Aging and Rural Mental Health: “I don’t think I’ll ever get better”

1. Aging and Rural Mental Health: “I don’t think I’ll ever get better” Presentation for the Aging in America ASA Conference Chicago, IL March 15, 2013 NuelleNovik Faculty of Social Work, Saskatchewan Population Health and Evaluation Research Unit (SPHERU), University of Regina, Saskatchewan, Canada Juanita Bacsu SPHERU, University of Saskatchewan, Saskatchewan, Canada Shanthi Johnson Faculty of Kinesiology, SPHERU, University of Regina, Saskatchewan, Canada

2. We would like to acknowledge our funders for their contributions and support.

3. Thelma’s Story “No, nobody over here does play cards. No, no everything is dead here (laughter). And the main road, you know, you see the main road there. There’s nobody there.”

4. Presentation Overview • SPHERU • Context & Rationale • Research Objectives • Research Methods • Research Model • Findings • Discussion

7. SPHERU: Who are we? • The Saskatchewan Population Health & Evaluation Research Unit (www.spheru.ca) is an interdisciplinary research unit committed to critical population health research. • Research funded at provincial and national levels (Saskatchewan Health Research Foundation and Canadian Institutes of Health Research).

8. Why are we here today? • Exchange insight and share mental health findings from our Pilot Study and Healthy Aging in Place Study.

9. Context: Aging in Canada • In 2011, seniors accounted for 85% of hospital patients; • 47% completed treatment but were waiting for long-term care.

10. Canadian Demographics • By 2036, seniors will reach approximately 25% of the total population.

11. Why is Rural Aging Important? • Compared to urban seniors, rural seniors are reported to have: • Poorer physical health; • Higher occurrences of functional disability; • Increased sedentary lifestyle; • More chronic illness; • Less use of preventative health care; • Poorer mental health status; • Greater prevalence of mental health stressors than their urban equivalents.

12. What do we mean by mental health? “A state of well-being in which the individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his own community” (World Health Organization, 2009).

13. Rural Mental Health Risk Factors? • Compared to urban seniors, rural seniors often have isolating conditions, socioeconomic disadvantage, less education, transportation and access issues, and shortage of health services.

14. Rural Aging & Mental Health • Rural areas often characterised as idyllic pastoral settings, with less stressful living, strong community networks, and close connection to the land. • “Unidimensional” views problematic and leave little scope for addressing rural seniors’ health disparities (Keating & Philips, 2008).

15. Research Objectives • To address gaps in our understanding of the health and support needs of seniors living in rural communities. • To identify the policy, community and kin level actions that facilitate healthy aging in place. • This presentation will focus on the mental health related findings.

16. Research Locations • Rural communities of Watrous, Wolseley, and Preeceville, Saskatchewan, Canada. • 'Rural’ refers to Statistics Canada's (1998) definition, as a population living outside of urban centres with fewer than 10,000 people. • Rural conceptualized as being underserviced, sparsely populated and geographically disperse.

17. Research Approach • Community-based participatory research (CBPR) • Collaboration, capacity building and shared decision-makingwith local partners. • Community partners were involved in all stages of the research from the research questions to knowledge translation.

18. Data Collection • 2009- 2010 - Pilot study conducted 42 interviews with rural seniors in Watrous and Preeceville, SK. • 2011-2014 – Longitudinal study conducting interviews with 40 rural seniors in Watrous and Wolseley to identify seniors’ changing needs of over the aging process.

19. Research Model Cantor’s Social Care Model Image from J. Sims-Gould and A. Martin-Matthews, Family Caregiving or Caregiving Alone: Who Helps the Helper? 2007, Canadian Journal of Aging, 26(1), 27-46, originally adapted from M.J. Cantor, Family and Community: Changing Roles in an Aging Society, 1991, Gerontologist, 31(3), 337-346.

20. Research Findings Five key themes were identified in relation to mental health: • Gender • Spousal Health • Finances • Isolation • Mobility

21. Gender • Gender interwoven throughout. • Men described greater difficulty in loss of mobility. • Inability to complete outdoor work influenced men more negatively. • Women identified stress of learning new tasks (driving, finances), when spouses no longer able.

22. Gender “Well if I was healthy I could do a heck of a lot more. But I have a hard time even looking after the yard…”

23. Spousal Health • Mental health linked to spousal health, especially for caregivers • Caregivers often put spouses’ wellbeing first • Fear of spousal separation in long term care • Grief and loss of spouse identified as key issue • Need for service awareness (respite and long term care)

24. Spousal Health “ I am depressed ‘cause now I have more time to think… somehow I had this strange idea that because I’ve been running after him and doing things and making decisions for years that when he was gone it would be only a relief, it doesn’t work that way…”

25. Finances • Increasing cost of medications, ambulance, home care and cost of living. • Women had difficulties handling finances after their husbands were no longer able to. • Women identified training on finances would be useful.

26. Finances “That’s a big thing, that’s a big thing. And you have to constantly worry about how you’re going to pay your bills this month.”

27. Isolation • Limited interaction on farms and small villages • Isolation exacerbated by limited mobility and winter (ice, cold, daylight) • Caregivers isolated but unaware of supports • Reluctant to ask for help, don’t burden others • Limited seniors’ housing, fear of being sent away • Newcomers had difficulties being accepted

28. Isolation “I just can’t find my niche here. I’m sure there’s people that are shut in that need visiting. I’m sure I will...”

29. Mobility • Falls and loss of mobility can exacerbate isolation • limiting activities, housebound during winter • loss of confidence, mobility, and independence • stress and anxiety of fear of falling • 85% of seniors’ injury hospitalizations from falls • Participants downplayed seriousness of falls • “I fell and skinned off the knee a little bit but I was able to get on.”

30. Mobility • Men reported falls performing high risk activities • “I was using a ladder to climb up and I fell off the damn thing and I came down my ribs…” • Women reported fallsperforming day to day activities • “I tripped... coming out of my bathroom. • Women often kept falls to themselves “Oh, not mention it to anybody. It’s none of their business.”

31. Mobility “I’ve got to move, I just can’t sit in the house... I was thinking about it the other day, this is it for the rest of my life now. I don’t think I’ll ever get better…”

32. Actions to Support Rural Healthy Aging & Mental Health • Individual • Kin: Family and Friends • Community • Policy

33. Individual-Level Actions • Staying active was key to healthy aging • Exercising, reading, gardening, music, employment • Sundays identified as difficult day • Optimism and not letting age determine abilities • Using humor to cope with loss of abilities • Ability to drive enhanced mobility/accessibility

34. Individual-Level Actions “We’re lucky as long as we can drive... We’re a little too remote, we’re away from hospitals. And for emergencies, a half hour is a long time when somebody is dying…”

35. Kin-Level Actions • Social interaction with family and friends was vital • Not all family interaction was positive, desire to make their own decisions • With advancing age seniors lose friends, making organized activities more important • Need for more intergenerational opportunities but unaware how to initiate

36. Kin-Level Actions “If my curtains didn’t open by noon my neighbor would be phoning to find out what’s going on. It’s our small town version of neighborhood watch.”

37. Community-Level Actions • Community activities identified as central to healthy aging (seniors’ centre, church) • Need for social spaces in seniors’ housing for activities and interaction • Support groups (grief groups and Alzheimer's) • Need for older adult education and information on local programs and services (list of drivers)

38. Community-Level Actions “You know the thing is, if you were to stay in your house and just look at the four walls... That's why it's so important that we've got the seniors’ center where there's carpet bowling, there's cards…”

39. Policy-Level Actions • Need to enhance access to information about existing mental health services for seniors. • Need for expansion of measures beyond formal healthcare services, including: • Social supports, seniors’ housing, education, transportation, homecare, finances, built environment and caregiver supports.

40. Policy-Level Actions “We’d like a pamphlet on costing information on home care. That would even apply to if you had to get into assisted living or nursing home. What really is involved in getting in there?”

41. Conclusion • Efforts to improve rural seniors’ mental health must consider the unique context and specific needs of seniors living in rural communities. • Need to engage with rural seniors to develop culturally informed and more effective interventions to support mental health and rural healthy aging in place.

42. Discussion Questions We are interested in hearing about your experiences of rural aging and mental health: • Best practices • Community level innovations • Interdisciplinary approaches and collaborations

43. Contact Information Juanita Bacsu SPHERU, University of Saskatchewan, Canada Phone: 1 (306)966-7942 Website: www.spheru.ca Email: juanita.bacsu@usask.ca

44. Researchers Stakeholders • Marc Viger, MD, Fellowship in Gerontology, Saskatoon HealthRegion • Donna Lamoureux, Regina Qu'Appelle HealthRegion • Maggie Petrychyn, Regina Qu’Appelle HealthRegion • Liz Durocher, Keewatin Yatthé Regional Health Authority (KYRHA) Community Partners • Dennis Fjestad, Wolseley, SK • Noreen Johns, Watrous, SK • Murray Westby, Watrous, SK Research Team • University of Regina: • Bonnie Jeffery, SPHERU & Faculty of Social Work • Shanthi Johnson, SPHERU & Faculty of Kinesiology & Health Studies • NuelleNovik, SPHERU & Faculty of Social Work • Colleen Hamilton, SPHERU • University of Saskatchewan: • Sylvia Abonyi, SPHERU & • Community Health & Epidemiology • Diane Martz, SPHERU & Geography & Planning • Juanita Bacsu, SPHERU • Sarah Oosman, SPHERU • Ivan Peterson, Preeceville, SK • Joanne Bodnar, Preeceville, SK • Jay Prekaski, Preeceville, SK

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