Health Reports
Aging in the community: Factors associated with home adaptations and receipt of informal care, home care, and community support services among older Canadians

Abstract

Background

Most older Canadians would prefer to stay in their own homes and communities rather than move to long-term care (LTC) facilities. A growing older population, limited LTC capacity, and costs have increased demand for initiatives that enable people to age in their communities for as long as possible.

Data and methods

Data from the 2019/2020 Canadian Health Survey on Seniors were used to estimate the prevalence of four types of supports and services (SSs) that assist with living in the community: home adaptations, informal care, home care, and community support services. Separate multivariable logistic regressions for each SS, stratified by age group (65 to 79 years and 80 years or older), examined associations with need-related factors, enabling resources, and predisposing characteristics.

Results

At 25.0% of 65- to 79-year-olds and 51.9% of those aged 80 years or older, home adaptations were the most prevalent SS used in Canada. Use of home care, community support services and informal care was less common, ranging from 5.5% to 11.6% among Canadians aged 65 to 79 and 17.2% to 33.2% among those aged 80 or older. Nonetheless, substantial proportions of the younger (65.4%) and older (31.8%) age groups reported no SS use. In general, having a poor health status, having impairment, not driving, being older, living alone, having a regular health care provider, and being a woman increased the odds of using SSs. 

Interpretation

Understanding the factors associated with SS use can help inform policies and programs aimed at assisting older Canadians with aging in the community.

Keywords

cross-sectional study, home modifications 

Authors

Heather Gilmour and Michelle Rotermann are with the Health Analysis and Modelling Division at Statistics Canada. 

 

What is already known on this subject?

• Living independently in the community as they age is the desire of most Canadians, and it can contribute to their quality of life.
• Longer life expectancy, changing demographics, rising costs, limited availability of long-term care (LTC) spaces, and concerns about quality of LTC contribute to the current and future demand for supports and services (SSs) that can help older adults live independently in their community.
• The ability to live safely and independently generally declines with advancing age, while the proportion of older Canadians who live in nursing homes or residential care facilities increases with age.

What does this study add?

• Based on the 2019/2020 Canadian Health Survey on Seniors, home adaptations were the most prevalent SS used by older Canadians—25.0% of 65- to 79-year-olds and 51.9% of those aged 80 years or older. Use of informal care, home care, and community support services was less common, ranging from 5.5% to 11.6% among Canadians aged 65 to 79 and 17.2% to 33.2% among those aged 80 or older.
• Use of SSs was most strongly associated with need-related factors, characterized by having poor health, having impairment, and not being a driver. Several predisposing characteristics, such as being older, being a woman, and living alone, were also significant. In some instances, being an immigrant or part of a racialized population group was associated with a lower likelihood of SS use.
• Nearly two-thirds (65.4%) of those aged 65 to 79 years and about one-third (31.8%) of those aged 80 years or older reported not using any SSs. This finding may mean that they did not need SSs or they did need SSs but were unable to access or afford them.

Introduction

While there is no formal definition of the term “aging in the community,” it is commonly used (along with the related terms “aging in place” and “aging at home”) and generally refers to the desire and ability of older adults to remain in their own homes as they age. This concept embodies the importance of maintaining independence in one’s residence, as well as social connectedness and participation in one’s community.^Note 1

Aging in the community may take place in an older adult’s own—sometimes longstanding—home or, alternatively, in assisted living or retirement communities.^Note 2 It is believed that living in a familiar environment can contribute to an individual’s quality of life, particularly when the home or neighbourhood is accessible and safe.^Note 2, ^Note 3

Policies and programs that support aging in the community are important given the growing number of older Canadians, coupled with concerns about long-term care (LTC) affordability and capacity.^Note 4, ^Note 5, ^Note 6, ^Note 7 In 2021, 18.5% of the Canadian population was aged 65 years or older, an increase from 13.0% in 2001.7 By 2073, this share is projected to reach 21.9% to 32.3%.^Note 8 Longer life expectancy and more years lived in poor health^Note 9 contribute to current and future needs for supports and services (SSs) that mitigate health challenges and allow older adults to age in the community safely and with dignity.^Note 11, ^Note 12, ^Note 13

Most older Canadians indicate a preference for aging in their home,^Note 10, ^Note 11 and the majority will do so. However, the ability to live safely and independently generally declines with age.^Note 14 The proportion of older Canadians who live in nursing homes or residential care facilities increases with age. For example, in 2021, 2.5% of those aged 65 to 79 lived in these institutions, rising to 11.0% among those aged 80 or older.^Note 15, ^Note 16 Other societal changes, such as families having fewer children and experiencing greater geographic mobility, also reduce the potential supply of family caregivers.^Note 17 Although the COVID-19 pandemic affected all Canadians, LTC residents were especially hard hit. About 8 in 10 COVID-19-related deaths in Canada occurred among these residents,^Note 18 further entrenching the intention of many to remain where they live for as long as possible.

Together, changing demographics, rising costs, limited availability of LTC spaces, and concerns about the quality of care and safety of LTC facilities have led to the increasing emphasis placed on SSs that can help older Canadians to live independently in their community.^Note 4, ^Note 5, ^Note 6 A better understanding of SS use by older Canadians aging in the community can inform related policies and programs and potentially reduce costs and improve outcomes.

Using data from the 2019/2020 Canadian Health Survey on Seniors (CHSS), this study examined the use of four types of SS—home adaptations, informal care, home care, and community support services—among community-dwelling Canadians aged 65 or older. Andersen’s Behavioral Model of Health Services Use is a widely used framework for examining determinants of health care service use.^Note 19 Following this framework, multivariable logistic regression was used to identify individual predisposing characteristics, enabling resources, and need-related factors associated with the use of each type of SS. This analysis applied Andersen’s model^Note 19 of health service use to assess the determinants of each SS.

Data and methods

2019/2020 Canadian Health Survey on Seniors

The CHSS is a cross-sectional supplement to the Canadian Community Health Survey, which collects detailed information on health status, health care services, social provisions, and social determinants of health for respondents residing in the provinces. It excludes individuals living in the territories, on reserves, and in other Indigenous communities in the provinces; full-time members of the Canadian Forces; the institutionalized population; and individuals living in certain remote regions.

Data from people aged 65 or older were collected via in-person or telephone interviews conducted from January 2019 to December 2020, with a pause from mid-March until September 2020 because of the pandemic. The CHSS response rate was 40.1%, corresponding to a sample of 41,635. Detailed documentation for the CHSS is available elsewhere.^Note 20

Analytical sample

This study’s analytical sample included 41,624 respondents aged 65 years or older for whom gender was reported (18,127 men and 23,497 women), representing 6.4 million people living in the community in the 10 provinces. Missing cases for the four outcomes (0.3% or less) and the covariates were low (0.0% to 2.6%). There were 2,311 proxy respondents (i.e., another knowledgeable person answered on the selected respondent’s behalf because of illness or health-related difficulties). More information about the characteristics of the study population is available in Appendix Table A.

Definitions

Outcome variables

Respondents were asked about their use of four types of SS in their home.

Home adaptations include any of the following adaptations to respondents’ home to facilitate their daily activities, whether made by them or already in place:

• grab bars
• handrails
• lever handles on doors or faucets
• adapted bathing facilities (e.g., lowered or walk-in bathtub or shower)
• access ramp
• chair lift or lift device
• other.

Informal care refers to short-term or long-term assistance with a range of activities because of a health condition or limitation that affects respondents’ daily life from family, friends or neighbours (excludes assistance from paid workers or volunteer organizations) received during the past 12 months for any of the following activities:

• personal care such as assistance with eating, dressing, bathing, or toileting
• medical care such as help taking medicine or help with nursing care (e.g., dressing changes or foot care)
• management of care such as making appointments
• help with activities such as housework, home maintenance, or outdoor work
• transportation, including trips to the doctor or for shopping
• meal preparation or delivery.

Any home care includes any of the following types of care received in the past 12 months (includes services received in the home because of a health condition or a limitation in daily activities and does not include help from family, friends, or neighbours):

• nursing care (e.g., dressing changes, preparing medications, Victorian Order of Nurses visits)
• other health care services (e.g., physiotherapy, occupational or speech therapy, nutrition counselling)
• medical equipment or supplies (e.g., wheelchair, pads for incontinence, help with using a ventilator or oxygen equipment)
• personal or home support (e.g., bathing, housekeeping, meal preparation)
• other services (e.g., transportation, meals-on-wheels).            

Community support services include the following services provided by organizations and not individuals, for free or for a minimal payment (excluding assistance from family, friends, or neighbours), and received during the past 12 months because of a health condition or a limitation that affects respondents’ daily activities:

• friendly visiting (e.g., regular visit from a companion, providing friendship and company)
• adult day program (e.g., specialized programs of therapeutic, social, and recreational activities)
• grounds maintenance services (e.g., snow removal or lawn mowing)
• faith outreach services
• transportation, including trips to the doctor or for shopping
• foot care
• food bank
• support groups (e.g., grief support group)
• other.

Covariates

The selection of covariates was guided by availability in the CHSS and Andersen’s Behavioral Model of Health Services Use.^Note 19 Andersen’s model was developed to understand health service use in relation to different characteristics and factors known as need-related factors, enabling resources, and predisposing characteristics. Need-related factors, such as health status, influence the need for services. Enabling resources refer to the availability of services and personnel, as well as the knowledge and ability to access them. Predisposing characteristics are related to the tendency to use health care services.

Need-related factors

Need for assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs) variables categorize respondents’ abilities based on the number of times they indicated needing help with an activity or being completely unable to do an activity. Seven questions assessed ADLs (ability to feed oneself, dress and undress oneself, take care of one’s own appearance, walk, get in and out of bed, bathe or shower, and get to the bathroom on time), and another seven questions assessed IADLs (ability to use the telephone, get to places that are out of walking distance, go shopping, prepare one’s own meals, do housework, take medicine, and handle money). In accordance with the Older Americans Resources and Services Multidimensional Functional Assessment Questionnaire,^Note 21 respondents were then categorized as having (1) no impairment; (2) mild impairment; or (3) moderate, severe, or total impairment. Because of a limited sample, moderate, severe, and total impairment was grouped together.

Self-perceived health was categorized as excellent or very good, versus good, fair, or poor.

Driving is a complex activity requiring a certain level of functional health. To operate a motor vehicle safely, one has to be able to see, make quick decisions, and remember the rules of the road. It requires the use of one’s arms and legs for steering, acceleration, and braking.^Note 22, ^Note 23 A recent driver was defined as having a valid driver’s licence and having driven at least once in the past month.

Enabling resources

The highest level of household education was classified as less than high school graduation, high school graduation, or postsecondary.

Household income was divided into three categories based on the adjusted ratio of household income to the low-income cut-off corresponding to household and community size: (1) lowest (deciles 1 to 4), (2) middle (deciles 5 and 6), and (3) highest (deciles 7 to 10).

Province of residence reflects where the respondent lived at the time of the survey.

The timing of the survey was based on the survey collection period and was coded as before COVID-19 restrictions (January to December 2019 and January to March 2020) or during the COVID-19 pandemic (September to December 2020).

Predisposing characteristics

Among the three gender categories available (male, female, and gender diverse), the first two were selected for analysis as the third category contained fewer than 10 respondents.

Living arrangementwas dichotomized as living alone, or living with family or others.

Immigrant status was categorized as immigrant (landed immigrant or non-permanent resident) or Canadian-born individual.

Respondents were asked whether they were First Nations (regardless of Indian Status), Métis, or Inuk (Inuit) and, if not, whether they belonged to one or more racial or cultural groups. Based on these questions, respondents were categorized as Indigenous, racialized, or non-Indigenous and non-racialized.

Analytical techniques

Weighted frequencies were calculated to examine estimates of the four SS outcomes (home adaptations, informal care, home care, and community support services) by the selected predisposing characteristics, enabling resources, and need-related factors. Associations between each of the four SS outcomes and covariates were also assessed using separate multivariable logistic regressions to account for the potential confounding of the other factors. Detailed data on types and combinations of SSs used are also presented. All analyses and models were stratified by age group (65 to 79 years and 80 years or older). Differences between age groups and reference categories were calculated with t-tests.

Bootstrap weights were applied using SAS 9.4 and SUDAAN 11.0.3 to account for the underestimation of standard errors resulting from the complex survey design.^Note 24 Results at the p < 0.05 level were considered statistically significant.

Results

Use of supports and services

At 25.0% of 65- to 79-year-olds and 51.9% of those aged 80 years or older, home adaptations were the most prevalent SS used by older Canadians (Table 1). Use of informal care, home care, and community support services was less common, ranging from 5.5% to 11.6% among Canadians aged 65 to 79 and 17.2% to 33.2% among those aged 80 or older.



Grab bars and handrails were the most frequent types of home adaptations reported. For informal care, help with household activities and transportation were most frequently reported. For home care, personal or home support and nursing care were most frequently reported. Among community support services, grounds maintenance and food bank use were some of the most frequently reported SSs, followed by friendly visits for the younger age group and transportation for the older age group.

Nearly two-thirds (65.4%) of those aged 65 to 79 years and about one-third (31.8%) of those aged 80 years or older reported not using any of the four SSs examined (Table 2). Relatively few older Canadians used all four SS types—0.8% of 65- to 79-year-olds, compared with 4.9% of those aged 80 years or older.



For both age groups, exclusive use of home adaptations was the most prevalent category—16.6% of 65- to 79-year-olds and 21.1% of those aged 80 or older. Informal care only (4.2% and 7.1%, respectively) and a combination of informal care and home adaptions (3.3% and 9.2%, respectively) were the next leading combinations of SSs used.

Factors associated with use of supports and services

With few exceptions, need-related factors (ADL/IADL impairment; good, fair, or poor self-perceived health; and not being a recent driver) were significantly associated with a greater likelihood of using each type of SS (tables 3 and 4), even in multivariable analysis that accounted for all need-related factors, enabling resources and predisposing characteristics together (tables 5 and 6).

   

For example, about one in five adults aged 65 to 79 with no ADL or IADL impairment (20.9%) reported having home adaptations, whereas the use of this support type was more than double (46.1%) for people with mild impairment and triple (60.9%) for those with more severe impairment. Adjusted odds ratios were 2.6 for those with mild impairment and 4.6 for those with more severe impairment, compared with those with no impairment. Moreover, the use of SSs was almost always more common among those aged 80 or older compared with the younger age group.

For both age groups, there were instances where SS use differed by education and income level in multivariable analysis (tables 5 and 6). Among those aged 65 to 79, lower levels of education were associated with a lower likelihood of receiving informal care, while lower income levels were associated with higher odds of having home adaptations and using community support services. Among those aged 80 or older, in some instances, having an education below a postsecondary education was associated with a lower likelihood of having home adaptations, receiving home care and using community support services, while lower income levels were associated with greater odds of having home adaptations (Table 6).

Some provincial differences in the use of each type of SS were apparent when compared with Ontario in the adjusted analysis. Notably, several provinces had higher odds of informal care use and lower odds of community support service use.

In most cases, women were significantly more likely than men to have used each type of SS (tables 3 and 4), an association that persisted in multivariable analysis (tables 5 and 6), apart from home care services, regardless of age. Similarly, those living alone had higher odds than those living in other arrangements of using each SS type, except for home adaptations and informal care for those aged 80 or older.

Use of SSs among Indigenous peoples did not differ from use among non-Indigenous and non-racialized populations in multivariable analysis. However, racialized populations had significantly lower odds of having home adaptations (65- to 79-year-olds), using home care (both age groups), or using community support services (65- to 79-year-olds), compared with their non-Indigenous and non-racialized counterparts. Similarly, immigrants were less likely than their Canadian-born counterparts to have home adaptations or to use community support services among 65- to 79-year-olds and less likely to use home care for those aged 80 years or older.

Having had data collected during the COVID-19 pandemic was associated with lower odds of informal care among those aged 80 years or older.

Discussion

While most older Canadians prefer to live independently, the ability to do so tends to decline with advancing age as the need for help with some or all activities essential to remaining in their own homes increases: personal care, everyday housework, grocery shopping, meal preparation, etc. In this study, about one-third of 65- to 79-year-olds and two-thirds of those aged 80 years or older had used at least one of the SSs examined (home adaptations, formal home care, informal care and community support services). Those aged 80 years or older were at least twice as likely to have used each SS than those aged 65 to 79.

For older individuals with very high levels of dependency and complex medical needs, a transition to LTC may be desirable or necessary. By contrast, in Canada, somewhere from 11% to 20% of new LTC admissions had low to moderate care needs, suggesting that some could have stayed in their own homes, had proper home care support and other services been available.^Note 25, ^Note 26

Previous Canadian studies of SS use among older Canadians have examined receipt of formal home care and informal care,^Note 27, ^Note 28, ^Note 29, ^Note 30 while this CHSS-based study is the first to also include national estimates of home adaptation and community support service use.

Many of the covariates associated with SS use in this study align with other studies of formal or informal home care use, including being older, having ill health and living alone.^Note 27, ^Note 28, ^Note 29, ^Note 31, ^Note 32, ^Note 33

According to the CHSS, the most prevalent SS used was home adaptations—for one-quarter of those aged 65 to 79 and half of those aged 80 or older. The installation of grab bars and handrails was most frequent. Home adaptations are important not only because they support autonomy and the ability to maintain the current housing situation, but also because they limit the need for institutionalization by reducing fall risk, related injuries and loss of independence with ADLs.^Note 34, ^Note 35, ^Note 36, ^Note 37 However, other data indicate that most home modifications in Canada are paid for out of pocket.^Note 10 Nonetheless, in this study, those with lower income levels had greater odds of having home adaptations, suggesting that some form of financial assistance may have been available or possibly that home adaptations were considered a more affordable option than LTC.

American research on Medicare beneficiaries aged 65 years or older found that 60.8% to 69.3% had home or bathroom modifications,^Note 38, ^Note 39 suggesting that use of this type of SS may be more commonplace in the United States. However, the survey’s design and coverage differ somewhat from those of the CHSS.

Support from friends and family plays an important role in helping older Canadians to age in the community.^Note 28, ^Note 31,^Note 40, ^Note 41 According to the CHSS, 1 in 10 65- to 79-year-olds and 1 in 3 of those aged 80 or older had received this type of care. Provision of unpaid, informal support can fill care gaps and supplement other SS types.^Note 31, ^Note 33, ^Note 42, ^Note 43

Older adults living alone often report poorer health and social well-being.^Note 32 In most cases, they were more likely to have used SSs, possibly reflecting a lack of informal support. Targeting SSs to this group could improve health outcomes for older adults in the community.

In this study, racialized populations had a lower likelihood of home care use than their non-racialized, non-Indigenous counterparts. Other research has found that older adults in ethnic minority groups may underutilize SSs and can face additional barriers to help-seeking because of language and cultural differences.^Note 43, ^Note 44 Cultural expectations (including filial piety) have also been hypothesized as an explanation of greater reliance on informal care by some population groups, but this association was not identified in this study.^Note 44

A review of populations with reduced likelihoods of having used community support services in this study identified some groups for which programs could be targeted—including the younger age group of immigrants and racialized populations and individuals in the older age group from lower-education households.

Geographic variations in the use of SSs were also apparent in this study. However, because the delivery structure of home care, community support services and programs that support home adaptations (including grants and tax credits, eligibility criteria, hours of care provided, and copayments) varies across Canada, interpretation of differences is difficult.^Note 44, ^Note 45 Provincial variability in the use of informal care is likewise difficult to explain and potentially influenced by the use of other SSs.

Substantial numbers of community-dwelling seniors did not use any of the SSs examined in this study. It is unknown whether those who had not used any did not yet need them, have access to them, or choose to seek these forms of help.

Additionally, barriers to obtaining home care or other SSs are quite common^Note 31, ^Note 42 and have been associated with additional stress, loneliness, and sleep difficulties.^Note 46 Lack of awareness, including not recognizing that one has a need for SSs, and concerns about affordability, difficulties navigating multiple service-providing agencies, and even avoidance of asking for help because of not wanting to be a burden are all factors that contribute to the barriers to obtaining SSs.^Note 10, ^Note 43, ^Note 47, ^Note 48, ^Note 49 Conversely, other studies have found that some older adults view help-seeking as a threat to their independence, while some opt not to complete home modifications because they do not believe changes would be effective.^Note 43, ^Note 50

Strengths and limitations

Among the strengths of this study are the use of a representative Canadian data source with a cross-sectional sample of more than 40,000 older Canadians, enabling stratification by two age groups, and an analysis of four SS types, including home adaptations and community support services, which are not normally included.

Nonetheless, this study has some limitations. CHSS data collection was interrupted by the COVID-19 pandemic, and the inability to conduct in-person interviews resulted in lower response rates. All analyses used survey weights, which minimized non-respondent bias that could arise because of low response rates. However, the increase in non-response rates may have influenced estimates (e.g., an increase in the total variance) produced using the survey data.^Note 51

Despite the sizable sample, further disaggregation of population groups that may differ in their use of SSs was not possible (e.g., more detailed breakdowns of racialized population groups; estimates for non-binary or transgender individuals; and separate estimates for First Nations people, Métis and Inuit). Built environment features can also influence the ability of older adults to age in the community but have not been accounted for in this study.^Note 2 Data were also limited to individuals living in the provinces and excluded those living in the territories or on Indigenous reserves or settlements. Exclusion of covariates of interest (e.g., cognition) that were not available in the data could influence the observed associations. A bias could result if participants in the CHSS differed in physical and cognitive health from those who did not respond to the survey.

Conclusion

Based on the CHSS, the use of SSs was most strongly associated with need-related factors, characterized by having poor health, having impairment, and not being a driver. However, several predisposing characteristics were also significant—notably being older, being a woman, and living alone—while, in some instances, being an immigrant or from a racialized population group was associated with lower likelihood of SS use.

This study also found that many older people reported not using any SSs. This may mean they did not need SSs or had needs but were unable to access or afford services. Future research could examine unmet needs and barriers to better understand potential inequities in SS use.