UNDERSTANDING SOCIAL VULNERABILITY IN AGING POPULATIONS: INSIGHTS ACROSS DIFFERENT HEALTHCARE SETTINGS

Abstract

Social vulnerability is the degree to which a person’s overall social circumstances leave them susceptible to adverse events, driven by the relative disadvantages from the conditions in which they were born, live, work and age. This thesis explores the complex nature of social vulnerability, conceptualizes its measurement through social vulnerability indices (SVIs), and examines its associations with health outcomes for older adults. Across eleven chapters, social vulnerability is explored using systematic and scoping reviews, qualitative interviews and quantitative data analyses in different populations of community dwelling and hospitalized older adults, primarily in Nova Scotia. This thesis begins with an exploration of the potential value of intervening to reduce social vulnerability by demonstrating complex interventions with a predominant social component were associated with improved function, better subjective health and lower hospital use. The next chapters describe the theory, method, and strengths of constructing a multiple level and multiple domain SVI and demonstrate feasibility in both a smaller clinical study and a larger population-based dataset. Using the SVI to understand how social vulnerability influences hospital outcomes among older adults in the emergency department showed that while frailty drove admission and mortality, social vulnerability prolonged hospitalization and increased risk of long-term care home entry. Within the hospital setting, qualitative interviews revealed healthcare providers’ perceptions of “socially admitted” patients including individual, institutional, and system challenges to providing patient centred care for this population. In later chapters, dynamic relationships are found between social vulnerability and mortality, home care hours, and long-term care home entry even after accounting for frailty and cognition. The findings presented in this thesis support the importance of considering social vulnerability for older adult health and use of healthcare and home care resources. The findings also suggested healthcare systems appear less responsive to older adults with high social vulnerability and potentially, unintentionally, facilitate care pathways towards institutionalization. Lastly, this thesis presents a model of caring for older adults at risk of frailty and social vulnerability across healthcare settings to guide future research, emphasizing the need for systems level thinking, comprehensive redesign, and proportional funding reform to effectively support the goal of aging-in-place in Canada.