Introduction
Promoting and supporting ageing in place is a highly popular option for governments to meet the growing care and support needs of older citizens (Colombo et al., Reference Colombo, Llena-Nozal, Mercier and Tjadens2011; Gori et al., Reference Gori, Fernandez and Wittenberg2015). This policy approach reduces public spending on care and support for older adults, mainly by avoiding, or at least delaying, the cost of institutionalization (Chappell et al., Reference Chappell, Havens, Honorary, Hollander, Miller and McWilliam2004; Kaye et al., Reference Kaye, LaPlante and Harrington2009) and by relying on family caregivers’ unpaid work (Greenfield, Reference Greenfield2012; Lavoie et al., Reference Lavoie, Guberman and Marier2014). As a governance approach to ageing, it initially involved a broad community commitment to promoting older adults’ well-being and autonomy through the local organization and provision of care services (Pynoos and Cicero, Reference Pynoos and Cicero2009; Chen, Reference Chen2011), reflecting the growing importance attached to adapting the local environment to the needs and practices of the ageing population (WHO, 2007; Buffel and Phillipson, Reference Buffel and Phillipson2024).
Although countries vary in their ability to implement the model, ageing in place remains a central policy objective for the governance of ageing in industrialised countries. It is deployed in different ways in different places, with the main differences being in the way services are organized, funded and accessed, and how responsibilities are shared between the public, private and community sectors, and the family (Ranci and Pavolini, Reference Ranci and Pavolini2013; Gori et al., Reference Gori, Fernandez and Wittenberg2015; Marier, Reference Marier2021). In discursive terms, national ageing strategies generally emphasize that the ageing-in-place approach reflects seniors’ repeatedly expressed residential preferences (Mestheneos, Reference Mestheneos2011; Forsyth and Molinsky, Reference Forsyth and Molinsky2021) and is consistent with the healthy/active ageing paradigm (Dillaway and Byrnes, Reference Dillaway and Byrnes2009). It is therefore valued as bolstering the autonomy and independence of older people and facilitating their participation in the community (Dalmer, Reference Dalmer2019).
The discursive connection between the notion of autonomy and the ageing-in-place policy approach, in a context of population aging and budgetary restraint, is the main focus of this study. We argue that these elements of the policy discourse on ageing represent a governance strategy (Rose and Miller, Reference Rose and Miller1992; Fairclough and Fairclough, Reference Fairclough and Fairclough2012) that defines ageing in place as the prevailing standard for ageing well. Drawing upon the political sociology perspective, and taking Quebecois ageing policy as a case study, this paper investigates the meaning of autonomy in the discourse on ageing in place and analyses this quasi-systematic discursive connection with regard to the social and politico-administrative context of the implementation of the ageing-in-place policy approach. Findings show a disconnect between national policy frameworks and the reality of ageing in place. The issue of ageing in place is strongly bound up with the idea of autonomy, which is mainly expressed in terms of responsibility (for one’s health and independence) and freedom of choice (as to one’s living arrangement), while its implementation overlooks the social structural determinants of individual autonomy and their impact on older people’s opportunities and processes of ageing in place.
The first section of the paper sets out the theoretical framework that guides the analyses and provides a brief overview of the literature connecting autonomy and the ageing-in-place policy approach. It first discusses the concept of individual autonomy from a governance perspective and then explores the conceptualization of autonomy in later life. Finally, it examines the connection between ageing in place and autonomy, both in scientific and policy literature. The second section presents the results of our discourse analysis of selected ageing policy documents. The conclusion describes the main contributions of the study and discusses further avenues for research.
Autonomy and the governance of ageing
Governing (through) autonomy
Individual autonomy has been conceptualized as both an individual claim and a normative injunction in political sociology (Wellmer, Reference Wellmer and Wellmer1990; Wagner, Reference Wagner1994; Miller and Rose, Reference Miller and Rose2008). On the one hand, the concept of individual autonomy may be understood as the liberation of the individual from various constraints that impede the pursuit of their own life path. Such liberty may be asserted as a claim right, thereby informing social practices and institutional arrangements (Beedon, Reference Beedon1992; Wagner, Reference Wagner1994; Forst, Reference Forst, Christman and Anderson2005). However, fostering and supporting the autonomy of all citizens, including the vulnerable, implies guaranteeing certain material, social and institutional conditions conducive to its achievement (Anderson and Honneth, Reference Anderson, Honneth, Christman and Anderson2005; Ben-Ishai, Reference Ben-Ishai2009; Betzelt and Bothfeld, Reference Betzelt and Bothfeld2011). For instance, responding to physically impaired individuals’ claim for autonomy necessitates that the physical environment be adapted and that a comprehensive range of services be available to meet their needs.
On the other hand, the concept of autonomy has been increasingly used to support a post-welfarist approach to governance, in which social issues are thought and acted upon with an emphasis on responsibility, freedom of choice, and indeed, individual autonomy. Under ‘neo-liberalism’ (Ilcan, Reference Ilcan2009; Juhila et al., Reference Juhila, Raitakari and Hall2016), or ‘advanced liberalism’ (Rose, Reference Rose, Barry, Osborne and Rose1996; Miller and Rose, Reference Miller and Rose2008), governments rely on citizens’ ability to realize their full potential, to control the course of their lives, and to maximize their quality of life by making the ‘right choices’ (Brown and Baker, Reference Brown and Baker2012; Moulaert and Biggs, Reference Moulaert and Biggs2013). Insurance against social risks (including those related to ageing) increasingly becomes an individual responsibility, giving rise to ‘prudentialism’ (O’Malley, Reference O’Malley, Barry, Osborne and Rose1996) and encouraging citizens to ‘bring the future into the present’ (Rose, Reference Rose, Barry, Osborne and Rose1996:58). As noted by Miller and Rose (Reference Miller and Rose2008: 205),
From this time forth, liberal governmentalities will dream that the national objective for the good subject of rule will fuse with the voluntarily assumed obligations of free individuals to make the most of their own existence by conducting their life responsibly. At the same time, subjects themselves will have to make their decisions about their self-conduct surrounded by a web of vocabularies, injunctions, promises, dire warnings and threats of interventions, organized increasingly around a proliferation of norms and normativities.
It is through discourse that the advanced liberal governance approach is primarily implemented. Notions of autonomy, responsibility and freedom of choice are mobilized through various dissemination channels including the mass media, opinion polls, advertising and marketing techniques, and public policies, translating government objectives into individual choices and commitments (Rose and Miller, Reference Rose and Miller1992; Rose, Reference Rose, Barry, Osborne and Rose1996; Laliberte Rudman, Reference Laliberte Rudman2006). The present study is concerned with policy discourse, which Rose (1992: 178) sees as a ‘domain for the formulation and justification of idealised schemata for representing reality, analysing it and rectifying it …’. It seeks to investigate how the concept of autonomy is mobilized in the ageing-in-place discourse, and more broadly, what role it plays in the governance of ageing.
Conceptualizing autonomy in later life
Theoretical developments on the concept of autonomy in older adults have been influenced by the field of disability studies and the independent living movement, which are concerned with how disabled people are represented and how the services intended for them are designed and delivered (Simon-Rusinowitz and Hofland, Reference Simon-Rusinowitz and Hofland1993; Morris, Reference Morris2004; Kittay, Reference Kittay2011). These authors emphasize the importance of viewing people with disabilities as individuals with the capacity for self-determination, participation and contribution to society, rather than as sick people with needs. This is reflected in the conceptual distinction between decisional autonomy and autonomy of execution, put forth by Bart Collopy (Reference Collopy1988, Reference Collopy, Gamroth, Semradek and Tornuist1995), which is widely adopted in studies on the living conditions of older adults (Glendinning, Reference Glendinning2008; Rabiee, Reference Rabiee2013; Hillcoat-Nallétamby, Reference Hillcoat-Nallétamby2014).
In Collopy’s typology, Decisional autonomy refers to an individual’s ability to make decisions according to personal preferences and values, regardless of being able to carry them out independently. According to the author, ‘Individuals can be intellectually and volitionally autonomous, and yet be incapacitated, constrained, or otherwise prevented from acting’ (Collopy, Reference Collopy1988: 11). By contrast, autonomy of execution refers to ‘the ability and freedom to act on this decisional autonomy, that is, to carry out and implement personal choices’ (idem). Autonomy of execution must be understood as encompassing a decisional dimension, while decisional autonomy may – and most generally does – exist in the context of an individual’s decline (or absence) of functional autonomy. As Collopy and many others note, physical ability is not the sole indicator of autonomy for older people. Studies have demonstrated that measuring autonomy in terms of physical ability tends to result in disabled individuals being perceived as non-autonomous (Becker, Reference Becker1994; Collopy, Reference Collopy, Gamroth, Semradek and Tornuist1995; Gilbert, Reference Gilbert2019), which may in turn affect the attitude of medical personnel towards them (McCormack, Reference McCormack2001; Tuckett, Reference Tuckett2006).
From an ethical standpoint, the distinction between autonomy of execution and decisional autonomy calls for greater protection of older individuals’ decisional autonomy, particularly in cases of loss of physical capacity. In this regard, research has shown the importance of recognizing that older people’s definition of autonomy is also contingent upon their capacity to access resources to fulfil their needs (Morris, Reference Morris, Glendinning and Kemp2006; Plath, Reference Plath2008; Hillcoat-Nallétamby, Reference Hillcoat-Nallétamby2014). According to these studies, the range of services and resources available, how they are accessed, and whether they are provided to older people as an entitlement exert a significant impact on their sense of autonomy. Research also shows that older adults’ sense of autonomy is defined by their ability to control their level of dependence on their families, particularly their children (Hammarström and Torres, Reference Hammarström and Torres2010; Peace et al., Reference Peace, Holland and Kellaher2011). Accessibility, availability and affordability of home care services are therefore central to this perspective.
Connecting autonomy and ageing in place
Most ageing strategies are embedded in the healthy/active ageing paradigm, which (re)defines old age around notions of health, participation and autonomy (Asquith, Reference Asquith2009; Dillaway and Byrnes, Reference Dillaway and Byrnes2009). Ageing strategies also typically promote ageing in place as the primary way to bolster autonomy and self-reliance in older adults (Hillcoat-Nallétamby, Reference Hillcoat-Nallétamby2014; Marshall et al., Reference Marshall, Dalmer, Katz, Loos, Lopez Gómez and Peine2022).
Although increasingly contested in the scientific literature (Hillcoat-Nallétamby, Reference Hillcoat-Nallétamby2014; Buffel and Phillipson, Reference Buffel and Phillipson2024), the conceptual connection between ageing in place and autonomy is widespread, both in public policy and among the ageing population (WHO, 2015; Dalmer, Reference Dalmer2019; Lebrusán and Gómez, Reference Lebrusán and Gómez2022). This may be attributable to a shared understanding of the notion of autonomy as a normative and consensual societal value (Bellah, Reference Bellah1985; Secker et al., Reference Secker, Hill, Villeneau and Parkman2003). As Becker (Reference Becker1994: 60) notes, ‘American values that are based on rational determinism, such as independence, responsibility for oneself and one’s health … articulate fundamental American notions about personhood, individual autonomy, and the power of thought to shape life course …, and constitute an American ideology of individualism’. As a result, the reference to individual autonomy to justify personal choices and institutional practices remains largely unquestioned.
From a public policy perspective, connecting the ageing-in-place approach to the maintenance of older adults’ autonomy provides a compelling rationale for governments to promote an affordable model of healthcare provision which is also popular with the electorate. The language of autonomy is therefore used as a driver of policy making and action. As Thomas and Blanchard (Reference Thomas and Blanchard2009: 13) argue, ageing in place has developed into a ‘… powerful idealized counter-narrative, the opposite of a dreadful old age cursed with indignity, a loss of autonomy, and the looming terror of institutionalization’. Several studies support this, showing that older adults’ preference for ageing in place is closely linked to their fear of losing their autonomy and being seen as non-autonomous should they relocate (Söderberg et al., Reference Söderberg, Ståhl and Melin Emilsson2013; Vasara, Reference Vasara2015). It is this very connection between the concept of autonomy and the ageing-in-place policy approach that our study investigates. By examining the policy discourse on the governance of ageing, it moves away from data based on older individuals’ perceptions on which recent research is largely reliant. It also takes the analysis of older adults’ autonomy outside the context of institutionalized long-term care, which has been extensively studied.
Methods
This article reports on a critical discourse analysis of key ageing policy documents released by the government of Quebec between 2012 and 2023. Following Fairclough’s (Fairclough, Reference Fairclough2003; Fairclough and Fairclough, Reference Fairclough and Fairclough2012) and van Dijk’s (Reference van Dijk1997) approach, this project highlights the predominantly argumentative nature of policy discourse. It considers the political context (e.g., contestation of the government and its management of the health and social services system), economic context (e.g., budgetary restraint, labour shortage), and sociodemographic context (e.g., ageing population) in which the ageing-in-place discourse takes place. Analyses focus on expected outcomes of policy discourse as ‘the purpose of the speech, what it is designed to achieve, may be to convince an audience that a certain course of action is right or a certain point of view is true …’ (Fairclough and Fairclough, Reference Fairclough and Fairclough2012: 18).
Five policy documents of three types were reviewed: (1) Québec’s first (and current) ageing strategy (MFA and MSSS, 2012a); (2) Two action plans arising from the ageing strategy (MFA and MSSS, 2012b, 2018); (3) Two calls for briefs for the action plans on ageing (MFA, 2017; MSSS, 2023). The latter two consultation documents set out the guidelines for future action plans and invite actors from various sectors working in the field of ageing to comment on their content.
Documents were selected based on authorship and publication (Provincial government or one of its Ministries) and their direct link with the provincial ageing strategy. In Canada, ageing policies primarily fall under Health and Social Services, which is a provincial responsibility. The province of Quebec released its first ageing strategy in 2012. The analyses presented in this study include that strategy as well as all the action plans and public consultations that directly flow from it (2012–2023).
The analytical approach we borrow from Fairclough and Fairclough (Reference Fairclough and Fairclough2012) recognizes the performative value of language, that is, the possibility of considering discourse as an instrument of governance, or a tool to ‘engineer social, cultural or institutional change …’ (Fairclough and Fairclough, Reference Fairclough and Fairclough2012: 84). In this sense, our analyses seek to investigate how the concept of autonomy is used in order to promote and support ageing in place as a policy goal. Our focus is both on (1) the meaning of autonomy (Walton, Reference Walton2007), and on (2) its use in the construction of the argument in support of the ageing-in-place policy approach (Fairclough and Fairclough, Reference Fairclough and Fairclough2012).
Selected documents were analysed on two levels: (1) the meaning of autonomy, which is based on the conceptual distinction between autonomy of execution and decisional autonomy, and (2) how the relationship between autonomy and ageing in place is used in the discourse on the governance of ageing, which is based on the distinction between the conceptualization of autonomy as an individual claim and as a normative injunction.
In each of the documents, we identified all the text segments that connect ageing in place with the concept of autonomy and coded each occurrence for each level of analysis. For level 1 (autonomy of execution/decisional autonomy): text segments connecting ageing in place with the autonomy of action, physical capacities and self-sufficiency were coded as ‘autonomy of execution’ while those connecting ageing in place with decision-making, choices, freedom of choice and preferences were coded as ‘decisional autonomy’. For level 2 (autonomy as normative injunction/autonomy as individual claim): each segment was analysed in light of how it figures in the policy document as a whole. Excerpts from the reviewed documents quoted in the article have been translated from French into English by the author and validated by another researcher.
Findings and discussion
Autonomy of execution and the responsibility to age in place
Autonomy of execution is central to the documents reviewed, with its functional dimension identified as an attribute of individuals who age in place. By positioning ageing in place as a symbol of older adults’ autonomy, the discourse on the governance of ageing equates the conditions of functional autonomy with those of ageing in place. It therefore situates (functional) autonomy – the ability to carry out daily activities – as the basis for ageing in place, emphasizing ageing in place as the best setting for healthy/active ageing.
This is exemplified in Quebec’s ageing strategy which states that ‘Among the actions to be taken under the ageing strategy are those aimed at promoting health and preventing loss of autonomy, as well as providing an appropriate response to people’s desire to remain in their homes …’ (MFA and MSSS, 2012a: 27).
Functional autonomy is valued as something to be protected and maintained so that older people can remain in their homes for as long as possible. The first action plan arising from the ageing strategy advances:
The government is reaffirming its commitment to developing services for seniors and making home support the cornerstone of [the ageing strategy]. In this respect, the government: … pays particular attention to health promotion and disability prevention, in order to preserve the health and autonomy of seniors for as long as possible (MFA and MSSS, 2012b: 99).
Accordingly, the call for briefs for the second action plan states that ‘Falls prevention, combined with accessible and adapted housing, are among the factors that can help people age at home safely and independently’ (MFA and MSSS, 2017: 36). And the second action plan (2018: 30) further specifies that ‘Nearly 80% of seniors who stay in a transitional functional recovery unit quickly regain the autonomy they need to return home safely’.
As these excerpts show, ageing in place is connected with older adults’ autonomy of execution, emphasizing functional autonomy as the main indicator of ageing in place well, or, as the main characteristic of people who age in place well. They also capture that the ageing policy aims at fostering older people’s autonomy through health promotion and falls prevention, with successive action plans featuring various measures aimed at maintaining and restoring physical capacities, and at ‘extending’ autonomy (MFA and MSSS, 2012b: 68, 148, 2018: 31).
In light of Collopy’s (Reference Collopy1988, Reference Collopy, Gamroth, Semradek and Tornuist1995) conceptualization of autonomy of execution, which he defines as one’s ‘ability and freedom to make decisions without external coercion or restraint … and to act on this decisional autonomy’ (Collopy, Reference Collopy1988: 11), the discourse on ageing in place leaves little room for older people’s decisional autonomy. According to the author, in theory, the decisional dimension of autonomy remains independent of its functional dimension. In practice, this translates into the capacity of older individuals with declining physical capabilities to define their own needs and determine the most appropriate means of meeting them (Plath, Reference Plath2008; Hillcoat-Nallétamby, Reference Hillcoat-Nallétamby2014). This does not necessarily involve freedom of choice in terms of service provider, which may result in an additional burden for them and their caregivers (Lent and Ardent, Reference Lent and Ardent2004; Beresford and Sloper, Reference Beresford and Sloper2008; Dansereau et al., Reference Dansereau, Kelly, Aubrecht, Grenier and Williams2022). Rather, considering the decisional dimension of older people’s autonomy would mean that they can determine whether it is acceptable for the responsibility for their care and support to rest primarily with their family, and more particularly with the female members of their family and extended networks.
By emphasizing its functional dimension, and overlooking its decisional dimension, the discourse defines older people’s autonomy, and even more so that of individuals with disabilities, as a transferable individual attribute over which they have little control. As Collopy (Reference Collopy1988: 11) warned, ‘if autonomy is defined principally in terms of execution, the frail elderly will be relegated to non-autonomous status [while] decisional modes remain quite intact’. To this extent, the autonomy of people with declining physical capacities is framed as a form of delegated autonomy, the terms of which remain unclear. Yet the delegation of autonomy can be partial, Collopy argues: for physically impaired older adults, ‘self-determination may be supported and survive longer when there are opportunities to delegate certain activity and decisions to others. When delegation is recognized as a valid form of autonomy, the elderly are clearly positioned as agents and active participants, indeed as authorizers of the circumstances and processes of care’ (Reference Collopy1988: 12). Thus, in a discursive context where the focus is on the functional dimension of autonomy, the older person’s care configuration becomes the responsibility of a third party, both in terms of decisions and execution.
Autonomy as responsibility
Although ageing in place is a central pillar of Quebec’s ageing strategy, there is an acknowledgement across reviewed documents that health and social services are not organized to meet the needs of a population that is ageing at home. The 2012–2018 action plan, for instance, notes that ‘the consolidation and development of home care and support services are essential … [and] the government is making major investments to ensure that more people have access to these services … so that home support takes a more prominent place in the organization of services’ (MFA and MSSS, 2018: 100). Similarly, the call for briefs for the 2024–2029 action plan underscores the government’s determination ‘to make a major shift in home care and support to better meet the growing needs of people, including seniors’ (MSSS, 2023: 48).
As evidenced by research conducted in recent decades, the implementation of the ageing-in-place policy approach is contingent upon the establishment of partnerships between governments and non-profit/community organizations (Bookman, Reference Bookman2008; Conway and Crawshaw, Reference Conway and Crawshaw2009; Iecovich, Reference Iecovich2014), and families (Chappell, Reference Chappell2011; Lavoie et al., Reference Lavoie, Guberman and Marier2014; Davies and James, Reference Davies and James2016). These findings are reflected in a recent report on homecare services in Quebec, which describes access to services as limited, particularly for people with loss of autonomy who are supported by family caregivers (CSBE, 2023: 28–29). The report also notes that the rate of response to needs is low, with only 13.5% of the hours required to meet home care and support needs actually delivered (idem). It is therefore family caregivers who provide the most care for older people living at home.
This reality is echoed across the reviewed documents, where loss of autonomy is explicitly identified a few times, but not equated with not ageing in place. The discourse is rather focused around the notion of shared responsibility for the care of physically impaired older adults between the state and other stakeholders – especially families – with the help of technology. The crucial role played by caregivers features prominently across the review. They are portrayed as enabling older adults to live as long as possible in their own homes and communities and offering ‘invaluable emotional and psychological support’ to the person they care for. They are also identified as ‘essential providers of personal care and help with shopping, banking and taking medication’ (MFA and MSSS, 2012a: 28). The heavy reliance on caregivers’ free work is justified, in the ageing strategy, by the fact that ‘The state alone cannot assume the impact of a rapidly ageing population [and] that a balance must be struck between issues that are the responsibility of individuals and families, the responsibility of the communities where older adults live, and the responsibility of government’ (MFA and MSSS, 2012a: 44).
By valuing family caregivers as key players in the implementation of ageing-in- place policy approach, and by equating autonomy with ageing in place without equating loss of autonomy with not ageing in place, the discourse positions the autonomy of older individuals, as well as the implementation of the ageing in place approach (along with homecare), as an individual responsibility, namely that of older adults and (mostly female) family caregivers. Alongside the key role of family caregivers, the emphasis is also on older people’s ability and responsibility to take charge of their own lives, particularly through making choices that enable them to stay healthy and remain at home for longer:
The behaviours and habits that contribute to a person’s health and development are forged throughout life. There is no age limit for modifying a behaviour or changing a habit that is detrimental to one’s health and well-being. It is desirable to maximize quality of life in old age through information and education (…) Concrete actions can help promote health, prevent loss of autonomy and improve quality of life (…) (MFA and MSSS, 2012b: 90).
How the connection is established between autonomy and ageing in place reveals a tension between an understanding of autonomy as responsibility (remaining healthy and maintaining functional autonomy as an individual responsibility) and autonomy as a claim right (receiving home care services as an entitlement), with the former understanding largely prevalent over the latter. Accordingly, the concept of autonomy is used to advance the achievement of ageing in place as a policy goal, and to valorise the role of individuals who contribute to its implementation. This instrumentalization of the concept of autonomy for the benefit of a policy objective is also at odds with the principles of feminist care theory, which suggest, on the one hand, that formal and informal care practices still mainly involve women, which undermines their personal autonomy, and in the end, perpetuates unequal power relations (Tronto, Reference Tronto1993; Fraser and Vogel, Reference Fraser, Vogel and Bhattacharya2017). On the other hand, they emphasise the relational aspect of care, i.e. that although autonomy remains primarily defined in terms of independence and self-sufficiency, and therefore in opposition to the notion of dependence, it can only develop, and be realised, through (trusting, caring, etc.) relations with others (Keller, Reference Keller1997, Verkerk, Reference Verkerk2001).
Decisional autonomy and the ‘choice’ to age in place
The previous section studied (functional) autonomy framed as a responsibility, or an institutional demand. This section investigates how the ageing-in-place discourse mobilises autonomy as an individual claim. The shift from individual responsibility to individual claim indicates a different perspective in policy discourse, which builds the argument from the injunctive social norm and free choice. By emphasizing the freedom of choice older people have over their living arrangement and where they want to live, the policy discourse frames ageing in place as a manifestation of their decisional autonomy, and an outcome of their individual agency. Indeed, the ageing strategy notes that ‘Staying at home, in the same habitat or in their community, is the first choice of seniors’ (MFA and MSSS, 2012a: 35), suggesting that it is both a living arrangement available to all, and one residential option among others.
This framing of ageing in place as the result of older adults’ free choice features in the ageing strategy, which intends to ‘enable seniors who wish to do so to remain in their own homes for as long as possible, and to ensure that their safety is not compromised’ (MFA and MSSS, 2012a: 15). The 2018–2023 action plan reiterates this idea in similar terms:
[the action plan] … innovates with a view to encouraging the social participation of seniors, valuing their contribution and improving their living conditions, particularly for the most vulnerable among them, as well as enabling those who wish to do so to remain in their own homes for as long as possible (MFA and MSSS, 2018: 19).
As mentioned earlier, ageing in place is a policy approach that aims to facilitate the continued residence of older adults in their own homes for as long as possible, with access to services that accommodate their evolving care and support needs. And the reviewed texts indeed identify home care and support services as ‘the cornerstone of the ageing policy’ (MFA and MSSS, 2012b: 65). In this context, ‘enabling seniors who wish to do so to remain in their own homes for as long as possible’ implies that older people may choose to age in their own homes for as long as they desire, or not. This raises the question of how decisional autonomy is supported in practice.
Ageing in place is strongly bound up with ideas of choice and preference across the review, reinforcing the injunctive norm – one’s perception of what most people approve or disapprove (Cialdini et al., Reference Cialdini, Kallgren, Reno and Zanna1991) – around individual autonomy and its connection with ageing in place. However, reviewed texts remain unclear on the articulation of other choices, namely not ageing in place and their connection with autonomy. Throughout reviewed documents, the ageing-in-place approach is promoted and valued as the favourable and preferable living arrangement for all older people. It is framed as a natural choice and universal preference and depicted as an ideal lifestyle. The revised texts invoke personal values, linking ageing in place with family memories and meaningful social ties, yet taking into account the diversity of ageing paths: ‘Despite the wide variety of profiles and life paths, older adults share the same aspiration: to remain in their own homes and communities for as long as possible, in environments that bear witness to their family and personal history, where they have their roots, social ties, and habits’ (MFA and MSSS, 2018: 64).
The ageing strategy does mention the possibility of relocating ‘within the community’ or ‘to another dwelling in the same building’ when ‘loss of physical ability occurs’ (MFA and MSSS, 2012a: 35), which is consistent with the tenets of healthy/active ageing and its focus on physical health and community participation (WHO, 2015). However, the framing of ageing in place as an individual choice, and that of relocation within the community as an accessible and available residential option for all older people, contribute to an idealized portrait of their residential conditions and mobility, and of access to home care.
The body of research on the ‘constrained residential immobility’ of older people (Caradec, Reference Caradec2010), and the housing conditions of older ‘involuntary stayers’ (Strohschein, Reference Strohschein2012) has grown in recent years, highlighting the variety of factors that limit older people’s choice of living arrangements and residential location (Aurand et al., Reference Aurand, Miles and Usher2014; Finlay et al., Reference Finlay, Gaugler and Kane2020; de Jong et al., Reference de Jong, Rouwendal and Brouwer2022). Studies show that remaining at home can become a matter of constraint rather than choice (Simard, Reference Simard2019; de Jong et al., Reference de Jong, Rouwendal and Brouwer2022; Yarker et al., Reference Yarker, Doran and Buffel2024) and that private collective housing offering shared spaces and different levels of services are not accessible to everyone for a variety of reasons, including price and location, which are typically intertwined (Carder et al., Reference Carder, Kohon, Limburg and Becker2018; Simard, Reference Simard2019). Although this is a political priority for most governments in the industrialised world, socio-economic status remains a key structural factor in older adults’ ability to age in a place that meets their needs. This is particularly true in countries like Canada which are home to ‘liberal’ housing markets (Schwartz and Seabrooke, Reference Schwartz, Seabrooke, Schwartz and Seabrooke2009) where governments intervene relatively little and mainly support homeownership.
With regard to Quebec in particular, recent data show that 43% of renters aged 75 and over living in unsubsidized private dwellings (which excludes seniors’ residences) live in a dwelling that needs major repairs, is unsuitable due to its size, or costs 30% or more of household income. This proportion rises to 57% among tenants aged 75 and over who live alone (Statistics Canada, 2023). Furthermore, the residential situation of homeowners aged 75 and over, which is not statistically linked with issues of adequacy, suitability or affordability, may conceal many other issues, including those of person-environment fit (Golant, Reference Golant2008; Weil, Reference Weil2017; Henning-Smith et al., Reference Henning-Smith, Lahr, Mulcahy and MacDougall2023).
It is rhetorically convenient to position the ageing-in-place policy approach as a response to older individual’s claim for autonomy. The language of decisional autonomy used in the texts reviewed, along with their positioning in an egalitarian scheme based on universal access to care and recognition of the diversity of ageing paths, frame ageing in place as the prevailing standard for ageing well. However, this rhetoric may obscure the significant influence of structural and socio-political factors on one’s ability to choose to age in place, or not. Agency is always shaped by one’s position in society and by relations of power and dominance. As pointed out in several studies, the intersecting structures of inequality (gender, ethnocultural/migration background, socioeconomic status, sexual orientation, etc.), influence the opportunities, as much as the processes, of ageing in place (Greenfield and Buffel, Reference Greenfield and Buffel2022; Nazroo, Reference Nazroo2017; Yeh, Reference Yeh2022).
Conclusion
Through a political sociology approach, this article highlighted how autonomy and ageing in place are connected in the discourse on the governance of ageing, with functional autonomy framed as an individual responsibility related to ageing in place, and decisional autonomy identified as an individual claim to which the state responds by enabling older individuals to age in place if they so wish. In this discourse, ageing in place is promoted as a natural choice and universal preference of healthy/active agers, and positioned as a primarily individual responsibility. Analysing these connections, and the meaning of autonomy within each of them, makes a significant contribution to critical social gerontology research, which has challenged the systematic connection between ageing in place and autonomy primarily from the perspective of older people ageing in long term care facilities (Wiles et al., Reference Wiles, Leibing, Guberman, Reeve and Allen2012; Hillcoat-Nallétamby, Reference Hillcoat-Nallétamby2014; Caspari et al., Reference Caspari, Råholm, Sæteren, Rehnsfeldt, Lillestø, Lohne, Slettebø, Heggestad, Høy, Lindwall and Nåden2018; Moilanen et al., Reference Moilanen, Kangasniemi, Papinaho, Mynttinen, Siipi, Suominen and Suhonen2021; Spiers et al., Reference Spiers, Kunonga, Stow, Hall, Kingston, Williams, Beyer, Bower, Craig, Todd and Hanratty2022).
By investigating policy discourses on ageing, this research has expanded knowledge on the governance of ageing, identifying the discursive connection between ageing in place and autonomy as a governance mechanism to advance ageing in place as a policy goal. Findings show that discourse on the governance of ageing makes rhetorical use of the concept of autonomy, drawing on the cultural values ascribed to it, and using it as a driver of policy making and action. This draws implications for research and policy in Quebec in the first instance, and in other national contexts where ageing in place is central to ageing policy and care configurations are similarly arranged.
First, the article broadens the understanding of the governance of ageing in place, emphasizing its equation with the functional dimension of older adults’ autonomy. Older people who have (or have regained) the ability to carry out their daily activities are seen as being able to (and wishing to) age in place and are encouraged to do so. In Canada, as in most if not all industrialised countries, ageing in place represents an affordable model of healthcare provision (Kaye et al., Reference Kaye, LaPlante and Harrington2009; Gori et al., Reference Gori, Fernandez and Wittenberg2015), and therefore a way of responding to the ‘problem’ of population ageing, by delivering services at home rather than developing residential care. This paper demonstrated that the connection between autonomy and ageing in place focuses on the functional dimension of autonomy, overlooks its decisional dimension, and brings responsibility for home care and support to the individual and family level.
Theoretically, these findings take the analysis of older adults’ autonomy outside the context of institutionalized long-term care, which is necessary at a time when ageing in place is being promoted in all industrialized countries. They prompt reflection on governments’ conceptualization of older adults’ autonomy, with a particular focus on how the decisional autonomy of physically impaired older adults is understood and considered in social programs. It highlights the fact that ageing-in-place processes are still rooted in an active/healthy ageing paradigm that is more reflective of the cultures of the third age than the reality of the fourth age, which remains poorly represented and addressed in ageing policies and strategies.
In practical terms, study results address the implementation of the ageing-in-place policy approach. In Quebec, older adults’ autonomy is primarily assessed based on health indicators (Gilbert, Reference Gilbert2019), and decisional autonomy is given little consideration in defining needs and care configurations. Connecting ageing in place and autonomy by considering the latter in its full measure – including its functional and decisional dimensions – promotes and values the contribution of older people in defining their needs and choosing how to meet them. In a context of rapid population ageing, where most older people will age in place, ageing policies that recognize their decisional autonomy and understand it as distinct from their functional autonomy could foster the well-being of older people who ‘choose’ to remain at home, and of their caregivers.
Second, this study broadens knowledge of how ideas of decisional autonomy, free choice and preference are used as governance tools in the context of an ageing population. The connection between ageing in place and decisional autonomy (and its related concepts) is core to the discourse on the governance of ageing. At the same time, ageing in place is framed as an outcome of individual agency and a policy direction responding to older adults’ preferences. Yet in the context of the allocation of resources for home care and support, and of access to housing, it is illusory to consider ageing in place as generally stemming from older people’s decisional autonomy. As this article shows, ageing in place is depicted as an ideal lifestyle, and identified as a living arrangement accessible and available to all. This policy discourse tends to downplay the importance of multiple and intersecting structural and socio-political factors shaping the opportunities and processes of ageing in place.
Study findings suggest the need for further research into the relationship between conceptualisations of autonomy in ageing policy discourse and program and policy definition, care configurations, and the well-being of older people and their caregivers. Furthermore, our theoretical framework opens the door to comparative studies on conceptualizations of older individuals’ autonomy in different countries, as well as on understandings of autonomy in policies and programs aimed at different population groups.
Financial support
The work was supported by the Fonds de recherche du Québec – Société et culture. This organization played no role in the conduct of the study.
Ethical statement
No ethical approval was required for this study.
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