Nurses' Role in Addressing Social Frailty for Healthy Ageing Promotion

Abstract

The rapid ageing of the world's population catalyses the global initiative for promoting healthy ageing. Whereas the United Nations declares the Year 2021–2030 as the Decade of Healthy Aging, the World Health Organization operationalises the goal of this global action as to optimise the functional status of older adults. To guide the strategic aged care service planning, frailty evolves as a multi-domain concept to describe the lack of functional reserve for coping with the different aspects of late-life vulnerability. Social frailty is the domain that captures the aspect relating to social functioning. Referring to the latest system review (Jia et al. 2024), social frailty affects more than one-fifth of community-dwelling older adults worldwide, but this problem has received the least attention from nurses or other healthcare professionals in geriatric and gerontological care. The aim of this editorial was to explore the scope of social frailty, focusing on its role in shaping the health of older adults and the challenges of addressing social frailty. The editorial concludes by discussing the nurses' role in managing social frailty.

Defined in the realm of overall frailty, social frailty refers to the threats of social functional reserve to cope with vulnerability which might compromise social well-being. Social functional reserve, in fact, is a wide-ranging concept, and current research exploring its components is limited. Referring to a systematic review (Bunt et al. 2017), social functional reserve may potentially include any social factors that influence an individual's social needs, well-being and social functioning. These social factors not only capture the tangible and intangible social resources (e.g., social behaviours, social activities and even self-care abilities) but also relate to an individual's psychological capital and intrinsic needs to achieve fulfilling social well-being. Of note, an ecological framework may be most relevant to enable systematic evaluation of social functional reserve by which the quality and quantity of resources available at the micro-, meso- and macro-levels, including intrapersonal, interpersonal, organisational, community and public policy, needs to be considered. Social frailty is determined by the complementary distribution and integration of the resources between these ecological layers. Social frailty would be resulted when individuals are unable to mobilise adequate and relevant social resources across these layers to meet their basic or higher-level social needs. Of note, a holistic approach is recommended to comprehend one's social frailty, considering how one's social networks, social environment, cultural background, social support systems, and the ability and preference to utilise resources interact with one another in shaping the social functioning and well-being.

A recent meta-analysis by Li et al. (Li et al. 2023) indicated that social frailty independently predicts more incident disability, depressive symptoms and even mortality. Whereas the resources at each ecological layer intertwine and supplement each other, a single social factor is unlikely to independently contribute to such devastating health impact. This is because any deficit in one ecological layer to tackle a social vulnerability situation may kick-start a compensatory mechanism to solicit resources at the other layers. The devastating health impact of social frailty is, therefore, more likely to be related to the accumulation of resource deficits across the layers of the ecological framework among older adults. Failure to achieve compensation stimulates a chain of reaction to exacerbate the health impact of social frailty among older adults.

Following the ecological framework, the decrease in physical and cognitive function among older adults may be the first to alter their social engagement and behaviours (Kastner et al. 2024). The resulting decline in social reserve, complicated by low income and widowhood, may arouse feelings of loneliness, loss of perceived social roles and decreased social identity which results in widening barriers to external layers. At the interpersonal level, major life events such as an empty nest, retirement and loss of a spouse may shrink the social support and social activities of older adults and outwardly reduce the individual's access to necessary resources such as medical resources and health counselling, and inwardly increase the risk of psychological problems such as depression and decreased motivation to maintain healthy behaviours. For the organisational and community levels, which are usually a stable source of general resources for individuals, the presence of resources to support the needs of the elderly including basic livelihood security, medical institutions, community services and age-friendly environments, will affect health decision-making and well-being. Lastly, at the level of public policy, the policies and objectives of health management will have a direct impact on the overall health of older adults. Health insurance systems, long-term care insurance systems and so on will also serve as social protection for access to healthcare resources for seniors. Referring to these, social frailty impacts health outcomes as a complex process involving the accumulation of interactions and resource impairments at all levels, from micro, meso to macro, and from internal to external. It plays a catalytic role in the deterioration of health outcomes in older adults by further weakening an individual's capital or resilience to cope with stress, thereby limiting health management behaviours such as adherence to self-care, seeking professional care and so forth. Towards healthy ageing, it is critical to emphasise the prognostic impact of social frailty on health but also to be mindful of its reflection on the accessibility, equity, friendliness, and supportiveness of area resources and policies.

There is no doubt that social frailty is a roadblock to healthy ageing. Addressing this complex matter requires accurate identification of social frailty in the population. One of the major challenges in these endeavours is the lack of standardised assessment approach to guide large-scale censuses. The most common items of questionnaires measuring social frailty include financial status, social resources, social behaviours and activities, and sense of purpose (Montayre et al. 2024). However, cultural and social factors influence the development of scales, leading to regional differences in the applicability of scale items. Considering the extensive components of social frailty, its evaluation can be done in stages. Nurses need to conduct research to develop regional and standardised screening tools for social frailty to identify individuals at risk. Then, a comprehensive assessment of the accessibility and impairment of social resources is conducted in collaboration with the community, healthcare systems and government departments. Understanding areas of resource impairment and needs is essential to developing interventions.

To tackle social frailty among older adults, nurses need to advocate for interdisciplinary collaboration with professionals in sociology, economics, architecture and others to address resource needs at different ecological layers. Jointly advocate for public health policy development and implementation. We also need to encourage professional/non-professional organisations and commercial/public interest, to complement the maintenance of the social status and health of older adults. Moreover, we need to establish an integrated resource referral platform and response mechanism to facilitate the precise and efficient allocation of limited resources. Optimising access to resources for the elderly promotes accessibility and equity as well as maintains the stability of individual social reserves.

Realising the significance of social frailty is a priority issue. This can be done by introducing content related to social frailty in the education and training of nurses to raise awareness and to coach nurses to properly understand its meaning. Nurses should also be empowered and given access to transfer resources for developing their capacity to address social needs. In addition, nurses can encourage the participation of family and friends in health management, thereby constructing a closer support network for the elderly. Although it takes time to adequately evaluate social frailty, it is relatively stable over a period. There is therefore a need to encourage healthcare providers in primary and community healthcare settings to conduct routine assessments.

Although the scope of social frailty is broad, each layer acts as a buffer to limit the pace of deterioration when impairment occurs. We must emphasise its role as a predictor of health outcomes rather than leave it alone and hope for other sectors and disciplines. Addressing this issue is not a matter for a single discipline, but a shared responsibility of public health, academia, communities and government. If we can mitigate or even reverse social frailty, this will help to protect the quality of life of older adults and move towards the goal of healthy ageing.

Conceptualisation: Doris Sau-fung Yu and Miao Miao. Writing – original draft: Miao Miao. Writing – review (intensively revise and final editing): Doris Sau-fung Yu.

The authors have nothing to report.

The authors declare no conflicts of interest.