Many factors affect the level of involvement in community programs by the Aboriginal frail elderly across Canada. In October 2002, NIICHRO conducted surveys with CHRs in communities across Canada and asked them about their programs for their frail elderly. Overall, the main points gathered from the surveys showed that to increase physical activity opportunities for the Aboriginal frail and elderly, the focus should be on the following:

Retaining Culture in Activities and Programs

"(Elders need) outings such as fishing, berry picking, attending drum dances or other community events."
Tracy Kushneryt - CHR from Beaver First Nation, Alberta

Aboriginal elders need opportunities for social interaction, exercise, recreation and leisure time activities that are culturally specific. Activities that are too different from what they have known throughout their life are not as effective as more traditional Aboriginal ways. Cultural activities and events are very meaningful for elders especially those who cannot get around as well as they used to. Elders need to feel that their culture is not lost despite their age.

Isolation, Loneliness, Depression

"Elders love it when they are visited regularly. Invite them to different functions that are happening in your community. Invite them all the time; don't expect them to come on their own."
Olive Halfe - CHR from the Saddle Lake Health Care Centre, Alberta

Isolation from family, friends and resources remains a barrier to becoming more physically active. Many older people are no longer independent enough to participate in organized activities and need care at home even for the most basic living activities. Aboriginal seniors show a strong desire for to remain independent, but many simply cannot do so without help. In some households, a "generational squeeze" may occur where families find it to difficult to work all day and look after their elderly parents' needs. By leaving the reserve, many Aboriginal elders become isolated, losing contact with their communities of friends and family. Language can be a barrier to social integration for Aboriginal seniors who do not speak English as their first language.

Physical activity programs for the frail elderly must consider isolation, depression and loneliness factors. Some elderly people feel much fear about losing their independence. Programs must boost self-esteem and promote the feeling of self-reliance.

Getting Elders Involved

"It seems with group settings, it's usually the same people. Some elders are reluctant to participate."
Stephen Odjig - CHR Coordinator, Wikwemikeng, Ontario

Elders are often not willing to become involved in activity programs particularly because they do not have someone to support them and help them understand the pleasure they will gain from activity. Maintaining hope is vital to maintaining health and the motivation to exercise for wellness. Elders are motivated by their cultures and traditions - the "old" ways of life. Effective activity programs should incorporate life review process or reminiscing as a way of motivating and stimulating elders to remain as active as possible as long as they can.

It is essential to realize that many seniors are anxious, tense, and nervous in an "exercise" setting, which may make them reluctant to try something new or different. Therefore, enjoyment and variety in program structure is needed. With careful attention to the physical activity program design, a CHR can help the elderly learn to feel more comfortable with the inevitable changes that are occurring in their bodies. There are several essentials when working towards motivating the elderly to become more physically active:

· Meaningful conversation and discussion is encouraged and rapport with the CHR or caregiver is essential.
· The elders must be given the opportunity to express themselves so that they know they are being heard and understood.
· Demonstrate interest in them, it will enhance their own self-esteem.
· Encourage all aspects of socialization with program activities. Offer attainable targets and recognize those who achieve these them.
· Be flexible with your program design, adapting appropriately to the welfare of the elders.

It is important to be very supportive when teaching elders to be more physically active. As elders age, they may feel self-doubt and experience depression. Activity programs must empower them to feel a sense of self-control with the success they enjoy through physical activity.

Transportation/Mobility

"(I wish) there would be more participation for outings to different communities for visiting, as a person hardly ever sees another unless it's at a funeral."
Doris Courtoreille - CHR and Home Care Worker from the Swan River First Nation in Alberta

Transportation issues are important considerations when developing programs for the frail elderly to keep them physically active. The four most common problems regarding elderly people and transportation include difficulty getting in and out of vehicles, standing in the vehicle while it is moving, getting to a location where a vehicle can pick them up, and waiting for the vehicle. To make matters worse, many non-housebound seniors with disabilities in Canada have no available public transportation. Seniors with disabilities who live in the community need greater availability of specialized van services. Adequate and appropriate transportation and access to medical escort services are an important and critical health service need for elders.

The development of any activity program for the frail elderly must consider transportation issues on reserve. Lack of adequate transportation is a legitimate health concern of elders. Communities should consider developing training that focuses on home-based physical activities.

Diet/Nutrition

"(Our community needs) a Meals on Wheels program for frail elders/all elders."
Lee Ann Sock - Nurse and Home Care Nurse Coordinator, Big Cove Health Centre, New Brunswick

Elders, particularly frail elders, are often compromised financially, making the purchase of fresh, attractive food more difficult. For older people, both access to food and a decreasing appetite may become problems. As a result, the amount of food they eat and the amount of exercise these older people can enjoy become less and less, and they become frailer. As people become frail, access to food becomes a problem at all levels, from obtaining the food, to preparing it, to eating it.

Clearly it is important to provide food for homebound elderly. For many older people, especially in urban areas, going out of the house to get food or to exercise may be a dangerous proposition. In addition to helping elders with exercises, physical activity programs must also educate about the need for adequate nutrition for elderly people on reserve.

Home and Community Care

"We need to teach family members how to care for their elderly mom or dad."
Lorraine Little Mustache - CHR from Pukani Nation, Alberta

Families can play a huge role in ensuring that their frail elders retain their sense of dignity and independence. Most Aboriginal elders desire to remain in their own homes and in their own communities as long as possible. Programs like Health Canada's First Nations and Inuit Home and Community Care can support and improve the care provided by families and the community. The program allows elderly people who want to and can remain at home the ability to do so. The services are provided in a holistic manner that looks at each person's unique physical, social, spiritual and emotional needs. It would be beneficial for a physical activity program for the frail elderly to work in partnership with home care programs to integrate into the lives of people who choose to age at home.

Facilities such as the Turtle Bay Elders' Lodge in Kahnawake, Quebec provide independent living for older community members (at a cost per month) but with nursing supervision. Meals and other amenities are also provided. For those who don't want to be dependent on others and yet find it hard to have the upkeep of a large home, this is a nice alternative.

The Costs of Running Programs

"(There is a) lack of a facility that is accessible to all elders."
Lee Ann Sock - Nurse and Home Care Nurse Coordinator, Big Cove Health Centre, New Brunswick

Existing public recreation and physical activity services have a negative image problem among some Aboriginal people. Criticism includes the cost of such services and the perception that services do not meet the needs of Aboriginal people, especially the elderly. Very often there are no available facilities in communities fit to handle programs for the elderly. If facilities are available, many need modifications such as ramps for wheelchairs and other assistive devices to help elders use the facility safely and effectively. The reality is that sometimes there is no money to fund these needs and the community must do its best to adapt its programming. Programs that involve visits at home and activities that frail elders can do without travelling very far away from home tend to be the most successful at the community level.

In addition, there can be costs associated with activities that effectively make them prohibitive for some seniors. Physical activity programs for the frail elderly must take into account cost and locations to better serve those that need them. Activities that are good for health do not have to cost a lot of money.

Caregiver Training and Family Support

"(My suggestion) is to have people take training that pertains (to) how to work with elderly people. To learn about their wants and needs."
Brian Youngchief - CHR from Kehewin, Alberta

Like the rest of the general population, First Nations people with disabilities, the elderly or the frail elderly require assistance offered through home care programs in order to maintain a healthy lifestyle. However, unlike the off-reserve population, additional services, such as hauling water and gathering wood are usually required on a daily basis. Although most First Nations communities provide minimal home care services, funding from government is often inadequate to meet the needs of the community, particularly the special needs of the frail elderly.

Many communities do not have adequate numbers of caregivers to provide services to their frail elders. Typically, CHRs are the first line of support for health issues in their communities and have many responsibilities to their clients. This can leave less time for the elderly in their communities. In some cases, there are simply not enough CHRs and caregivers and particularly not enough that have experience with the needs of frail elders. Family support is a key factor in alleviating some of the gaps in the services that CHRs can realistically provide in their communities. Family members need to have an active role in their frail elders' lives by helping them with daily activities.

Reading and Understanding All Those Instructions!

"Our elders like to be educated as well (on) such topics as: diabetes, home security, phone scams etc."
Carolyn E. Michelin - Community Health Worker for Happy Valley-Goose Bay & North West River, Newfoundland and Labrador

CHRs and family members must try to increase their efforts to educate elders about the benefits of active living and healthy eating, including their essential role in maintaining independence. Many frail elders - especially those who do not speak English as a first language - may have trouble reading and understanding medical instructions. Consideration must be given to those elderly who speak English as a second language and must be inclusive of those who speak their native languages. Sometimes barriers exist in terms of reading and comprehension but also in terms of failing eyesight or hearing. Physical activity programs must also consider all reading levels and also those who have difficulty seeing and hearing, as this may be a barrier to following instructions. The ability to solve problems, read and comprehend self-care messages also improves the likelihood that a person will practise healthy lifestyle behaviours. Those who can read or at least understand feel more independence and have higher self-esteem.

Carrying on Traditions - Involvement with Youth

"In our society, both adolescents and the elderly are often isolated and afraid. They are either "too young" or "too old" for many activities valued by the community. Referring to the elderly, one youth has said: "We're afraid of growing up, and they're afraid of growing old. Both groups can really help each other. One by providing comfort, the other by providing guidance."
"(We need) more interaction with our youth/children for story-telling, education and cultural events."
Liz Yellowquill - CHR from Long Plain First Nation, Manitoba

Elders have a lot to teach our youth. The traditions and stories the elders carry are invaluable to maintaining culture. Youth can learn a lot from "the old ways" and from the struggles their elders endured.

The Goals for Youth Involvement with Elders:

o To create an awareness of and sensitivity to the issues of the elderly.
o To eliminate stereotypes among both groups - the young and the elderly.
o To enable the frail elderly to remain in the comfort of their own homes and receive needed nutrition and companionship.

Programs that Work - Community Examples Across Canada

The communities that enjoy the greatest success with their frail elders have many programs encompassing a whole range of activities for elders. This includes a holistic array of activities that involves personal home care, nutrition, physical activity and cultural events. Liz Yellowquill is a CHR of the Long Plain First Nation in Manitoba. Her community provides many home care programs that include homemakers, health care aide, adult day care program, and meals and meal delivery programs. Liz's community also has physical activity programs including range of motion exercises. Other areas of activity in her community include respite care and cultural activities including traditional meals.

Liz feels that her community has successful programs because her day programs involve social interaction, socialization, exercise and a health education component. The CHRs do home visits to provide one-on-one health education. The one-on-one visits also alleviate loneliness and feelings of isolation. In her community, the CHR acts as an interpreter or translator to accompany frail elders to their doctor's appointments. This is to ensure that elders understand their doctor's instructions or any prescriptions they are given. CHRs provide elders with monthly shopping trips to the nearest town. There is also a regular monthly bingo for elders.

Despite all of the programs in her community, Liz still feels that more interaction with youth would be very beneficial. She feels the children and youth in her community could benefit from elders' story telling, education and cultural events.

Verna Popejoy is a nurse in the Tsewultun Health Centre of Cowichan on Vancouver Island in British Columbia. Her community provides many opportunities for its frail elders. There is a swim program with a dedicated time available at the local pool, and a day program with lunch provided for which elders are picked up in an accessible wheelchair van. Elders are taken to elders' conferences throughout British Columbia with transportation provided. There are home support programs and community care programs for frail elders. The community provides a Healthy Lifestyle program for those with diabetes and elders' lunches on Wednesdays and Fridays. Arthritis education is also provided. There is an elders building where the community members can come for baths and equipment.

Verna knows that the success of her community's programs depends on input from the elders themselves and the elders' families. She also advocates visiting the frail elders just for company and not only when there is a problem. The day program that involves socializing is very important to limit elders' feelings of isolation and loneliness. In her community, local schools and youth play a big role in the lives of the frail elders by helping serve at elders' lunches and events. She feels a big part of the success of local programs has to do with providing services that elders have trouble with in their daily lives, such as bathing and doing their own laundry.

Family involvement is needed to ensure elders stay active in the community. Verna finds that give and take between generations is needed and families need to give back to their elders for all of the gifts they have given over the years. For the families that are involved with their elders, good respite care is required so that families can get a break from each other too. Elders need other elders - even if they just sit together in a group and watch television or talk.

In Inuvik, Northwest Territories, CHR Alfred Moses runs programs for the frail elderly in his community. He has set up a healthy living program that involves maintaining flexibility with stretching, exercising and the ability to perform daily living activities. Alfred is working on an elders fitness program that will involve the three components of being active: stretching, strength and cardiovascular endurance.

Alfred feels that it is important to provide frail elders with programs that involve the things they love to do with help from the community members themselves. He suggests starting with light and easy workouts and slowly building the intensity and endurance levels over time. He also provides social situations for elders like outings, lunches, trips and teas.

Alfred feels that physical activities should vary in order to keep people interested in participating. The barriers he experiences in his community have mostly to do with weather conditions and travel distances to get to the programs he runs. These factors often create a lack of interest or motivation to attend because it is hard for people to travel or get around in snowy conditions. In addition, in Alfred's community it is sometimes difficult to find facilities to host activities that people can attend. He also finds that the experience the CHRs have often does not include work with the frail elderly and this can be improved with more training.

Lynda Gamble is a CHR from Beardy's Okemasis Willow Cree Health in Saskatchewan. She describes home visits in her community as very successful because lack of adequate transportation is a problem where she lives. Lynda wishes there was an easily accessible transportation service such as a taxi in her community. In addition to a lack of funding to run programs for the frail elderly, Lynda experiences a lack of motivation from elders to attend certain programs. Family involvement is a key factor in the frail elder's life and Lynda feels this should be a major concern in all communities. When families have more involvement, she feels the elders are in better spirits and become involved in activities much more readily.

In Makkovik, Labrador, Kim Anderson is new to running the seniors programs in her community and she feels they are very successful. Annie Evans has now retired after 16 years as a CHR in Makkovik. The seniors' socials are held once a month. They include a nutritious snack, a short presentation and socializing. Kim also provides home visits and sees many elders who are extremely happy with anything that the CHR or home care workers can do for them. Kim has about 12 clients receiving home support including personal care and physiotherapy. In her community, there are regular lunches and snacks and Kim has also started home visits.

This past summer the home support workers held an event every Wednesday. One Wednesday there would be a nutritious snack and the second week, a nutritious home-cooked meal. Many of the elders in Makkovik attend church regularly and are involved in the community sewing circle and community feasts.

In Old Crow in the Yukon, Marion Schafer has helped to provide her community's elders with home care and adequate accessibility in their homes. Each elder who needs it has had a ramp installed in his/her home. CHRs also provide translation services for the elderly so that they can understand their prescription and instructions for health care. A Home Care Coordinator position is now in the works in her community, which will help tremendously with the care of frail elders. Transportation is not as much of an issue in her community and she feels that if the elders can walk, it is a great way for them to get out there and be active!

Mary Basque of Eskasoni, Nova Scotia feels that the elders in her community need a home where all activities and outdoor events can take place or be coordinated. She feels the barrier in her community is the lack of a place for elders to organize formally. She feels if an elders' centre existed, it would be a place to gather and be a "nucleus" for socializing, and such things as cooking classes and recreational activities. She would like to see them have a place for fundraising and where elders could become more empowered and involved in schools with youth and in local politics.

In Maniwaki, Quebec programs are provided for the elders by staff at the Health Centre such as the nurse, the CHR and the social worker. Eliza McGregor is the CHR in her community. One of the programs in her community gives elders the opportunity to better get around in their homes. They offer wheelchair ramps, bathroom bars, bath chairs, walkers and canes. CHRs assist in making appointments and escort the frail elders to the doctor's office. Eliza conducts weekly lunches and bingo with transportation provided if necessary. There are out-of-town trips for elders and a yearly Christmas party.

For health education, health workers have a diabetes support group, and workshops with speakers on diabetes and various health topics such as heart disease and blood pressure. There are also workshops with traditional medicine as a theme. Eliza speaks her native language with the elders in her community and provides traditional meals with moose, deer and bannock. At the local school there are grandmother and grandfather activities to get the young children and youth involved with their elders.

Eliza feels that the most successful programs for the frail elderly involve interaction with CHRs, with other elders and especially with family members.

2Ibid

3O'Brien Cousins, Sandra EdD. Promoting Active Living And Healthy Eating Among Older Canadians: 2001. Retrieved from: http://wwwnfh.hc-sc.gc.ca/publicat/execsumm/cousins.htm.

4Project Touch. A Series of Intergenerational Programs for Teens that Help both the Youth and the Elderly: 2002. Retrieved from: http://www.pry.org/touch.htm.