In total, nine females and six males were interviewed (18% of the total number of residents who attended the program), with ages ranging from 63 to 89. Three of the participants lived with a spouse and the remainder were single or widowed. All participants interviewed had at least one health problem. Twelve out of the fifteen participants had hypertension and several had an additional comorbid condition, such as diabetes or chronic obstructive lung disease. Thirteen participants had been using the program for over two years, however all participants varied in their weekly attendance. Our interview sample (60% female, 30% male) was similar to the overall gender composition of the residents attending the program (68% female, 32% male). At the time of this study there were 79 residents in the CHAP-EMS/CP@clinic program (34.8% of the total residents in the building). Of these, 90% of participants had a family doctor, and the majority were of low socio-economic status.
This research identified four dominant themes that can be described as direct and indirect health effects. The direct effects were: the CHAP-EMS/CP@clinic program filled a health care need; and the program facilitated access to health knowledge and resources. The indirect health effects were: the program brought changes, and challenges to improving social connectedness amongst participants; and older adults expressed varying degrees of loneliness amongst themselves and their peers. While the first two themes address how the program directly impacted individuals health, the third and fourth themes discuss the social aspects of the program as an indirect means of achieving or improving health.
1. Filling a health care ‘need’
As participants spoke of their health care experiences, it was clear that many perceived the CHAP-EMS/CP@clinic program as filling a ‘need’ in their current access to health care. For many participants, their experiences within the CHAP-EMS/CP@clinic program contrasted sharply with their interactions with other elements of the health care system or their health care provider. As such, the program provided a way to mitigate their frustrations with the health care system, which were mainly concerned with a lack of time with their primary medical provider. Participants often stated that during the program, paramedics took time to address their concerns and they felt they could ask for help about any problems they had. Their interactions were personal and they felt that they were being listened to. Further, because the program operated on a weekly basis, they saw the CHAP-EMS/CP@clinic paramedics more frequently than other health care providers.
Participants expressed views that there was simply not enough time in the current health care system to address all of their questions or concerns, hence they had unmet ‘needs’. They often discussed situations in which they felt their health concerns had not been taken seriously, misdiagnosed, or missed entirely. At times, they had difficulty making an appointment or seeing their family doctor as often as they would have liked and felt they had to find other avenues to address their health care needs. Further, participants expressed concerns at a broader level, expressing that their frustrations with the overall health care system itself often overshadowed positive interactions with their family doctor. Participant 109 stated:
“I mean when you have your ten minute doctor’s appointment you get one question and that’s it. I mean he is a great doctor. But they don’t have time. Unfortunately the system doesn’t have time.”
In contrast to these concerns and experiences, participants who attended the CHAP-EMS/CP@clinic program stated they valued the ability to have all of their questions and concerns discussed at once, at a time that was convenient for them. Gradually, participants developed relationships with the paramedics to the point that they stated they trusted them. Previously hidden social, medical or mental health problems emerged, and support was provided. The one-on-one relationships between the residents and paramedics were described as close and residents felt they were “being taken care of”. We frequently heard these sentiments voiced:
Participant 101: “I am sure he is a good doctor, but he doesn’t have the people skills that I need. He was an emergency room doctor and I don’t think he realizes he is actually going to see us again. We aren’t one offs you know (laughter). So unless you are in crisis he isn’t really aware of what is going on. He is blasé about it. The last three or four times I have gone in the diagnosis I have got is that I am “old”. I don’t process that as a diagnosis. So what do I do? I just use the other systems.”
Some residents had started to use the program as an alternative to seeking medical attention in other settings, such as the hospital or their family doctor. Many of the residents who were reluctant to go to the hospital for medical concerns trusted the paramedics to advise them on the best course of action for their health. The program offered flexibility and options when making decisions about their health, and a more convenient and pleasant alternative to seeking care elsewhere. For some residents, if they were not feeling well throughout the week they would wait until the next CHAP-EMS/CP@clinic session to address the problem. Participant 107 stated:
“A lot of people don’t wish to go to the doctor. And I thought well this is a good way for them to be monitored without actually having to go to their doctor.”
For some participants the CHAP-EMS/CP@clinic sessions were readily embraced as part of how they managed and maintained their health, instead of relying on their family doctors, the emergency department, or other health care providers. While none of the participants reported that they no longer valued physician services, the CHAP-EMS/CP@clinic program was able to provide an additional health care service that addressed unmet needs such as having a long appointment and receiving additional support, that participants perceived were unavailable in the current health care system. In circumstances where the paramedics had not been able to deal with the medical issues, they had facilitated the patient’s next appointment with the family doctor, or urgent transport to the emergency department as appropriate. Residents felt appreciative of this extra communication that had been made by the paramedics with the health care system.
Several program features facilitated benefits for residents: the program was available to all residents regardless of their current health status; participants had a flexible time to see the paramedics without making an appointment; they were not limited to seeing the paramedics only once during a single session; they had access to a minimum of one and often two paramedics with whom to discuss their health; and they were able to form long-term relationships with them.
2. Access to health knowledge and resources
Consistent with the program’s original goals, CHAP-EMS/CP@clinic provided participants with knowledge about their health and access to resources to help them learn more about their health. Those who were concerned about their current and future health could learn how to regularly and reliably monitor it. In general, participants had an interest and concern about their health. This was expressed both by those with chronic health conditions, and those who claimed to be healthy, with only minor health problems. Participant 107 stated:
“Just the idea that people have to be aware of their blood pressure, their sugar problems and it keeps them on a weekly basis about their problem so that they keep on top of it. It’s easy to forget and just ignore it. That’s the biggest thing, catch it early, get on top of it.”
Some felt that although they were healthy now, they wanted the program to remain in the building in case they needed it in the future. Interestingly, many of the participants denied currently requiring other community support resources, such as home care services. This suggests that for some older adults, having access to out-of-home supportive health and social services is beneficial. Participant 104 stated:
“I am always interested in health and everything. It feels good that someone is there to help you if you have any questions because you know, I am getting older. Who knows what types of questions I might have. So that feels good.”
Another motivator for residents to attend was the ability to seek advice or clarification on a variety of short and long term health care issues, such as chronic health problems, medication changes, and new injuries. For some, when they were uncertain about their complex medical problems they valued the advice they were given at the program. Participants 115 stated:
“I talk to them generally about everything. Basically, I still deal with specialists because of my conditions every three months. But if anything happens to me in between then I go and talk to them and see what is going on. And they will let me know what I should do.”
The sessions with the paramedics did result in some lifestyle changes, such as maintaining or initiating a healthier diet, changes to a daily routine, or exercise regimens. Upon following the advice of the paramedics to be more conscientious following her heart operation, one resident stated she now took the elevator instead of the stairs, in case a medical event occurred while walking.
For many participants, the health advice the paramedics gave them, such as to ask their doctor about certain diseases or concerns, made the most impact. For example, new diseases or medical problems were diagnosed, unaddressed mental health problems were discussed, and clarifications about their health problems were made. For example, Participant 110 stated:
“They gave me some information when I had this lump on my leg. I thought it was just “part of the process”. But he [the paramedic] wanted me to go to get it checked. So I did. I wouldn’t have gone if he didn’t tell me to do it.”
For one participant who had an undiagnosed mental health problem, the program also addressed analogous personal issues that equally impacted her life:
Participant 111: “I was having problems with my apartment, and I was talking to him [the paramedic] about it and with that they were able to transfer me to another apartment. So yes, he helps us outside of medical reasons.”
The program also made residents more aware of their health. This was a combination of both knowledge gained from the paramedics at the program, and being given advice from the paramedics on who to ask for more information, such as a specialist. Participant 109 stated:
“It made me more aware of my blood pressure. We went out a bought a good blood pressure monitor so we can check. So in that sense yes, it has helped. I am curious. I want[ed] an understanding of why it [my blood pressure] goes up and down.”
Following participation in the program, participants expressed that they were more informed and aware of their own health problems and how to manage them. While some residents admitted they were unlikely to change some elements of their lifestyle, such as diet or exercise, they still valued the CHAP-EMS/CP@clinic sessions. The program made participants feel in-control of their health and the sessions increased their personal health awareness. The feeling of being listened to, as well as having control and autonomy (rather than being at the mercy of booking an appointment) when deciding to seek medical advice, was of high value to participants.
3. Challenges and changes to social connectedness
The weekly CHAP-EMS/CP@clinic sessions became a place not only to receive health information and support, but to have a social gathering, organize a group event, or hear the weekly building gossip. There was an obvious change in the relationships that were formed between the building residents, highlighting the importance of the social aspect of the program in addressing older adults’ wellbeing and enhancing participation in the program.
A session usually began at 9 am with a regular group of residents waiting in the common room for the session to start. One resident often brought down coffee and home-made baked goods for the paramedics. The common area was a large space filled with couches and tables where other events were hosted in the building. The “lineup” for having blood pressure checked consisted of the residents waiting on these couches or chairs and this layout encouraged residents to socialize with each other or with the paramedics. While participants discussed their health one-on-one with the paramedics, many social interactions between residents involved discussing their health problems. Considering past conflict between some building residents, the fact that this personal information was shared openly was surprising.
Residents would also bring their family members, such as their children or grandchildren to the sessions where the small children would often play with the paramedics. A substantial portion of the regular residents who attended the sessions came down to the common room multiple times throughout the day. Participant 101 stated:
“We all go there and see each other and say ‘how are you’ and so on. Some people you know them better and so you stick around and you talk a little bit. We all like to go when the people are here, we all go down. And some people you see in the afternoons, we go down and chat a little bit and have a good time, half an hour or what, and it gives us a break during the day.”
While these new relationships between residents were not described as close or trusting, as those with the community paramedics, their effects should not be minimized. Following an interview with an elderly female resident who had just joined the program, another resident approached her to ask her: “Oh are you new?”. Both of the residents noted how they had been living in the building for over five years and had never met. They ended up staying in the common area following this interaction to continue socializing (field notes, April 23rd, 2015).
Attending the program connected residents to other events occurring in the building (such as through the building association) and also instigated new social events for residents. For example, during one session a paramedic who had previously staffed the program attended a session just to visit with the residents (field notes, June 25th, 2015). The visit was enjoyable for the residents who were excited to hear about her international volunteering experience that they had previously donated towards. The residents set up a food table for her visit, and even residents who were not frequent attendees of the normal CHAP-EMS/CP@clinic sessions participated in order to see her. This activity was discussed before and after the event. The contact with the paramedic had provided an extra social opportunity to look forward to, bringing residents together, not only to plan the event but to enjoy it as a group.
During the course of this study, changes to social connectedness and isolation was discussed as a benefit by all participants. Based on our observational data, it was clear that some female residents participated in the social component of the CHAP-EMS/CP@clinic program more then other residents, such as males who lived alone in the building or non-English speaking residents. This was in part because they identified as healthy and stated they did not require all of the services provided at the program at the time of the study, however enjoyed attending the program for social reasons. Several of these individuals also took on a larger role in organizing informal and formal social events in the building.
Because the program provided a vehicle for residents to discuss many of the issues that were affecting the social life and cohesion of their building, issues with the building association or other volunteer groups in the building often spilled over into the sessions. There was some negative history between building residents prior to the CHAP-EMS/CP@clinic sessions occurring resulting in hesitation for some residents to engage in social activities in the building.
Tension amongst residents and barriers to the programs’ functioning were created when the normal ebb and flow of life in the building was interrupted. There were incidents of theft in the building (in one instance there were allegations that artwork had been removed from the common area) and problems initiated by the group calling themselves the ‘Building Association’ that created conflict during CHAP-EMS/CP@clinic sessions. The Building Association, a group of residents responsible for organizing social events in the building, prior to the program being implemented, had caused turmoil between building residents. Participants stated that although things had improved since the implementation of CHAP-EMS/CP@clinic and the involvement of the paramedics assisting with the Building Organization, there remained some personal problems between residents. These problems often surfaced at the sessions and were discussed during the interviews.
Negative past experiences made it difficult for some residents to participate in other events in the building beside the CHAP-EMS/CP@clinic program. For some, this prevented them from participating in future events, even after acknowledging that many improvements to the building had been made since CHAP-EMS/CP@clinic was implemented. One participant described:
“We play bingo every now and then. Before [another building resident] and them took it over it was just too much in-fighting. It was just terrible. They were all sniping at each other. Since they have done it, they did it right, no arguments. Here is how it is, if you don’t like it tough. So things are a lot better now. The hierarchy of the association is all changed, which was very important. Because they used to think they owned the building. It caused a lot of problems. It was a dictatorship, you couldn’t do anything.”
The fact that the paramedics served as a mediator between residents (for example promoting conversation and actively joining in), meant that the CHAP-EMS/CP@clinic sessions remained overall a positive opportunity to meet new people and form new casual relationships. Barriers towards communication between people yielded, and there was less ‘stand offishness’ between residents, and more willingness to reach out and talk to each other, even to those with whom they had never spoken before. Participant 106 stated:
“ It has brought people together. When I say together I mean communication. It has added a bit of social integration of people in the building. I know there are a lot of people here who don’t come out at all. But they come here. For some reason they meet and they get talking.”
Another factor regarding whether individuals may have not participated in social events or the program in general, was language. There was also evidence from both the interviews and the observational periods that there were language barriers for some residents that may have impacted their involvement in the program. English speaking residents were aware of this barrier for other residents. One participant explained:
“It’s the [same] people that always come down. We keep trying to encourage more people, but its basically stayed the same people. We are dealing with a language issue. Why should we leave them out? They have health problems. Look around? Do you hear any accents out there. Not many.”
Only a three non-English speaking residents attended the program regularly. However, they had limited interactions, other than a simple greeting with other residents or the paramedics. Occasionally, English speaking family members served as translators for residents who did not speak English, however to aid the paramedics in conducting their family member’s health assessment only.
Overall, the program enhanced the social connectedness of the building by allowing residents to have an opportunity to socialize and meet other building residents, both at the sessions and during other events when the paramedics were not present. Further, residents were comfortable enough with each other to openly discuss some of their health problems. However, a history of conflict created a barriers to improving social connectedness that resulted in the relationships between residents being casual and not close, personal relationships. For a portion of residents, this history prohibited them from engaging in some types of social events entirely. While there were clear issues with regards to access and inclusivity of the social events in the building (for example, the dominant language in the building was English) residents still expressed value in forming casual relationships with others, even thought their participation in activities varied.
4. The paradox of loneliness
During the one-on-one interviews, participants often discussed loneliness. However, residents rarely discussed their own feelings of loneliness, but they instead discussed their peers in the building who they saw as ‘being lonely’. The common perception amongst participants was that they themselves attended the program because they enjoyed the social interactions that occurred there. However, others in the building needed the program more than they did, in particular for its social benefits, because they were lonely. One participant stated:
“There is an emotion thing to say someone is there and you can go talk to them… A lot of them [other residents in the building] especially in the winter, can be too isolated.”
Instead of discussing their own loneliness, many participants admitted to enjoying the social aspects of the program. For some, it was their primary reason for attending. This was exemplified during the observation sessions. Many participants attended the program multiple times throughout the day, not to get their blood pressure checked, but to talk with other residents and the paramedics. In this way, it is possible that isolation and loneliness felt by individuals were mitigated, since they now had something to look forward to. They would be able to interact with others, including the paramedics, in their building. One participant stated:
“They [the other residents] look forward to a Wednesday, because now they can go and talk to somebody. That’s how bad it is here. They are lonely. But I am the opposite. I have a wife and all my grandkids and you know, I have all I need. But, I like to talk to [the paramedics]. They make themselves known.”
Participants perceived that the program brought the building residents together in ways that had not existed before in the building. They spoke about how the program went beyond mere health and allowed other connections to happen, implying that this was of tremendous benefit to those who were lonely and isolated. They described their peers’ lifestyle as a lonely one, with little or no opportunities to go anywhere without time or monetary investment. Only three participants in our sample had a spouse and many discussed that there were limited opportunities for informal social engagement in their lives. The fact that minimal effort was required to gain this socialization was a strength of the program. There was always the possibility for those not wishing to take part that they didn’t have to. Where other activities may require more formal clothing or more preparation for residents, the idea that they could talk to someone else in their own building, without requiring a purpose or formal plans, was very restorative. Participant 112 stated:
“I mean I am talking about our situations here. We are all on our own, we are all singles. Those people don’t get out that much or when they do, they go to the doctor, they go to shopping and that’s that. When they go out to things like the [the CHAP-EMS sessions], they don’t have to get dressed up, they just have to go downstairs and meet some people. It’s very soothing, to go down and talk to people. And I think that this should be more places like that.”
These findings point to the underlying complexity and possible vulnerability of how older adults perceive themselves as being socially isolated or lonely.