1. Community Conversations…Rural Health: Past, Present, & Future March 15, 2011 Bonnie Jeffery, University of Regina Shanthi Johnson, University of Regina Jim Daschuk, University of Regina Diane Martz, University of Saskatchewan Juanita Bacsu, University of Saskatchewan Noreen Johns, Community Partner

2. Saskatchewan Population Health and Evaluation Research Unit Bonnie Jeffery, PhD. Director, SPHERU Professor and Prince Albert Campus Coordinator Faculty of Social Work, University of Regina

3. Who are we? The Saskatchewan Population Health & Evaluation Research Unit (SPHERU) is an interdisciplinary research unit committed to critical population health research Collaboration between U of S and U of R with 10 researchers working out of 3 locations in the province: Regina, Saskatoon, Prince Albert Funded by the Saskatchewan Health Research Foundation (SHRF) and other national and provincial project funding

4. What guides our health research? Vision Working with communities and policy makers to improve the health of Saskatchewan people. Mission The promotion of health equity by understanding and addressing population health disparities through policy-relevant research.

5. What do we do?

6. New Mapping slide from Paul H.

7. Studies the role that culture plays as a health determinant. Our projects explore the role of culture in population health by looking at culture as a determinant of health, by considering culturally relevant definitions of health, and through refining cultural identity as an indicator of heath. Considers how context shape children’s health and development outcomes. Through our research in this area, and by working closely with decision- makers, community groups, policy-makers, etc., we hope to contribute to achieving better health and development for all children in Saskatchewan.

8. SPHERU also engages in research evaluation projects and promotes health equity by addressing health disparities through policy relevant research. Rurality is a powerful determinant of women’s and men’s health. Rural people’s poorer health is a result of significant inequities in health- determining conditions. Rural health research projects conducted by SPHERU provide a better understanding of the impact of economic and cultural determinants on the health of rural women, men, and youth.

9. Knowledge Transfer and Exchange

10. Our Presentation We are pleased to have this opportunity to share our research findings with you this evening. Our presentation will focus on SPHERU’s Rural Health theme.

11. The Past Jim Daschuk, PhD Changes in Rural Health from Past to Present

12. The Present Shanthi Johnson Falls and Injury Prevention in Older Adults Diane Martz The Role of Social Systems in the Health of Senior Women Living in Rural Saskatchewan Juanita Bacsu The Role of Social Systems in the Health of Senior Men Living in Rural Saskatchewan

13. Next Steps Noreen Johns Community Partner

14. Changes in Rural Health from Past to Present Jim Daschuk, PhD. Assistant Professor Faculty of Kinesiology and Health Studies University of Regina

15. Hospital and Nurses 1910s

16. 1919 The Spanish Flu

17. 20 th Century-Decline in Contagious Diseases USA (CDC 1997)

18. 1920s-Long Term Care-Sanatoria, “Mental” Hospitals

19. Improved Technology

20. Polio

21. 1946 The Swift Current Experiment

22. Public Health Inequalities 1950s

23. Smoking and Cancer

24. Diabetes in Canada - Public Health Agency of Canada

26. Falls/Injury Prevention Among Older Adults Shanthi Johnson, PhD Professor & Associate Dean (Research & Graduate Studies), Faculty of Kinesiology and Health Studies University of Regina

27. Healthy Aging…Falls Common Causes of falls Preventable Bellwether … health status Costly … physical, psychological, economic, and human costs –$6.2 billion –85% of all injury hospitalization for those over 65 years of age –75.7% of all in-house hospital deaths. Public Health Agency of Canada, 2005; SmartRisk, 2009

28. Research Focus Epidemiology of falls (Surveillance) fall, injury, hospitalization rates Intervention research Exercise and nutrition Community-based Delivered through existing infrastructure (home care, LTC)

29. External causes of injury hospitalizations by age-group, Saskatchewan (1995 – 2005)

30. Seniors hospitalized with fall injury, Saskatchewan, 1995/96 - 2004/05

31. Fall injury hospitalizations among older adults by area of residence at time of injury, 1995/96 – 2004/05 (N=30,757)

32. Survival analysis by sex for older adults (n=30,445) with fall- injury hospitalization, Saskatchewan, 1995/96 – 2004/05

33. Survival analysis by residence for older adults (n=30,445) with fall-injury hospitalization, Saskatchewan, 1995/96 – 2004/05

34. Common, costly Difficult to reach (frailty, rural/remote areas, transportation issues,..) Need to consider population and the place in trying to address falls. Falls Prevention is Key

35. Healthy Aging in Place

36. Presentation Overview Study Objectives Theoretical Framework Pilot Project Methods & Overview Preliminary Findings

37. Why study rural healthy aging? Compared to urban seniors, rural seniors are often more disadvantaged by having lower incomes, less education, less access to health services and overall poorer health outcomes (Sylvestre et al., 2006). Rural communities are facing escalating challenges in meeting the health care needs of a rapidly aging population (Skinner et al., 2008). In rural Saskatchewan, approximately 17% of the population are senior (Dandy & Bollman, 2008).

38. STUDY OBJECTIVES 1.To address gaps in our understanding of the health service needs of seniors living in rural communities 2.To identify the supports that enable rural seniors to stay independent and remain in their homes and communities longer a)How well are these supports represented in Cantor’s Social Care Model (1991)

39. Theoretical Framework Taken 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 Cantor’s Social Care Model

40. Healthy (not frail) (social) Intermittent assistance and socialization Moderately frail (moderate support) Assistance with shopping and errands, escort to medical services, and some help with the management of finances Greater incapacity (greater support) Complete care of the home, including heavy housekeeping, laundry, and preparation of meals. Personal care level of assistance (care) Washing, bathing, toileting – and performing some medical procedures Theoretical Framework: Cantor’s Model (1991)

41. Pilot Study Overview Conducted a pilot study in the community of Watrous and Preecevillle, SK from May –July 2010 Worked with community partner, Noreen Johns who provided local insight and recruited study respondents 42 semi-structured interviews were conducted with 24 women and 18 men, ages 67 to 98 years old Interviews were digital audio-recorded where permissible, transcribed, and processed in Atlas-ti.

42. The Role of Social Systems in the Health of Senior Women Living in Rural Saskatchewan Diane Martz, PhD Director, Research Ethics Office University of Saskatchewan

43. Preliminary Findings: Rural Networks People have networks of varying sizes and compositions from large networks with family and non-family to very small networks. The strength of people’s networks and social interactions are important predictors of health and wellbeing (Cohen, 2004). As people age, their networks tend to get smaller and family supports become more important. If networks can no longer provide supports, and formal services are not adequate, people may leave communities (Wenger and Keating, 2008)

44. Supports for Senior Rural Women Preliminary analysis shows that the vast majority of support comes from family (spouses and children). Support networks expand during medical emergencies. There is a strong element of reciprocity in the informal support system

45. Supports for Senior Rural Women… cont’d Senior women know formal support services are there, but are much more likely to rely on family. Implications for rural communities that are losing population: Increased burden for those who remain in the community; and Increased worry for family living in distant places.

46. Accessibility: Driving Mobility is an important social connector Because rural communities do not have well developed transportation systems, people’s mobility depends on being able to drive. Those who do not drive have significantly more unmet needs. ‘little things come up and you put them off or wait until you think someone has time to help or someone comes around” ‘When you lose your license, you lose your independence’

47. Accessibility: Driving… cont’d Rural communities need to develop transport systems that reflect the context of limited resources, low population density and long distances (Dobbs and Strain, 2008). SHR Rural Health Strategy identified the need to work with communities to create transportation options for seniors.

48. The Role of Social Systems in the Health of Senior Men Living in Rural Saskatchewan Juanita Bacsu Project Coordinator, SPHERU University of Saskatchewan

49. Why study healthy aging among rural men? Currently, little information is known about the support systems and the health care needs of rural senior men. Compared to urban seniors, rural seniors are often more disadvantaged by having lower incomes, less education, less access to health services and overall poorer health outcomes. Rural communities are facing escalating challenges in meeting the health care needs of a rapidly aging population.

50. Preliminary Findings: Support Perceptions Rural men are less likely to identify that they are receiving support if it was provided by a spouse or a family member. Supports often accessed by rural senior men include foot care, housekeeping and yard work. Our findings suggest that formal supports are only accessed if informal supports such as family and friends are unavailable to help.

51. Preliminary Findings: Support Perceptions Many senior men identified feeling a sense of shame in having to ask for help with tasks such as help with yard work or transportation. “I’m the type of person that’s overly independent, that’s why I hate to have to get somebody to help... But now I can’t do it. It hurts for awhile. It’s hard to get past that you know?” “I kind of feel bad that I can’t do it myself...”

52. Preliminary Findings: Support Perceptions Senior men were forthcoming toward discussing their emotional supports.  “Well mostly the help I get is social activities, they keep me from becoming depressed.”  Emotional support? “I keep it to myself. Who wants to listen to my problems?”

53. Preliminary Findings: Caregivers Rural senior men who were caregivers for their wives expressed a strong need for more support. “Ever since she’s got sick, everybody seems to stay away, you know. I find well, even family stays away...” “Because I just got to get away... I like to golf, I like to fish, but I haven’t got anybody to leave her with, I can’t anymore...”

54. Preliminary Findings: Driving In describing health and well-being many rural senior men made reference to the importance of driving. “What’s Healthy? There’s no pain and I take only a few pills, I feel good, I enjoy driving around out in the country and looking at the land and the air...”

55. Preliminary Findings: Driving… cont’d Rural men living in remote areas expressed greater importance with driving in direct relation to their quality of life. “We’re lucky as long as we can drive, you know... 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.”

56. Preliminary Findings: Falls Many of the rural senior male respondents had experienced falls. Injury sustained from falls often resulted in the use of walking aids and hip replacements. “I fell the other day and got hurt, I just grab a hold on something and hold on for dear life, I’ve had a couple of ribs cracked.”

57. Preliminary Findings: Mobility Rural senior men who experienced loss of mobility and their ability to walk expressed feelings of depression and hopelessness. “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.”

58. Next Steps and Future Plans Noreen Johns Community Partner

59. Future Plans Rural seniors’ health in Saskatchewan from the past to the present. Taking the next steps to move forward to improve rural seniors’ health in Saskatchewan.

60. Importance of Community-Based Research Rural communities face increasing challenges in meeting the health care needs of a rapidly growing population. Addressing the challenges: –Direct input from and collaboration with community members is key to identifying their needs and discovering solutions.

61. Community Involvement Short Term Community workshops –sharing findings and gaining feedback; –community input guides the future direction of the research process; and –community dialogue informs the next steps and how to best move forward. Long Term Expansion: –Allows for comparison within different contexts and health regions; Collaborative efforts will identify solutions that will lead to solutions that better address healthy aging in place.

63. Contact Us: Bonnie Jeffery Bonnie.Jeffery@uregina.ca (306) 953-5311 Jim Daschuk James.Daschuk@uregina.ca (306) 337-3272 Juanita Bacsu Juanita.Bacsu@usask.ca (306) 966-7942 Shanthi Johnson Shanthi.Johnson@uregina.ca (306) 337-3180 Diane Martz Diane.Martz@usask.ca (306)966-2975 Noreen Johns n.johns@sasktel.net (306) 257-3911

64. For more information … Please visit our website for details on all SPHERU projects

65. References Cohen, S. (2004) “Social relationships and health’, American Psychologist, vol 59, no 8, pp 676-84. Dobbs, B and L. Strain (2008) “Staying connected: issues of mobility of older rural adults” in Keating, Norah (ed) Rural Ageing: A good place to grow old? Bristol: The Polity Press. Wenger, G.C. and N. Keating(2008) “The evolution of networks of older adults” in Keating, Norah (ed) Rural Ageing: A good place to grow old? Bristol: The Polity Press.