The Connection between Age-Friendly Communities & the Social Determinants of Health

September 2020 blog post by Micayla Maiorino BSc, BScN and Nicole Hill BSc, MSc, BScN

An age-friendly community is a community where policies, services, and physical spaces are secure and accessible both physically and socially for people of all ages to live in (WHO, 2007). As Canada’s elderly population is growing, the transition to “age-friendly communities” is believed to be one of the best ways to allow seniors to remain in their homes as long as possible which has been shown to maximize overall health and minimize the impact of age-related morbidities on the healthcare system (WHO, 2007). Age-friendly communities promote good health and well-being, as well as allow people to continue to participate in society and their community throughout their lifetime (WHO, 2007). In 2007, the World Health Organization (WHO) identified eight interconnected domains that can help to identify and address barriers to the well-being and participation of seniors in a community. These domains are:

• Outdoor spaces and public buildings
• Transportation
• Housing
• Social participation
• Respect and social inclusion
• Civic participation and employment
• Communication and information
• Community support and health services

The social determinants of health (SDH) are personal, social, economic and environmental factors that influence individual and population health (Pooler & Srinivasan, 2018). Individuals that experience the SDH in a positive way, such as with adequate access to food and nutrition, gainful employment and stable income, safe and affordable housing, safe neighborhoods, and reliable transportation, often have better health and can maintain good health long-term (Pooler & Srinivasan, 2018). Alternatively, those who experience the SDH in a negative way are at a greater risk for poor health, morbidity, and mortality (Pooler & Srinivasan, 2018).  Research shows that the social determinants of health can be more important than health care or lifestyle choices in influencing health (Mikkonen & Raphael, 2010). The Government of Canada (2019) reports 12 social determinants that influence individual and population health. These determinants are:

• Gender
• Culture
• Social Environments
• Social Support Networks
• Health Services
• Healthy Child Development
• Employment/Working Conditions
• Physical Environments
• Financial and Social Status
• Education/Literacy
• Biology and Genetic Endowment
• Personal Health Practices and Coping Skills

Below is a concept map depicting the connection between age-friendly communities and the social determinants of health:

The SDH play an important role in aging by impacting the health and well-being of older adults and facilitating their ability to thrive in their home and community. Understanding the role of the SDH is critical in supporting older adults residing in age-friendly communities and wishing to age in place (Pooler & Srinivasan, 2018).

Physical Environment
Transportation

• Reliable transportation is a key factor that governs the independence of older adults (Pooler & Srinivasan, 2018).
• Older adults with reliable access to transportation are better able to get to medical appointments, run errands, and attend social events (Pooler & Srinivasan, 2018).
• Low-income adults are more likely to experience stress or become concerned about having access to adequate transportation for appointments and/or social events (Pooler & Srinivasan, 2018).
• Since transportation links older adults to not only health services but also with community life and opportunities for social participation, the absence of affordable and accessible transportation may create barriers to health services, contribute to social isolation and decrease health equity (Levasseur et al., 2017).

Housing

• Housing needs change over time (Pooler & Srinivasan, 2018).
• Affordable, accessible, and maintainable housing can be a challenge for older adults (Pooler & Srinivasan, 2018).
• A combination of modest incomes and high living costs mean that older adults often spend 30% or more of their income on housing costs (Federation of Canadian Municipalities, 2015).
• Low-income older adults are more likely to experience stress and uncertainty about being able to afford or maintain their homes as they age when compared to higher-income individuals (Pooler & Srinivasan, 2018).
• A large number of older adults in Canada’s larger cities and communities are renters which further limits affordable, accessible and appropriate housing options for older adult renters (Federation of Canadian Municipalities, 2015).
• Housing arrangements also vary among cultures. Multigenerational housing (multiple familial generations living in the same household), which is common in Asian culture, can positively impact the health and wellbeing of older adults by minimizing social isolation and housing costs while fostering the opportunity for family members to assist with care needs (Muennig et al., 2017).
• It is also important to note that Aboriginal people in Canada experience less adequate housing conditions which can impact the health and well-being of not only older adults but all the individuals of this population (Federation of Canadian Municipalities, 2015).

Outdoor Spaces and Public Buildings

• Age-friendly outdoor spaces and public buildings facilitate community involvement, allow older adults to maintain their independence, and foster opportunities for outdoor physical activity which can positively impact overall health and well-being (Zhai et al., 2018).
• Unlike public buildings, which are typically mandated to be accessible based on municipal and provincial regulations, most outdoor spaces are not accessible for older adults (Zhai et al., 2018).
• More specifically, the location where older adults live can greatly impact whether or not they can utilize and enjoy outdoor spaces and public buildings due to factors such as accessibility, safety, and the location of these spaces (Zhai et al., 2018).
• Minority and low-income neighbourhoods are less likely to have recreational facilities and well-kept, accessible parks and green spaces than higher-income communities (Moore et al., 2008).

Social Environment
Social Participation

• Being socially connected is an important factor for health and well-being at all ages (Holt-Lunstad et al., 2015).
• Loneliness and isolation have the ability to potentially worsen the risk of mortality, morbidity and rehospitalization for older adults (Holt-Lunstad et al., 2015).
• Social participation in older adults is largely associated with socioeconomic position and life events such as widowhood and affliction with multiple morbidities (Ahmad & Hafeez, 2011).
• Moreover, poverty, patriarchy, and poor functional status can severely impact the ability of older adults to participate in social activities (Ahmad & Hafeez, 2011).
• Older females have been shown to be more socially isolated than older males due to cumulative effects of life circumstances in childhood and adulthood (Ahmad & Hafeez, 2011).

Respect and Social Inclusion

• Social inclusion refers to the opportunities for older adults to cultivate social relationships, have access to resources and feel part of the community they live in (Ronzi et al., 2018).
• Respect refers to the attitudes and behaviours of the community towards older adults so that older adults feel accepted, valued and appreciated by the community regardless of their age (Ronzi et al., 2018).
• Social inclusion and respect have a variety of benefits for older adults including social exchanges that may foster independence and role fulfillment that may assist older adults in preserving their self-esteem and self-efficacy (Scharlach & Lehning, 2013).
• The social inclusion and intersectionality of older adults in the community is closely tied to cumulative disadvantage and life course trajectories (Gonzales et al., 2015).
• Older adults who are at risk of being excluded from the community have often already experienced disadvantage and social exclusion in earlier periods of their life (Gonzales et al., 2015).

Civic Participation and Employment

• Civic participation and volunteer/employment opportunities for older adults can positively impact psychosocial outcomes (minimize depression and optimize social inclusion), physical health (functional independence and lower mortality), and cognitive health (mental status and executive function) (Anderson et al., 2014).
• Unfortunately, a majority of older adults do not work and tend to have very few opportunities for continued civic participation and employment following retirement (Gonzales et al., 2015).
• Moreover, older adults who work are less likely to maintain employment as their health declines (Wenger et al., 2003).
• There is also great concern about the ability of disadvantaged older adults to successfully engage in working, caregiving, and volunteering opportunities in the community despite the best efforts of programs and policies to be inclusive (Gonzales et al., 2015).

Personal Well-Being
Communication and Information

• Effective communication is necessary for older adults to perform many functions including employment/volunteering, social and leisure activities, community involvement, personal relationships, and activities of daily living (Yorkston et al., 2010).
• Moreover, the ability of older adults to communicate successfully, including speaking, listening, reading, and writing, is a critical factor in obtaining health care (Yorkston et al., 2010).
• However, the prevalence and complexity of communication disorders increase with age. Communication disorders that affect the elderly include but are definitely not limited to dysarthria, aphasia, and hearing loss (Yorkston et al., 2010).
• In addition, socioeconomic factors such as childhood development, reading level, and education can impact how older adults communicate and receive/retain vital information (Office of Disease Prevention and Health Promotion, 2020).
• Cultural beliefs and language barriers may also impact the ability of older adults to communicate and receive information in both the community and health care settings (Office of Disease Prevention and Health Promotion, 2020).

Community Support and Health Services

• Community-based supports and health services are essential to facilitate aging in place and to optimize the overall health and well-being of older adults in the community (Public Health Agency of Canada, 2011).
• However, health inequalities may limit some older adults from accessing the community-based supports and health services they need to optimize their health. For example, low income older adults are more likely to have complex health and care needs and may experience more difficulties obtaining adequate care due to various factors such as limited access to appropriate transportation poor communication skills (Public Health Agency of Canada, 2011).
• Health inequalities include material factors (economic and physical environments as determined by the SDH), psychosocial stressors (negative events, stressful circumstances, lack of support), and behavioural factors (cigarette smoking, diet, alcohol consumption, physical exercise) (Levasseur et al., 2017).
• Tackling health inequalities involves addressing the unequal distribution of the SDH, such as income and social status, education and literacy, physical environments, social supports and coping skills, healthy behaviours, and access to health services (Levasseur et al., 2017).

Based on this information, it is important to recognize that the careful implementation of age-friendly communities can significantly minimize the negative impacts of the SDH on the overall health and well-being of older adults in the community. However, due to the complexity of the SDH, please note that this summary may not address all of the connections that exist between the SDH and age-friendly communities.