The World Health Organization (WHO) has defined social determinants of health (SDoHs) as non-medical factors that influence health outcomes and healthy inequity and include the conditions in which people are born, grow, work, live, and age, as well as the wider set of forces and systems that shape the conditions of daily life.Footnote 1 The latter forces and systems are the economic policies and systems, development agendas, social norms, social policies, and political systems. Thus, this is a very broad list of various SDoHs. Growing evidence has shown that the SDoHs have a greater impact on health and longevity than traditionally considered medical risk factors such as hypertension, diabetes, smoking, and substance use. Some SDoHs are important across the lifespan and for people with different types of health problems, for example, early life adversities, social connections, access to healthy environment, and positive factors like resilient or compassionate communities, that apply to nearly all the people. However, certain specific social factors may be more relevant for specific groups of people or for specific groups of conditions. In recent years, there has been growing interest in social determinants of mental health for people with psychiatric illnesses (Jeste and Pender, Reference Jeste and Pender2022). Similarly, while perinatal issues have greater impact in early life, ageism would affect the health of older adults more than that of the youth.
This issue of the International Psychogeriatrics brings together six articles – five data-based studies and a literature review – along with six respective Commentaries, on SDoHs in older adults. These cover divergent SDoHs – viz., ageism, awareness of age-related changes (AARC), social isolation due to the COVID-19 pandemic, receipt of social support services, health of caregivers, and economic considerations. While the factors other than ageism may not be unique to older people, their specific application to older adults may be different from that in younger people. These articles also focus on several nuances of those constructs that were not adequately addressed in the past.
Ageism is widespread, and its adverse effects on health are well documented. Ayalon and Cohn-Schwartz (Reference Ayalon and Cohn-Schwartz2022) studied the relevance of culture and group membership in the understanding of the experiences of ageism in three groups of Israeli nationals: Veteran Israelis (majority community) and two minority groups (Israeli Arabs and immigrants from the former Soviet Union). Being older was related to better self-perceptions of aging (SPA) in Israeli Arabs, but worse SPA in immigrants. As they got older, the immigrants were more likely to report ageist experiences. Israeli Arabs reported higher levels of ageist experiences, regardless of their age. The authors correctly suggest that certain population groups require education about aging processes and also further protection from the experiences of ageism. These findings are not restricted to any one country or region and are generalizable to other parts of the world.
A uniquely disturbing aspect of ageism is that its underlying assumption of an inevitable functional decline with aging is generally accepted by many older people themselves, primarily because this perspective is ingrained in everyone from very early childhood. It reflects on the expectation and perception of changes that occur with aging. Sabatini et al. (Reference Sabatini2022) assessed AARC in 609 UK individuals over 50 years of age. Several categories were consistent with conventionally held negative conceptual framework of AARC (e.g. experiencing worsening of functioning and attitudes toward aging), but others were positive (e.g. engagement in purposeful activities or in activities that distract from age-related negative thoughts). As the authors point out, these findings suggest ways in which the prevalent theoretical conceptualization of AARC can be modified, thereby seeking to reduce societal ageism and contributing to better health of older people.
Older adults are among the most vulnerable groups affected by the COVID-19 pandemic. Giebel et al. (Reference Giebel, Ivan, Burger and Ddumba2022) sought to explore the impact of COVID-19-related public health restrictions on the lives of 30 older adults living in Uganda, who were interviewed over the phone. COVID-19-related public health restrictions had severe impacts on their lives, with many people not even having sufficient food to eat, due to poverty. Overall avoidance of transportation also resulted in a lack of access to healthcare services and difficulty in getting food. Public health restrictions not only had a severe impact on older adults but also on the entire families in Uganda. This clearly highlights the critical role of government policies in providing support to socioeconomically disadvantaged people to get basic necessities like nutrition in order to survive let alone stay healthy.
Cheung et al. (Reference Cheung, Chai, Troya and Luo2022) investigated self-harm among older adults with physical illness and functional impairment, who receive support services in New Zealand, using a national dataset. The overall incidence of nonfatal self-harm was 160 per 100,000 person years. Depression, alcohol use, and bipolar disorder were the most significant risk factors. We hope that these results can be used to inform healthcare professionals for identifying people at high risk of self-harm and for developing effective and pragmatic prevention and intervention strategies among older adults with disabilities, who receive social support services.
It is almost universally recognized that the health of older people with dementia is significantly dependent on the health and well-being of their caregivers, a large majority of whom are the patients’ family members. Therefore, an important goal in geriatric healthcare is to provide care to the carers. Sadavoy et al. (Reference Sadavoy, Sajedinejad and Chiu2022) examined the effect of the Reitman Centre CARERS program on family caregivers (spouses or children) of people with dementia in Canada. This was a group psychotherapeutic skills training intervention based on integrated problem-solving therapy, simulation learning, and group psychotherapy. The study found a significant improvement in caregivers’ stress, depression, burden, overload, mastery, coping, and reaction to memory issues. Such intervention strategies need to be an integral part of the healthcare of people with dementia.
Finally, national and regional policy making increasingly needs evidence for cost-effectiveness of different strategies to inform allocation of resources. Pelone et al. from UK (Reference Pelone, Jacklin, Francis and Purchase2022) reviewed economic evaluation studies published since 2003 on various types of interventions for supporting adult caregivers. The main types of strategies evaluated were psychological and emotional support, training, and education support interventions. The authors found that the cost-effective interventions were usually tailored to the specific caregivers’ circumstances and delivered face to face (rather than remotely), and were multicomponent, with elements of psycho-education, training, and psychological and practical support. The authors are right on the mark in concluding that, given the high socioeconomic impact of unpaid caregiving, future economics research should focus on programs for providing caregivers with support and advice to help them to enter, remain in, or return to paid work.
To conclude, this special issue of the International Psychogeriatrics presents a collection of diverse studies from across different continents that illustrate the vital role played by adverse SDoHs such as ageism, social isolation, and poverty as well as positive SDoHs like enhanced well-being of family caregivers. Expanding research, clinical care, education, and public policies related to the SDoHs is essential for enhancing the well-being of all the older adults in the world.
