Good health can be described in many ways. Achieving and maintaining good health depends on a variety of factors stretching far beyond just the individual. Using a multilevel model of health affords us the ability to take a closer look at the dynamic relationship between all the influences on a person’s health and examine what drives the health of a population (Galea, 2015). The social ecological model of health is an example of a multilevel model of health. This model demonstrates the relationship between the individual, their social network and interpersonal relationships, the community to which they belong, and the physical, social and political environments (Kilanowski, 2017). These relationships are interconnected and dynamic and illustrate that health promotion plans must be comprehensive and hit several levels in order to have the desired impact on the health of a population.
During my career, I have spent a great deal of time assisting seniors to recover from falls and prevent future falls. I have also observed a number of seniors lose lose their independence as a result of falls and many never return to live independently. Each year falls directly cost the province of British Columbia $200 million. 30% of individuals over the age of 65 experience one fall per year and many individuals fall frequently (Canadian Institute for Health Information). The Canadian Institute for Health Information (CIHI) , reports that 137,568 injury hospitalizations in 2017-18 involved seniors and that 81% of these admissions were due to falls (2019). Of note, is that seniors hospitalized for a fall spend an average of 9 days longer in hospital then with any other reason for admission (Government of Canada, 2014). The Government of BC (n.d). website states “by 2031, close to 1.5 million British Columbians across the province will be over 65—almost a quarter of the province’s population.” Parachute, Canada’s national charity dedicated to injury prevention, reports that falls cause 95% of hip fractures and that 20% of seniors die within one year of a fall. Lee (2020) found that participation in physical activity significantly reduced the risk of falls. The quote below demonstrates the important impact that preventing falls by just 20% will have on our seniors in Canada.
Given that the reasons for falls are multi factorial, dynamic and interconnected and that physical activity reduces fall risk, let us take a closer look at how we can apply a social ecological framework of health to the complex issue of fall prevention, specifically keeping our seniors physically active within their communities. As demonstrated in Figure 1 by Zdemir (2013), the social ecological model can help us understand that aiming activity programs at individuals alone will not result in increased physical activity and that we must create social and physical environments that enable people to be active (Bornstein & Davis, 2014).
Figure 1
Note: A pictorial representation of the factors and environments that impact physical activity in communities.
INDIVIDUAL DETERMINANTS:
Gharaveis (2020) describes the things that impact physical activity at the individual level as genetics, overall health, demographics and attitudes towards physical activity. Not surprisingly Boulton (2017) noted that poor health and a lack of previous physical activity history were barriers to physical activity. Other intrapersonal factors that impact mobility limitations and lead to falls include age, gender, marital status, lifestyle factors such as smoking and obesity and the presence of chronic illness (Hye et. al., 2008). Interestingly, women have greater mobility limitations then men (Hye et. al, 2008). Another important intrapersonal characteristic was self-efficacy and the belief in oneself to engage in activity and healthy behaviors (Hye et. al., 2008).
SOCIAL AND INTERPERSONAL ENVIROMENT:
The interpersonal environment has been shown to increase physical activity and decrease functional decline among seniors. Hye et. al. (2008) discuss the positive impact of social networks and social participation on physical activity and the maintenance of functional abilities. In one study, it was noted that the friendships and relationships built at the exercise sessions became the reason people returned (Boulton et al., 2017). Expanding on this concept, another study noted group cohesion as an important factor on whether seniors returned to attend future classes (Hawley-Hague, 2014). Boulton et al. (2017) also found that designating one person to greet and welcome participants to the activity dictated future participation. Conversely, it was also noted that over reliance on supports and caregivers can lead to dependency and a lack of physical activity and that a pre-existing mobility limitation may lead to decreased social activity as the ability to participate is impacted (Hye et. al., 2008).
An example of the complex relationship between levels is seen at the personal and social environment levels where older adults with incomes below $25,000 and less education, experience more mobility limitations (Coppin et. al, 2006). They found that older adults with less than 5 years of education had slower gait patterns and poorer functional performance compared with those that had higher education levels.
BUILT ENVIRONMENT:
The built environment appears to play the most significant impact on sustained physical activity in the elderly (Ottini et al., 2016). Gharaveis (2020) describes how the built environment impacts physical activity in the elderly and can increase or decrease participation in activity. Environments found to be appealing, safe and convenient all increased participation in activities such as walking (Gharaveis, 2020). Other considerations, such as security, supervision and space for the use of assistive devices were also highlighted by Gharaveis (2020). Although outdoor environments were cited to have additional impacts of improved mental health and be more visually appealing, Gharaveis found that indoor environments were favored by the elderly population (2020). A study conducted by Ottini et al (2016) in Vancouver, BC found a connection between the built environment and the social environment emphasized by the placement of benches within the built environment. This relatively small piece of the built environment not only increased physical activity by providing opportunity for rest or steadying, but also created an environment for social interaction (Ottini et al, 2016).
My Health My Community (n.d.) conducted a survey in 2013 that asked adults 18 and older to report on aspects of their health and community. The community of Langley is broken into two distinct municipalities, the City of Langley and the Township of Langley. Of note, people aged 65 plus make up 16% of The Township of Langley and 19% of the City of Langley (My Health My Community, n.d.). I took a closer look built environment reports for each of these two communities with the results shown in Figure 2 for the Township of Langley and in Figure 3 for the City of Langley. The Metro Vancouver average is also shown.
Figure 2
Note: My Health My Community (n.d) survey of the Built Environment for the Township of Langley
Figure 3
Note: My Health My Community (n.d) survey of the Built Environment for the City of Langley
I was not surprised to see the higher numbers for the City of Langley given its urban and condensed environment compared to the large number of rural areas within the Township of Langley. This may have an important impact on access to facilities and the ability to participate in physical activity for those older adults living in the more rural areas of Langley.
The aforementioned findings and research results have implications for policy makers and city planners as community health is a shared responsibility. Gharaveis (2020) notes the importance of educating society about how the built environment impacts physical activity in the elderly. They go on to describe imploring designers to consider the aspects of the built environment that promote physical activity in the design of new environments. Gallagher & Mallhi (2010) recommends partnerships at the local, regional and provincial government levels, and between businesses, the community, the health care system and seniors advocacy groups in order to achieve an age-friendly British Columbia.
After applying the social ecological framework in order to understand how to increase the physical activity of seniors in order to prevent falls, it is apparent that the creating accessible and safe built environments are key. This framework helps demonstrate the interconnectedness of whether or not a senior will exercise by showing that the creation of these environments inadvertently creates social networking opportunities, that in turn creates motivation for the older adult to continue. It is the relationship between factors at all levels that gives us the best chance for a healthier seniors population that stays on their feet.
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