Social isolation can have the same impact on health as smoking an entire pack of cigarettes a day (Tiwari, 2013). Though much of the older population is faced with chronic illnesses, co-morbidities and other health challenges, a redefined definition of health tells us that despite the existence of health conditions one can still perceive themselves to have overall good health and well-being. Yet, our older population continues to face discrimination, ageism, and health inequities that inhibit their ability to have accessible and equal health care. In reviewing health outcomes of older adults, we must first understand the social determinants of health. In doing so we learn that factors such as our level of education, our income, where we live, the quality of our early childhood experiences and the physical environment that surrounds us are what guide our health outcomes throughout our life course. To understand and address health outcomes of older adults it is fundamental that health professionals integrate the life course approach into their practices. This approach allows health care professionals to better understand individual and population health of older adults by evaluating the impact of life transitions and experiences of health outcomes in later life. This paper will use the ecological model with a life course approach to explain the health issue of social isolation in older adults living in the community while drawing on my professional role in home & community care. I will identify the individual, interpersonal, community, organizational and public policy influences on the health outcomes of older adults in regard to social isolation.
Firstly, it is necessary to clearly define the terms associated with social isolation. Social exclusion is a key social determinant of health that negatively affects the health outcomes of older adults. Mikkonen & Raphael (2010) refer to social exclusion as “specific groups being denied the opportunity to participate in Canadian life (p.32).” Levitas et al., (2007) further define social exclusion as:
A complex and multi-dimensional process. It involves the lack or denial of resources, rights, goods and services, and the inability to participate in the normal relationships and activities available to the majority of people in a society, whether in economic, social, cultural or political arenas. It affects both the quality of life of individuals and the equity and cohesion of society as a whole (p.25).
Defining social exclusion clarifies the link between social isolation and health inequalities in older adults. “The social isolation of seniors can cause communities to suffer a lack of social cohesion, higher social costs, and the loss of an unquantifiable wealth of experience that older adults bring to our families, neighbourhoods and communities.” (National Seniors Council,2016). Approximately 43% of older adults living in the community feel socially isolated causing negative health outcomes such as depression, stress, functional decline and death (AGE-WELL, 2017). Social isolation can have equivalent negative health outcomes as smoking (AOHC,2016). The video below captures the emotions of older adults experiencing social isolation and loneliness in a society that has seemed to have forgotten all about them.
Social isolation occurs when an individual has minimal social contacts and often leads to negative health comes including loneliness, psychological and physical distress. As Singer (2018) explains, though loneliness and social isolation are often associated, those socially isolated do not always feel lonely and those alone are not always socially isolated. However, both social isolation and loneliness are risk factors for poor health outcomes in older adults. “Isolation is a situation; loneliness is a feeling (Elmer, 2018, pg. 19).
The ecological model is useful in exploring the facilitators for social isolation in older adults living in the community. This model demonstrates multiple levels of health influence based on individual risk factors at five levels (micro to macro) as displayed below in Figure 1. While social isolation occurs at the level of the individual, the negative health outcomes further impact multiple levels of health and “interventions to reduce social isolation must act on the structural determinants, including economic disadvantage and discrimination, as well as supporting the immediate needs of socially isolated and/or lonely individuals (NSC, 2016).”
The figure below contrasts the relationship between social isolation and the ecological model. While the ecological model supports that there are multi-level influences that impact our health Figure 2. below incorporates the life course approach in understanding social isolation. Our experiences throughout the life course influence our susceptibility to poor health outcomes later in life. I will now address each level of the ecological model in the context of social isolation of older adults living in the community incorporating my role within the system.
Intrapersonal/Individual
Individual risk factors of social isolation at the individual level can be explained as distal and proximal risk factors. Distal factors influence the individual’s living conditions such as gender, attitudes and beliefs, genetics and social perceptions. Proximal risk factors refer to the size, functionality and quality of one’s social networks and relationships, for example if a person lives alone or not (Elmer, 2018).
As indicated by the National Seniors Council (2016) and displayed below in Figure 3. other individual risk factors that put older adults at higher risk of social isolation can also include social relationships, poverty and lack of resources, knowledge and awareness, sexual and gender identity, geography, health and disabilities, and life transitions.
Research supports that social isolation and loneliness have detrimental health outcomes (Menec et al., 2019). Social isolation compromises the psychological, physical and social health outcomes and overall wellbeing of older adults while putting them at higher risk for negative behaviours, higher risk for falls and increased likelihood of hospital visits. (NSC,2016).
Most older adults (85%) prefer to remain in their own home and live independently for as long as possible. According to Home Care Ontario (2018) sixty percent of older adults are users of home care services. Older adults receiving home care services considered to be ‘high need clients’ (those living with two or more chronic conditions) are more likely to be socially isolated (Lewis et al., 2018).
Interpersonal factors
The quality of interactions one has with others strongly influences a person's likeliness or unlikeness of feeling lonely and/or being socially isolated. As described above, many individual factors one has guides the outcome of how and who we interact with. For example, an older immigrant widow with no children, low socioeconomic status and living alone in the community has no social network as she has difficulty communicating with others due to language barriers and unequal access to resource's due to her determinants of health. These circumstances endanger her ability to create, build and maintain social relationships and result in poor health outcomes. To contrast, picture an older woman with strong family connections. This older woman’s family has encouraged her to become a part of an exercise program at the local seniors centre where she made a friend and now speaks to every week. Meaningful social connections help guide healthy behaviours and outcomes.
Institutional and organizational factors
The Ontario Human Rights Commision has identified regulations, and policies that are responsible for putting constraints on older adults health in addition to increasing the likelihood of social isolation.The OHRC argue that ageism and discrimination is deeply routed in the code and is responsible for creating barriers in accessing equitable health care and treatment within the societal structure. “In effect, ageism, in its various forms, serves to disempower older persons within these very important aspects of their lives (OHRC,2001).”
Canada’s health care system is partly responsible for social exclusion of older adults. The way we provide health care services to older adults is not always delivered in a way that promotes healthy behaviours and outcomes. Shiovitz-Ezra, Shemesh & McDonnell/Naughton report in their study that doctors frequently misdiagnosed or dismiss health concerns of older patients as they believe their experiences are an inevitable result of old age (2018). This denies older adults the ability to manage their health conditions successfully and equally as others in do in the population. Policies toward eliminating ageism should be a priority among organizations and institutions as misconceptions around ageing play a role in social isolation of older adults and in turn constrains health behaviors. Shiovitz-Ezra,Shemesh & McDonnell/Naughton (2018) support this in stating:
“Widely held ageist beliefs and attitudes can coalesce and become institutionalized forms of discriminatory norms and practices. Society-wide ageist norms and practices can, in turn, act as barriers to older adults’ active participation in social activities.”
In the context of home care professionals interact with the clients, caregivers, families and field staff to identify and prevent risks such as social isolation. Home care plays a significant role in health promotion and health behaviours as policies, procedures and priorities guide healthy outcomes and reduce risk while facilitating relationships that provide links to other community programs to the person in need. Home care service providers have policies in place for those living in the community with less support from family and friends. A displayed in figure 4 it is not uncommon for high need clients to have little to no social support. Despite the effort put forth by home care providers, high need, socially isolated clients are at extreme risk for poor health outcomes.
The government of Canada has developed a Social Isolation Toolkit to support organizations in preventing social isolation of older adults.
Community factors
The community plays a large role in either promoting social inclusion or exclusion in older adults. There is a need for communities to encourage meaningful interactions and connections among individuals within the community (NSC, 2016). Older adults prefer to age in place and remain in their own homes for as long as safely possible. For older adults to age in place successfully communities must offer age-friendly environments that promote social inclusion. Age-friendly communities include accessible and affordable transportation, adequate and affordable housing, safe sidewalks and crosswalks, and other systems that allow individuals to live in the community as equals despite age differences. Another part of an age friendly community is one that is free of discrimination.
Community programs such as; HouseCalls. REACH, 211, Friendly to Seniors Program, South Shore Helping Hands, Niagra GateKeepers and Technologies for Aging Gracefully Lab
work toward eliminating social isolation and support active aging in the community. Some of these programs enable older adults to be a part of the community and feel reciprocity through helping others and in turn builds the community as a whole.
Public Policy Factors
As the ecological displays in figure 1 health issues such as isolation impact all levels of influence. As a result, public policy plays a significant role in setting the standards and guidelines to help reduce risk factors associated with social isolation and promote social inclusion. The ecological approach teaches us that to prevent, reduce or postpone the risk of health issues such as social isolation there needs to be changes within micro and macro levels. The House of Commons have identified the need to address social isolation in disadvantaged groups. Four policy goals on the governments seniors agenda include:
1. Improving seniors' access to affordable housing
2. Improving the income security of seniors
3. Promoting healthy aging and improving access to health care
4. Fostering the social inclusion and engagement of seniors
The province has identified the need for policy change in promoting social inclusiveness for older adults. The House of Commons: Advancing inclusion and quality of life for seniors developed recommendations on reducing social isolation in regard to home care, housing, informal caregivers, age-friendly communities and provide a national strategy. Resources such as First Link Program and The Campaign to End Loneliness can help reduce the risk of social isolation in older adults at various levels and guide public health policy to support action for prevention, early detection, and assist in managing health outcomes and behaviours associated with social isolation.
In conclusion, the ecological model allows us to comprehend risk factors associated with social isolation in older adults and moreover how to combat these outcomes at the individual, interpersonal, organizational and public policy levels. The findings of this paper support that multiple spheres of health guide health outcomes and behaviours in older adults. The application of social isolation and the ecological model demonstrate the interconnectedness of the model. Social isolation is experienced by the individual but in turn impacts all levels within the ecological model. The model allows us to identify, address and work to eliminate social isolation on the individual level and community at large.
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Written submission from AGE-WELL, 20 October 2017.
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