Challenging what is known : A mixed method study of perceptions and experiences of social exclusion among the oldest old

Introduction People aged 80 and beyond constitute the fastest growing sector of the Australian population. Referred to as the ‘oldest old’, they are generally assumed to be most vulnerable to social exclusion, yet their voices are seldom studied. Although there is no consensus when it comes to a definition of social exclusion, nor measurement, or systematic collection of data, social exclusion is often conceptualised as a dynamic process by which individuals, groups and populations are prevented from realising their rights and opportunities for health and wellbeing (Popay et al., 2008). This thesis addresses a key gap in the literature, namely, to examine the context, causes, and consequences of social exclusion among the oldest old. Method Guided by the paradigm of constructivism, this thesis employed a critical gerontology theoretical framework and a mixed-methods research design (quantitative and qualitative). The first study was a cross-sectional analysis of a national data source (Housing, Income and Labour Dynamics in Australia wave 16, n= 307) and examined whether individual- and neighbourhood-level characteristics were associated with perceived social exclusion, and whether these factors relate to health using ANOVA and multivariable linear regression. Measures of individual-level characteristics included household composition, housing tenure, annual equivalised income, country of birth, level of education, and disability status. The neighbourhood-level characteristic measured was neighbourhood area disadvantage. The social exclusion measures covered perceived unsupportive relationships, perceived neighbourhood exclusion and community disengagement, and were derived via Principal Components Analysis. The contribution of social exclusion to the relationship between sociodemographic characteristics and health was examined using effect modification analysis. The qualitative study consisted of in-depth semi-structured interviews with a subgroup often missing in population surveys but singled out in the literature as being at risk of social exclusion: public housing residents who live alone. Purposive sampling, which included doorknocking, recruited 13 participants. Transcriptions of interviews were examined using thematic analysis. Findings based on the integration and interpretation of the quantitative and qualitative study are drawn together to offer new knowledge about social exclusion amongst the oldest old. Results Household composition, level of education and neighbourhood disadvantage were found to be associated with differing vulnerability and differing measures (domains) of social exclusion for men and women. Oldest old men who live alone (compared to those in multi-person households) were more likely to perceive themselves to be lacking in supportive relationships. For men, living in poorer neighbourhoods was associated with a heightened perception of feeling their neighbourhood was unsafe. Conversely, living alone for women was associated with higher levels of community engagement. For women, living in poorer neighbourhoods was associated with higher levels of neighbourhood cohesion. Both men and women with lower levels of education than their counterparts were more disengaged from their community. These associations remained significant after adjustment for sociodemographic factors. The second component of the quantitative study revealed limited evidence that individual- and neighbourhood characteristics influenced self-reported health. For men, higher income and disability status were significantly associated with poorer general health, and for women, living in a multi-person household and reporting a disability were significantly associated with poor general health. For both men and women, disability was the only factor found to be significantly associated with poorer mental health, suggesting that mental health was similar irrespective of household composition, housing tenure, income level, country of birth, education, and whether one lived in an advantaged or disadvantaged neighbourhood. There was limited evidence of the moderating effect of social exclusion on the relationship between individual- and neighbourhood characteristics and health. Contrary to expectations, it appeared that higher levels of social exclusion contributed to better health. For example: for women who were born in a country where English was not the native language, higher perceptions of neighbourhood exclusion (i.e. crime and noise) had a positive effect on mental health; and for women living in disadvantaged neighbourhoods increasing neighbourhood noise had a positive effect on general health. From the qualitative study, seven themes emerged from the interviews which seemed to have a protective effect on perceptions of non-social exclusion. These were sense of supportive relationships, sense of neighbourhood, sense of physical and mental health, sense of home and autonomy, life-course experiences, psychological beliefs and adaptations, and contributing to society. The qualitative interviews showed that lone dwelling oldest old living in public housing did not identify with social exclusion. Discussion and Conclusions A growing body of literature suggests that the oldest old, especially those from a disadvantaged background, are vulnerable to the poor health and wellbeing outcomes of social exclusion. The oldest old are underrepresented in social exclusion research. The integration of the mixed method findings via meta-inference provides new and deeper insight into the interrelationship and pathways between ageing and exclusion from participants own perceptions and lived experience. First, there was limited compelling evidence of social exclusion amongst vulnerable groups of oldest old. Second, some characteristics thought to increase vulnerability to social exclusion, such as living alone and lower socioeconomic position (e.g. public housing residents) appeared to reduce the likelihood that the oldest old perceived themselves to be socially excluded. Third, the findings point to the need for critical reflection on the definition and measurement of social exclusion, and researchers’ role in the propagation of ageist assumptions equating advanced age with social exclusion. The findings support a public health response that includes prevention and intervention. Prevention strategies addressing socioeconomic inequalities over the life-course, such as access to health, education, community care, housing and income security, are examples that could reduce oldest old social exclusion. Individual-level intervention strategies that foster social relationships also have potential. Recommendations for further research are to increase representation of the oldest old in social exclusion research and to explore life-course resilience - both of which are important for challenging current negative ageist stereotypes that equate old with exclusion