Social participation needs of older adults living in a rural regional county municipality: toward reducing situations of isolation and vulnerability

While longer life expectancy increases the number of people aged 65 and older around the world, longevity is not necessarily without disabilities [1]. About a quarter of older adults live in rural communities [2] and face specific challenges, such as restricted access to some health and social services, and limited housing and transportation options [3]. Moreover, approximately half of older adults will present disabilities at some point [2]. Since a common desire of older adults is healthy aging [1], interventions on determinants of health such as social participation are essential.

Social participation is defined as a person’s involvement in activities that provide interaction with others in the community [4]. In meeting their basic socialization and self-actualization needs, it is critical for retired older adults to develop abilities and make life meaningful, promote health, and prevent disabilities [5]. Even in industrialized countries, many older adults do not have equitable opportunities to achieve full social participation due to, for example, inequitable access to activities and information. In Canada, approximately half of older adults experience restricted social participation [2]. Diminished social participation is a critical element affecting older adults’ health [1] resulting in a 29% greater risk of mortality [6]. However, it is possible to intervene to maintain or increase social participation by optimizing a person’s abilities and environment [7], e.g., improved mobility, or providing an environment that promotes interaction. Interventions targeting the social participation of older adults in rural communities are currently delivered by community organizations, healthcare professionals and municipalities across Canada. However, they take little advantage of older adults’ personal and environmental resources [8] and reach only a limited number of people [9], which increases health inequities [10].

To foster social participation, it is important to know more about the needs of older adults. One multiple case study found that a majority of urban older adults with disabilities had needs that were unmet, especially for social activities, including responsibilities, interpersonal relationships, community life and leisure, and for some daily activities such as fitness, as well as housing and mobility outside the home [11]. Older adults and their caregivers often have limited knowledge about interventions available in the community and limited ability to use them. Even healthcare providers report having limited knowledge of interventions available in the community and limited time to evaluate and implement interventions to meet older adults’ needs, including supporting them and their caregivers in taking steps to use community services [11]. To improve and maintain older adults’ social participation, needs should be assessed more comprehensively, including social activities. More support should also be provided regarding the use of resources, and partnerships with community organizations should be optimized. Interventions fostering age-friendly environments should also be targeted.

As interventions on environmental factors may have a greater impact on social participation than those targeting individual factors [12], it is important to identify environmental facilitators for, or barriers to, doing social activities in rural communities [7]. However, few social participation studies have been carried out with rural older adults [13] or have compared those living in metropolitan, urban and rural areas. According to three quantitative studies, the social participation of older Canadians was found to be similar in metropolitan, urban and rural areas [14‐16] but was associated with different environmental factors [15]. In all areas, greater proximity or accessibility to resources and having a driver’s license were positively associated with social participation. However, public transportation use and the quality of the social network were associated only with the social participation of older adults living in metropolitan areas while the presence of children living in the neighborhood and more years spent living in the current dwelling were correlates of social participation identified in rural areas [15]. The social participation of aging adults in metropolises was higher than in medium and large urban centers, but similar to rural and small centers [16]. Barriers show that rural and metropolitan respondents were most likely to report being too busy to participate more, and less likely to report limitations due to health conditions. However, one respondent out of ten in rural areas, i.e., twice the proportion found in metropolises, reported that certain activities were not available [16]. Finally, results support the importance of various physical factors (e.g., user-friendliness of the walking environment) as well as social factors (e.g., support from family and friends) that affect the social participation of older adults [15]. Despite widespread acceptance of the role of the environment in social participation, a comprehensive portrait of the needs of older adults living in rural areas to participate socially is still lacking. Greater understanding could help community organizations, healthcare professionals and municipalities to craft interventions to enhance the social participation of older adults living in rural communities. This study thus aimed to identify and prioritize the social participation needs of older adults living in a rural regional county municipality (RCM).

To reach and mobilize a significant part of the population, as well as foster deep exploration and data saturation, a total of 139 participants/experts were involved in the study: 61 adults aged 65 or older, 18 caregivers of older adults, nine healthcare and community organization managers, ten healthcare and community organization employees, ten community partners (e.g., pharmacist, rural and cultural development officer) and 31 key informants from the RCM. The key informants were all members of the seniors’ consensus committee, who represented of the region’s older adults and involved in improving and maintaining their quality of life in the RCM as well as their development in society. At the beginning of the study, no personal or professional connections existed between the research team and the participants and partners. Participants were involved in needs identification (n = 86), prioritization (n = 113) or both (n = 60). While only 26 of the participants who helped to identify needs were not involved in prioritizing them, none dropped out of the focus groups. The older adults and caregivers lived in the RCM, had preserved cognitive functions based on interviewer judgment, and could communicate orally. Managers, employees, partners and key informants worked with the aging population in the RCM. Participants were recruited using a convenience strategy, including advertisements in local newspapers and public places, and word of mouth. To ensure diversity, recruitment of older adults targeted both women and men, with and without disabilities, who lived in urban and rural areas, and spoke French or English.

To identify needs, 16 focus groups and two individual interviews lasting approximately 90 min were conducted between February and June 2015. Eight focus groups involved older adults, three with caregivers, and one with every other category of participants, i.e., managers of healthcare services, providers of healthcare services, community organization managers, community organization employees, and partners. Key informants from the RCM participated in these groups according to their profile. Among the eight focus groups with older adults, one exclusively involved older adults with disabilities, another included English-speaking older adults, and a third comprised older men. This strategy was designed to target different cultural and living conditions that might influence older adults’ perceptions and needs regarding social participation. In addition, homogeneous groups can facilitate openness among the participants during discussions. The focus groups and interviews were conducted by four female interviewers of different ages (30 to 40 years old), with different academic backgrounds (occupational therapy, gerontology, sociology, health promotion, special education and speech therapy) and with different roles in the research team (one academic researcher (ML) and three experienced research assistants, including SR). Focus groups and interviews were held in a library, a volunteer center and a health center. Participants were warmly welcomed by the research team and offered snacks and beverages. They were told that there were no “correct answers” and comments would be kept confidential. A semi-structured guide was pretested and used to stimulate discussion about facilitators and barriers to social participation to help with identifying needs. The guide included open-ended questions such as: “What helps you to participate in your activities?”, “What prevents you from doing your activities?”, and “Overall, what is necessary for you to take part in activities in your community?” to identify needs. The semi-structured guide was validated by the seniors’ consensus committee (for example, an effort was made not to stigmatize the isolation of older adults). Interviewers avoided asking questions that could influence participants’ responses and, when necessary, they reformulated questions or responses to ensure or verify comprehension, respectively. The research team also discussed preconceived ideas and hypotheses. The data saturation point was reached, i.e., data collection was considered complete when the material collected no longer produced new ideas. All groups and interviews were digitally audiotaped and transcribed for further analysis. After each group and interview, a summary prepared by an observer was presented to the participants. Most of the time, this was done verbally right after the meeting or by mail, followed by a phone call, to validate the interpretation of the main content of the exchanges. This validation strategy ensured that the interpretation of the discussions did not overlook individual accounts but did encourage/advocate the co-construction of knowledge.

To prioritize needs, 12 forums, i.e., groups of experts (study participants) who discussed and adopted proposals by consensus, lasting approximately 60 min, were held between November 2015 and January 2016. During these forums, three steps were followed. First, identified needs were explained, orally and in written form (handouts), to participants in a random but consistent order. This explanation of the previously identified needs also validated earlier analyses as participants indicated their agreement with the needs presented. Second, participants individually rated the three most important needs for the social participation of older adults in the RCM. After doing this rating for older adults in the RCM in general, participants were asked to repeat this procedure twice, specifically for groups of older adults with disabilities and those living in a rural area. Third, during each forum, individual prioritizations were summed and transposed onto paper boards to examine trends and initiate discussion. A semi-structured guide was used and included open-ended questions such as: “What do you think about the results concerning older adults in general?” and “In your opinion, which results adequately reflect the social participation needs of older adults in the [name of the main city] area? Explain.” Five stakeholders, i.e., one community organization manager and four partners, could not attend the forums so they completed the prioritization grids electronically and sent in their responses by email. All forums were digitally audiotaped and summarized to enrich interpretation of the prioritization process. A self-administered questionnaire was used to collect the usual sociodemographic and clinical data.

To describe their context, the participants’ sociodemographic characteristics were described by means, standard deviations, median and interquartile interval, or frequencies and percentages according to the type of variable (continuous or categorical, respectively). Data related to number of diseases, marital status, relationship with the older adult, living arrangement, main language or feeling depressed were collected for older adults and caregivers (but not for healthcare and community employees, managers, community partners or key informants). To identify factors associated with social participation and needs, the groups and interviews were analyzed for thematic content as described by Miles, Huberman and Saldana [21]. To provide information about their recurrence, overlap, combination, complementarity and discrepancies [22], themes and content emerging from the qualitative data analysis were also quantified. Themes were classified according to an extraction grid based on the interview guide developed from the Human Development Model–Disability Creation Process (HDM-DCP), an anthropological model of human development and disability. The HDM-DCP illustrates interactions between intrinsic personal factors (e.g., age, gender, abilities), extrinsic physical and social environmental factors (e.g., distance to resources, family), and participation. Consistent with the constructionist perspective, themes that emerged were only later organized and defined using the coding guide based on the HDM-DCP. Two research assistants coded the data and one third was co-coded by other members of the team. In line with PAR, results were iteratively presented to, discussed with and enriched by the governance committee to ensure that needs and prioritization reflected real-world experiences. Analyses were performed using NVivo (version 10.0) software. Prioritization of needs was calculated by adding the scores assigned by each participant, who identified the most important (three points), second most important (two points) and third most important need (one point). The sum was performed for each of the three populations in the following order: older adults in the RCM in general, those with disabilities, and those living in a rural area. Frequencies and the total score were calculated for each need in each population. Finally, needs were combined for the overall situation (all three populations considered together).

All factors that influenced social participation were reported as potential facilitators or barriers, depending on each participant’s experience (Table 2). For example, a family can be supportive, visit often and facilitate the social participation of one older adult, while a family living far away, unavailable to help, might be a barrier for another. However, five factors, three personal and two from the social environment, were principally facilitators, while one personal factor was mainly a barrier (Table 2).

Among personal factors, desire, motivation, interests and habits with respect to being socially active were important for social participation (Table 2), as highlighted by participants from one group of older adults (O): ‘My husband and I have been involved with many organizations since we were young [ …]. We did a lot of volunteering and we still do [ …]. When there are volunteer dinners, we go! We don’t miss anything!’ (O6: number identifies the discussion from which the quote was taken). The desire of older adults to be involved in the community and volunteer was also an important factor (Table 2), as reported in another group of older adults: ‘I’d like to help someone who is unable to go out.’ (O8). Finally, the health of older adults was also influential (Table 2), as described by one group of workers from healthcare and community organizations: ‘[My mother] is in great shape. She is involved in a lot of things.’ (Workers, W1).

Among physical environmental factors, the availability and accessibility of infrastructures and meeting places were important for social participation (Table 2): ‘Not all towns and villages have meeting rooms.’ (O2). Distance to resources, recreational facilities and social partners were also reported as factors that influenced social participation: ‘There’s one thing with paratransit; it’s easier for older adults in the city to use [compared to those living in rural areas]. They’re closer to it.’ (Community partner, C2).

Finally, many social environmental factors such as the availability and organization of various resources such as transportation, assistance, adapted activities, volunteers and information were reported as important for the social participation of older adults living in the rural RCM (Table 2): ‘We know, transportation is a limitation here [ … ] Since it is limited here, older adults cannot take part in certain activities.’ (Healthcare and community organization managers, M3). The support, presence and habits of family and friends in interacting were also important, as noted by these older adults with disabilities: ‘My husband pushes me [in the wheelchair]. Also, when we visit our children, one of my sons brings me up to his house. Our children are very helpful.’ (O4-Disability).

Factors that influence social participation were often reported as being interrelated. For example, when health was not an issue, organizing transportation was easier when older adults still drove their own car. However, when older adults who lived far from the main town experienced declining health, the availability of volunteers to assist and transport them became important. Discussing facilitators and barriers in focus groups beforehand generated a better understanding of the overall situation and helped the process of identifying needs.

Nine needs emerged from the discussion concerning factors influencing social participation (Table 3). One third of those needs focuses on adapting activities or the physical environment (accessibility, adapted activities and transportation), another third mainly targets the initiation of activities (information, identification and personalized approach), while the remaining needs relate to the social environment (assistance, support network and recognition).

First, needs were related to the adaptation of activities or physical environment, such as having access to meeting places, as mentioned by the group of English-speaking older adults: ‘[We need] a center where we could go, you know, a place we could go to.’ (O7-English). Places for socializing and doing activities include community halls, local businesses and churches. These places must also be adapted to health conditions, with access ramps and suitable maintenance, including snow removal. Having access to activities adapted to their needs is important for older adults: ‘We need to find activities, either walking or … I don’t know … cycling. However, 70-year-olds won’t be cycling. We need to try to vary the activities offered.’ (O2) or ‘Just an afternoon of getting together and we could do whatever people bring with them, it’s still a social exchange.’ (O7). Activities should be interesting for older adults, tailored to their schedule, offered at a reasonable cost, in their main language and suited to their health conditions. The last need identified involved information about access to transportation options: ‘We will need to have transportation, which can be carpooling, partnering, etc.’ (Healthcare and community organization managers, M2) and ‘People should know transportation services that can go and get people in the villages, take them to the community center or any other activity.’ (O8). All kinds of transportation were discussed, including public transportation, assisted transportation and individual transportation [own car]. As for activities, transportation must be suited to the schedules, budget and health conditions of older adults, including those with mobility issues.

Second, regarding initiating activities, older adults need to be better informed about social opportunities, as illustrated by this quote from one group of healthcare and community organization workers: ‘We should find ways to ensure that information gets to people, that people understand how to access resources, as clearly as possible.’ (Workers, W2). Such information can reach older adults themselves or anyone interacting with them, for example, their family or healthcare providers. Second, it is necessary to reach out to older adults who are isolated, as reported by one group of managers: ‘Nowadays, nobody knows “who” is isolated, “who” has needs in the municipality. This information is lacking.’ (Healthcare and community organization managers, M1) and by one older adult: ‘It’s not just waiting for the older adults to get moving, it’s getting [information to them] in their homes.’ (O8). More isolated older adults need to be identified, located and helped when they have less contact with others. Often, older adults also need to be personally invited and welcomed to activities: ‘It’s not because they don’t want to, but I have the feeling that it would take someone to come pick them up, someone who can motivate them.’ (Workers, W1). Upon arrival at activities, this personalized approach should include a warm welcome, which could be from family members, relatives, healthcare providers, community organizations, volunteers or other contacts.

Among needs related to the social environment, some older adults need assistance in initiating or taking part in activities in the community: ‘Some older adults could go [to the activity], but they would need to be accompanied for a while, so they don’t show up alone.’ (Community partners, C1). Such support could be provided when the older adult does an activity for the first time, or more regularly, to ensure that a routine is established to participate in the activity. Social support from a network is also important to simply socialize, to provide psychological support, or to help with domestic tasks (for example): ‘There are people who need our help. Just to talk … they are alone. They are just happy when we go and talk to them.’ (O2). Being valued and recognized was one of the nine needs of older adults, as noted by one group of managers: ‘We have to value our older adults if we want them to participate socially. They need to feel that they’re important, that they have something to say, and that they’re still helpful.’ (Healthcare and community organization managers, M4). Such acknowledgement refers to the feeling of making a significant contribution to the community, having status in society, and being respected and appreciated by others.

Specifically, these nine needs identified by all types of participant mainly targeted older adults, not stakeholders, the community or healthcare organizations. Two needs, i.e., ‘being healthy’ and ‘wanting to participate’, were both indirectly considered under the needs ‘having access to activities suited to their needs’ and ‘being personally invited and welcomed to activities’, respectively. As they involved mainly personal factors and might be seen as prerequisites for social participation, these two needs were not directly targeted in the following step.

Overall prioritization, i.e., when the perspectives of the three populations were merged, suggested six important needs for older adults in the RCM (Fig. 1; above 200 points), some of which are interrelated. For example, needs for information, assistance and transportation were frequently discussed as being closely related to the social support network that could inform, transport and accompany the older adult. Specific prioritization, i.e., considering each population separately, revealed differences in social participation needs (Table 3). When targeting older adults in general, the main needs were information, adapted activities, support network and identification. For older adults with disabilities, the needs prioritized were assistance, adapted activities, accessibility and transportation. Finally, transportation and information were two central needs of older adults living in a rural RCM.

To our knowledge, this action research is the first to identify and prioritize the social participation needs of older adults living in a rural RCM using a process in which stakeholders played a significant role. In accordance with the guidelines of Raymond and colleagues [9], this action research directly involved older adults, caregivers and community members from many different backgrounds, and therefore provides an inclusive understanding of the needs of older adults in a rural RCM. The study was based on a strong partnership with the community and involved a personalized approach to the experiences and cultures of older adults in the RCM. Moreover, as recommended by Laperrière [32], having several sources of data and participants enabled triangulation, rich information and good internal validity. The limitations included recruitment based on a convenience strategy, where the sample may include more active or healthier older adults, although participants with disabilities, older men and English-speaking older adults were specifically recruited. Older adults with different social participation needs, including men and ethnic minorities, might be underrepresented, as well as people living in rural versus small urban areas. As with other qualitative studies, the findings of this study are time- and context-sensitive and influenced by the researchers. Despite using various strategies (no “correct answers”, confidentiality assured and homogenous groups), the nature of the questions could also have been subject to a social desirability bias and limited the sharing of facilitators, barriers and needs. Lastly, the study involved only one RCM and needs to be reproduced in other areas.