Social participation is critical to seniors’ health

Social participation, which refers to any activity that encourages human interaction, helps older adults improve their health and quality of life.

Mélanie Levasseur, erg., Ph.D.

Summary: Essential for promoting health, including mental health, and preventing disabilities, social participation is nevertheless restricted for approximately half of elderly Quebecers. Although generally targeted by health professionals including nurses, few effective interventions truly promoting social participation reach vulnerable populations and are implemented in Quebec. Prior studies have shown the feasibility and positive effects of promising and complementary interventions including personalized citizen support for community integration (APIC; individual intervention for participation in the community with volunteers) and inclusive environments (population intervention on policies, services and structures and including breaking with ageism). Optimized and implemented across Quebec, these interventions represent one of the most promising ways to support current social participation practices and allow seniors to age better, while remaining healthy for longer.


The aging of the Quebec population is one of the most important challenges requiring innovative and effective interventions on the determinants of health and involving the contribution of all health professionals, including nurses. Defined by a person's involvement in activities that provide interactions with others (Levasseur et al., 2010) in the community, in community life and in shared and important environments, in an evolving manner, according to the available time and depending on what is desired and meaningful for them (Levasseur et al., 2021), social participation is modifiable (Abu-Rayya, 2006) and constitutes an important determinant of active and healthy aging. Better social participation is associated with several positive health outcomes (Bath and Deeg, 2005) including greater functional independence (Levasseur et al., 2011), increased life satisfaction (Levasseur et al., 2008), shorter hospital stays (Newall et al., 2015) and a reduction in the risk of morbidity (Berkman et al., 2000) and even mortality (Nyqvist et al., 2014). Thus influencing mental health, that is, a state of well-being in which a person can realize themselves, overcome the normal stresses of life, carry out productive work and contribute to the life of their community (World Organization of Health [WHO], 2001), social participation is facilitated when the capabilities of the person and their environment are optimized (Fougeyrollas et al., 1998). In the presence of good adaptation skills or an accessible environment that encourages interactions, social participation is increased and the person is more integrated into their community, exercises their power to act, enjoys respect and esteem. others and maintains supportive and affectionate relationships (Maier and Klumb, 2005).

In order to improve the social participation of seniors, it is important to intervene along a continuum of interventions including both a population perspective, by creating favorable and inclusive environments for seniors in general, and an individual perspective, by offering seniors losing their autonomy personalized support that considers their social and functional needs. This continuum thus targets all seniors, from the general population to those at risk or with disabilities.

From a population perspective, it is important to act both at the level of individuals and their environments (Government of Quebec, 2008) and to better understand the influence of key components, that is to say policies, services and structures, including accessibility to resources, opportunities for social participation, community support and the level of material and social deprivation of neighborhoods (Levasseur et al., 2012a). Seniors living in inclusive environments are more likely to participate socially within their community, including in rural areas (Clément et al., 2018). The health and social participation of seniors are also mitigated by ageism, that is to say stereotypes (thoughts), prejudices (feelings) and discrimination (actions) according to implicit or explicit age, whether whether directed towards oneself, between people or from institutions (World Health Organization, 2021). These limitations have consequences for both individuals and the community and are present in our society, especially during the pandemic (Fraser et al., 2020). To better guide policies, services and structures to reduce inequalities and improve the health and well-being of aging populations (WHO, 2007), it is important to promote mutual support and the creation of inclusive environments. and favorable to social participation, that is to say adapted to the abilities and needs of seniors.

To optimize individual interventions, considerable efforts have been made to consolidate the integrated network of services for the prevention of loss of autonomy (Beland et al., 2006; Hébert, 2004) and promote coordination between the different health care establishments. health and community. These efforts have contributed to improving accessibility and satisfaction with services (Beland et al., 2006), allowing seniors experiencing significant loss of autonomy to have better satisfaction of their needs (Dubuc et al. ., 2011). However, interventions by health professionals mainly focus on everyday activities and, rarely, on social and leisure activities (Levasseur et al., 2014; Turcotte et al., 2015). Furthermore, the continuity of services presents certain gaps, notably for long-term monitoring and for the use of community resources (Nikolova et al., 2011). However, community organizations offer a wide range of complementary services and activities and have the mission, among other things, to encourage social contacts and break the situations of isolation of seniors losing their autonomy. In order to meet the social and functional needs of elderly people losing their autonomy, personalized support, that is to say which recognizes each elderly person as a unique and complete person (Office des Personnes Disabilities du Québec, 2009) in a specific social context, must be privileged. Personalized support which allows interventions to be adapted to the individual, in a precise and preventive manner, has shown its effectiveness and would make it possible to optimize interventions to meet the social and functional needs of seniors (Restall et al., 2003 ). According to a systematic review of social participation interventions (Raymond et al., 2013), Personalized Citizen Support for Community Integration (APIC; Appendix 1) is the only personalized and partnership support intervention to promote social participation. people with reduced functional autonomy. Currently mainly available as part of research projects, APIC consists of a three-hour weekly follow-up carried out by a non-professional support person who is paid, trained and supervised. During personalized follow-up, the support worker encourages the person to carry out social participation activities that are meaningful, but difficult for them. This enhancement of friendly visits, an intervention currently offered to many seniors in Quebec, makes it possible to complete and extend the interventions of health professionals which are, most often, temporary and mainly focused on independence in daily activities and home security, and which only partially meet the social participation needs of people losing their autonomy. Successfully tested in Quebec, APIC was initially developed with adults who had suffered traumatic brain injury (TBI). Since there are significant similarities between the needs of people with TBI (Lefebvre and Levert, 2012) and elderly people losing their autonomy (Levasseur et al., 2014; Turcotte et al., 2015), the APIC needed to be adapted and tested with seniors (Levasseur et al., 2016), including those with mental health disorders (Aubin, 2018) to verify its effectiveness (Levasseur et al., 2018).

In short, based on current knowledge, it is important to develop, evaluate and implement a continuum of interventions promoting the social participation of seniors, from a population and individual perspective. Thus, in the presence of inclusive environments (Pellerito, 2006), APIC could significantly reduce health system costs (Levasseur et al., 2007), optimize the life trajectory as a determinant of active aging and satisfying and add quality to the final years of life. Finally, by equipping seniors with their health and social participation, it could also promote optimal use of private and community resources already available. Research must therefore continue the development and evaluation of a continuum of innovative health interventions and approaches complementary to the integrated network of services for the prevention of loss of autonomy and developed to meet social and functional needs, often complex and evolving, of the elderly.


From clinical experiences in community and public health settings, studies on the importance of social participation activities for the quality of life of seniors, large-scale epidemiological research using geomatics, training in health promotion seniors and networking with emerging teams working on inclusive environments including ageism, a continuum of social participation interventions for seniors has been developed. Of this continuum, two components will be presented here: APIC, an individual intervention, and inclusive environments, a population intervention.

Part 1. Personalized citizen support for community integration (APIC)

The work of our team made it possible to adapt the APIC to seniors losing their autonomy, to explore its feasibility, its effects and to document its implementation within a caring community in a rural environment, i.e. -say a place where they feel welcome, respected and cared for (Nguyen and Levasseur, Submitted for publication). When implemented by paid guides, APIC is feasible (Levasseur et al., nd; Piché et al., 2019) and makes it possible to increase mobility, social participation, leisure and travel space. seniors experiencing loss of functional autonomy (Levasseur et al., 2016). Twelve months after the end of the intervention, their overall quality of life and its dimension linked to health and functioning had also improved and their movement area had been maintained (Gagnon and Levasseur, nd; Pigeon et al. , 2019). When adapted and tested with seniors with visual impairment, APIC improves their social participation, leisure activities and quality of life (Pigeon et al., 2020). An adaptation of this intervention was carried out with elderly immigrants (Cherif et al., 2021). Implemented within a caring community in a rural environment and offered by citizen volunteers, the APIC is not only prioritized by partners (Clément et al. 2018), but has benefits for social participation, access to transportation, well-being and empowerment of seniors (Lacerte et al., 2021). An ongoing randomized clinical trial will assess the cost-utility and effects of APIC on health, social participation, life satisfaction and use of health and support services at home for seniors losing their autonomy in two metropolitan regions and two urban regions of Quebec (Levasseur et al., 2018). The preliminary results of this component support that APIC has a positive effect on the mental health and life satisfaction of seniors (Gobeil et al., 2020). Technological adaptations (e.g.: electronic portfolio and website facilitating the monitoring of activities and the identification of resources respectively) and intergenerational adaptations (e.g.: support for pairing seniors with people from other generations) were also started during of the pandemic and are currently being pursued through action research (Levasseur et al., 2022) which will make it possible to generate significant commitment from the main stakeholders concerned and to plan social change, according to an iterative process. Currently established in five regions of Quebec, the APIC promotes increased integration of public services and optimal use of community resources, will ensure maintenance or improvement of the health and social participation of seniors and, ultimately, allow them to age better for longer.

Part 2. Inclusive environments

The work in this component has already made it possible to develop a Social Participation Potential Index and to better understand how environmental characteristics promote health and social participation. To continue this work, we are identifying the key components that best promote positive health, social participation and health equity and documenting the planning of an inclusive revitalization of a city center. According to our preliminary work, one in four older Canadians would like to participate more and there are inequalities in social participation according to gender and metropolitan, urban and rural environments, particularly linked to the availability of activities and transportation (Naud et al., 2019a ), but also to the friendliness of cities and neighborhoods as well as the welcome and openness of residents (Naud et al., 2019b). Proximity to resources, social support, transportation and neighborhood safety are also important for the mobility and social participation of seniors (Levasseur et al., 2012b). Secondary analyzes of the NuAge database showed that, even if the frequency of carrying out social activities is similar for seniors residing in metropolitan, urban and rural areas, the associated environmental factors differ (Levasseur et al., 2015). ). For all environments, more frequent social participation of seniors is associated with having a driving license and living close to resources. In metropolitan areas, the use of public transportation and a quality social network are, however, associated with more frequent social participation of seniors, while in rural areas, having children in the neighborhood and participating there living for twenty years or more matters (Levasseur et al., 2015). Increased environmental friendliness towards older Canadians is associated with metropolitan municipalities, a higher proportion of seniors, lower material deprivation and an advanced Age-Friendly Municipality approach (St-Pierre et al., 2022). The health, social participation and health equity of elderly Estriens would be positively influenced by nature, a range of varied activities, effective means of communication and measures promoting equity, in particular by facilitating accessibility and the equitable performance of important activities (Maclure et al., Submitted for publication). According to a case study carried out in St-Bruno-de-Montarville and Sainte-Julie, these two Quebec municipalities promoted active aging by ensuring proximity (e.g.: neighborhood networks and resources and active listening to the needs of seniors) and transversality (e.g. intergenerational spaces and opportunities and unified and complementary policies; McNeil Gauthier et al., nd). In the presence of a good sense of belonging to the community, the resilience (i.e. the ability to cope with adversity (Campbell-Sills and Stein, 2007)) of elderly Estriens has an increased influence on their social participation (Levasseur et al., 2017). When resources are limited, social participation is less frequent among older Quebecers regardless of their abilities, but it increases when the resources and capabilities of older Quebecers increase (Levasseur et al. 2011). Work on this aspect is continuing to better understand what explains why residents of five Estrie (Levasseur, 2020) and Canadian (Levasseur, 2022) municipalities had positive health, social participation, greater health equity and proportion of the variance in social participation of seniors is attributable to municipalities. To encourage the continued development of inclusive environments, action research is also underway with key players in planning an inclusive revitalization of a city center (Braverman et al., 2022). This component will improve knowledge on inclusive environments and allow seniors, as well as various stakeholders in the community, to be mobilized in the overall development of their environment, including in the optimization of favorable and inclusive municipalities or city centers. for everyone.


Currently not offered to seniors, the interventions in this research program, including APIC and inclusive environments, have a high potential for individual and societal benefits. Since this program is based on a major multidisciplinary partnership, the implemented interventions will optimize the connection between the public network and community resources. More specifically, by promoting increased integration of public services and optimal use of community resources, the APIC could enable a significant improvement in the social participation of seniors with disabilities and, ultimately, the maintenance or increase of their overall and also mental health. By guiding municipal decision-makers, action research projects will enable the creation of environments favorable to the social participation of seniors, in municipalities and city centers. Finally, thanks to the involvement of various health professionals including nurses, it will be possible to promote the health and social participation of elderly Quebecers in a different way. 

Appendix 1: Details of the Personalized Citizen Support for Community Integration (APIC) intervention

Personalized Citizen Support for Community Integration (APIC) is a “tailor-made” program of weekly and regular support (approximately 3 hours per week) by people from the community, trained in CBT issues and in an approach to personalized communication, and supervised by a professional speaker. The guides encourage each person to set goals that are important to them and to carry out their activities of daily living (ADL) and leisure activities so that they become as independent and satisfied as possible with their integration into the community and their social participation. To achieve this, she learns, with the help of the support person, to mobilize her personal resources and those of her environment. Preliminary results from the original project after one year indicate that participants are more satisfied in terms of managing their ADLs and leisure activities. They say they are more positive about life, reflect constructively on their own life project and feel an improvement in their psychological well-being while their loved ones feel more supported in their role as caregiver. The preliminary results also tend to show the maintenance of these achievements over time. A second project is underway to evaluate the longer-term effects of APIC with initial moderate to severe TBI participants and to pilot it with adults (18 years and over) with mild TBI with persistent after-effects six months post-trauma. Some participants are aged 65 and over. The preliminary results of this ongoing project will serve as an anchor for the initial adaptation of the APIC for clients aged 65 and over who are losing their autonomy. This adaptation will be continued and documented throughout the proposed study, based on the specific needs of this clientele. The intervention is focused on specific needs, draws on the strengths and skills of people according to their life context, and requires that the support staff listen to their needs and what they are experiencing. APIC offers personalized support focused on objectives and a project for which the person is motivated. Thus, APIC recognizes the person as a competent actor in context and promotes their self-determination and autonomy. Depending on the needs of the people, some may require more sustained support while others will choose lighter support, that is to say over a shorter period of time or at a less intensive pace.

Companion training: The original APIC training is five days and includes two days of theoretical courses on head trauma and its physical, psychological, communication and social effects; one day of participation in interventions at home or in the community with an occupational therapist, a specialized educator, a psychoeducator or a remedial teacher; and two days of participation in social activities offered by an organization involved with people with TBI. For the proposed study with elderly people losing their autonomy, this training will be adapted and will include specific theoretical courses on aging and the promotion of the functional autonomy of elderly people as well as participation in social activities offered by community organizations aimed at keeping older people in the community. During the intervention, the guides write a weekly logbook in order to record the activities carried out according to the objective of the person being supported, the difficulties encountered, the impressions, etc. The logbook allows the Management and Partnership Committee (CGP) to supervise the support person and document the impact of the APIC.



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