Health and social participation of older people in Europe

Stimulating social participation of older people is a major goal for both the Dutch government and European policy in general. A central issue for the European Commission is to promote active and healthy aging. With the introduction of the Social Support Act (WMO) municipalities in the Netherlands have become responsible for supporting the independence and participation of people with physical or mental health problems. This support aims to ensure that people can continue to live in their own home and community for as long as possible. Social participation is a broad concept, which often focuses on social activities such as paid work, involvement in political organizations, volunteering or providing informal care. Social participation also includes consumptive or social-cultural activities which involves one’s personal development and wellbeing. Consumptive participation can include, for example, taking part in a sports activity, visiting a restaurant or museum, sporting event or amusement park. Also there is network participation where the contact with family, friends and neighbors is important. While social-cultural and network activities do not have direct economic value, they are important for the well-being and quality of life, and according to the WHO definition an important aspect of Active Ageing (WHO, 2002).

Despite the fact that older people often remain active into late old age, the number and diversity of activities decreases with age (van der Meer, 2008). This decrease is mainly due to a decline in physical and mental health. Especially functional impairment, depressive symptoms, and cognitive impairment affect the social participation of older people. Yet little is known about differences in social participation of older people in Europe, and especially the social participation of older people with health problems.

European countries show a large variety in the rate of of social participation. Figure 1 demonstrates social participation rates of people aged 65 and over in selected European countries, distinguishing between participation in consumptive activities (educational activities or taking part in sports or other clubs), providing informal care to adults or children outside the household, participation in volunteer work and participation in religious activities. Data come from the Survey of Health, Ageing and Retirement in Europe, ( www.share-project.org ). Compared with other European countries, the Netherlands shows the largest volunteer participation, but engagement in informal care and consumptive activities is also relatively high. Only Denmark has higher participation rates in these two kinds of activities. Poland and Portugal stand out with a high involvement in religious activities, while only a small share of older people in these countries participate in educational activities or in volunteer work. Each country has its own cultural context, which plays an important role in these differences. For example, the availability of care services and the extent to which the family is regarded as a source of care greatly influence the rate of participation in informal care in each country. In addition, large differences exist in the policies that promote Active Ageing at the European level.

Within the European project MOPACT (Mobilising the Potential of Active Ageing in Europe) research has recently been conducted on the effect of multimorbidity (i.e. the co-occurrence of at least two chronic diseases) on various types of social participation. Older people with multimorbidity had a lower chance of participation in almost all of the studied activities (except for religious activities). The impact of multimorbidity, however, depended on the type of activity. For participation in the labour market, in educational activities and in volunteering the negative effect of having multimorbidity was larger than for informal care and network participation (MOPACT, 2015).

Central in this research was the question if individual characteristics of active older people were different in people with and without multimorbidity. If so, interventions to promote social participation should also be different for older people who do, compared to older people who do not, have health limitations. However, predictors of participation were largely similar. In both the groups with and without multimorbidity, higher socioeconomic status, a larger social network and better physical and mental health were important for the rate of social participation.

Some predictors were only relevant for some of the participation domains. For example, older people with multimorbidity who were widowed had a higher chance of providing care, but a lower chance of doing volunteer work. In addition, transportation possibilities (driving a car, public transport) seemed more important for consumptive activities for those with multimorbidity, compared with older people without multimorbidity. The domains of social participation were strongly associated. This implies that older people who are active in volunteer work are often also the ones who provide care (to grandchildren) or who take part in educational activities.

This study shows that interventions targeted at enabling social participation of older people with health problems should not necessarily be different than for relatively healthy older people. At the same time, people with health limitations – and those with a low socioeconomic status and a small social network - do participate less, and this warrants special attention to these groups.

Certain chronic diseases may have more or less impact on social participation. Osteoarthritis is one of the most common chronic joint disorders in older people (Vos et al., 2012) and causes major functional limitations in daily life (Brooks, 2002). Previous research from EPOSA (European Project on Osteoarthritis) show that older adults with knee osteoarthritis participated less often in consumptive activities compared with those without knee osteoarthritis, but there was no difference in participation in voluntary work or network participation (Van der Pas et al, 2014). There were no differences between European countries. The results were controlled for other chronic conditions, functional limitations and depressive symptoms. However, social participation is still high among older adults with knee osteoarthritis (86% consumptive participation, 57% volunteer work, 80% network participation). This study suggests that having knee osteoarthritis mainly affects activities requiring physical mobility (consumptive activities) and to a lesser extent activities that can be adjusted (network participation). These are activities that can also take place at home or via phone or social media.

These findings show that older people who are active, often participate in different activities - consumptive activities, volunteer work, informal care and activities organized by religious organizations. Also, there are large differences between European countries. Older people with multiple chronic conditions generally participate less in consumptive activities and community activities such as volunteering and informal care than those who do not have a chronic condition. Furthermore, the same factors influence the social participation of older people with multiple chronic conditions compared with those with only one chronic condition. Netherlands is among the countries with the highest social participation, indicating that improvement may need to be sought in older people with health problems. Osteoarthritis mainly affects consumptive activities, but to a lesser extent network participation and volunteering. Having multiple chronic conditions did have an impact on volunteering. This may be due to the type of conditions involved, but these were not specified. Both studies seem to suggest a ranking of how the types of participation are influenced by health. Voluntary work and informal care seem to be abandoned before consumptive activities. Network participation is likely to be maintained the longest.

Voluntary work and informal care are precisely the activities that the Dutch government and the European Commission are currently focusing on, however there is no explicit focus on older people with chronic conditions. Both the type and the number of conditions appear to be important in this respect.