What is the Seasonal Influenza Vaccination uptake in
elderly persons (?65 years) in Denmark who suffer from social isolation?
The uptake of influenza vaccination in older people marks
a simple act of proactive care. Jain et al. in 2017 published a systemic review
emphasising the association between social factors and the under utilization of
the Seasonal Influenza Vaccination (SIV) in Europe 1. The researchers
concluded that to deliver equitable healthcare; healthcare providers should
pursue targeted interventions to specific social groups at risk, including
individuals living alone (summary odds ratios (OR) = 1.39 (95% CI: 1.16-1.68)),
amongst other findings. Stating however, that it did not examine the effect of social
isolation on SIV uptake, this following study hopes to address that knowledge
gap using a mixed methodological approach.
Loneliness is a common experience, with as many as 40%
of adults >65 years reporting being lonely at least sometimes 2. There has
been a growing body of longitudinal evidence to suggest that loneliness is a
social risk factor for morbidity and mortality 3, 4. There is
also evidence to suggest that a lack of social relationships is associated with
a 50% increase in mortality, comparable to the increased risk from smoking or
obesity 5. This association between health and social relationships is well
documented and there is considerable evidence that the quality, and extent, of
an individual’s social network and frequency of contact with other persons has
a significant impact on various aspects of health 6, 7. A systemic review
published by Santini et al. looked at the association between depression and
social relationships, finding that social networks play a protective role with
According to the ‘World Population Prospects: the 2015
Revision’ the number of older person aged 60 or older, has substantially
increased in recent years in most countries and regions, and indeed that the
growth is projected to accelerate in the coming decades 9. Globally, the
number of older persons is growing faster than the number of people in any
other age group. By 2030, older persons are expected to account for more than
25% of the population in Europe and North America.
The process of aging sees many individuals adapting to
progressively changing personal circumstances such as functional health losses,
bereavements and relocation. Evolving changes can lead one to experience social
isolation and loneliness as one modifies or even has to surrender life-long
activities that previously provided meaningful social engagements. It is now
recognized that the negative health impacts associated are a global health
concern, particularly for developed countries 10.
The terms ‘loneliness’, ‘social isolation’ and ‘living
alone’ are frequently used interchangeably in literature, however they are three
‘Living alone’ is perhaps the easiest to define and
can be measured objectively. As mentioned above, there is evidence to suggest
those living alone are at increased risk of not utilising the SIV (OR = 1.36)
1. A 2015 meta-analysis found that those living alone were associated with a
32% higher mortality (OR 1.32, 95% CL 1.14-1.53). This is increasingly relevant
in a global context given that in the European Union in 2013, 13% of households
consisted of individuals aged >65 years living alone 11.
‘Social isolation’ has been defined as ‘a deficiency
in social integration, and emotional isolation as a deficiency in intimacy and
attachments’ 12. There is a lack of uniform consensus however with this
definition, some studies have approached it as a one-dimensional concept,
defining social isolation as ‘the objective lack or paucity of social contacts
and interactions with family members, friends or the wider community’. There
exist other, multi-dimensional definitions that have incorporated the quality,
as well as the quantity of ones social relationships – treating loneliness
simply as a subjective component of social isolation 13. Generally, social
isolation is regarded as an objective state, where a person has a low level of
involvement in community life and minimal contact with other persons.
**Studies examining social isolation have found…** à Mention SI
‘Loneliness’ refers to how individuals evaluate their
quality and level of engagement and social contact. Loneliness is therefore
subjective, it is the feeling associated with the perception of being alone 14,
and it has also been suggested that it can be described as negatively perceived
social isolation 15. This is an important distinction to note, as individuals
can be lonely without being socially isolated, be socially isolated without feeling
lonely or experience both.
** Paper comparing loneliness to Social isolation in
terms of outcomes?**
Several gerotological theories exist focusing on the
social relationships of older people and trying to explain how aging impacts
them. Initially ‘Disengagement theory’ suggested by Cumming and Henry in 1961
argued that withdrawal or disengagement was a natural, unavoidable occurrence
of aging 16. This was largely debunked, by research asserting that
disengagement is often precipitated by life changes, making it more difficult
for older persons to stay socially active, and often leads to social isolation
and loneliness. ‘Activity theory’ formalised in 1961 suggested that elderly
people who maintained social contacts and participatory activity levels were
less likely to become lonely and withdraw from social networks, subsequent
debate ensued as to what types of activity were required 17. ‘Continuity
theory’ was proposed in 1968 (and further revised in 1989 by Atchley) 18,
suggested a life course perspective, with particular emphasis on the
significance of personality and how relationships from the past, present and
future were essential for coping with the aging process. Atchley noted that
while withdrawal was noted in aging people, essential aspects of personality
and activities undertaken in younger years were observed to be maintained 19.
‘Gerotranscendence theory’ proposed in 1997 by Tornstam applied a more positive
framework for social withdrawal. He suggested that as one grows older, wiser
and more mature, one develops a decrease in interest in materialism, decreased
interest in social interactions and an increase in solitary meditation 20.
Suggesting that if social contacts decrease in old age decrease, it may reflect
decreasing need and not necessarily imply loneliness.
Influenza is a major cause of morbidity and morality in the elderly 16.
It can offer up to 50% protection against infections, reduce hospital
admissions by 40% and deaths by up to 60% in the elderly 17. The influenza
uptake rate in Denmark between 2007-2015 is on average 50.5%, short of the 75%
target set by the WHO 18. This population was chosen for this study; as there
is free access to SIV for elderly persons, a good adherence record to SIV
uptake but which is short of WHO guidelines for persons aged >65 and to the
best knowledge of the researchers, no previous work undertaken exploring the
attitudes of health and well-being by elderly persons who are socially isolated
Given the deficits in the current knowledge base; this
paper aims to answer the following: What is the Seasonal Influenza Vaccination
uptake in elderly persons (?65 years) in Denmark who suffer from loneliness and
social isolation? What are the attitudes towards health and well-being of
elderly persons who are socially isolated or lonely in Denmark?
To determine what the SIV uptake is of lonely and socially
isolated elderly people (>65 years) living in Denmark.
social isolation in elderly people in Denmark and ascertain if there are any
influences affecting adoption of good quality health and wellbeing.
Assess the uptake of influenza vaccine in socially
isolated and lonely elderly people in Denmark.
By utilising a mixed methodology approach, this
methodological approach aims to first explore the perceptions and health behaviours
of elderly people in Denmark who are socially isolated and summarize the key
themes, using results to determine potential confounders for the quantitative
research and provide overall context, which may aid future research in this
area. To the best of the researchers knowledge there has been no previous research
in this area before.
Utilising a qualitative methodological approach, 10
participants aged over 65 years will be recruited from medical practices in
Denmark, 5 from a rural practice and 5 from an urban practice. The inclusion
criteria for selection include: Aged 65 or older, single or married, male or
female with social networks two or less persons and ‘limited meaningful
contact’ a week (defined as less than 2 hours total meaningful conversation)
and willingness to participate in the study following the process of informed
consent. The researchers aim to contact persons via local family physicians.
The sample population will be taken opportunistically
and is not intended to be statistically representative. Three interviews will
take place over a period of 1 year per participant; this will allow familiarity
and trust building to develop between the researcher and participant, essential
given the sensitive nature of the topics. As part of the research, there will
be 3 periods of participant observation that will be arranged between the
researcher and participant with the aim to both become more cultural immersed,
collect further data and provide perspective.
We plan to conduct semi-structured interviews and by
applying the framework of social constructivism we will ask participants semi-structured,
opened-ended questions in an attempt to fully and freely describe their own
perceptions and experiences. Researchers will apply symbolic interactionism to
represent a constructionist perspective, assuming that participants construct
themselves, society and reality through interaction with other persons. Researchers
will take field notes during and after interviews and participant observations
to summarize themes and trends that were noted.
The interviews will also be recorded and transcribed
in full. Lines from participant transcriptions, will be sequentially coded, to
identify commonly used descriptive words. By adopting this approach,
inter-related categories can be identified and sub-categories can be grouped
into major themes. Triangulating data between the semi-structured interviews,
field notes and participant observations will allow greater insight into the
health behaviours and perceptions of participants.
Denmark has a tax-funded state-run universal health
care system; with a long tradition of universality, comprehensive and an
egalitarian approach to welfare and health. Denmark provides free healthcare to
all residents, recommending the SIV to all persons aged ?65, where there is an
adoption rate of 50.5% 18. There is increasing concern from elderly persons,
due to the departmentalization of long-term care provisions in Denmark, people
are being enabled to stay in their own homes longer, without the care of the
Danish system, that it may lead to increased social isolation and loneliness
This study will be conducted by gathering rich data,
continually comparing codes, categories and performing critical reviews of the
analysis. It also involves an awareness of the researchers interactions and the
researchers reflexivity. The researchers readings of previous works may
influence ones own perception, or indeed their own academic background on the
interview process. Focusing strictly on engaging critically on the
understanding of the informant’s experiences and considerations will help
mitigate these pre-conceptions.
The framework utilised by researchers in the
qualitative aspect of the study focuses on the life course model and the value
of ‘continuity’ as described by Atchley 19. The conceptual framework model Figure
1 is based on the strive an individual has for continuity, relevant for the
changes one might experience in elderly life 20. As one grows older, with
personal losses and worsening health, one may experience discontinuity in
relation to corporeality, temporality and identity. Such processes initiate ‘recapturing
approaches’ in an attempt to prevent further discontinuity. This is an ongoing process that attempts to
produce ‘reconciliation’ with the new situations in the individuals life.