Reducing Social Disengagement Among Seniors: A Policy Prescription

Image retrieved from senioragenda.blogspot.com

This blog is part of a larger series that can be found here, which starts with introductory post titled “Why believing ‘health is due to lifestyle’ harms public policy.”

The Problem
Loneliness and isolation from social activities each affect 1 in 5 Canadian seniors [1].

Social isolation and loneliness are two similar but distinct concepts, with the former being a more objective measure of the number of contacts with friends and family, and the latter being a more subjective measure of the experience of ‘unfulfilled intimate and social needs’ [2]. These, along with other similar terms, can be grouped under the umbrella term social disengagement.

They are of considerable importance to mental and physical health: together, they are believed to be equally as damaging to health as smoking and obesity, due to their detrimental effects on mortality, disability, depression, cognitive function, self-rated health, and health-behaviours [1–3]).

Relevance to Aging
As we age, we experience a sort of ‘forced social disengagement’ due to a number of factors, three major ones being (1) dwindling financial resources as we move into retirement can limit opportunities, (2) functional limitations in mobility may prevent us from going out to see friends and family, and (3) deaths of family and friends, all of which narrow our social circles [2]. There is another important distinction to note here, which is that these are not forms of voluntary disengagement, but rather they are forms of involuntary social disengagement.

Voluntary disengagement is where people may begin to decrease the size of their social networks in order to focus on the relationships that matter most, and this may actually be adaptive [4]. This is in contrast to involuntary disengagement, which is associated with psychic suffering [4].

So, if it is involuntary and associated with suffering, why are these considered ‘normal’ changes (retirement/limited resources, functional mobility, death of loved ones) that we will almost all see as we age?

Largely, it boils down to the social determinants of health. The psychic suffering associated with this disengagement is less about the natural changes we experience, but the fact that public policy does not provide the support older adults need to cope with these changes.

Below is an infographic on social isolation from Connect2Affect.Org, an initiative of the AARP in the United States.

Retrieved from Connect2Affect.Org

I will now use two issues (functional limitations and retirement) as examples to narrate why this is about the social determinants, and how public policy changes could help reduce involuntary social disengagement and the associated suffering.

Issue One: Functional Mobility
Functional limitations in mobility that result in social disengagement are biological changes that may be typical of aging. However, if physical environments (a determinant of health) can be designed in ways that are more accessible for older adults, then these biological limitations may no longer be limiting.

To illustrate how even seemingly minor policy decisions about the physical environment can impact social disengagement, I’ll use an example of something I noticed when I was living in St. John’s, Newfoundland

Many seniors rely on public transit to get around, and so public transit needs to be accessible. Well, during my time in St. John’s, I noticed how rare it was for bus stops to have any form of seating. For some, it’s nice to have a seat, but for many older adults with chronic illness, frailty, or functional limitations might depend on being able to have a seat and rest while waiting for a bus. Compare this to Victoria, BC, where I find seating a much more common feature of bus stops.

While anecdotal, I believe this elucidates how the determinants of health (physical environment, such as seats at bus stops) interact with each other (income: if one is unable to afford a car and has to use a bus) and age-related functional limitations (like frailty, decreased muscle strength, and easily becoming fatigued) might ultimately culminate in social exclusion if it impedes older adults from social engagement in social, cultural, civic, or leisurely activities.

Using Hamilton & Bhatti’s model of Population Health Promotion [5], one area of action would be to apply a ‘healthy public policy’ lens on all policies at the community level. Looking at city design policies through a healthy public policy lens would allow decision-makers to create supportive environments that are more accessible to those with limited mobility, such as by ensuring seating is available at bus stops. This thereby addresses multiple determinants of health at once:

• physical environment (seating is more supportive of people with physical limitations);
• income (social engagement will be less limited by one’s ability to afford a car or taxi to get around, as public transit is now more accessible to people with functional limitations); and,
• biology (social engagement will now be more accessible to people who have limited mobility or other related functional health concerns).

In short, adding seating at bus stops could hypothetically improve social engagement in older adults, or at the least reduce barriers people may otherwise experience.

Issue Two: Retirement and dwindling financial resources
Not only is retirement a stressful event that substantially changes a person’s social environment [6], but it also means a change in income source. Some are lucky enough to have a private pension or enough money saved to keep a steady source of income throughout retirement, but many rely on Government pensions such as the Canada Pension Plan, Old Age Security, and for those with low-income, the Guaranteed Income Supplement.

Half of Canadians 50–64 have no accrued private pension benefits, fewer than one in five have enough savings for even just five years of expenses in retirement, and one in nine Canadian seniors is living in poverty [7]

It’s hard to be socially engaged when you’re struggling to pay bills, keep a roof over your head, and put food on the table.

Indeed, low-income is the most consistent factor that drives social engagement in late life [8], and one reason for this may be monetary costs may be associated, either directly or indirectly, with social and leisure activities. For example, while visiting friends may not have a real cost, there would be costs related to travel (public transit, taxi, or maintenance of a car) or to the social activity (having a cup of coffee, dinner, or drink at a restaurant). Visiting friends also requires that one be in good enough health to visit. Maintaining one’s health — even in a universal system like Canada — requires economic resources to afford, for example, prescription medications, dental services, private health insurance, physiotherapy, psychological counselling, mobility-equipment, and nutritious food.

Evidence from the UK Longitudinal Study on Aging found that older adults are four times as likely to experience persistent social detachment when they do not have access to public or private transportation, and twice as likely when they do not have access to a landline telephone, mobile telephone, or the internet [9].

Access to any of these services are dependent on whether one has the economic resources to do so. Thus, it is clear that inadequate economic resources are a problem that contributes to social detachment in late life.

Using Hamilton & Bhatti’s model again [5], let’s take a look at how we this issue might be ameliorated by ‘building healthy public policy’:

Since wealth is the most consistent driving factor of social disengagement [8], one logical policy action would be to consider increasing seniors’ benefits, like OAS and GIS. Currently, these social benefits are falling behind, and it expected that poverty rates among seniors in Canada will continue to rise in the future [7].

Research in Canada suggests that having guaranteed income from seniors’ benefits leads to significantly better mental health and overall health [10]. Considering the direct link between wealth and social engagement, in addition to the reciprocal relationship between social engagement and both mental and physical health, it is thus probable that enhancing seniors’ benefits would lead to better social engagement and well-being among seniors.

When considering how benefits program should be implemented, the fewer ‘conditions’ required to receive the benefits the better. Benefits with fewer conditions are more accessible to the people who need them, and less likely to cause stress, stigma, marginalization, or disempowerment [10]. These negative feelings are typical of many current social welfare programs in Canada, which often have such stringent eligibility criteria that they are too unreliable and insufficient to meet peoples’ needs [11]. For these reasons alone, it is recommended that any social policy changes aimed at improving the economic conditions of seniors be specifically focused on improving current Old Age Security and Guaranteed Income Supplement benefits.

So, what have we learned?
In short, involuntary social disengagement among seniors in Canada is a pressing issue that is having a substantial negative impact on seniors’ well-being. But, more importantly, many of these issues are amenable to policy changes.

1. Gilmour, H. (2012). Article Social participation and the health and well-being of Canadian seniors. Component of Statistics Canada Catalogue №82–003-X. Health Reports, 23(4). Retrieved from www.statcan.gc.ca
2. Courtin, E., & Knapp, M. (2017). Social isolation, loneliness and health in old age: a scoping review. Health and Social Care in the Community, 25(3), 799–812. https://doi.org/10.1111/hsc.12311
3. Holt-Lunstad J., Smith T.B. & Layton J.B. (2010) Social relationships and mortality risk: a meta-analytic review. PLoS Medicine, 7(7). https://doi.org/10.1371/journal.pmed.1000316
4. Kim, J. H., Kim, M., & Kim, J. (2013). Social activities and health of Korean elderly women by age groups. Educ Gerontol, 39(9), 640–54.Hamilton & Bhatti, 1996
5. Hamilton, N., & Bhatti, T. (1996). Population Health Promotion: An Integrated Model of Population Health and Health Promotion. Ottawa, ON. Retrieved from https://www.canada.ca/en/public-health/services/health-promotion/population-health/population-health-promotion-integrated-model-population-health-health-promotion.html
6. McKee, K. J., & Schüz, B. (2015). Psychosocial factors in healthy ageing. Psychology & Health, 30(6), 607–626. https://doi.org/10.1080/08870446.2015.1026905
7. Shillington, R. (2016). An Analysis of the Economic Circumstances of Canadian Seniors. The Broadbent Institute. Retrieved from https://d3n8a8pro7vhmx.cloudfront.net/broadbent/pages/4904/attachments/original/1455216659/An_Analysis_of_the_Economic_Circumstances_of_Canadian_Seniors.pdf?1455216659
8. Jivraj, S., Nazroo, J., & Barnes, M. (2012). Change in social detachment in older age in England. London, UK. Retrieved from https://www.elsa-project.ac.uk/uploads/elsa/report12/ch3.pdf
9. Tomaszewski, W., & Barnes, M. (2012). Investigating the dynamics of social detachment in older age. London, UK: English Longitudinal Study on Aging. Retrieved from http://www.elsa-project.ac.uk/uploads/elsa/report08/ch5.pdf
10. Mcintyre, L., Kwok, C., Herbert Emery, J. C., & Dutton, D. J. (2016). Impact of a guaranteed annual income program on Canadian seniors’ physical, mental and functional health. Can J Public Health, 107(2), 176–182. https://doi.org/10.17269/CJPH.107.5372
11. Raphael, D. (2011). Poverty in Canada: Implications for Health and Quality of Life. Toronto, ON: Canadian Scholars’ Press Inc.