By Craig E. Brewer
In honour of Social Work month, I thought that I would start a discussion relating to an issue that has raised concern with me over the past few decades. As technology becomes more ubiquitous in society it brings with it the irony that although we are more connected, we communicate less. We have hundreds of friends, but feel more lonely and insulated, than we have before. With the ever increasing age of people living in the community, I feel that the problem of Social Isolation is going to be a major challenge as the population grows older.
Demographers have identified a trend which suggests that the number of people aged 65 and over living in Australian communities has increased. The evidence implies that the numbers will only continue to increase in the future, placing greater demands on a struggling health and welfare system that is constantly under attack from more conservative elements of society. Those changes have impacts on the individual, their families and friends as well as the community in which they live. There is also a direct implication for the social policy development in the welfare and health sector in Australia (Australian Bureau of Statistics, 1996, 1999, 2001).
Whilst a full and in-depth examination of these issues is unrealistic in this forum, due in the main to the level of complexity and the multitude of issues that are involved. I see the importance of starting the conversation so that policy makers, members of the professions and the general community can start the dialogue to identify possible solutions to the inherent problems. That being the case, it is still important to start a conversation around these issues by critically reviewing the available data in order to highlight the effects of social isolation on older people living in the community. The impacts that social isolation can have on the local community and society in general should also be considered. Although this discussion is from an Australian perspective many of the understandings can readily form an overlay for many other communities in international society.
The Australian Bureau of Statistics (ABS) reported an increase in the number of people living alone in Australia. Research conducted by the ABS would indicate that being widowed is the major cause for older people living alone, identifying an average age 73 years. The number of older people living alone in the community has increased from 1.1 million people in 1986 to 1.5 Million in 1995 (Australian Bureau of Statistics, 1996). ABS estimates based on the current trend suggests that by the year 2021 approximately 21% of people over 65 of years living alone will be older women compared to 8% for men of the same age group due to data that indicates women tend to have a longer life expectancy than men (Australian Bureau of Statistics, 2001). The ABS project that by the year 2031 that proportion of the population is expected to reach 22% with a further increase to 24% by the year 2051(Australian Bureau of Statistics, 1999).
That data may not fully inform the discussion as it relies on self-reporting by participants and may not have fully identified the number of older Australians living alone in the community. No reference was made to homeless people or those people from low socio-economic groups who reside in temporary or transient accommodation, nor does it assist in identifying the extent to which social isolation affects older couples living in the community. The ageing of the population and the effects of social isolation and exclusion and the challenges that it poses has been acknowledged by the Australian Government with the development of national protocols relating to elderly Australians living alone (Elliot, 2008). Unfortunately outside of the aged care and welfare sectors, those protocols appear to be all but unknown and even in the sector very few people can speak to them.
Complexity of the issues
A review of literature by the British Columbia Ministry of Health identified a relationship between social isolation, loneliness, emotional isolation and social exclusion and how they relate to the health and social outcomes for older people as being “complex and varied”. Often that complexity leads to confusion and difficulty when policy decisions are needed to be made (British Columbia Ministry of Health, 2004, pp. 8 & 18). Cattan, White, Bond and Learmouth (2005) understood the complexity also becomes problematic when attempts are made to identify the effects of social isolation due to the interchangeability of many terms used together with the use of inconsistent definitions for age, they saw many of the terms as subjective further confusing the matter (Cattan, et al., 2005, pp. 42-43). Extensive research has been conducted in to the effects of social isolation and social exclusion by organisations including the World Health Organisation which reported that “social exclusion has major impacts of health and premature death”, whilst similar associations between an older person’s health and wellbeing have been linked as being influenced by social isolation and loneliness (Wilkinson & Marmot, 2003, p. 16; Wu & Zhang, 2011, p. 7).
Research conducted by the Social Exclusion Knowledge Network (SEKN) revealed some interesting insights, which may give reason to challenge the validity these causal links to social isolation and exclusion. Mathieson, Popay, Enoch, Escorel, Hernandez, Johnston and Rispel (2008), undertook a review of the evidence in an attempt to identify a relationship between “social exclusion, population health and health inequalities” the outcome of which revealed the complexity and the lack of reliable empirical research explicitly focusing on the relationship being available became problematic (Mathieson, et al., 2008, p. 60). Other issues that were identified related to difficulties in defining social exclusion as they believed it was “impossible to develop globally appropriate rules for the aggregation and weighting of data, given the general consensus that ‘social exclusion’ (whether a ‘state’ or ‘process’) is multi-dimensional, dynamic and context specific”(Mathieson, et al., 2008, p. 61). Social isolation on the other hand is believed to be related to the individual focusing on loneliness and their access to social networks and interactions (British Columbia Ministry of Health, 2004, p. 8). Although both terms are seen by some to have different focuses others use the terms interchangeably, this could be as a result of the difficulty in firstly defining the terms and secondly identifying when the political is converted to the personal (Aronson & Neysmith, 2001, p. 151). Mathieson et al (2008) believed that any attempt to quantify the causal relationship between social exclusion and health outcomes was contentious as it was unclear if social exclusion and isolation was a risk factor to poor health or a whether poor health was a contributing element to social exclusion further adding to the complexity of the issue. This semantic argument however, neglects to address the real human cost of social exclusion and Isolation.
Regardless of the problematic nature the lack of empirical evidence presents the theoretical relationship between health outcomes and social exclusion and isolation was acknowledged by Mathieson et al. (2008), who cited Beall (2002), who identified the importance of exploring the micro and macro causes and effects of both poverty and inequality (Mathieson, et al., 2008pp. 61-62). It is at the site of those theoretical relationships of social isolation and exclusion that inferences can be drawn to illustrate the effects of social isolation on older people living in the community. Those effects can be divided into those effects that act directly on the individual’s health and wellbeing and the systemic effects on the community and society in general that arise from social isolation and exclusion of individuals. According to Poulsen, Christensen, Lund and Avlund (2011) there has been a growing interest in the importance of Social Capital and its relationship to older people over the past 10 years. Studies would suggest that environmental influences may be more important to older people in the residential setting providing insight to the “Place Effect” through a social capital lens; however the results of their study identified differences between communities and the impact of those differences on the communities was not known (Poulsen, et al., 2011).
Attempts have been made to identify the dynamic that surrounds social isolation and exclusion of older people from society. Zastrow and Kirst-Ashman (2001), identified disengagement theory as one possible explanation, citing Cummings and Henry (1961), referring to a functional process by which older people withdraw from certain roles in society as they grow older; however, it would appear that society also withdraws from the individual as they age. The assertion that older people welcome this disengagement has been challenged as having less to do with old age, with critics claiming that the process is more related to the effects of old age such as ill health, death of a spouse, close friends and poverty. A major criticism of disengagement theory is that “it may be used to justify society’s failure to help the elderly maintain meaningful roles” (Zastrow & Kirst-Ashman, 2001, pp 591-592). Biordi and Nicholson (2012) believed problems relating to the isolation of the individual from their community often led to depression and loneliness or other social or cognitive impairments resulting a further isolation (Biordi & Nicholson, 2012, 89-91). The Adult Guardian Queensland recognised social isolation as a issue faced by older people living in the community resulting in their vulnerability in placing them at risk of self-neglect, ill health and incapacity claiming that the older person who is living alone being subjected to “entrenched social exclusion and poor access to mainstream goods and services” (Irons, 2011, p. 9; Prendergast, 2010, p. 27). Heslop and Gorman (2002) saw social exclusion as “the distancing of older people from their societies” and it was that distancing, that prevented them from accessing adequate and appropriate services and engaging in “political, economic and social life”, citing Maltby (1997), Heslop and Gorman claimed that it went further than income and wealth translating into “poor housing, ill-health and personal security”(Heslop & Gorman, 2002pp. 11-12).
Aronson and Neysmith (2001) claimed that the reduction of government spending in developed countries and an increased focus on the individual taking responsibility for their health care cost, combined with the reorganising of home care from paid to un-paid informal arrangements having the effect of older people needing to rely on informal options (Aronson & Neysmith, 2001, pp. 151-152). Heslop and Gorman (2002) believed that it was this increased individualisation of risk coupled with the inequalities of resources provided between rural and urban areas that dictated the extent isolation governs the ability for older people to gain access to health and social services (Heslop & Gorman, 2002p. 12). Marmot (2005) claimed that all policy makers need to be concerned with the social determinants of health for older people as much as they are with the young (Marmot, 2005, pp. 1099- 1101). This move towards austerity and requiring people to provide for themselves through the purchase of health insurance, income protection and superannuation whilst reducing services traditionally provided by government places greater pressure on the older Australians who feel the financial pressure and often can not maintain pace with the economic demands resulting in them falling through the cracks in the system.
The ABS research indicates that there will be a higher demand on limited resources and appropriate accommodation and increased health and social service provision will be required (Australian Bureau of Statistics, 1999, 2001; 2011, p. 5). Bosworth and Schaie (1997) conducted research indicating that environmental supports have a direct relationship on the older persons ability to access support services (Bosworth & Schaie, 1997, p. 197). Cattan et al (2005), believed it was important for government policy and practice to address the issue of social isolation on a national level to enhance the health, quality of life and wellbeing of older people in the community (Cattan, et al., 2005p. 41).
Social Isolation of older people living in the community is a growing issue in Australia, which will require the community and Government to work together if the challenges that social isolation presents to society are to be met. Due to the complexity of the issue and the lack of empirical evidence the true effects of social isolation are difficult to isolate. Current investigations into the relevance of Social Capital and its relationship to older people in the community may present the best avenue by which the effects of social isolation can be identified. Unfortunately as services are reduced and the increasing cost of private supports continues many older Australians are becoming disillusioned and are disengaging from services. Further research is required to unpack all the issues and implications of social isolation; however, Australia is not alone in this trend with many countries in the western world also experiencing similar issues as society becomes more individualistic. There is a need as a community to ensure that older people are not left behind or forgotten as they still have much to experience and teach the community.
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