تفاوت های جنسیتی در مورد اثرات طرد اجتماعی بر مرگ و میر در میان ژاپنی های مسن تر: مطالعه سن کوهورت

To evaluate the gender-specific impact of social exclusion on the mortality of older Japanese adults, we performed a prospective data analysis using the data of the Aichi Gerontological Evaluation Study (AGES). In AGES, we surveyed functionally independent residents aged 65 years or older who lived in six municipalities in Aichi prefecture, Japan. We gathered baseline information from 13,310 respondents in 2003. Information on mortality was obtained from municipal databases of the public long-term care insurance system. All participants were followed for up to 4 years. We evaluated social exclusion in terms of the combination of social isolation, social inactivity, and relative poverty. Cox’s proportional hazard model revealed that socially excluded older people were at significantly increased risk (9–34%) for premature mortality. Those with simultaneously relative poverty and social isolation and/or social inactivity were 1.29 times more likely to die prematurely than those who were not socially excluded. Women showed stronger overall impact of social exclusion on mortality, whereas relative poverty was significantly associated with mortality risks for men. If these associations are truly causal, social exclusion is attributable to 9000–44,000 premature deaths (1–5%) annually for the older Japanese population. Health and social policies to mitigate the issue of social exclusion among older adults may require gender-specific approaches.

There is a growing interest in the concept of social exclusion. Social exclusion is closely associated with material deprivation due to poverty but it covers wider and dynamic dimensions, including deprivation in social networks, living arrangements, goods, employment, access to benefits, and cultural capitals ( Berghman, 1995). Social exclusion is a “multidimensional” problem and a “dynamic process”, whereas the traditional concept of poverty focuses on “income” and “static outcome”. As shown in Table 1, various methods for measuring social exclusion exist. Barnes (2002) emphasized the importance of measuring the dimensions of interpersonal relationships and social participation. As Barnes argued, because “poverty is not simply about income, but about a lack of resources that impedes participation in society, measuring poverty requires detailed analysis of multiple deprivation and participation issues. Social exclusion focuses more on relational issues; in other words, inadequate social participation, lack of social integration and lack of power.” Note that the term “social exclusion” has been used in a different context in social psychology. Specifically, the negative consequence of unfavorable interpersonal relationships (e.g., being rejected by one’s peers) is similar to other concepts, such as social rejection and social ostracism ( Baumeister et al., 2005, Nolan et al., 2003 and Williams et al., 2005). Table 1. Existing indices/measures of social exclusion. Study Domain (Dimension) European Commission (2002) “non-monetary indicators from EUROSTAT” (1) Enforced lack of desired possessions (2) Absence of basic housing facilities (3) Problems with accommodation and the environment (4) Lack of ability to afford most basic requirements (5) Inability to meet payment schedules Bradshaw, Williams, and Levitas (2000) (1) Poverty / Lack of socially perceived necessities (2) Exclusion from the labor market (3) Service excluded (4) Exclusion from social relations Burchardt, Grand, and Piachaud (2002) (1) Consumption (2) Production (3) Political engagement (4) Social interaction Choffe (2001) (1) Income exclusion (2) Employment (3) Housing (4) Health (5) Family exclusion (6) Cultural exclusion Percy-Smith (2000) (1) Economic (2) Social (3) Political (4) Neighborhood (5) Individual (6) Spatial (7) Group Tsakloglou (2003) (1) Poverty (2) Amenities deprivation (3) Durables deprivation (4) Necessities deprivation Table options The World Health Organization has mentioned that “Poverty, relative deprivation and social exclusion have a major impact on health and premature death” (Wilkinson & Marmot, 2003). In fact, there are a large number of studies that focus on specific dimensions of social exclusion and health, for example, relative poverty, socioeconomic inequality, and neighborhood relationships (Kawachi, 2000, Kondo et al., 2008, Kondo et al., 2009 and Leclerc et al., 2006). However, there are few studies that have analyzed the impact of accumulation of poverty and social disintegration. It is highly likely that an individual’s experiences overlap in multiple dimensions of social exclusion, and we should focus on the overall impact of status for socially excluded individuals rather than the individual impact of each specific dimension. Scharf, Phillipson, and Smith (2004) conducted a cross-sectional survey in three socially deprived areas, and observed that older people who experienced multiple forms of social exclusion were significantly likely to rate their quality of life as poor or very poor. To our knowledge, there has been no large-scale cohort research that has assessed the relative and attributable impact of social exclusion on health among older Asian people. In addition, gender differences have not been well studied. The issue of social exclusion may be of particular importance in Japan, where the population is currently the oldest in the world (Ikeda et al., 2011 and United Nations, 2001). Older persons are likely to be financially vulnerable and at risk for being isolated (O’Rand, 1996). The Japanese government has recognized that 25% of older (aged 65 years or more) citizens live below the official poverty line, whereas the proportion is 16.0% among the general population (Cabinet Office of Japan, 2010a and Cabinet Office of Japan, 2010b). This is not a small proportion for a developed country (MHLW, 2011, OECD, 2005 and OECD, 2011). However, social exclusion and other key socioeconomic determinants of health are rarely applied in health and social policy in Japan. The purpose of this study was to evaluate the relative and attributable impact of social exclusion on mortality among older Japanese adults.

Worldwide, the population has been aging at an unprecedented pace (United Nations, 2001). In this study in Japan, where the society is the oldest in the world, we have revealed that there is a considerable proportion of the older population that is socially excluded and the attributable risk is large. Thus, policy intervention to promote social inclusion of the population, along with effective social security to support economically disadvantaged older adults should be required in Japan and many other countries. Numerous studies have suggested that older men tend to have narrower interpersonal relationships than women and they are more likely to experience social isolation (Saito et al., 2010 and Tunstall, 1966). In fact, we found that the prevalence of social isolation was two times higher among men than women (20.7% vs. 10.5%). On the other hand, although most women are likely to have richer social networks than men, their health risks could be larger, if they lose their networks. Therefore, community activities aiming to promote social inclusion should be designed with a good understanding of these gender-specific factors of social exclusion. Future important research tasks might be to clarify the mechanisms of these gender differences and to develop effective gender-specific approaches for the issue of social exclusion of older adults.