Perspectives on ageing: a qualitative study of the expectations, priorities, needs and values of older people from two Canadian provinces

Abstract

Background

Understanding the needs and values of older people is vital to build responsive policies, services and research agendas in this time of demographic transition. Older peoples’ expectations and priorities for ageing, as well as their beliefs regarding challenges facing ageing societies, are multi-faceted and require regular updates as populations’ age.

Objective

To develop an understanding of self-perceptions of ageing and societal ageing among Canadian retirees of the education sector to define a meaningful health research agenda.

Methods

We conducted four qualitative focus groups among 27 members of a Canadian retired educators’ organisation. Data were analysed using an inductive thematic approach.

Results

We identified four overarching themes: (1) vulnerability to health challenges despite a healthier generation, (2) maintaining health and social connection for optimal ageing, (3) strengthening person-centred healthcare for ageing societies and (4) mobilising a critical mass to enact change. Participants’ preconceptions of ageing differed from their personal experiences. They prioritised maintaining health and social connections and felt that current healthcare practices disempowered them to manage and optimise their health. Although the sheer size of their demographic instilled optimism of their potential to garner positive change, participants felt they lacked mechanisms to contribute to developing solutions to address this transition.

Conclusion

Our findings suggest a need for health research that improves perceptions of ageing and supports health system transformations to deliver person-centred care. Opportunities exist to harness their activism to engage older people as partners in shaping solution-oriented research that can support planning for an ageing society.

Key points

• Understanding the needs and values of older people today is vital to build responsive policies, services and research agendas.

• Preconceptions of ageing often differ from and are more negative than older peoples’ personal experiences.

• They prioritise maintaining health and social connection, yet feel current healthcare practices run counter to this pursuit.

• Future research is needed on how to effectively confront self-ageism and outdated societal ideals of successful ageing.

• Engaging older people as partners in solution-oriented research is also needed for meaningful improvements in healthcare.

Introduction

Public discourse in countries with rapidly ageing populations has been dominated by concerns of how and whether health, social and economic systems will be able to meet growing demands for solutions to late-life problems [1]. These concerns include fiscal pressures on healthcare and income support programmes for older people; outdated healthcare systems that have not kept pace with the need for chronic disease management as people live longer; long-term care waitlists; and reduced economic growth, among others. The voices of older people, though, have received less attention [2]. Understanding their needs and values is vital to set responsive research agendas that can inform the design and implementation of meaningful solutions; solutions that promote health and resiliency and in turn unlock social capital to realise the potential of a longevity dividend [3, 4]. How older people perceive ageing, as well as what they value and prioritise, is multi-faceted, complex and cohort specific; consequently, ongoing research is needed as populations’ age. Although a recent scoping review of the literature on ageing self-perceptions revealed that quantitative methodologies are the most common approaches to studying this topic, qualitative approaches provide opportunities to gain a deeper understanding of these complex views and have provided valuable insights on the construction of ageing identities and what it means to age well [5]. We conducted a series of focus groups with Canadian retirees from the education sector to give voice to their experiences of ageing. Our objective was to develop an understanding of their self-perceptions on ageing and societal ageing, to identify meaningful and resonant health research priorities that can benefit older people of today and tomorrow.

Methods

We utilised community-based participatory research (CBPR) methodology to partner with RTOERO on this study. CBPR is a partnered approach to research that equitably involves community members and researchers in all aspects of the research process; such partnerships enhance the understanding of a phenomenon through the contribution of unique strengths and knowledge, facilitate integrated knowledge exchange and mobilise knowledge with action [6]. RTOERO (https://www.rtoero.ca) is a national retired educator’s organisation that provides programmes and services, including group health insurance benefits, to >81,000 retired educators, administrators and educational support staff from childcare to post-secondary settings in Canada. The study protocol was developed collaboratively with RTOERO leadership. Members contributed expertise to refine the research aims, optimise recruitment and plan knowledge translation activities. We used the consolidated criteria for reporting qualitative research checklist as a reporting guide [7].

Study setting and sample

All eligible Canadians receive universal access to medically necessary healthcare [8]. Most RTOERO members reside in Ontario, where public prescription drug coverage is provided to individuals’ ≥65 years, and British Columbia, where drug coverage is also provided after exceeding an annual, income-based deductible [9].

We conducted four focus groups (n = 27 participants total, 4–10 participants per group) with RTOERO members in May and June 2018. Members were eligible to participate in the focus groups if they spoke English and attended one of two in-person member events in Toronto, Ontario. They were invited to participate by e-mail from the RTOERO leadership in advance. We selectively sampled from members who expressed interest to ensure representation of men and women, varying age groups (65–74 and ≥75 years) and geography (Northern, Eastern, Central, Southwestern Ontario and British Columbia). Participants were given a $10 gift card as renumeration.

Data collection

In-person focus groups were facilitated by R.D.S. (epidemiologist and experienced group interviewer) with assistance from K.H. (undergraduate health sciences student), lasted ~60 min and covered six broad topics. The topic guide was designed with RTOERO to facilitate a discussion on what older people perceive to be important with respect to ageing and ageing research, from each a personal and societal perspective (Supplementary Table S1). The guide was pretested with four family members of R.D.S. and K.H. aged ≥60 years but not RTOERO members.

Ethics approval was obtained from the Women’s College Hospital Research Ethics Board (#2018-0047-E). All participants volunteered, provided written consent and completed a short demographic survey. To protect confidentiality, participants assigned themselves pseudonyms. Focus groups were audio recorded and transcribed verbatim by a professional transcriptionist, with accuracy verified by K.H.

Data analysis

R.D.S. and K.H. performed a thematic analysis using guidelines by Braun and Clarke [10]. We wrote analytic memos to describe initial impressions of the data, noting similarities or differences from previous focus groups, viewpoints/quotations that stood out or surprised us, and reflexive thoughts on our role in generating the data. These notes were included in our data set for analysis. We developed a set of initial codes based on the first focus group using a data-driven, inductive approach. Codes were compared for consistency and formed the basis of a codebook that was applied to data from subsequent focus groups. R.D.S. and K.H. met following the coding of each focus group to ensure reliability and expand the codebook as new concepts arose, promoting ongoing reflexive dialogue that shaped how data were interpreted. All coding was performed in NVivo software, version 12 (QSR International).

Initial themes were presented first to RTOERO leadership at a board meeting in the fall of 2018, followed by a webinar accessible to all RTOERO members several weeks later and an in-person meeting of RTOERO district presidents (some of whom were study participants), for input and reflection. All groups deemed the themes to resonate and so no further substantive changes were made. Themes were further refined and integrated into a narrative by R.D.S. and A.M.B. RTOERO’s chief executive officer is a co-author (J.G.) and critically reviewed the manuscript.

Results

Study participants

Most of the 27 participants were women (70%), Canadian-born (81%) and in very good or excellent self-reported health (63%) (Table 1). All participants had post-secondary education.

Table 1.

Characteristics of focus group (FG) participants

Characteristics	Overall	FG 1	FG 2	FG 3	FG 4
	(N = 27)	(n = 6)	(n = 7)	(n = 4)	(n = 10)
Sex
Male	8 (30%)	3	1	2	2
Female	19 (70%)	3	6	2	8
Age (years)
Min/max	65/82	65/79	66/81	69/75	67/82
65–69	10 (37%)	2	3	1	4
70–74	10 (37%)	3	2	2	3
75–79	3 (11%)	1	0	1	1
80–84	2 (7%)	0	1	0	1
Missinga	2 (7%)	0	1	0	1
Country of birth
Canada	22 (81%)	4	6	3	9
Outside Canada	5 (19%)	2	1	1	1
Self-rated health
Excellent or very good	17 (63%)	5	4	4	4
Good	7 (26%)	1	2	0	4
Fair or poor	1 (4%)	0	0	0	1
Missinga	2 (7%)	0	1	0	1
Sense of community belonging
Very or somewhat strong	19 (70%)	5	4	3	7
Average	4 (15%)	1	1	1	1
Very or somewhat weak	2 (7%)	0	1	0	1
Missinga	2 (7%)	0	1	0	1
Living arrangement
Lives alone	12 (44%)	3	3	0	6
Lives with family	13 (48%)	3	3	4	3
Missinga	2 (7%)	0	1	0	1

^aAnswer not provided.

Key findings

We identified four overarching themes: ‘vulnerability to health challenges despite a healthier generation’, ‘maintaining health and social connection for optimal ageing’, ‘strengthening person-centred healthcare for ageing societies’ and ‘mobilising a critical mass to enact change’. Themes and sub-themes are outlined in detail below. Additional illustrative extracts of data are presented in Supplementary Table S2.

Vulnerability to health challenges despite a healthier generation

Expectations for ageing are rooted in familial experiences

Participants’ preconceptions of ageing were mostly formed by observing ageing relatives. In each focus group, a similar portrait of ageing emerged—that when you became older, you succumbed to a ‘quiet life’ of invisibility, inactivity and isolation. Participants used vivid accounts of grandparents confined to rocking chairs to provide a stark contrast with their expectations and current realities. Most participants described their own experiences with ageing to be more positive than expected:

So, you tend to look back to pictures of your parents when your own children were young and I think we’re younger as 65-year-olds, 55-year-olds, 75-year-olds than what our parents were. I think we’re more active, we do more things generally. Not to say that we don’t have the issues and we don’t heal slower, but I think it used to be like, oh, you hit 65, well, you stopped. Now, you hit 65, oh, let’s go and do some other exciting adventure tour, trip or something like that. (female participant, focus group 1)

There were subtle differences in how women and men spoke about their expectations, with female participants more frequently describing expectations for the quality of their life, whereas male participants raised expectations regarding longevity:

I really didn’t have any expectations or think about it because my father died when I was 18 and my mother lived until 103. So, there’s that big disparity. (male participant, focus group 3)

Health challenges get in the way

Despite this, participants grappled with health setbacks that challenged their generational hubris. A male participant described his experience with illness as:

It shattered my self-image, quite honestly, because I saw myself as extremely fit, capable of doing anything, and it taught me a tremendous lesson about how we can assume nothing in terms of our own personal health. (male participant, focus group 1)

These sudden changes in health were particularly transformative for individuals whose health was intrinsic to their self-image:

. . . but I’m surprised at all the little things that happen. One knee is gone now, and none of that was ever going to happen to me because I was a runner, and I ate right, and I did everything you’re supposed to do and then . . . but nothing major. Disappointed that my body is kind of falling apart, though, limb by limb. (female participant, focus group 4)

Participants described measures they took to safeguard their health but were often surprised and disappointed that these measures were not fail-safe. Some described feeling misled over the level of control they thought they had over their health, with one participant describing that she felt ‘naïve’ thinking that she could avoid all the health issues associated with ageing if she ‘did everything right’. Gradual, cumulative changes in health were described as just as insidious and damaging (or maybe even more so) to confidence and having a positive outlook on ageing as acute and catastrophic changes. Actively experiencing age-related health challenges led participants to realise that societal notions of successful ageing may be overly simplistic, foolish and deceptive.

Maintaining health and social connection for optimal ageing

Health as the foundation

Participants considered maintaining their health to be critically important as they age. Health was viewed as foundational, empowering participants to preserve their self-image as physically capable and independent, and allowing them to lead lives aligned with their values. Health maintenance focused on activities that could be controlled—eating well, exercising, finding opportunities for mental stimulation and minimising reliance on medications. A male participant described his priorities as:

. . . I would like to make sure that I’m physically fit to carry on . . . I certainly have no intention of ever going to a retirement home or nursing home. I have my own house, and I certainly expect to stay there. And hopefully I don’t have to use some of the aids that I see my colleagues using, such as canes and walkers and wheelchairs. . . [Moderator: So, for you, your priority is your health?] Yes, absolutely. (male participant, focus group 3)

Participants also shared how witnessing the physical or cognitive declines of a friend or family member, or experiencing loss, motivated them to adopt healthy lifestyles and to shift their priorities for retirement to health, happiness and maintaining social connection.

Loss and connection

When asked about priorities beyond health, a female participant responded:

I’d say friends, because with people passing on, I have a frame of university friends . . . at graduation, we all took each other’s pictures and I so proudly put my four friends into a frame. And three of them have died. And the other one we lost track of a long, long time ago. So, I look at that and I think, ah, you know? . . . And so like, where are my close friends? They have all died . . . the long-standing friendships that were so important and are gone. (female participant, focus group 3)

Many participants had similarly expected to spend their later years in the company of close friends and now were in an unexpected position of being the sole, remaining member of their peer group. The amount and rate of change participants experienced was described as ‘traumatic’, emphasising the emotional toll of these losses. Female participants were particularly candid about their losses and feelings of loneliness. Isolation arising from such changes to their social networks was talked about in every focus group; although, participants were reluctant to use terms like social isolation or loneliness to describe their situation or emotions, perhaps highlighting the stigma inherent in this topic. Instead, many participants, particularly men, voiced challenges relating to isolation more abstractly and in the context of others.

To cope with diminishing social networks, many participants shared personal strategies of how they maintained social connections, from joining social, civic and/or exercise groups to enrolling at local universities. These exchanges suggested that, like health, participants viewed maintaining social connection as their personal responsibility and within their control. Not all shared this view. Several participants acknowledged broader, structural challenges older people face, including access to housing, transportation and seniors’ centres, particularly in rural communities (Supplementary Table S2). In response to a female participant describing how she built friendships when she moved to a new city to be closer to her daughter, a male participant countered:

. . . the location of long-term care homes or senior's homes doesn’t make any sense. It should be in the heart of the community so they can get out and walk. Transportation shouldn’t be an issue because in many cases it’s more than an issue, it’s a danger to them. But we don’t have the foresight yet to say, we need to locate where it makes sense for people to stay connected which is what we’re talking about. How do you stay connected? Not everybody has the initiative that you do . . . (male participant, focus group 1)

This claim was supported by other participants who acknowledged that formalised supports and infrastructure was important to maintain social connection, especially for marginalised older people. These first two themes demonstrate how deeply important health and connection are for ageing, yet how entrenched outdated societal ideals of ‘successful ageing’ are. There is a need for research that promotes a new way of thinking of what success in ageing is, including the role and responsibilities societies have in helping individuals achieve this success.

Strengthening person-centred healthcare for ageing societies

Although there was uncertainty around the degree to which improving social connection for older people was a personal versus societal responsibility, study participants in all focus groups viewed strengthening healthcare as a key challenge for ageing societies. For male participants, improving accessibility to healthcare was discussed frequently; female participants focused more on quality of care. Although they did not use the term ‘person-centred care’ (PCC), the aspects of healthcare participants described as needing improvement were those that are foundational components of PCC models—time for patient care, continuity of care, engaging patients in managing their care, and cultivating communication and trust.

Adequate time for care

Participants described a desire to be viewed as a whole person during clinical encounters, to be heard and to have the opportunity to build relationships with healthcare providers. They recognised a tension between these desires and current healthcare practices that often restrict primary care encounters to one issue per visit. One woman described:

Nobody cares about my health more than I do. I need to be informed, to realise that I own my health, more than giving it to someone who says, ‘one problem’. That appalls me. (female participant, focus group 2)

Many participants were frustrated with the need to triage their health concerns during doctors’ appointments and found it emotionally taxing to be unable to express all their concerns.

Continuity of care

They also expressed frustration when healthcare practices impeded continuity of care. For example, one participant described how distressing it was for her mother to have her general practitioner excluded from her stroke rehabilitation, given their long-standing and trusting relationship (Supplementary Table S2). Many participants attributed suboptimal care to practices or policies that infringed on their abilities to build trusting relationships with their healthcare providers.

Engagement, communication and trust

Communication and shared decision-making were viewed as essential to these relationships. Miscommunication and/or healthcare providers not providing sufficient rationale for clinical decisions left some participants feeling disempowered and lacking ownership of their health. Changes in the type of care they were receiving, such as discontinuing routine cancer screening, without an adequate explanation of why, signalled to participants that their lives were no longer valued by healthcare providers and by society:

. . . I would like to have responsibility for my health . . . I remember there was one test or something that I needed, oh, it was my pap, and she (sic) said, well, we’ll do it now, but now you won’t need one anymore, you’re all done. You’re all done with that. You’re going to be 70, so we don’t worry about you anymore. To me, that is very hurtful. I find that I cannot look after myself like I want to. (female participant, focus group 1)

Shared decision-making also emerged in the context of medication prescribing behaviours. Across all focus groups, participants were wary of polypharmacy (i.e. concurrent use of multiple medications) for fear of adverse effects and drug interactions. One participant talked about how ‘scary’ it was for her to see her friends being put on more medications at every physician visit. Because of this, participants valued medication reviews, learning about non-pharmacologic alternatives to managing their chronic conditions, and thoughtful prescribing that considered their desire to minimise polypharmacy.

Mobilising a critical mass to enact change

Although participants were quick to identify healthcare, housing, transportation and social support-related challenges of ageing societies, they struggled to identify the upside of an ageing society. This may reflect public discourse that has focused on the burden ageing populations place on health and social resources. With prompting, participants acknowledged that they were advantaged compared with previous generations in terms of their access to opportunities that have allowed them to be more educated and critical consumers. Ultimately, they recognised that the greatest opportunity of the current ageing society rested in the sheer volume of their demographic. Participants spoke about being a critical mass of people who were interested in making a difference and were politically self-aware, which they recognised as an opportunity for improving the lives of older people:

. . . I think we need to create new ways for things to be done, because there are a lot of us. So, self-advocacy, political advocacy. I don’t know about you guys, but I’m always writing to somebody if there’s something that I want to get my opinion across about . . . So, we can all do that kind of stuff. And, we’re not dead yet. That’s what I tell my kids, who are in their 30s, they don’t need to babysit us, we can do things. We need to do things for ourselves. And, there is a big group of us, so we need to stay together. We were the 60s kids, we didn’t think we’d live to be this old and now we’re facing some challenges, and I think that it’s our responsibility to do something about it. We don’t have to age the way our parents did. So, let’s get on with it. (female participant, focus group 2)

This quotation suggests an optimism that issues can be addressed by rallying a critical mass of older people to advocate and play an active role to find solutions to these pressing problems. These last two themes demonstrate how healthcare improvement is viewed as one of the most pressing societal challenges of an ageing society. These findings speak to the continued need for research that engages older people as partners in research designed to transform health systems.

Discussion

This research provides an understanding of how older Canadian retirees from the education sector perceive ageing and societal ageing. We found that participants’ preconceptions of ageing often differed from their personal experiences, that they prioritised maintaining their health and social connections, and despite feeling optimistic regarding their potential to enact change, were disenfranchised by many current healthcare practices that ran counter to their values and priorities. Understanding older peoples’ values and experiences can help shape research and policy agendas that resonate with a current generation of older people.

Our findings point to key areas for future research. First, is the need to identify effective ways to confront outdated societal ideals of successful ageing that attribute how we age solely to our individual actions, and promote updated understandings that recognise the importance of social responsibility for creating equitable access to supports throughout the lifespan that promote health, longevity and happiness [11]. Addressing self-ageism is also important to confront negative ideas of advanced age and frailty. Evidence for such interventions is lacking; future research could leverage the examples of successful programmes delivered to younger age groups and consider how they could be adapted and rigorously tested in older people [12].

Second, is the need to continue research that supports system transformations toward a person-centred approach to healthcare. Engaging older people as partners in healthcare quality improvement research is essential to attune care providers to their priorities and values and ensure meaningful improvement that also mitigates ageism in healthcare. Such research should ideally position older adults as prominent and equitable research partners; be inclusive of older adults with chronic conditions or disabilities; and give older adults opportunities to enact personal and social transformation [13]. Our study participants were motivated to enact change, and indeed, baby boomers have been characterised as fighters for a ‘more equal and tolerant society’ [14]. Harnessing this activism to engage older people in health research provides a clear and meaningful mechanism for engagement and will pay dividends in improving the health of all by designing more inclusive approaches to healthcare.

Third, is the need to explore how factors, such as age, gender, socioeconomic status, ethnicity, culture, religion or migration, shape ageing self-perceptions to better understand and respond to the needs and values of a diverse ageing population. Expectations and priorities for ageing are socially situated and context dependent. We found that female participants shared mostly similar views to male participants on personal and societal ageing; however, there were subtle differences in their priorities for quality of life, social connection and person-centred healthcare. Friendships, losses and resulting loneliness were particularly poignant for female participants. Older women report higher rates of loneliness than men [15], which has been hypothesised to be due in part to prolonged widowhood, given their longer (on average) life expectancy [16, 17]. Friendships play a vital role in how women reconstruct their identities and cope with loss and widowhood, as women often define themselves by their connections with others [18, 19]. Although this study was not designed to explore other factors beyond gender, this work is critical.

Our findings highlight the continued importance today’s older people place on health and social connection, consistent with research from Canada [18, 20] and other settings [21]. We observed how health and functional ability were central to participants’ self-image, as in other work [18], and how they grappled with feelings of disappointment, foolishness and loss of self when they experienced ageing-related health challenges despite concerted efforts to live a healthy lifestyle. This ideal and thoughts of how it can be achieved may be the result of generational or cohort values and prevailing paradigms on health and ageing. Baby boomers (i.e. born between 1945 and 1954) have been characterised as more health conscious and active in seeking solutions to ageing-related health problems than preceding generations [22, 23]. As they came of age, health was viewed both as an individual responsibility [24] and as a task to accomplish successfully, with the acceptance of Rowe and Kahn’s [25] ‘successful ageing’ paradigm that described how disease and disability could be avoided by lifestyle choices of individuals. This paradigm has since received considerable scrutiny, with critiques highlighting that it promulgates ageism, classicism and ableism by defining success using an implicit standard of middle age [26, 27]. These criticisms have led to a second iteration that shifts the responsibility of successful ageing towards societies [11]. Despite this, many older people still feel they have failed to age well if they experience disease or disability, and we need to work to change this.

These internalised values also affected how participants described their priorities for ageing. Few participants described or acknowledged that their aspirations may change and evolve in later age, perhaps because maintaining health, well-being and social connection was paramount. Hurd, in their ethnographic study of older Canadian women, similarly observed this distancing from those they considered as old and the work undertaken to re-frame what it means to age [18]. Higgs and Gilleard [28] described the active exclusion of ‘agedness’ from discourses of later life as an important cultural feature of the third age (i.e. a period post-retirement free of physical impairments). The high level of education of the baby boomer generation has also been theorised to contribute to this distancing, with boomers being less accepting of ageing-related functional decline [22]. Participants may have distanced themselves from the negative aspects of ageing, like frailty and dependency, to cope with the ageing process [28]. There are important repercussions to this ‘othering’. Fear and dissociation may prevent older people from advance care planning, potentially leading to a loss of control, care that is inconsistent with their preferences, and disempowerment to lead a life of meaning and satisfaction [29]. A person-centred approach to healthcare may mitigate this ‘othering’ by promoting agency and personal growth in the face of disability [30].

Our findings are consistent with research on healthcare decision-making for older people that find communication and shared decision-making are critical to developing trusting relationships with healthcare providers [31]. Study participants clearly valued such an approach, but felt that the care they received did not reflect these values. Other Canadian studies have also reported preferences of older adults for holistic care and adequate time to discuss their health with providers [32, 33]. The 2017 Commonwealth Fund survey supports these findings, with only two-thirds of older Canadians (67%) reporting satisfaction with the quality of healthcare they received, well below Switzerland (84%), Norway (83%), Sweden (80%), and the United Kingdom and Netherlands (76%) [34]. This dissatisfaction may be partly attributable to ageism within healthcare systems. Study participants shared accounts of impatient physicians, poor communication regarding clinical decisions and experiences with polypharmacy. Ageism pervades medical education [35] and research suggests physicians are less likely to treat older patients with respect, optimism, allow sufficient time for dialogue during appointments or involve them in clinical decision-making [36]. Older people also have poorer access to medically necessary healthcare and are less likely to receive care consistent with current guidelines [37]. Policies that require patients to triage their medical appointments to ‘one issue’ further restrict healthcare access and ignore that older people often have multiple chronic conditions [38].

Limitations

Although our partnered approach to research was a strength of this study, the participants whose views we represent were retirees from the education sector, who were mostly White, Canadian-born, well-educated and in good health. Views and experiences may be different for marginalised older people or those in poor health. Although studies of older people experiencing frailty have emphasised similar priorities for ageing like sustaining social connection and maintaining identity, there are reported differences in how ageing is viewed, with those in poorer health being more likely to focus on the immediate need of maintaining their everyday lives [39]. Qualitative research on experiences and priorities for ageing in older migrants additionally identified priorities of financial security, meaningful, active lifestyles and spiritual fulfilment beyond health, independence and social connection [40, 41].

Conclusion

We found that older Canadian retirees of the education sector prioritise health and social connections and are disenfranchised by healthcare practices that oppose their preferences for a person-centred approach to care. Future research is needed to identify how to effectively confront self-ageism, as well as outdated societal ideals of successful ageing, to promote a more positive outlook on ageing. Opportunities exist to make meaningful improvements in healthcare that support planning for an ageing society by harnessing the activism of older people as partners in shaping solution-oriented research.

Acknowledgements

The authors thank RTOERO staff who assisted with recruitment, and specifically Jo-Anne Sobie and Joanne Murphy for their expertise, support and assistance throughout the study. A special thank you also to study participants who shared their stories with the authors.

Declaration of Conflicts of Interest

None.

Declaration of Sources of Funding

Drs R.D.S. and S.A.C. are supported by Canadian Institutes of Health Research Postdoctoral Fellowships. Dr N.M.S. receives funding from the Canadian Institutes of Health Research Vanier Scholarship Program, the Eliot Phillipson Clinician–Scientist Training Program and the Clinician Investigator Program at the University of Toronto. Dr P.A.R. is the RTOERO Chair in Geriatric Medicine at the University of Toronto. Dr L.Z. received support from the RTOERO Foundation. Dr K.L. is supported by the Veterans Affairs Office of Academic Affiliations through the VA Quality Scholars Program.