Abstract
[Purpose] This study aimed to identify factors that inhibit the social activities of adult daycare users. [Participants and Methods] Based on participation in social activities, we categorized adult daycare users into two groups; socially active and inactive. Using a questionnaire, the socially inactive group were surveyed for their reasons for non-participation in social activities. Factor analysis was conducted to determine the structure of the reasons for the lack of social activity in the socially inactive group. Factors inhibiting social activities were identified. [Results] A three-factor structure was derived for the reasons of the lack of social inactivity in the socially inactive group. The three factors were mobility-, hearing-, and psychology-related. [Conclusion] These three aspects of inhibitors should be recognized, and comprehensive interventions that address them simultaneously are necessary.
Keywords: Adult day care, Social activity, Disincentive
INTRODUCTION
Participation in social activities among older adults is believed to reduce physical health risks, frailty, depressive symptoms, and suicide risk1). The Japan Gerontological Evaluation Study (JAGES) project examined the relationship between social activity participation and the development of frailty in older adults who were not certified for long-term care. The results showed that older adults who participated in social activities had a lower risk of developing frailty 3 years later2). The importance of participation in social activities among older adults is clear from these findings.
Fujiwara presents a framework of social activities according to the life functions of older adults: 1. employment, 2. volunteer activities, 3. self-development and lifelong learning (hobbies), 4. Interaction with friends and neighbors, and 5. day-care services3). In Japan, the long-term care insurance system supports the lives of older adults. According to this system, adult day care centers must maintain and improve older adults’ performance of activities of daily living and promote their social activities4). While adult day care serves as a venue for social activities, we believe that older adults who use these services should not give up their participation in social activities that are more advanced than adult day care.
Previous studies on social activities among older adults have been conducted by randomly selecting participants of 65 years or older in specific areas5, 6) or by targeting older adults who are not certified for long-term care7, 8). There are no studies targeting older adults who use adult day care services. Since that adult day care users have some kind of disability and are certified for long-term care, it is necessary to conduct a survey targeting this population. In addition, we believe that the balance between facilitating and inhibiting factors leans toward the facilitating factors, leadings to increased participation in social activities. First, it is important to identify the reasons for the lack of participation in social activities. Second, we should identify the factors that facilitate participation in social activities. Finally, we should intervene in both the inhibiting and facilitating factors to encourage participation in social activities among adult day care users.
The purpose of this study was to clarify the factors that inhibit participation in social activities among older adults who use day-care rehabilitation, and to help develop intervention methods.
PARTICIPANTS AND METHODS
We surveyed adult day care users with the cooperation of an adult day care facility in Hachioji City, Tokyo. The facility operates a short-hour center with a capacity of 120 people, offering classes that last 1–3 hours, several additional fees are calculated, including an additional fee for the implementation of short-term rehabilitation or rehabilitation aimed a improving activities of daily living. The average number of days of use by older adults is 1–2 times per week. The participants were individuals who had used the facility in March 2023 and had provided their consent to participate in the study. Those who could not move around independently in their homes, those who had cognitive problems that made it difficult to complete the face-to-face questionnaire (i.e., those who scored 20 or less on the Revised Hasegawa’s Dementia Scale), and those whose responses had missing data were excluded.
This study was approved by the Eiseikai Medical Corporation Ethics Committee (Approval no. E-2022-14) and the Tokyo Metropolitan University Arakawa Campus Ethics Committee (Approval no. 23803). The purpose and methods of the study, the voluntary nature of participation, and the freedom to stop participation were explained on the corporate website using the opt-out method, and contact information was clearly indicated for inquiries. If a participant refused to participate or withdrew from participation, their refusal or withdrawal was promptly accepted, and the participant did not face any disadvantages.
To determine participants’ demographics, we collected information on their age, sex, care level, total number of diagnoses, and household composition. These lines of information were obtained from medical information forms prepared by physicians and care plans prepared by care managers. Care levels were determined according to the Japan’s long-term care insurance system; which designate the necessary care. There are seven levels in the long-term care insurance system: Support levels 1 and 2 and Care levels 1–5. The user receives service benefits based on their care level9). The Ministry of Health, Labour and Welfare classifies individuals requiring care between Support level 1 to Care level 1 as having “light severity” and those requiring care between Care level 2 to Care level 5 as having “moderate severity”10). Following this system, we classified the care levels of participants into either “light severity” or “moderate severity”. Regarding the total number of diagnoses, Hayakawa et al.11) investigated the number of receipt disease names to examine the prescribing background in relation to polypharmacy. Considering that older adults suffer from multiple diseases and that disease severity varies, we considered it appropriate to investigate the total number of diagnoses to capture their disease background. First, we organized the diagnoses listed in physician-prepared medical information forms according to the “ICD-10 (2013 edition) Basic Classification Table”12), which is used by medical institutions for medical classifications. Then, we excluded diseases that did not correspond to the ICD-10 (2013 edition) Basic Classification Table and calculated the total number of diseases. Regarding household composition, Furuta et al.13) conducted a survey about the frequency of going out among older adults living at home and reported that those living alone or with only their spouse are significantly less likely to go out. Therefore, based on the classification used in the Comprehensive Survey of Living Conditions14), single-person households and households with only a couple were classified as “elderly households”, and all other households were classified as “non-elderly households”.
Social activity among older adults is defined as “interpersonal activity outside the home” in the “Social Activity Index” developed by Hashimoto et al15). The Social Activity Index was put into practical use in the “Lively Activity Checklist”16). The participants were asked whether they participated in the six items in the “social participation and service activities” category of the checklist. The six items were “participation in community events (such as festivals and Bon dances)”, “neighborhood association activities”, “senior citizen club activities”, “activities among friends, such as hobby group activities”, “service (volunteer) activities”, and “activities to share special skills and experiences with others”. The survey on reasons for lack of participation in social activities in this study was conducted using a questionnaire form originally developed by a consensus of rehabilitation professionals engaged in adult day care rehabilitation with reference to the “Reasons for not wanting to participate in social activities” in the 2023 White Paper on Aging Society17) (Q1–9, Table 1). In this study, social activities were defined as those more advanced than day-care services, based on the framework of social activities outlined by Fujiwara, which includes: 1. employment, 2. volunteer activities, 3. self-development and lifelong learning (hobbies), 4. Interactions with friends and neighbors, and 5. day-care services3). To gain a broader understanding of social participation among older adults in general and identify the factors that inhibit social activity participations among day care users, we referred to a questionnaire administered to individuals aged 65 years and older. To increase the simplicity of the questionnaire and allow rehabilitation professionals to clearly and easily understand the reasons for the lack of social activity in the face-to-face survey, the answer options were limited to “yes” or “no” format.
Table 1. Responses of participants in the no social activity group about the reasons for the lack of social activities (n=93).
| Reasons for no social activities | Yes n (%) | No n (%) |
| Q1. Lack of confidence in health and fitness | 58 (62.4) | 35 (37.6) |
| Q2. Need help from others to get to the target point | 26 (28.0) | 67 (72.0) |
| Q3. No activity location in nearby area | 23 (24.7) | 70 (75.3) |
| Q4. Lack of confidence in using buses and trains | 30 (32.3) | 63 (67.7) |
| Q5. Want to participate with others, but not alone | 19 (20.4) | 74 (79.6) |
| Q6. Afraid to associate with others | 28 (30.1) | 65 (69.9) |
| Q7. Families worry about going out alone | 22 (23.7) | 71 (76.3) |
| Q8. Difficulty in speaking owing to a lack of hearing | 7 (7.5) | 86 (92.5) |
| Q9. Do not know what activities are taking place | 32 (34.4) | 61 (65.6) |
In analyzing the data, we divided the participants into two groups: the “socially active group” and the “socially inactive group”. Participants who answered that they participated in at least one of the six “social participation and service activities” in the checklist were put in the “socially active group”, while those who answered that they did not participate in any of the six items were put in the “socially inactive group”. We then compared the demographic data of the two groups (age, sex, care level, total number of diagnoses, household composition). The normality of continuous variables was confirmed using the Shapiro–Wilk test. Unpaired t-tests were used for items for which normality was confirmed, and the Mann–Whitney U test was used for items for which normality was not confirmed. Categorical variables were tested using the χ2 test and Fisher’s exact tests.
Finally, we analyzed the factor structure of the reasons for the lack of social activity in the socially inactive group. Before checking the factor structure, the correlation coefficients for each question were researched to determine if there were any items with strong correlations. We replaced “yes” with “1” and “no” with “0” in the questionnaire responses. Then, factors with eigenvalues of one or more were extracted using factor analysis (the maximum likelihood method and promax oblique rotation solution). By doing so, we extracted items with factor loadings of less than 0.4 for each variable. All statistical analyses were performed using SPSS version 22.0, and the significance level was set at less than 5%.
RESULTS
A total of 185 participants met the selection criteria, and 66 were excluded. Finally, 119 participants were included in the analysis. Among them, 26 were classified into the socially active group (bone and joint disease n=12, fall/fracture n=11, heart disease n=6, cerebrovascular disease n=5, dementia n=0), and the rest were classified into the socially inactive group (bone and joint disease n=52, fall/fracture n=23, cerebrovascular disease n=19, heart disease n=13, dementia n=2). The breakdown of activities of the group with social activities was “activities among friends, such as hobby group activities (n=12)”, “senior citizen club activities (n=8)”, “neighborhood association activities (n=4)”, “service (volunteer) activities (n=2)”, and “activities to share special skills and experiences with others (n=1)”.
Table 2 presents the results of comparing the demographic data of the two groups. The mean age of participants in the socially active and inactive groups was 81 (range=59–88) years and 81 (range=51–96) years, respectively. In both groups, the number of females was higher (69.2% in the socially active group and 63.4% in the socially inactive group). In both groups, individuals with light severity were higher in number (96.2% in the socially active group and 80.6% in the socially inactive group). On average, the total number of diagnoses was 2 (range=1–6) in the socially active group and 2 (range=1–5) in the socially inactive group. Age, sex, care level, and total number of diagnoses did not differ significantly between the two groups (p=0.582, p=0.585, p=0.070, and p=0.656, respectively).
Table 2. Comparison of the demographic data of the social activity group and the no social activity group.
| Social activity group (n=26) | No social activity group (n=93) | ||
| Age (years), X (min–max) | 81 (59–88) | 81 (51–96) | |
| Sex, n (%) | Male | 8 (30.8) | 34 (36.6) |
| Female | 18 (69.2) | 59 (63.4) | |
| Care level, n (%) | Light severity | 25 (96.2) | 75 (80.6) |
| Moderate severity | 1 (3.8) | 18 (19.4) | |
| Total number of diagnoses, n (min–max) | 2 (1–6) | 2 (1–5) | |
| Household composition, n (%)* | Elderly households | 22 (84.6) | 52 (55.9) |
| Non-elderly households | 4 (15.4) | 41 (44.1) |
*p<0.01.
Regarding household composition, the socially active group consisted of 22 (84.6%) older adults-only households and 4 (15.4%) non-older adults-only households. In contrast, the socially inactive group comprised 52 (55.9%) older adults-only households and 41 (44.1%) non-older adults-only households. Thus, household composition differed significantly in the two groups (p=0.008).
Table 1 shows the responses of participants in the socially inactive group about the reasons for the lack of social activities. The highest percentage of “yes” responses was 62.4% for Q1, and the lowest was 7.5% for Q8. The percentage of “yes” responses to the other questions ranged from 20–30%.
The correlation coefficients for each question item ranged from 0.21 to 0.49, a weak to moderate correlation. Factor analysis was conducted using all items, assuming that there was independence among them.
Table 3 shows the results of the factor analysis. Q3 and Q7 were excluded because their factor loadings were less than 0.4 and their factor eigenvalues were less than 1.0. The remaining seven items exhibited a three-factor structure. The cumulative contribution rate was 42.786%.
Table 3. Factor structure of the reasons for the lack of social activity in the no social activity group.
| Factor 1 | Factor 2 | Factor 3 | |
| Q4. Lack of confidence in using buses and trains | 0.730 | 0.129 | −0.095 |
| Q2. Need help from others to get to the target point | 0.700 | −0.118 | 0.059 |
| Q1. Lack of confidence in health and fitness | 0.542 | 0.043 | −0.184 |
| Q8. Difficulty in speaking owing to a lack of hearing | 0.064 | 0.999 | 0.011 |
| Q9. Do not know what activities are taking place | −0.041 | −0.070 | 0.624 |
| Q5. Want to participate with others, but not alone | 0.047 | 0.023 | 0.555 |
| Q6. Afraid to associate with others | −0.171 | 0.239 | 0.430 |
| Eigenvalue | 2.268 | 1.738 | 1.232 |
| Contribution rate (%) | 12.462 | 18.535 | 11.799 |
| Cumulative contribution rate (%) | 42.786 | ||
Italicized: Items with factor loadings of 0.4 or over.
DISCUSSION
We obtained several insightful results. First, a comparison of the demographic characteristics of the socially active and socially inactive groups revealed significant differences in household composition. According to the Cabinet Office’s survey about the benefits of being socially active18), the most common responses among many older adults were “I was able to gain new friends (56.8%)” and “I had connections in the community that helped me feel safe (50.6%)”. It is necessary to further study and examine whether single person households and households with a couple only were participating in social activities to connect with people outside the family and community.
Second, seven items were extracted from nine items in the factor analysis, and a three-factor structure was derived. The items in each factor are written within [ ], and the extracted factors are written within {}. Factor 1 consisted of [Lack of confidence in using buses and trains], [Need help from others to get to the target point], and [Lack of confidence in health and fitness]. Previous studies have shown that inconvenience experienced in using trains and buses impacts social activities6), hardships experienced in going out affect social participation6), and the availability of support for going out influences the frequency of going out13). Aligning with these findings, we found that anxiety about mobility is a factor that inhibits social activities, even among adult day care users. More specifically, when social activities are located beyond walking distance, using public transportation is often a problem for adult day care users. Most of them use the transportation services provided by the office or take support from their family members. Therefore, the first factor was named {mobility-related inhibitors}.
The second factor comprised [Difficulty in speaking owing to a lack of hearing]. A previous study found that older adults with senile hearing loss do not want to bother others, feel frustrated that they can no longer do the things they want to do, and feel left out of their surroundings19). Aligning with this finding, we found that anxiety about hearing while communicating with others is a factor that inhibits social activities, even among adult day care users. Therefore, the second factor was named {hearing-related inhibitors}.
Factor 3 consisted of [Do not know what activities are taking place], [Want to participate with others but not alone], and [Afraid to associate with others]. Previous studies have reported that one’s awareness of activity information, the number of friends one has, the presence of peers to work with, and not liking activities in which people gather influence one’s engagement in social activities6, 20). Aligning with these findings, we found that anxiety to participate in new social activities is a factor that inhibits social activity. More specifically, most adult day care users who are not socially active do not gather information about social activities taking place in their surroundings. Additionally, some of them focus on rehabilitation with professionals and do not prefer group activities. Therefore, the third factor was named {psychology-related inhibitors}.
Overall, our results suggest that mobility-, hearing-, and psychology-related factors inhibit the social activities of adult day care users who do not engage in social activities. It is important to determine how to eliminate these inhibitory factors. For mobility-related inhibitors, we believe that environmental interventions may help eliminate mobility-related inhibitors. Most adult day care users have a disability, and it takes time for them to improve their functionality. Therefore, walking aids and human support may help them reach their destination. For hearing-related inhibitors, we suggest hearing aids as well as devices that can transcribe conversations, such as smartphones and tablets. For psychology-related inhibitors, we believe that organizing information on social activities and presenting it in a positive manner will be a good idea. For example, easy-to-understand maps can be created about social activities, and they can be made available around the home. Providing opportunities to view the map with family members and increasing the understanding of family caregivers may also be beneficial. Another solution can be to promote adult day care users’ participation in activities of interest with family members, care managers, rehabilitation specialists, and other people they trust. In addition, comprehensive interventions that work on all three inhibitors simultaneously, rather than tackling them individually, are needed.
This study has the following limitations. First, the results cannot be generalized because the study was conducted at a single adult day care facility. Second, the questionnaire surveying reasons for lack of participation in social activities was originally developed through a consensus of rehabilitation specialists with reference to the “Reasons for not wanting to participate in social activities” from the 2023 White Paper on Aging. Validation of the questionnaire remains a task for future research. Third, this study did not examine differences based on disease, environment (e.g., households, proximity to public transportation, etc.), or ability (e.g., ability to participate but not currently participating). Future studies should analyze the data considering the above factors and explore more specific intervention methods. Fourth, future research should be conducted on facilitating factors because the promotion of social activities requires not only the elimination of inhibiting factors but also the strengthening of facilitating factors.
Conflict of interest
There were no conflicts of interest in conducting this study.
Acknowledgments
We express our deep appreciation to the staff of the Adult Day Care office of SMILE EISEI.
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