Social Participation of Older Adults: A Concept Analysis.

BACKGROUND: The concept of social participation is highly valued in old age. However, there is ambiguity and disagreement in the definition and attributes of this concept among the elderly. This study aims to clarify and reduce the ambiguities in the concept of social participation in order to achieve a clear and understandable definition among the elderly people.
METHODS: For concept analysis, Walker and Avant's 8-Step method of concept analysis was used. The published papers between 2000 and 2018 were searched. 57 articles related to the concept were included in the study and accordingly, the definition, applications, attributes, antecedents, consequences and empirical referents of the concept were extracted after reviewing the resources.
RESULTS: According to the analysis, the defining attributes of the concept of elderly people's social participation included emphasis on community-based activities and interpersonal interactions, based on resource sharing, active participation and individual satisfaction. Social participation among the elderly people had individual, environmental, and social antecedents as well as individual and environmental consequences.
CONCLUSIONS: The present study provided an objective and understandable picture of the concept of the elderly people's social participation. The study has pedagogical implications for promoting this concept and developing tools. Copyright: © Shiraz University of Medical Sciences.

INTRODUCTION

Since the beginning of the new millennium, aging has become a major socio-demographic issue. [1] According to 2015 World Health Organization estimation, the population over the age of 60 will reach 12% to 22% between 2015 and 2050. [2] The population pyramid in Iran also shows that at present a high percentage of the population is in the age group of 15-64 years which will lead to a large population of elderly people during the subsequent decades. [3]

Population aging is perceived as a major challenge for the countries that are seeking safety and welfare for their ever-increasing elderly population. [1] Social participation is viewed as one of the important and effective factors influencing the elderly’s welfare and health as well as an important issue of the elderly people’s rights. [4]

Social participation is an organized process in which individuals are characterized by specific, collective, conscious and voluntary actions, which ultimately leads to self-actualization and achievement of goals. [4] For over 20 years, researchers have become increasingly interested in the concept of social participation. [5] As various research suggests, developing and sustaining social participation is a vital need for all ages, including the elderly people. [6]

Social participation is a very valuable concept in old age since it is considered as one of the most important components of the elderly people’ health, [7] and a key component of many functional conceptual models in the elderly. [8] Several studies indicate that diseases, mortality, and quality of life of the elderly are related to their social participation. [7]

The elderly social participation is considered as one of the major areas of age-friendly cities, [9] the central component of successful aging, [10] a component of social capital, [11] and one of the important components affecting the health of the elderly people. [12] Thus, paying attention to the concept of social participation in the elderly people is of particular importance, [8] and its promotion is one of the key recommendations of the World Health Organization in response to concerns about the aging population. [13]

Nurses have the most interactions with the elderly in the community and play a vital role in promoting the social participation of the elderly people by taking into account the concept of social participation in nursing care plans as well as introducing and providing resources in the community. [14]

Despite the importance of social participation concept, less attention has been paid to it, and few researches have been conducted in the field of aging. [15] The insufficient evidence can be attributed to the lack of clarity of this concept since social participation in the elderly people is a concept which has not been developed much and has not been clearly understood and measured. [16] There is no agreement on the concept of social participation as it has been defined in a variety of ways in several different studies; hence, different measurement methods have been proposed for it. [11] Another issue which complicates the situation is diversity in the definition of the concept of social participation. [17] Although each specialist has addressed a particular dimension of this concept, a clear definition has not yet been provided, and the definitions vary. The ambiguity in the social participation concept is so much that several authors use terms such as social integration and social activity as an alternative to the concept of social participation, suggesting the lack of clarity of this concept. Hence, providing a clear definition that distinguishes social participation from other similar concepts such as participation, social capital, social support and social network has been a challenge, and additional studies are required. In response, concept analysis is one of the strategies for clarifying it. [18]

A concept analysis can be defined as dissection of a concept into simpler elements to promote clarity. [19] The basic purpose of concept analysis is to clarify ambiguous concepts and propose a precise operational definition. In addition, concept analysis can clarify obscure concepts in a theory and offer a deep understanding of the basic attributes of the concept. [20] Concept analysis is a valuable methodology enabling us to define and clarify the concept that originates from the function, research, or nursing theory. [21] In contrast to other conceptual analysis methods introduced so far, the approach introduced by Walker and Avant 2005 contains clear and systematic steps that have been welcomed by many scholars and also cited in many studies. This approach is capable of clarifying an empirical concept by simplifying it and can be efficacious in clarifying vague concepts such as the concept of social participation. [22]

Accordingly, the aim of this study is to analyze the social participation of older adults using Walker and Avant concept analysis method. The clarification of this concept can facilitate its usage in order to improve the elderly quality of life and make it measurable for evaluating health promotion interventions and producing scientific evidence.

MATERIAL AND METHODS

In this study, Walker Avant’s approach (2005) was used for concept analysis. This model consists of eight stages including select a concept, determine the aims or purposes of analysis, identify uses of the concept, determine the defining attributes, identify model case, identify additional cases, identify antecedents and consequences, and define empirical referents. [23]

To find relevant papers, we searched the published papers between 2000 and 2018 indexed in Scopus, Pub Med, web of science, SID, Magiran, Irandoc databases, using keywords including Aging OR Ageing OR Elderly OR Older OR Seniors AND Community involvement OR Community participation OR Social engagement OR Social involvement OR Social participation.

The inclusion criteria were written reviews and quantitative or qualitative articles in Persian and English languages whose titles or abstracts contained the keywords as well as their full texts were available. Articles containing the definitions, uses, attributes, antecedents, consequences, and empirical referents of concept were included in the study, while non-related articles were excluded. Eventually, 61 papers were selected for the analysis based on the inclusion criteria (Table 1). Throughout the search, no book was found pertaining to the elderly’s social participation (Figure 1).

Table1

Articles reviewed in the study

Title	Authors/Years	Definition	Antecedents	Consequences
Social Participation in Very Old Age Cross-Sectional and Longitudinal Findings From BASE	Levasseur and et al/ 2011	Person’s involvement in activities that provide interaction with others in the community
Social networks, social participation and self-perceived health among older people in transitional Kosovo	Jerliu and et al/ 2014			Health Behavior Management
Neighborhood resources and social participation among older adults results from the VoisiNuage Study	Richard and et al/ 2013	The actions in which an individual shares some resources with others.
The portrayal of older people’s social participation on German prime-time TV advertisements	Kessler and et al/ 2009	Active participation in small societies, such as communication with friends; or in large societies, such as employment
IImportance of proximity to resources, social support, transportation and neighborhood security for mobility and social participation in older adults: results from a scoping study	Levasseur and et al/ 2015	person’s involvement in activities that provide interaction with others in the community	A high level of social support and satisfaction with these supports, access to local resources and facilities, availability of services to meet daily needs, and appropriate weather conditions	Social mobility, improving the quality of life, protection against cognitive impairment, reducing mortality rate
Daytime sleepiness: a risk factor for poor social engagement among the elderly	Lee and et al/ 2013		No sleep disorder, hearing and cognitive impairment
Environmental factors associated with social participation of older adults living in metropolitan, urban, and rural areas: The NuAge Study. American journal of public healt	Levasseur and et al/ 2015	person’s involvement in activities that provide interaction with others in the community	Having a driver’s license, the number of years of staying at home
Does social participation by the elderly reduce mortality and cognitive impairment? Aging & mental health	Hsu/ 2007	Sharing community-based individual resources
Accomplishment level and satisfaction with social participation of older adults: association with quality of life and best correlates. Quality of Life Research.	Levasseur/ 2010	Active engagement in the society and individual satisfaction with these interactions
Coping strategies and social participation in older adults. Gerontology	Demers Levasseur and et al/ 2008	Social roles and daily activities are valued by the individual and her social cultural environment.		Improving adaptation strategies
Identification and feasibility of social participation initiatives reducing isolation and involving rural older Canadians in the development of their community	Clément and et al/ 2017	Person’s involvement in activities that provide interaction with others in the community		Physical and psychosocial well-being, life satisfaction, increasing self-esteem
Association between social participation and hypertension among older people in Japan: the JAGES Study	Yazawa and et al/ 2016	Reducing the risk of cardiovascular disease and hypertension
Social participation and dental health status among older Japanese adults: a population-based cross-sectional study	Takeuchi and et al/ 2013	engagement in social activities		Improving oral health
The effect of widowhood on older adults’ social participation an evaluation of activity, disengagement, and continuity theories	Utz and et al/ 2002			Decreasing suicide, creating and maintaining individual identity
Does social participation improve self-rated health in the older population? A quasi-experimental intervention study	Ichida and et al/ 2013	Good health conditions		Improving the general health
Community engagement: an essential component of well-being in older African-American adults	Tiernan and et al/ 2013		Absence of racial tensions
Barriers to social participation among lonely older adults: The influence of social fears and identity	Goll and et al/ 2015	Engagement in interpersonal interactions outside the home	High self-esteem, age compatibility, appropriate social economic status, and lack of age discrimination in society
The effect of social engagement on incident dementia	Saczynski and et al/ 2006	Maintaining social communication and engagement in social activities
Social engagement in the elderly	Wang/ 2009		Literary
Social participation among older adults living in medium-sized cities in Belgium: the role of neighbourhood perceptions	Buffel and et al/ 2013			Social development
Social participation and healthy ageing: a neglected, significant protective factor for chronic non communicable conditions	Holmes and et al/ 2011			Protecting the body against a wide range of physical and mental ailments, facilitating the process of healing, improving self-care
Social participation among older adults not engaged in full-or part-time work is associated with more physical activity and less sedentary time	Kikuchi and et al/ 2017			Increasing physical activity, maintaining cognitive function, reducing mortality
Everyday Life in the Suburbs of Berlin: Consequences for the Social Participation of Aged Men and Women	Giesel and et al/ 2015		Absence of racial tensions
Social participation and the prevention of decline in effectance among community-dwelling elderly: a population-based cohort study	Tomioka and et al/ 2015	Individual engagement in formal and informal group activities		Reducing the likelihood of a disability to do daily activities
The impact of obesity on the social	Zettel and et al/ 2008	Interacting with other people in the society and spending time with them
Social participation predicts cognitive functioning in aging adults over time: comparisons with physical health, depression, and physical activity	Bourassa and et al/ 2015			Promoting self-efficacy, self-esteem, belonging, and attachment
The Study of Relationship Between Social Participation and Quality of Life of Old People Who Are Member of Senior Association of Tehran City in 2011	Moradi and et al/ 2013			Maintaining social order
An analysis of structural relationship among achievement motive on social participation, purpose in life, and role expectations among community dwelling elderly attending day services	Sano and et al/ 2016	Social activity in the social environment	The motivation to succeed more
Is social engagement linked to body image and depression among aging women?	Sabik/ 2017	Various activities carried out in social settings
Factors related to low social participation in older adults: findings from the Fibra study, Brazil	Pinto and et al/ 2017	Person’s involvement in activities that provide interaction with others in the community	high level of social support, under 80 years of age
Occupational therapists’ contributions to fostering older adults’ social participation: A scoping review	Turcotte and et al/ 2018	Person’s involvement in activities that provide interaction with others in the community		Reduced health care costs, improving the quality of life,
Influence of social participation on life satisfaction and depression among Chinese elderly: Social support as a mediator	Li and et al/ 2017			improving the mental health and cognitive function
Social participation and health over the adult life course: Does the association strengthen with age?	Ang/2018			Health-related behavioral formation, Promoting self-esteem, Improving functional status,
Social Engagement and Health Findings From the 2013 Survey of the Shanghai Elderly Life and Opinion.	Zhang/ 2015	Social interactions and participation in productive activities.	Absence of limited social norms	Helping in order to maintain personal identity and create meaning and purpose
Social participation, willingness and quality of life: A population-based study among older adults in rural areas of China	He and et al/ 2017	Spending time on social interactions with others		Maintaining social identity, improving the quality of life, decreasing depression, preventing cognitive decline
Neighborhood Disorder, Perceived Social Cohesion, and Social Participation Among Older Americans: Findings From the National Health & Aging Trends Study	Latham and et al/ 2018	Engagement in formal and informal social roles	A high level of trust, communication, security and social cohesion Lack of physical abnormalities in the neighborhood, including crime and a large number of empty houses, garbage, and wall murals
Association Between Social Participation and Instrumental Activities of Daily Living Among Community-Dwelling Older Adults	Tomioka and et al/ 2018	Interacting in social groups
Social capital, social participation and life satisfaction among Chilean older adults	Ponce and et al/ 2014		Existence of social policies in relation to social participation of elderly people, high level of social participation of other members of the family	Increasing life satisfaction
Types of social participation and psychological distress in Japanese older adults: A five-year cohort study	Amagasa and et al/ 2017			Reducing depression symptoms, improving the quality of life and cognitive function, reducing disease and mortality
The role of social participation and walking in depression among older adults: results from the VoisiNuAge study.	Julien and et al/ 2013	Person’s involvement in activities that provide interaction with others in the community		Reducing depression symptoms
Social participation and mortality among older adults in Singapore: does ethnicity explain gender differences?	Ang/ 2018	Person’s involvement in activities that provide interaction with others in the community		A barrier to the negative effects of stress, strengthening the common norms related to health promotion behaviors, developing a sense of mastery in health behaviors
Social participation and maintaining recommended waist circumference: Prospective evidence from the English longitudinal study of aging	Kouvonen and et al/ 2011			Improving physical and mental status, improving memory performance, and preventing dementia
Active Social Participation and Mortality Risk Among Older People in Japan Results From a Nationally Representative Sample	Minagawa and et al/ 2015			Reducing the risk of death, psychological distress, and physical problems
Social participation and older adults’ sleep	Chen and et al/ 2016	Sharing resources with other society members	High level of professional and educational resources of the society	Increasing material and social support, having access to essential health information
Social participation of older adults in Quebec	Desrosiers and et al/ 2004	Essential social roles for well-being and health
Staying connected: neighbourhood correlates of social participation among older adults living in an urban environment in Montreal, Quebec	Richard and et al/ 2009		Homeownership, housing satisfaction
Social Participation and Cognitive Decline Among Community-dwelling Older Adults: A Community-based Longitudinal Study	Tomioka and et al/ 2018	Engagement and interacting in social groups		Increasing social support, increasing body resistance to diseases, improving the physiological function of the body, improving synaptic density and nerve growth, maintaining cognitive function, and promoting thinking strategies.
The relationship between wealth and loneliness among older people across Europe: Is social participation protective?	Niedzwiedz and et al/ 2016			Reducing the feelings of loneliness
Influence of Social Engagement on Mortality in Korea: Analysis of the Korean Longitudinal Study of Aging	Kim and et al/ 2016			Improving functional status, reducing mortality rate
Social engagement and health literacy decline during ageing in a longitudinal cohort of older English adults	Kobayashi and et al/ 2014			Increasing health literacy
The association between social participation and cognitive function in community-dwelling older populations: Japan Gerontological Evaluation Study at Taisetsu community Hokkaido	Sakamoto and et al/ 2016			Social cohesion, improving the health indicators of aging, reducing the burden of disease and disability in elderly people
Changes in social participation and volunteer activity among recently widowed older adults	Donnelly and et al/ 2010			Increasing the self-confidence
Relationship between social participation and general health among the elderly	Yazdani and et al/ 2014	Interacting with the society so that the community benefits from individual actions and the individual benefits from services and resources in the society

Figure1

Flow diagram of review process

RESULTS

Select a Concept

The concept of elderly social participation was selected due to ambiguity in the definition, uses, attributes, and indicators of its measurement; [16] no differentiation of this concept with the same concepts in related texts; [18] and the importance of this concept in the elderly. [24]

The researcher developed an interest in this field during frequent contacts with the elderly and subsequently observed their interest in social interactions and activities, and the lack of appropriate community and family conditions for such activities. Finally, he selected the elderly’s social participation for concept analysis.

Determine the Aims or Purposes of Analysis

The ambiguities in the concept of elderly social participation are such that in many cases similar concepts are used interchangeably, such as participation, social connectedness, social capital, social support, social network, and social integration leading to communication problems between people who use the concept, production and selection of inappropriate tools for measuring it, and ineffective efforts of social policies to promote it. [7] The current paper aims to analyze the concept of elderly social participation using Walker and Avant’s systematic approach in order to reduce ambiguity, clarify attributes, and provide an operational definition of the concept.

Identify Uses of the Concept

Walker and Avant argue that presenting the overview of the applications of the concept under consideration enables a richer understanding of the concept and validation of the defining attributes. [23] In order to depict a representation of the concept’s applications, we inspectedmall aspects of the elderly social participation, and a wide range of definitions, dimensions, and levels of the concept were identified.

Social participation is defined as a person’s involvement in activities that provide interaction with others in the society or the community [25 - 27] and expresses interpersonal interactions outside the home. [28] It also captures active participation of individuals in small societies, such as engagement with friends or large societies like the interactions of the work environment [29] and their satisfaction with these interactions. [17]

According to the international classification of function (ICF), social participation is defined as the activities and duties required to participate in social life outside the family environment, and in the society, community, and civil society environment. [15]

Social participation does not take place without social relationship, [30] and it involves actions, whereby an individual shares his or her resources with others. [31] Depending on the resources shared, there are three types of social participation; collective social participation is defined as activities shared among members of a group, where time is the main source of sharing, and its purpose is directly related to the group itself, like group travel. Productive social participation involves provision of services, products, or specific benefits to others. In this type of participation, specific skills and competencies are shared in addition to time, such as volunteering, paying for money or caring for another person. Political social participation involves making decisions on social groups and allocating resources. These decisions are services provided by individuals or groups such as political parties in collective environments, where in addition to time and special skills, other resources such as knowledge and social competence are also shared. [8] The community social participation seems to be more important for the health of the elderly people among the three types of social participation. [31]

Formal social participation takes place through social and religious organizations [32 - 34] and involves social relationship with pre-designed groups, such as membership and participation in formal groups and associations. On the other hand, informal social participation means casual and occasional social communication such as meetings and contacting friends. [25 , 35]

Fougeyrollas et al. (1998) contributed significantly to the development of knowledge related to the concept of social participation by developing the Conceptual Model of the Disability Development Process (DCP). In this model, participation is the result of the interaction between individual characteristics such as age, gender, disabilities, as well as personality disorders and the environmental factors of the place of residence. Participation is conceptualized through the concept of life habits referring to daily activities and social roles; it is valued by the individual coupled with the cultural and social environment. In this model, social roles are not in their usual sense and they are not limited to roles such as a mother, student or worker; rather, they involve participation in financial or civil responsibilities, interpersonal communication, social life, employment, education, and entertainment. [36]

Levasseur et al. (2010) proposed four levels of social participation based on aging studies. Initially, the person is in social contact with others, while he does not do anything special with them, such as the shopping time where an individual communicates with others to find the item they are looking for and pay for it. Secondly, the individual collaborates with others to perform a specific activity and to achieve a common goal, which includes most recreational activities, such as team sports. Thirdly, the individual helps others during their activities, such as the time when an individual plays a role as a caretaker or volunteer, and participates. Finally, the individual is widely involved in societal and civil activities. [37]

Sometimes, there are disagreements among different fields concerning the definitions and uses of social participation. As an example, the field of rehabilitation mainly focuses on the individual’s performance regarding the concept of social participation than social activities and groups and organizations, whereas the field of ageing refers almost exclusively to social interactions and rarely focuses directly on performance.

Determine the Defining Attributes

The emphasis is on community-based activities and interpersonal interactions, based on resource sharing, active engagement and individual satisfaction. Exploring the definitions and uses of the concept of social participation of the elderly people indicated that the attributes repeatedly mentioned are as follows:

Emphasis on community-based activities. This attribute indicates the engagement of person in outdoor social activities in various social settings and includes a wide range of social activities namely religious, cultural, sports and leisure activities. [8 , 9 , 11 , 17 , 28 , 34 , 36 - 45]

Emphasis on Interpersonal Interactions. This attribute implies that the person has to interact with other members of the society during social activities; that is, the individual spends time with others and communicates with them. Indeed, it implies interpersonal interactions out of home. The significance of this attribute is the extent to which social participation cannot take place without social interactions. [10 , 11 , 13 , 25 - 28 , 30 , 34 , 35 , 37 , 40 , 43 , 45 - 51]

Based on Resource Sharing. This attribute implies sharing resources with other members of the society. This means that the individual shares personal resources, like time, knowledge, and skills with others in their social activities and engages with other people in the society. [8 , 31 , 35 , 42 , 49]

Based on Active Participation. This attribute indicates that the person has an active and conscious participation in the social activities. [16 , 29]

Based on Individual Satisfaction. This attribute implies that the person has a personal satisfaction resulting from performed social activities and interactions. [17]

Identify Model Case

According to the concept analysis, the model case is an example of the use of the concept which includes all the critical attributes of it. The model case clarifies the concept and can be derived from real life, texts, or fictitious contexts. [23]

“Mrs. B, is 70 years old and her spouse has passed away and her three children got married. She states that although she lives alone, she prefers to hang out with others in her free time; therefore, she always meets her children and helps them when they are in need. She is also an active member of the Charity Association of her neighborhood and attends the meetings of the association, communicates with the members and presents a solution; hence, it becomes an integral part of her life, and without it, she feels empty.”

The proposed model is a real model of social participation of the elderly people since all the attributes of the concept are present in it.

Identify Additional Cases

The additional cases are not the same concept; however, they have similarities or differences with the concept making it clearer. These cases include borderline case, related case, and contrary case. [23]

Borderline Case

The borderline case contains some of the critical attributes, but not all of them. It clarifies our thought about the defining attributes of the concept. [21]

“Mrs. B, 65, lives with her husband and two sons. She states that she gets along well with her family members and instead of spending time on activities outside home or with friends, neighbors, and others, she prefers to spend more time at home and to create a happy home with relaxed atmosphere. She talks to her children daily and tries to understand them and resolve their problems with her husband.”

The proposed model case is a borderline case, since from among critical attributes it has only the interactive nature and the sharing of resources with others. On the other hand, community-based activities, satisfaction with social interactions, and active participation have been ignored.

Related Case

The related case is an instance which is related to the concept but does not contain the critical attributes. It is similar to the concept and is somehow linked to the key concept. [23]

“Mrs. C, 70, is widowed and has a child with cerebral palsy. Taking care of her child is arduous; hence, her friends and acquaintances always aid her in house chores, shopping, and caring for her child, giving her a sense of security and value.”

The proposed model case represents the concept of social support and does not possess the attributes of the social participation concept; however, since an elderly woman is receiving support from other members of the society and is in interaction with them, it is pertinent to the concept of social participation.

Contrary Case

The contrary case is an instance that does not contain any of the critical attributes of the concept, and whose introduction determines what the analyzed concept is not. [23]

“Mrs. D, 67, lives with her husband. Their only child is living abroad. She has no interest in going out as a result of her depression. She is always at home and has no relationship with others such as friends, relatives, and neighbors.”

Identify Antecedents

The antecedents include events that must occur prior to the occurrence of the concept. [23] According to the literature, social participation antecedents in the elderly people can be classified into environmental, social, and individual factors.

Environmental factors include access to local resources and facilities, including public transport, walking paths, recreational facilities, and amenities, along with essential services to meet daily needs such as access to food, health services, and banks. [26] The presence of physical abnormalities in the neighborhood, including crime and the large number of empty houses and garbage lead to a reduction in social participation of the elderly people. [33]

Social factors include a high level of social support and satisfaction with these supports, [26 , 52] high level of trust, communication, security and social cohesion; [33] appropriate social policies in relation to social participation of the elderly people, especially after retirement; [53] and absence of limiting social norms, [45] age discrimination, [28] and social stress. [26]

Individual factors include the age under 80 years; [52] lack of physical, psychological, cognitive, auditory, visual [54 , 55] and communication disorders; high success motivation; [41] and compatibility with aging [28] and socioeconomic status. [56]

Identify Consequences

The consequences include events that occur as a result of occurrence of the concept. [23] According to the literature, the consequences of the elderly social participation can be classified into individual and social consequences.

In terms of individual consequences, social participation leads to improvement of the physical and mental condition of the elderly people and prevents them from dementia. [57] As the process of thinking improves the synaptic density, neural growth, and cognitive function, [46 , 58] it helps maintain meaningful social [13] and personal meaning. [45] Further, social participation reduces loneliness, [59] depression, [13 , 27 , 60] and stress in the elderly people, and improves the self-care process, [24] functional status, [54] quality of life, [13 , 26 , 60] life satisfaction, [53] adjustment strategies, [36] self-efficacy, self-esteem, and attachment. [39] In addition, social participation enhances the physical activity [61] which greatly reduces the ability of the elderly to do daily activities [34] and improves health promotion behaviors, fosters sense of personal mastery, [25] and leads to health-related behavioral formation [62] and more healthcare follow ups. [6] Finally, it increases health literacy [63] and health information and also boosts the available resources for material, spiritual, and social supports. [32]

Concerning social consequences, social participation in old people leads to a reduction in the mortality rate [61 , 64] and improvement of other health indicators. It reduces the burden of illness and disability among them in the society, and leads to social cohesion, [65] the maintenance of social order [4] and reduced health care costs. [66]

Define Empirical Referents

Empirical referents are the classes or categories of actual phenomena demonstrating the occurrence of the concept through their existence or presence. [23] There is no agreement on a common definition of social participation; thus, a variety of measurement strategies are found in the literature. [37] These measurements are criticized for being very null and very low in validity to be used for the elderly people, [15] for instance the Elderly Activity Inventory Questionnaire which has been used in various studies. The social dimension of this questionnaire has been suggested to measure the elderly social participation. This questionnaire aassesses social activities in the elderly in terms of meeting friends and family members, taking part in outdoor activities, attending recreational/social centers, attending cultural or sports events, attending classes, participating in discussion groups or self-help groups, going to cultural or library centers, and doing voluntary activities. [5 , 27 , 37 , 48] Similarly, Impact on Participation and Autonomy Questionnaire (IPAQ) measures participation through the ICF framework. This questionnaire includes 31 questions in 5 aspects of social communication, autonomy in self-care, mobility and fun, role of family, and educational plus work opportunities. This tool has not been specifically designed for social participation, and has been validated only in elderly people with Parkinson’s, and its validity and reliability have not been estimated for healthy elderly people. [15] Further, the Life Habits scale (LIFE-H) which is based on the Disability Conceptual Model (DCP), has been designed to measure the aspects of social participation of people with and without disabilities and includes 77 life habits in 12 categories of nutrition, fitness, personal care, communication, housing, mobility, responsibilities, interpersonal communication, social life, education, employment, and constraints. [16 , 17] The validity and reliability of this scale have been estimated in a study on the elderly people with functional restrictions and healthy elderly people. It seems to be the only valid tool for the elderly population. [15]

Regarding the defining attributes, including the empirical referents, elderly social participation involves civil activities such as membership in a political party, trade union, religious group or charity organization; sports activities such as attending a sports class; cultural activities such as going to libraries, cultural centers, cinemas, art galleries, museums, theaters or concerts; [63] productive activities such as caring for grandchildren or helping the family economy; [45] social activities like membership in social organizations and clubs, going out or meeting friends; [67] and entertaining activities, such as going to a recreational center, restaurant, or traveling. [65]

DISCUSSION

Using the Walker and Avant’s approach, we set up a systematic approach to identify and clarify the concept of social participation among the elderly, so that we can achieve a more specific and distinct description of it. The current study collected scattered evidence to provide a more comprehensive definition of social participation among the elderly. Given that each of the previous studies referred to one aspect of social participation in the old people, in the current study, a new conceptualization of this concept was presented. It gives the healthcare providers a comprehensive and fundamental view in order to take care of the elderly.

Regarding the attribute of the concept, older people’s social participation in this survey can be defined as the conscious and active engagement in outdoor social activities leading to interacting and sharing resources with other people in the community, and the person has a personal satisfaction resulting from that engagement.

Since social participation greatly influences all health aspects of the elderly, health care providers and nurses in particular should be provided with an appropriate understanding. [5] To develop a proper understanding, the concept has to be clarified. This can lead to promoting its status, importance, and application.

Since designing and implementing effective interventions to improve social participation is an important aspect of providing services for older adults, [54] this study can provide the ground for the necessary interventions to improve the social participation of the elderly in society and to develop more complete instruments in this area. Also, the findings of the current study can help develop theories by clarification of the social concept.

Moreover, the findings of the present study revealed that social participation of the elderly was affected by various environmental, social and personal factors. And it is necessary for the managers and policymakers of the healthcare system, and providers of health services, especially nurses, to be aware of them and pay great attention to providing the appropriate care to the elderly. Accordingly, the current study can be helpful in all these aspects.

Furthermore, given that social participation is effective in many aspects of the health of elderly people, it is recommended that further research should be conducted to investigate the social participation of the elderly people. Encouraging social participation using appropriate resources has important clinical consequences and should be integrated into aging care and rehabilitation programs.

One of the limitations of this investigation was restricted access to full text of some related articles. Furthermore, also, budget constraints prevented the inclusion of papers written in a language other than English or Persian

CONCLUSION

Having clarified the concept of social participation of the elderly people, the present study can provide a comprehensive understanding of this concept and provide a step toward paying more attention to it and create the tools to measure it. Future studies on the current topic are, therefore, recommended to identify the barriers and facilitators, and provide the necessary executive tools to enhance it.