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Social network and its effect on selected dimension of health and quality of life among community dwelling urban and rural geriatric population in India

Open AccessPublished:June 02, 2022DOI:https://doi.org/10.1016/j.cegh.2022.101083

      Abstract

      Background

      As the age increases, elderly people experiences more changes in physical, mental and social well-being. Quick growth of the elderly in India draws into consideration of the factors that are contributing to their altering health realities. Social isolation is one of the major risk factor affecting the health particularly in elderly.

      Methods

      A cross sectional study was conducted with 1000 older adults aged ≥60 years, using multistage systematic sampling technique, in a selected urban and rural block. Individual's interviewed with standard questionnaire. Data was entered in excel and analyzed using SPSS software version 20.

      Results

      Among the participants, 36.4% were men and 63.6% were women with the mean age 64 years. Majority of them were in the age group of 60–69 (65.6%). Participants those with good social network is only 29.9% remaining 70.1% were having poor social network. In rural setting illiterate were socially connected (p = 0.001) whereas in urban setting literate elderly were more socially connected (p = 0.0001). Multiple regression analysis showed that depression, stress, severe cognitive impairment, poor health status, and poor quality of life are tend to be significant in poor social network (p = 0.0001).

      Conclusion

      Most of the elderly are at risk of isolation. Elderly with poor social network are negatively associated with selected dimension of health and quality of life. Health care intervention programs by public health services need to focus on protecting social health of elderly. Alignment of health system to the needs of elderly will definitely promote health and graceful ageing.

      Keywords

      1. Introduction

      Ageing is one of the common global phenomena. As the science gets advanced, longevity of human life span increasing. This extra years lived by the elderly should be meaningful, healthy and dignified. Impaired physical functioning in old age increasing the dependency on others.
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      Geriatric Depression Scale (GDS): recent evidence and development of a shorter version.
      However, there has hardly been any study in India that has looked at the effects of social networks with dimensions of health and quality of life among elderly. Present study aims at assessing the social networks and its effect on selected dimension of health and quality of life, among elderly living in urban and rural setting.

      2. Methodology

      A cross sectional study was conducted with 1000 elderly individuals from the period of August 2021–January 2022. After obtaining clearance from Institutional Ethics Committee, elderly included in the study were debriefed about the nature of the research, their role in the study, and were educated about the research purpose and obtained informed consent.

      2.1 Participants

      Elderly ≥60 years, and who had no hearing loss and were able to communicate effectively and who had there residence for atleast 1 year, were included for the study. People aged above 60 years but not willing to participate and who were not available even after three visits, bed bound elderly people were excluded from the study. The participants were interviewed individually.

      2.2 Sampling technique

      Using Multistage Systematic random sampling method, based on assumption of 50% presence of social networks in the population, 5% precision, and 20% non-respondent rate, sample size was calculated as 500. Each 500 from Rural and Urban, total 1000 elderly were selected for the study. For rural sample, under Kattankulathur block, among the 3 Primary Health Centers, 1 Primary Health Center was randomly selected using lottery method, the selected PHC covering villages and its population were enlisted, then PPS was done to select samples in each village and every 5th household was selected systematically till the sample size achieved. For urban sample, under Tambaram block among 3 urban PHC, 1 urban Primary Health Center was randomly selected using lottery method, the selected urban PHC covering town panchayat and its population were enlisted, then PPS was done to select samples in each town panchayat and every 8th household was selected systematically till the sample size achieved.

      2.3 Study tool

      Socio demographic characteristics: The socio-demographic questionnaire was developed to assess the demographic characteristics of participants, such as age, gender, education, marital status, occupation, income etc.
      Lubben Social Network Scale (LSNS) was developed by Lubben and Gironda (2004), it consist of 18 items which help to assess the nature of the relationship with friends, relatives and neighbours. This scale was validated in India, it evaluates social isolation by quantifying frequencies of social contact with friends, neighbours and family members, and perceived social support. The scores for each LSNS item range from 0 to 5, with lower scores indicating smaller networks. Total scores are an equally weighted sum of the 18 items, ranging from 0 to 90. For LSNS-6 cut off 12, for LSNS-18 cut of score 36. High scores indicate strong social networks. The instrument was translated to local language, for the present study.

      2.4 Physical dimension

      Assessment of functional ability using ADL Questionnaire (Kartz Index) which includes six functioning-Bathing, Toileting, Dressing, Transferring, Feeding, Continence, and Homemaking.
      Self-Assessment of Overall Health, Self-Reported Morbidity verified from previous medical records, Healthy Behaviour assessment includes Smoking, Alcohol Consumption, Tobacco usage and sleep pattern and General physical examination which includes Anthropometry measurements, Blood Pressure, Random blood sugar and haemoglobin level.

      2.5 Mental dimension

      Mini-Mental Scale Examination (MMSE) was used to evaluate cognitive impairment. Scoring 24 and below indicates cognitive impairment. Geriatric depression scale 15 (GDS short version) was used to assess the depression. A score >5 suggests mild, and ≥10 is severe depression.
      • Sheikh Jay J.I.
      Geriatric Depression Scale (GDS): recent evidence and development of a shorter version.

      2.6 Vocational dimension

      Semi-structured questionnaire to assess leisure time activity includes Voluntary work, Cultural activity.
      Reading book, Shopping, Gardening, Hobbies, Watching television.

      2.7 Quality of life

      Older people quality of life (OPQOL) questionnaire to assess the quality of life. Each of the 13 items is scored strongly agree = 1, Agree = 2, neither = 3, Disagree = 4, strongly disagree = 5. The items are summed for a total OPQOL-Brief score, then positive items are reverse coded, so that higher scores represented higher QOL. Score below 33 (very bad), score 33–50 (bad), score 51–55 (alright), score 56–59 (good), and score 60–65 (very good).

      2.8 Statistical analyses

      All the responses were coded and entered into excel. Descriptive statistics and inferential analysis was done to observe baseline differences in both the groups and chi-square test done for categorical variables, Odds Ratio was calculated to predict the risk factor and multiple linear regression analysis adjusted for sex, age, education, comorbidities was done to observe the independent predictors and to know the interactive effect of social network with GDS score, MMSE score, stress score, ADL score. All statistical analysis were performed with Statistical Packages for Social Sciences (SPSS) version 21.

      3. Results

      Total thousand elderly populations were included in the study; among them 43.1% were men and 56.9% were women with the mean age 64 years (see Table 1). Most of the elderly were married (73%). Majority of the elderly were illiterate (40.9%). Hindus (61.2%) were predominant in the study population. Most of the elderly were residing with their children (55.8%) followed by with spouse (21.5%) and living alone (20.4%). Private health care utilization is seems to be higher in urban elderly (72.8%) then rural elderly (46%). Other demographical details for the participants were presented in the table: 1. Among the total participants those with decent social network is only 29.9% remaining 70.1% were having poor social network. Social network classified as three main domain family, friends and neighbor social network, among this more family (35.2%), friends (29%) and neighbours (32.2%) network is seen in rural, whereas in urban family, friends and neighbours network was 17.4%, 19.8%, 18% respectively (Table 2). Elderly with ADL dependence (OR-5.32), moderate (OR-9.18) and high stress (OR-19.75), severe cognitive impairment (OR-12.42), very bad quality of life (OR-18.75), living alone (OR-8.97) and poor health status (OR-3.67) had higher risk of poor networking than others (Table 3).
      Table 1Distribution of baseline characteristic stratified by region.
      CharacteristicsUrban (n = 500)Rural (n = 500)Total (n = 1000)
      Sex
      Male207(41.4%)224(44.8%)431(43.1%)
      Female293(58.6%)276(55.2%)569(56.9%)
      Age
      60–69383 (76.6%)243 (48.6%)626(65.6%)
      70–7988(17.6%)200 (40%)288(28.8%)
      80 & Above29(5.8%)57 (11.4%)86(8.6%)
      Marital status
      Married375(75%)355(71%)730(73%)
      Unmarried30(6%)9(1.8%)39(3.9%)
      Widow93(18.6%)107(21.4%)200(20%)
      Widower2(0.4%)29(5.8%)31(3.1%)
      Education
      Illiterate91 (18.2%)318 (63.6%)409(40.9%)
      Primary school166(33.2%)94(18.8%)260(26%)
      Middle school124(24.8%)58(11.6%)182(18.2%)
      Secondary & Higher secondary81(16.2%)10(2%)91(9.1%)
      Graduate38(7.6%)20(4%)58(5.8%)
      Religion
      Hindu284(56.8%)326(65.2%)612(61.2%)
      Christian167(33.4%)148(29.6%)315(31.5%)
      Muslim54(10.8%)19(3.8%)73(7.3%)
      Economic Dependency
      Independent193(38.6%)274(54.8%)467(46.7%)
      Dependent307(61.4%)226(45.2%)533(53.3%)
      Living Arrangement
      Alone117(23.4%)87(17.4%)204(20.4%)
      With spouse102(20.4%)113(22.6%)215(21.5%)
      With children270(54%)285(57%)558(55.8%)
      With Relatives11(2.2%)15(3%)26(2.6%)
      Utilization of health care services
      PHC53(10.6%)183(36.6%)236(23.6%)
      CHC21(4.2%)43(8.6%)64(6.4%)
      Tertiary62(12.4%)44(8.8%)106(10.6%)
      Private364(72.8%)230(46%)594(59.4%)
      Table 2Distribution of social network pattern in regions.
      Social NetworkUrban (N = 500)Rural (N = 500)Total (n = 1000)Chi-Square, df, p-value
      Poor social Network382(76.2%)319(63.8%)701(70.1%)18.936, df-1,p > 0.0001
      Decent social Network118(23.6%)181(36.2%)299(29.9%)
      Family Network
      Poor social Network413(82.6%)324(64.8%)737(73.7%)22.515, df-1,p > 0.0001
      Decent social network104(20.8%)176(35.2%)263(26.3%)
      Friends Network
      Poor social Network401(80.2%)355(71%)756(75.6%)12.009, df-1,p > 0.001
      Decent social network99(19.8%)145(29%)244(24.4%)
      Neighbours Network
      Poor social Network410(80.2%)339(67.8%)749(74.9%)26.814,df-1,p > 0.0001
      Decent social network90(18%)161(32.2%)251(25.1%)
      Table 3Odds Ratio for selected variable with social network.
      VariablesSocial Network (N = 1000)
      Decent

      Social network (n = 299)
      Poor

      Social network (n = 701)
      ORCI (95%)P-value
      ADL
      Independent260(13.5%)53753.7%)1
      Partially dependent72(7.2%)98(9.8%)1.4370.94–2.190.09
      Dependent06(0.6%)66(6.6%)5.3252.279–12.445<0.0001
      Depression
      Present34(3.4%)545(54.5%)0.03670.024–0.054<0.0001
      Absent265(26.5%)156(15.6%)1
      Stress
      Low stress126(12.6%)39(3.9%)1
      Moderate stress121(12.1%)344(34.4%)9.18506.067–13.9042<0.0001
      High stress52(5.2%)318(31.8%)19.7512.4274–31.410<0.0001
      MMSE
      Severe06(0.6%)138(13.8%)12.6016.656–23.87<0.0001
      Mild59(5.9%)139(13.9%)3.1542.217–4.486<0.0001
      No impairment201(20.1%)132(13.2%)1
      Quality of life(OPQOL)
      Good225(22.5%)168(16.8%)1
      Alright18(1.8%)171(17.1%)12.7237.525–21.5120.001
      Bad26(2.6%)288(28.8%)14.83529.474–23.2280.0001
      Very bad28(2.8%)2(0.2%)18.7504.405–79.8070.0001
      Living Arrangement
      With children221(22.1%)334(33.4%)1
      Alone14(1.4%)190(19%)8.9795.084–15.8590.0001
      With spouse59(5.9%)156(15.6%)1.7491.239–2.4680.001
      With relatives5(0.5%)21(2.1%)2.771.032–7.4790.04
      Health Status
      Good172(17.2%)206(20.6%)1
      Fair107(10.7%)407(40.7%)3.1752.367–4.2600.001
      Poor20(2%)88(8.8%)3.6732.171–6.2160.0001
      The networking state was selected as the study's dependent variable. On request, the variables that were statistically significant in univariate analyses and were associated with social networking were included into multivariate analyses. The final multivariate logistic regression model's findings are shown in Table 4. Poor quality of life, depression, cognitive impairment, stress, and leisure activity are all factors linked to the development of poor networking in the elderly population. On the other hand, positive aspect of maintaining good social network will able to cope up with depression and stress, helps to delay the onset of dementia, make elderly involve in various physically active leisure activity and it shows significant (p < 0.0001).
      Table 4Multiple Linear regression of independent predictors of social network.
      Health AttributesEstimate (Beta)P value
      QOL Bad−0.0120.01*
      QOL Good0.9810.84
      QOL Very bad−0.22811
      QOL Very good0.5540.45
      No cognitive impairment0.4200.78
      Severe cognitive impairment0.130.03*
      Depression Present−0.5360.001*
      Low Stress0.1560.11
      Moderate Stress0.2420.001*
      Perceived Health status- Good0.0070.88
      Perceived Health status- Poor0.0060.93
      ADL Independent0.0930.34
      ADL Partially dependent0.0040.96
      Leisure Activity-gardening0.0020.98
      Leisure Activity-hobbies0.4130.52
      Leisure Activity-No0.0260.03*
      Leisure Activity -Reading book0.3650.05
      Leisure Activity –Shopping−0.1830.18
      Leisure Activity-Voluntary Activity0.5010.12
      Leisure Activity-Watching tv−0.2380.01*

      4. Discussion

      We found the extent of social networks and its relation between physical, mental, vocational dimension and quality of life. The importance of social connectedness has been honored since antiquity. Still, not all individuals are equally capable of developing and maintaining friendships and social ties. Our study found out that most of the senior who reside in a rural and urban settings were under the threat of getting isolated. Our results revealed that social isolation was strongly associated with physical, mental and cognitive health. The family network, friends network and neighbours network are high among rural when compared to urban. Former studies states that Alzheimer's diseases could be directly related to the size of the social network, seems more likely that social network size can act as a reserve capacity capable of reducing the chances of developing the disease pathology, which will be clinically expressed as cognitive impairment.
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      When stratified by Living arrangement, our study found a significant relationship with poor social network in elderly individuals living alone than those living with family. This in agreement with the study by Saito, Fujiwara, et al. (2010), they measured the prevalence of social isolation and assessed the frequency of interaction with people other than family members in Japan, was 24.1% for those living alone and 28.7% for those living with family. They measured only the frequency of contact with people other than family members living together. But, in our study, we also considered contact with family members who were living together.
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      Perhaps this inconsistency is due to the differences in study population. In the above study, the Lubben social network tool (10 questions) was used, but we used the Lubben social network tool (18 questions), which was more comprehensive, and probing further dimensions regarding elderlies’ social network.
      In another study by Heidary et al. the relationship between social support and size of social network with the life quality of person's affected with cancer was explored.
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      But in the present study, the importance of social network in all aspect was elucidated, however family network is found to be more, hence the results can be considered as analogous and this can also correlated with the aspect of having great role of family in our country and culture.
      A previous study using the LSNS-6 by Iliffe et al. reported that there is a relationship between social isolation and depression, and this is in agreement with our findings.
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      • Fratiglioni L.
      Mental, physical and social components in leisure activities equally contribute to decrease dementia risk.
      Leisure activities mainly includes physical, mental and social component. In our study we found that most of the elderly were involved in very less leisure activities. Most of the elderly in our study are reported to have the habit of watching tv as their leisure activity and it is predicted that this habitual will decreases if social network is improved (p < 0.001). Behavioral change education is needed for elderly and it is essential to make involve them in a variety of social, physical and cultural activities to reduce the risk of isolation and to promote healthy ageing.
      For instance, in the Indian context family provide instrumental support and emotional support to the older adults. Only a few studies have recognized the growing importance of friends on older adult's health and well-being.
      • S T.
      Household Context, Social Capital and Wellbeing of Older Adults in India.
      Few studies argue that older adults who have friends network will help them to improve well-being through different ways like sharing health information, mutual assistance, economic and emotional support, this help them to deal with distress related to age and sickness.
      • Webster N.J.
      • Antonucci T.C.
      • Ajrouch K.J.
      • Abdulrahim S.
      Social networks and health among older adults in Lebanon: the mediating role of support and trust.
      • Berkman L.F.
      • Glass T.
      • Brissette I.
      • Seeman T.E.
      From social integration to health: durkheim in the new millennium.
      • Kawachi I.
      • Kennedy B.P.
      • Glass R.
      Social capital and self-rated health: a contextual analysis.
      For greater understanding about the factors related to social isolation is likely to provide public health professionals with multiple opportunities for developing effective and targeted interventions.
      • Nicholson N.R.
      A review of social isolation: an important but underassessed condition in older adults.
      Thus, to provide support for preventing social isolation in community-dwelling elderly people regardless of household composition, it is important to maintain and promote mental health, to deepen relationships with old friends, and to provide support through social or cultural activities. Moreover this finding appear to reflect changing perception of traditional Indian family structure and life. . Furthermore, some of the current pressing social issues in the country like, the elevated prevalence of depression and a suicidal rate among elders may be contributed by the prevalence of relatively restricted social relations.
      • Conwell Y.
      • Van Orden K.
      • Caine E.D.
      Suicide in older adults.
      Multiple studies constantly noted that one of the leading factor for suicide among older adult and high level of depression is high level of isolation.
      • Park S.
      • Smith J.
      • Dunkle R.E.
      Social network types and well-being among South Korean older adults.
      The present study shows that although the elderly live with children, they are vulnerable due to their having few friends. Our findings suggest that this validated lubben social network scale help us to identify at-risk older people and help us to guide the design and implementation of service programs for this vulnerable group. The understanding of association between social network and health dimension possibly will encourage programs especially designed for older adults to enhance healthy ageing, with focus on bridging social capital so that it can break the vicious cycle between poor health condition and social isolation.
      • Pillai J.A.
      • Verghese J.
      Social networks and their role in preventing dementia.
      Further research studies are needed to identify the older adults at risk of isolation and to generate a database for effective policymaking and planning for interventions. Longitudinal observation study is needed to know how social network impact on overall health of the elderly. A better understanding of age related issues and changing trends helps in making a progress on Healthy Ageing.

      4.1 Limitation

      Only quantity of the network is assessed, not the quality of the network. Majority of the population in our study was women in both the groups due to their availability on data collection time. Several factors and circumstances may cause social disconnectedness, in this study we did not considered the reason for social disconnectedness.

      5. Conclusion

      We found that poor social network as a social risk factor for adverse health outcome among older adults. Living alone, with poor social network also contribute adverse health outcome. Maintaining decent social network among elderly person is positively associated with selected dimension of health and quality of life. Government can play enormous role in maintaining social ties, it will be beneficial if public health services implement health care intervention programs by strengthening the social network of elderly. Social relationship– based interventions provides opportunity to enhance not only the quality of life but also survival. We also suggest that there should be more innovative approach to strengthen the social network of adults and more social network recreational centers for older adults, so that they can interact with friends within the community or between communities and participate in group activities.

      Funding

      No external funding was received for this study.

      Declaration of competing interest

      The authors declare that they have no competing interests.

      Acknowledgements

      We would like to sincerely thank all the participants in this study for actively volunteering to undergo the survey.

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