94–6 Métis 199, 230–1 rural Canada 136, 144, 145, 151–2, 166, 167–8, 193, 251 rural Canada: women 144, 180, 184 specialized and age-based transport 95–6 suburban Canada 84, 85, 86, 116, 135–6, 137 urban Canada 18, 20, 21, 46, 73, 249 see also automobility; e-bikes and e-scooters; public transport; services

U

urban Canada 15, 249 population 15–16, 16 urban Canada: aging in 15–22, 77–8, 249 aging in place 19, 20, 249 challenges to aging well 17–20, 45, 46–7, 77, 249 community support 20, 22, 74–6 ethnic diversity/diverse population 16–17, 17, 19, 20, 45

healthcare 18, 20, 21, 45, 48 housing 18, 19, 45, 48, 73 immigrants 17, 17, 19 low income 17, 17, 19, 73 mobility 17–18, 249 municipal age-friendly policy 20 older population 16, 115 opportunities to aging well 20–2, 45, 77 physical activity 21 recommendations 48, 76, 77, 249 social inclusion 20–1, 48 social isolation 17, 19, 21, 48, 73, 75, 76 social participation 18–19, 21 transportation 18, 20, 21, 46, 73, 249 see also accessibility; Calgary; MD users; Toronto urban Canada: walking 18, 21, 77 crosswalks 60, 61, 66 curbs 60, 61 falls 53, 66 insecurity 53, 66 MAPISE project 53, 54 methods and analysis 54–8 Montréal 21, 53, 54, 55, 58, 59, 61, 62, 66 PARI project 53 pedestrian path tracking 56–7, 62–4, 63 recommendations 66–7 research question 53 safety 53, 67 sidewalks 60, 61, 66, 73 study area and walkability audit results 55 walkability audit: MAPISE audit tool 54, 55, 56, 56, 58–62, 59, 61 walkabouts, interviews 57–8, 60

V

Vancouver 15, 81, 98 see also MD users vignettes 9–10, 252 community member vignette 9–10, 45–9, 109–13, 165–9, 219–22 practitioner vignette 10, 73–6, 133–6, 189–92, 241–4 voluntarism/voluntary service 231 AFC 7, 8

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Aging People, Aging Places rural Canada 145, 152, 156–7, 193, 251

W

walking 2 barriers to 116 benefits 51 promotion of 51 rural Canada 144, 190 safety 84 suburban Canada 83, 84, 116 walkability 29, 51–2, 77, 84, 144

walkability and aging 52–3 see also urban Canada: walking wheelchair 33, 35, 37, 47, 93 wheelability 29 WHO (World Health Organization) see AFC winter 95 crosswalks/sidewalks 35, 66, 73 e-bikes and e-scooters 127 rural Canada 144, 152, 167, 180 suburban Canada 109, 127, 137, 250

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“With a remarkable depth of insight into the diverse contexts of aging in Canada, especially the groundbreaking emphasis on Indigenous experiences of aging, this book is an excellent resource for better understanding 21st-century aging societies.” Mark Skinner, Trent University How well do the places where we live support the wellbeing of older adults? The Canadian population is growing older and is reshaping the nation’s economic, social and cultural future. However, the built and social environments of many communities, neighbourhoods and cities have not been designed to help Canadians age well. Bringing together academic research, practitioner reflections and personal narratives from older adults across Canada, this cutting-edge text provides a rare spotlight on the local implications of aging in Canadian cities and communities. It explores employment, housing, transportation, cultural safety, health, planning and more, to provide a wide-ranging and comprehensive discussion of how to build supportive communities for Canadians of all ages. Maxwell Hartt is Assistant Professor in the Department of Geography and Planning at Queen’s University. Samantha Biglieri is Assistant Professor in the School of Urban and Regional Planning at Ryerson University. Mark W. Rosenberg is Professor in the Department of Geography and Planning at Queen’s University and the Tier 1 Canada Research Chair in Aging, Health and Development. Sarah E. Nelson is Assistant Professor in the Department of Geography and Geology at the University of Nebraska Omaha.

ISBN 978-1-4473-5256-3

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